**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow written orders for wound care treatment for 1 out of 4 residents, (R2); reviewed for quality of care in a sample of 5. This failure resulted in R2 being admitted to the hospital with wounds declining. Findings include: R2's face sheet documented he was admitted to the facility on [DATE] and discharged on 5/2/25. R2's face sheet documented his diagnoses were, in part, burn of third degree of right foot, type two diabetes mellitus and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. R2's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact. R2's Care Plan dated 4/25/25 documented R2 was at risk for skin complications (entered on 5/4/25) with interventions, in part, to provide treatment as ordered (entered on 5/4/25). R2's discharge summary was faxed from hospital on 4/23/25 to the facility, it included his wound care orders. The discharge summary wound care orders documented the following: Donor site location: left thigh, Xeroform/bacitracin: leave adherent xeroform on donor site. Wash it daily with soap/water to remove any debris/old ointment. Reapply new bacitracin over adherent xeroform then leave it open to air. Trim loose xeroform as it lifts up. Once donor site is heeled (usually 2 weeks after surgery) xeroform should be able to be easily removed to reveal healed pink/dry donor site skin. Graft location: bilateral feet: bacitracin, xeroform and gauze daily to foot burns-separate toes with gauze. f/u (follow up) in 1 week with burn/plastic surgery clinic. R2's hospital discharge paperwork dated 4/23/25 documented to start bacitracin 500 unit/gram ointment on 4/24/25; apply to affected area daily. R2's Progress notes dated 4/28/25 documented V3, Wound Nurse Practitioner, wrote out the same wound care orders as mentioned in the discharge summary. R2's Orders documented on 4/25/2025 at 6:48 AM, are as follow: Left upper leg clean with soap and water cover old xeroform with bacitracin cover with either wrapped gauze or bordered dressing every day shift every Mon, Tue, Wed, Thu, Fri for wound care management. R2's Orders documented on 4/25/2025 at 6:00 AM, are as follow: Left upper leg clean with wound cleanser cover wound with xeroform cover with either wrapped gauze or bordered dressing every day shift every Mon, Tue, Wed, Thu, Fri for wound care management. R2's Orders documented on 4/24/2025 at 1:36 PM are as follow: right foot clean with wound with wound cleanser cover with xeroform wrap with gauze every day shift every Mon, Tue, Wed, Thu, Fri for wound care management. R2's Orders documented on 4/24/2025 at 1:33 PM, left foot clean with wound cleanser cover with xeroform cover with wrapped gauze every day shift every Mon, Tue, Wed, Thu, Fri for wound care management. R2's Progress note dated 4/25/2025 at 9:33 AM, documented V4 (Wound Nurse) charted she received a call back from surgeon's nurse and was informed by the nurse that the area where the skin graft was taken from was not to be changed. V4 continued to document We are to wash the area with soap and water and cover the xeroform that is on the area with bacitracin and leave open to air. I explain the clothing sticking to the clothing. Nurse stated that we can wrap it in gauze. I informed the nurse of removing one strip of the xeroform from the area do to what I read from the first set of orders. Nurse question if I covered it back up with xeroform, which I inform her that I did. Nurse stated that it is ok but not to do it again. R2's April Treatment Administration Record documented no wound care was signed off on 4/26/25 or 4/27/25 and there is no PRN (as needed) order for wound care on R2 in the TAR. R2's Progress note dated 4/30/25 at 3:43 PM documented R2 had a temperature of 100.8 degrees but asymptomatic and received new orders for labs. R2's labs collected on 4/25/25 resulted on 4/26/25 with a WBC of 17.10 where the normal range is documented to be between 3.4 - 10.8. On 4/30/25 R2's labs were done again and resulted with a WBC of 15.25. R2's orders documented Doxycycline Monohydrate Tablet 100 mg (milligram), give 1 tablet by mouth two times a day for infection for 7 Days with a start dated of 4/30/25 at 8:00 PM. Post-op paperwork documented R2 was admitted with diagnosis of wound cellulitis on 5/5/25. R2's Hospitalist Progress note dated 5/6/25 at 2:28 PM, documented under Assessment and Plan: Burn involving 5% of body surface status post grafting 4/16 and full-thickness third degree burns on feet with management per burn primary. Status post-split-thickness skin grafts on 5/5 with bilateral wound VAC (vacuum-assisted closure) in place. Wound cultures from 5/2 positive for Escherichia coli, Enterobacter cloacae, Staphylococcus aureus, Proteus mirabilis and Corynebacterium species. Continue ceftazidime for cellulitis. On 5/12/25 at 9:35 AM, R2 stated his stay at the facility was horrible, the treatment he was supposed to have, he didn't get. R2 stated they rarely changed his wound dressings or washed his feet. R2 stated the day or two right before he was going in for his follow up at the burn clinic, they did the dressing changes completely, out of nowhere. R2 stated he was concerned about getting an infection because it was so dirty at the facility, and they did wound care on the floor of his room not in a cleaned room or on his bed. R2 stated he asked the Director of Nursing (DON) if there was a more sanitary way to clean his feet but was told they'll just do it on his floor. R2 stated when he first arrived, the nurse just started to rip off the dressing from his thigh. R2 stated the nurse came back later and told him she didn't look at the second page of instructions where it said to leave the dressing in place on his thigh. R2 stated one nurse tried giving him wound care and told him she couldn't do it after she completed one of his feet and just left him sitting in his room for an hour with his foot undressed. R2 stated he can only remember the facility changing his wound dressings three times while he was there, his pain increased over time, and the wounds started to smell bad. R2 stated his surgeon asked him what the facility didn't do to his wounds because they shouldn't look the way they did. R2 stated his surgeon told him it pushed his recovery back but hopefully not too far and that his feet aren't as good as they would have hoped. R2 stated because of his stay at the facility he went backwards in recovery from the care they provided and had to undergo another surgery; now he is back in the hospital instead of home. On 5/8/25 at 2:41 PM, V13, R2's daughter in law, stated she arrived on 5/2/25 with R2. V13 stated she handed R2's discharge paperwork to the staff member that helped them get situated and emphasized how important it was because it has everything the facility needs to know on how to take care of R2 including his wound care. V13 stated the next day she went to the facility, and they had no idea what happened to it and said they didn't have any of R2's orders. V13 stated on 4/25/25 she talked to the wound care nurse who was rude to her, she said she had already done R2's wound care but later that day we received a phone call saying she removed R2's thigh dressing that was supposed to stay in place, so she obviously hadn't done his wound care yet or looked at the orders from the surgeon. V13 stated on 4/27/25 the facility was placing R2 on bedrest because when he walks around his bandages get dirty. V13 stated on 5/2/25 she took R2 to his follow up appointment with the surgeon at the burn clinic and he told them he was very sorry, R2's wounds are not supposed to look like this, they have gone backwards from when he was initially admitted with the burns, and he would like to admit R2 right away. V13 stated the surgeon said they could do another skin graft from the other thigh and redo it all. V13 stated on Monday 5/5/25, R2 had both of his feet skin grafted again and they also skin grafted the left thigh donor site from the skin loss that occurred there also. V13 stated all R2's wounds were infected on admission to the hospital. V13 started to cry and stated she thought we were sending R2 somewhere to get taken care of, she just hopes this doesn't happen to anyone else. On 5/8/25 at 10:26 AM, V12, R2's son, stated when R2 first got to the facility he dropped off the discharge paperwork with all the care instructions in it at the nurse's station. V12 stated the wound care nurse must not have looked at the packet because the first day she ripped off a strip of xeroform from R2's donor site that was supposed to stay in place for 2 weeks. V12 stated the facility barely did wound care to R2 and they weren't ambulating him like his surgeon instructed to. V12 stated all the wounds were to be done daily. V12 stated when he took R2 to his follow up appointment with the surgeon, you could smell the infection coming off R2's feet. V12 stated the surgeon said at the follow up all R2's sites failed, and they will probably need to do a skin graft to the donor site, redo his feet and use the other thigh for the skin graft. V12 stated the doctor said all R2's wounds were infected, and he was admitted to the Burn Unit ICU. On 5/7/25 at 10:30 AM, V4, Wound Care Nurse, stated that R2 came to the facility after burning his feet with tea, he was transferred from the hospital with 5% burns to his body. V4 stated R2's orders initially were to cleanse the sites, apply xeroform and wrap them up. V4 stated when she went to remove the xeroform from R2's thigh, he was in a lot of pain and later found out it was not supposed to be removed. V4 stated because R2 was in so much pain she only removed one strip and stopped. V4 stated she found the wound care orders several hours after she removed the one strip from R2's thigh. V4 stated there was supposed to be bacitracin applied to the thigh, but didn't have that at the facility. V4 stated she notified the surgeon's office and was told to leave the remaining xeroform on and apply more, cover with A&D ointment because the facility did not have bacitracin, and cover the area. V4 stated R2's feet were to be changed daily and PRN (as needed). V4 stated she wasn't concerned about R2's wounds until 2 days prior to him leaving the facility and notified the surgeon and sent pictures. V4 stated she was concerned about R2's wounds the entire time he was at the facility especially because he constantly dropped things on his dressings like urine from his urinal and juice. V4 stated she told the nurses to tell her anytime R2's dressing were wet. V4 stated she wanted to try to keep R2 in bed more to keep his feet safe but was told we couldn't do that. V4 stated two days prior to him leaving, parts were coming off his wound and reported it to the surgeon's nurse. On 5/8/25 at 10:05 AM, V4 stated that V3 (Wound Care NP) told her she could make R2's dressing changes Monday through Friday and PRN (as needed). V4 stated the surgeon's nurse also said R2's dressings could be done as needed. V4 stated she sent a picture of just one of R2's feet when she saw concerns but did not look at the other foot because it had a new dressing on it applied by another nurse. V4 stated the facility did not have bacitracin so she used A&D ointment on the thigh but did not see the discharge orders had instructions to apply bacitracin to the feet also. V4 stated the office only mentioned the xeroform on the phone. V4 stated the PRN wound care orders were not in the TAR, so that is why it does not document R2 had wound care over the weekend, and she had to make Progress notes instead for the treatment administration. V4 stated she had to enter those progress notes late because her computer wasn't working. On 5/7/25 at 2:35 PM, V4 stated wound care is documented as being completed on the treatment administration record (TAR) and should be completed there unless there is a question about the order, then hold doing it until clarifying. V4 stated wounds are supposed to be changed as needed when she is not at the facility by the staff nurses. V4 stated the TAR will show when the last dressing was done. On 5/8/25 at 9:44 AM, V7 Licensed Practical Nurse (LPN) stated when she took care of R2 over the weekend once and she remembered he spilled on his dressing but did not have to change them, she didn't feel comfortable changing his wounds because of how severe they were. On 5/7/25 at 2:56 PM, V11 (LPN) stated wound care is to be done according to the doctor's order. V11 stated she was concerned from the start with R2's wounds because of how severe they were but had never done his wound care. On 5/7/25 at 2:41 PM V9 (LPN) stated the Treatment Administration Record (TAR) will tell you what the wound care orders are, and will follow those when doing dressing changes. On 5/7/25 at 12:58 PM V3, Wound Nurse Practitioner (NP), stated V4 sent her a picture of R2's wound and it looked like it was failing. V3 stated V4 removed the donor site dressing and told said she didn't see the orders to leave it in place. V3 stated she was not told the facility did not have bacitracin to use on R2. V3 stated she would recommend following orders from the surgeon. On 5/8/25 at 10:52 AM, V3 stated her recommendations were to follow the surgeon's orders on R2 and she did not want to change anything. V3 stated she only put in orders as written by the surgeon. V3 stated she thinks they were supposed to be daily but would have to check the chart to make sure. V3 stated she did not put in for R2's wound care to be done on Monday through Friday and PRN because he was treated by a surgeon and would follow their recommendations. On 5/8/25 at 1:56 PM, V15, Facility's NP, stated she was concerned about infection for R2 after a nurse reported a low-grade fever on Thursday (5/1/25) and thought it could be related to his wounds, so she started him on a broad-spectrum antibiotic. V15 stated not administering the bacitracin ointment as ordered could have contributed to R2's wounds declining, it is an antibiotic ointment. On 5/12/25 at 10:06 AM, V14, Burn Unit Social Worker, stated upon discharge, she notifies the facilities of what patients need for aftercare and they never told her they didn't have bacitracin because if that was the case she would have sent some with R2 before he left. V14 stated the providers did not change any of their discharge orders for R2's wound care after he left and never said to use A & D ointment or to give dressing care Monday through Friday and PRN (as needed). V14 stated the wound care is very particular for burns and skin grafts. On 5/12/25 at 2:25 PM V2 (DON) stated R2 came with a donor site and skin graft wounds. V2 stated she started to have concerns about his wounds when he had an elevated temp and WBC (white blood cell). V2 stated V4 told her she notified the surgeon of this and provided updates on the wounds, but they wanted to hold off on doing anything until they saw him at his follow up appointment which was in the next day or two at that time. V2 stated she expects nurses to follow orders as written from the discharge paperwork and to only put in orders as a provider instructs to do so. V2 stated she was never notified that bacitracin wasn't available, she thought it was being applied to R2 the entire time. V2 stated no one made concerns to her that R2 wasn't getting wound care as ordered. The facility's Treatment/General Wound Treatment Policy dated 4/2024, documented under treatment guidelines to document routine and PRN treatments in the treatment administration record of the EHR (electronic health record) and to document all significant observations in the Nursing Progress Note. The facility's Skin and Wound Management Guidelines revised on 1/3/22 documented on admission or readmission to ensure the treatment order is in place and appropriate. The wound care nurse is to obtain or ensure appropriate treatment order is in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow wound care orders for 1 out of 4 residents, (R2) reviewed for quality of care in a sample of 5. This failure resulted in R2's experiencing severe pain. Findings include: R2's face sheet documented he was admitted to the facility on [DATE] and discharged on 5/2/25. R2's face sheet documented his diagnoses were, in part, burn of third degree of right foot, type two diabetes mellitus and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. R2's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact. R2's Care Plan dated 4/25/25 documented R2 was at risk for skin complications (entered on 5/4/25) with interventions, in part, to provide treatment as ordered (entered on 5/4/25). R2's orders documented acetaminophen 650 mg (milligram) tablet to be started 4/23/25 as needed for pain/fever/headache and oxycodone 5 mg tablet to be started 4/23/25 as needed for pain. R2's Medication Administration Record documented the first dose of acetaminophen he was given was on 4/24/25 at 8:53 AM and the first dose of oxycodone was administered on 4/24/25 at 11:25 AM. R2's discharge summary was faxed from hospital on 4/23/25 to the facility, it included his wound care orders. The discharge summary wound care orders documented the following: Donor site location: left thigh, Xeroform/bacitracin: leave adherent xeroform on donor site. Wash it daily with soap/water to remove any debris/old ointment. Reapply new bacitracin over adherent xeroform then leave it open to air. Trim loose xeroform as it lifts up. Once donor site is heeled (usually 2 weeks after surgery) xeroform should be able to be easily removed to reveal healed pink/dry donor site skin. Graft location: bilateral feet: bacitracin, xeroform and gauze daily to foot burns-separate toes with gauze. f/u (follow up) in 1 week with burn/plastic surgery clinic. Progress note dated 4/24/25 at 2:38 PM, V4 documented that R2 refused wound care treatment due to pain. After given pain pill and waiting 35 to 40 mins. Went back to resident to try to do wound care. R2 was still in a lot of pain. Resident agreed to let me cover the wound back up. Spoke with facility NP about resident's pain. NP increased frequency of pain medicine given. Called the wound NP and went over different ideas and how to help resident with dressing change and if she wanted to change any of the orders. The only change was to wrap or put a bordered dressing over graft area. Went over plan with R2 about changing dressings tomorrow. R2 did not want dressing change but stated that he will try. R2's son came into voice concerns about treatments. V4 explained R2's pain level and what she discussed with R2. Also went over that surgeon was called and left a voice message to see if anything needs to be changed with wound care due to the pain. R2's son was upset that the wound care was not completed and was worried about R2's mental status. NP called and orders for labs and urine to be collected by tomorrow. R2's Progress note dated 4/25/2025 at 9:33 AM, documented V4 (Wound Nurse) charted she received a call back from surgeon's nurse and was informed by the nurse that the area where the skin graft was taken from was not to be changed. V4 continued to document We are to wash the area with soap and water and cover the xeroform that is on the area with bacitracin and leave open to air. I explain the clothing sticking to the clothing. Nurse stated that we can wrap it in gauze. I informed the nurse of removing one strip of the xeroform from the area do to what I read from the first set of orders. Nurse question if I covered it back up with xeroform, which I inform her that I did. Nurse stated that it is ok but not to do it again. On 5/12/25 at 9:35 AM, R2 stated his stay at the facility was horrible, the treatment he was supposed to have, he didn't get. R2 stated when he first arrived, the nurse just started to rip off the dressing from his thigh, she didn't try to wet it down or peel it back slowly the way the hospital would do. R2 stated it felt like a strip of skin was ripped off his thigh. R2 stated he was screaming in pain, and they didn't give him medication before doing it; the nurse kept telling him It needed to be done until he finally told her to stop, he couldn't take the pain anymore. R2 stated he looked down at his leg after she ripped of the dressing, and it was bleeding. R2 stated they put in the charts that he refused care and ignored that it was causing him so much pain. R2 stated he's cut off a finger in his past and was treated better for that, they made sure his pain was managed first before providing the wound care but at the facility they didn't do any of that. R2 stated he was in severe pain screaming and she put him through hell. R2 stated the nurse came back later and told him she didn't look at the second page of instructions where it said to leave the dressing in place on his thigh. R2 stated because of his stay at the facility he went backwards in recovery from the care they provided and had to undergo another surgery; now he is back in the hospital instead of home. On 5/7/25 at 10:30 AM, V4, Wound Care Nurse, stated that R2 came to the facility after burning his feet with tea, he was transferred from the hospital with 5% burns to his body. V4 stated when she went to remove the xeroform from R2's thigh, he was in a lot of pain and later found out it was not supposed to be removed. V4 stated because R2 was in so much pain she only removed one strip and stopped. V4 stated she found the wound care orders several hours after she removed the one strip from R2's thigh. On 5/8/25 at 10:05 AM, V4 stated the initial time she took off the dressing from R2's thigh, R2 was in extreme pain. V4 stated we would pre-medicate R2 for wound care after that. On 5/8/25 at 9:44 AM, V7 Licensed Practical Nurse (LPN) stated R2 would complain of his wounds causing him pain. V7 stated the day V4 took the dressing off R2's thigh, he was bleeding, and she had to give him oxycodone after because he was in pain and wouldn't let anyone touch it afterward. On 5/13/25 at 9:53 AM, V16 (LPN) stated she would review orders first and see if there is pain medication to administer to the residents at least 30 minutes prior to providing wound care. V16 stated if the resident was in severe pain, then something is wrong and would stop. V16 stated she would soak the dressing first before removing it if it was dried to the skin. On 5/13/25 at 9:55 AM, V17 registered nurse (RN) stated she would pre-medicate if there were orders to do so prior to wound care. V17 stated she would not continue with wound care if it was causing the resident severe pain especially if it was sensitive. V17 stated she would wet the dressing first if it was dried to the skin before removing only if she had orders to remove it. On 5/13/25 at 10:56 AM, V2 (DON) stated she would expect the nurses to provide pain management if the resident is having complaints of pain. The facility's Pain Management Policy dated 1/2025 documented it will facilitate and provide guidance on pain observations and management. The policy continues to document the pain management program is based on a facility-wide commitment to resident comfort and pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. The policy further documented pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed assess, monitor, and treat a change of condition for 1 of 4 resident (R6) reviewed for quality of care in the sample of 15. This failure resulted in a delay of treatment for a significant change in condition resulting in R6's hospitalization. Findings include: R6's Face Sheet, print date of 2/19/25, documents that R6 was admitted on [DATE] and has diagnoses of Alzheimer's Disease and Dementia. R6's Minimum Data Set, dated [DATE], documents that R6 is moderately cognitively impaired and is independent with eating. R6's Nurses Note, dated 1/13/25, documents, Resident returned to the facility via (hospital) ambulance accompanied by EMS (Emergency Medical Services). The resident is alert and denies pain. The resident was a total assist into her bed and is 1.5 L (liters) of oxygen per nasal canula. Call light is within her reach. The resident is on droplet / contact isolation for influenza. R6's Nurses Note, dated 1/14/25, documents, Resident refused to leave O2 NC (oxygen) (nasal canula) on, repeatedly attempted to place NC on and resident takes it off. Resident educated on the importance of using her supplemental oxygen and resident still refuses. R6's Nurses Note, dated 1/15/25, documents, 'Resident refuses to keep on O2. Resident has been redirected several times. Resident is currently sitting in bed resting with nasal canal (cannula) on will continue to monitor. R6's Note Text, dated 1/15/25 9:53 PM, documents R6 received a DRIPT IV Therapy infusion per provider order with post infusion vital signs of 136/84 blood pressure and a heart rate of 82. R6's Progress Note, written by V12, Medical Nurse Practitioner, dated 1/17/25, documents, Patient seen and examined today for routine 30 day follow up. Patient reports good appetite. Is sleeping well overnight. Denies acute medical conditions. It continues, resident requires assistance with ADL's (activities of daily living) and mobility. Patient recently hospitalized for Influenza A. Continues to refuse to wear supplemental oxygen. R6's vital signs, dated 1/18/25, documents R6's blood pressure of 102/68, heart rate of 51, temperature of 98.2, respirations of 18, and oxygen saturation of 88%. R6's Meal Intake, dated 1/23/25, documents R6 at 75 to 100% of her meal at 11:15 AM and 12:45 PM. R6 has no other meal intakes documented before R6's discharge to the hospital on 1/27/25. The facility Weekly Weeks documents the week of 1/13 R6 weighed 173 pounds, the week of 1/20 R6 weighed 162.5 pounds. The facility Communication for Daily Facility Discharges documents R6 was sent to the hospital on 1/27/25 because of AMS (Altered Mental Status), Hypotension, and Dehydration. R6's Electronic Medical Record fails to document any other Nursing Notes, Vital Signs, Nursing Assessments, Doctor Notification, Change of Condition, or Hospital Transfer documentation between 1/13/25 and 1/27/25. R6's Emergency Department Disposition, dated 1/27/25, documents Hospital Problems present upon admission Pneumonia of right lower lobe, Acute on chronic hypoxic respiratory failure, Hypernatremia, Moderate malnutrition, SIRS (systemic inflammatory response syndrome) UTI (urinary tract infection). A/P (assessment and plan): lab's significant for leukocytosis 14.6, lab's look like hemo-concentrate. Hypernatremia 155 (high normal is 145) AKI (acute kidney injury), cre (creatine) 1.94 baseline 1.1, UA (urinalysis) showed 4 plus leukocyte estrase, 4 plus bacteria. CXR (chest x-ray) noted opacities right lower lobe concern for pneumonia, no pleural effusion, no pneumothorax. In the ED (Emergency Department), she was given ceftriaxone/azithromycin for pneumonia and UTI. 1 L of fluid and continuous fluid. Plan: Hypernatremia AKI cre 1.94 baseline 1.1 Free water deficit: 2.7 L. repeat labs, sodium q6h (every 6 hours) These fluid and electrolyte abnormalities are being treated, evaluated, or monitored. Dehydration - IVF's (Intravenous Fluids) and repeat electrolytes. On 2/20/25 at 11:43 AM, V2, Director of Nurses, stated, (R6) just came off of our NAR (Nutrition At Risk) watch on 1/6/25. The way that the weekly weights work is as long as the weight is done that week, I enter the weight on Friday, and then on Tuesday when the Dietitian comes, we talk about putting new interventions in place. (R6) was 173 the week of 1/13/25 and the week of 1/20/25 she was 162.5. I entered the (R6's) weight of 162.5 on the 24th which was a Friday. I had planned on talking to the Dietitian about her on Tuesday, but she was sent to the hospital on Monday (1/27/25) and did not return. We already had her on fortified pudding and supplements. We can put things in place but if she is not eating it is not going to help. I am not sure if the Doctor was notified of (R6) not eating. I did educate the staff to push fluids and encourage her to eat. The staff should have been charting on her decline, a note about her going to the hospital, meal intake, and notifying the doctor if they did. On 2/20/25 at 1:48 PM, V12, Medical Nurse Practitioner, stated, I saw (R6) on 1/17/25. I knew she had just come back from the hospital with Influenza. I was not notified that she had a decline, she was not eating, and had weight loss. I should have been. On 2/19/25 at 12:30 PM, V3, Assistant Director of Nurses, stated I took care of (R6) on 1/26/25 going into the 27th. I did hear she was not feeling well, wasn't eating, and didn't want to get her hair cut. She hadn't been herself after she came back from the hospital with the flu. She was not eating or drinking like before. She would go to the dining room for meals. Before she was independent with dining, after that sometimes we would have to help her and encourage her to eat. There should be nurse's notes of her decline and why when she was transferred to the hospital. On 2/19/25 at 2:30 PM, V16, Licensed Practical Nurse (LPN) stated R6 really did decline fast after she got the flu. On 2/19/25 at 2:45 PM, V17, Certified Nurse Aide (CNA), stated The last two weeks she was probably eating 25% of her meal. It came to where we had to feed her. She used to be able to eat. I would say she totally stopped eating 2 to 3 days before she went to the hospital. The nurses knew. It should be documented in our charting of the intakes. On 2/20/25 at 11:00 AM, V1, Administrator, stated that V24, agency LPN is the nurse that sent R6 out to the hospital. On 2/20/25 at 11:05 AM, V2, Director of Nurses, stated I was in the building the evening that (R6) went out to the hospital because I told (V24) to send her out. The aides came out and said that (R6) wasn't acting right. She was acting very sluggish just not herself. She had low blood pressure. On 2/20/25 at 11:07 AM, V22, CNA, stated, The last time I worked with her (R6) it was 2 days before she went out. She was really tired. I was able to get her eat a few bites. I had to fed her. I even tried to get her to take some bites of her fortified pudding, but she wasn't having it. She was ok just really really tired. She was still urinating like normal. I did chart her intakes. I let the nurse know that she did not have an appetite that day. On 2/20/25 at 11:39 AM, V24 stated, I haven't worked there often but I didn't send anyone out to the hospital while I was there. On 2/20/25 at 12:26 PM, V25, CNA, stated, I took care of (R6) the evening before she went to the hospital (1/26/25). Before she would talk to me. She was confused but she would talk. The last night I cared for her, she was completely out of it. She looked horrible. She would go ew ew ew she couldn't even talk anymore. I tried to get her to drink her water, but she couldn't even swallow it just sat in her mouth. The nurse was going in and giving her meds (medications). I asked what was going on and she said she has had a decline. On 2/20/25 at 1:20 PM, V8, Registered Nurse, stated, (R6) was more tired and less talkative but about her normal self. She would always sit in her doorway in her wheelchair wanting to go to her room which she was in her room. She wasn't doing that. As far as I know, she was eating and drinking just fine. I did not see anything alarming about her. The policy Change in Resident Condition, dated 9/2024, documents, Nursing will notify the resident's physician or nurse practitioner when: b. There is a significant change in the resident's physical, mental or emotional status. c. There is a pattern of refusing treatment or medication. It continues, e. It is deemed necessary or appropriate in the best interest of the resident. The Weight Change Policy, dated 9/22, documents, 1. Review weights and vitals dashboard for significant weight changes. 2. upon identification of a newly significant weight change, complete NARs weekly review tool. 3. Notify Dietician, Physician, and resident representative. The Policy Documentation by Exception, dated 9/2024, documents, 2. documentation should include any unusual event or change of condition of the resident. 3. Any communication with the physician, nurse practitioner, or consulting physician should be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess, and monitor pressure ulcers, and provide the Physician prescribed treatment for 4 of 5 residents (R1, R2, R4, R5) reviewed for pressure ulcers in the sample of 15. The failure resulted in R5 developing a pressure ulcer of unknown stage while at the facility, not receiving treatment for a pressure ulcer for 23 days at which time it was unstageable, and R4 developing 3 pressure ulcers while at the facility and a sacral pressure ulcer that became infected. Findings include: 1. R5's Face Sheet, print date of 2/20/25, documents R5 was admitted on [DATE] with diagnoses of Severe Protein Calorie Malnutrition, Delusional disorder, Schizophrenia, and Heart Failure. R5's Minimum Data Set (MDS), dated [DATE], documents R5 is moderately cognitively impaired, dependent on staff for dressing, toileting, and hygiene, frequently incontinent for urine and bowel, and R5 has 2 unstageable pressure ulcers. R5's Braden Scale for predicting Pressure Sore Risk, dated 1/8/25, documents that R5 is a high risk for pressure ulcers. R5's Electronic Medical Record fails to document a Braden Scale before 1/8/25. R5's Nurse's Note, dated 12/1/2024 11:12 AM, documents, Resident has 2 open wounds. 1 is on his right hip, and the other is on his inner left knee. I put TAO (Triple Antibiotic Ointment) and bandages on both of the wounds. His right heel on the left side is also becoming soft. I had CNA (Certified Nurse Assistant) put a pillow in between his knees and feet to take the pressure off. Plan of care ongoing. R5's Weekly Skin Assessments, dated 11/14/24 - 12/23/24 fails to document any pressure areas noted on R5. R5's Electronic Medical Record fails to document a pressure ulcer wound assessment for the pressure ulcer found on 12/1/24, Physician Notification, or Physician Orders for treatment for the pressure ulcer. There are no progress notes regarding the monitoring, assessment, or treatment of R5's pressure ulcer from 12/1/24 to 12/24/24 for the pressure ulcer to R5's right hip. R5's Nurse's Note, dated 12/24/24, documents, Was informed by CNA (Certified Nurse Aide) that resident has a bad wound on his right hip/ butt. Check wound with wound NP (Nurse Practitioner) and found an unstageable wound. Resident stated that its fine don't touch it. Resident stated that it is not a wound, its clothing. Did wound care on wound with resident upset with wound care being done. Resident stated that he would pull it off when I am gone. R5's Treatment Administration Record (TAR) for December 2024, documents, Start date 12/19/24 Discontinue date of 1/5/25, right buttock, cleanse wound with wound cleaner and apply Silvadene, calcium alginate, collagen and cover with gauze dressing. every day shift for wound care. This TAR documents R5 refused dressing changes 5 of the 24 ordered changes. R5's Skin and Wound Note, dated 12/24/24, documents, Patient seen today for a new unstageable PI (Pressure Injury) to his right hip. Per staff, patient refuses to roll to left side, always laying on right side causing pressure. Wound: 3 Location: Right hip Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: New. Size: 5.5 cm (centimeters) x 3 cm x 0.2 cm. Wound Base: 100% eschar Wound Edges: Attached Periwound: Intact, Fragile Exposed Tissues: Epithelium Exudate: None amount of None. Wound # 3 Right hip Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Hydrogel to base of the wound. 3. secure with Bordered gauze. 4. change Daily, and PRN (as needed). NEW RECOMMENDATIONS: The resident has a treatment change listed above. Please reference the recommended orders for updated treatments. R5's December 2024 Physician Orders or TAR failed to document a right hip pressure ulcer treatment recommendation, written on 12/24/24 of cleanse with wound cleanser, apply hydrogel to base of the wound, secure with bordered gauze, change daily and PRN (as needed). R5's Skin and Wound Note, 1/3/25, documents, Wound: 3 Location: Right hip Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: Improving with delayed wound closure Size: 4 cm x 4 cm x 0.2 cm. Wound Base: 100% eschar Exposed Tissues: Epithelium Wound Edges: Attached Periwound: Intact, Fragile Exudate: None amount of None. Wound # 3 Right hip Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Hydrogel to base of the wound. 3. secure with Bordered gauze. 4. change Daily, and PRN. NEW RECOMMENDATIONS: The resident has a treatment change listed above. Please reference the recommended orders for updated treatments. R5's January 2025 TAR, documents, Start date of 1/6/25 Discontinue date of 1/16/25, right buttock, cleanse wound with wound cleanser cover with hydrogel cover with boarder dressing every shift for wound care. This TAR documents that R5 refused 1 of the 10 dressing changes. R5's January 2025 TAR documents, right buttock cleanse wound with betadine and cover slough with silver alginate cover with boarder dressing every day shift for wound care. Start date of 1/17/25 Discontinue date of 2/4/25. This TAR documents that R5 refused the dressing change 2 of the 11 dressing changes. R5's January 2025 TAR documents, left hip clean with wound cleanser cover with silver alginate cover with boarder dressing every day shift for wound care. Start date of 1/17/25 Discontinue date of 2/4/25. 2. R4's Face Sheet, print date of 2/10/25, documents R4 was admitted on [DATE] with a diagnosis of compression fracture of T (thoracic) 11-T12. R4's MDS, dated [DATE], document that R4 was cognitively intact, required moderate to partial assistance for bed mobility, and totally dependent on staff for transfers, and was frequently incontinent of bowel. R4's Braden Pressure Ulcer Risk, dated 1/2/24 documents R4 is a high pressure risk. R4's Skin Condition Assessment, dated 1/2/25, fails to document a skin condition or pressure ulcer. R4's Electronic Medical Record fails to document an admission Assessment for R4 on 1/2/25. R4's Physician Order, dated 1/3/25, documents Cleanse sacrum with wound cleanser &/or NS (normal saline), apply dry dressing daily until wound MD (Medical Doctor) sees for new ordered. R4's TAR, dated 1/3/25, documents Cleanse sacrum with wound cleanser &/or NS (normal saline), apply dry dressing daily until wound MD (Medical Doctor) sees for new ordered. R4's TAR, dated 1/3/25, documents apply zinc oxide to buttocks every shift for redness and open area. R4's Nurses Note, dated 1/5/25, documents, called to resident room, resident is not responding to verbal or physical stimulation, breathing normally, vital signs at this time 99.7, 68/48, 129 hr (heart rate), 22 resp (respirations). It continues, Call placed to 911 for transport to hospital for eval (evaluation) and treatment. R4's Nurse's Note, dated 1/9/25, documents, Resident came from (local hospital). It continues, Resident has an open wound on her bottom, hospital said wound was not open; however, the area is open. R4's Nursing admission Observation, dated 1/9/25, documents R4 has Pressure Ulcers. This document fails to document the location, appearance, or measurements of the pressure ulcer (s). R4's Skin Note, dated 1/9/25, documents, No new skin issues noted. R4's Physician Order, dated 1/9/25, documents Apply Zinc Oxide to buttocks every shift for redness, open area. R4's TAR, start date of 1/9/25 end date of 2/5/25, documents apply zinc oxide to buttocks every shift for redness and open area. R4's Skin and Wound Evaluation, dated 1/10/25, documents, Wound Measurements Length 3.4 cm Width 1.1 cm. This Skin and Wound Evaluation fails to document the type of wound, location, appearance of the wound, or notification of the Physician of the wound. R4's Skin Screen dated 1/9/25 and 1/16/25 fails to document R5 having skin conditions or pressure ulcers. R4's Skin and Wound Note, dated 1/15/25, documents Wound: 1 Location: right buttock Primary Etiology: Pressure Stage/Severity: DTI (Deep Tissue Injury) Wound Status: Present on admission Size: 3 cm x 5 cm x 0 cm. Wound: 2 Location: sacrum Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: Present on admission Size: 4.5 cm x 2 cm x 0.2 cm. Wound Base: 10% granulation, 90% slough Wound Edges: Attached Periwound: Fragile, Erythema Exudate: Scant amount of Serous Wound: 3 Location: left buttock Primary Etiology: Pressure Stage/Severity: DTI Wound Status: Present on admission Size: 7.5 cm x 4 cm x 0 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Intact, Fragile PLAN: Wound # 1 right buttock Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Zinc Oxide Paste to base of the wound. 3. secure with Leave open to air. 4. change Q Shift. Wound # 2 sacrum Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Medical grade honey to base of the wound. 3. secure with Bordered gauze. 4. change Daily. Wound # 3 left buttock Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Zinc Oxide Paste to base of the wound. 3. secure with Leave open to air. 4.change Q Shift. The above dressing(s) was selected to promote autolytic debridement and moist wound healing within the wound bed. R4's Physician Order, dated 1/17/25, documents sacrum clean with wound cleanser cover open wound with medihoney cover with sacrum comfort foam dressing every day shift for wound care management. R4's TAR documents, Start date of 1/17/5 Discontinue date of 2/4/25, clean with wound cleanser cover open wound with medihoney cover with sacrum comfort foam dressing every day shift for wound care management. R4's TAR, start date of 1/9/25 end date of 2/5/25, documents apply zinc oxide to buttocks every shift for redness and open area. R4's Skin and Wound note, dated 1/21/25 WOUND ASSESSMENT: Wound: 1 Location: right buttock Primary Etiology: Pressure Stage/Severity: DTI Wound Status: Worsening Size: 5 cm x 5 cm x 0 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Fragile Wound Pain at Rest: 5 Wound: 2 Location: sacrum Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: Improving without complications Size: 4.1 cm x 2 cm x 0.4 cm. Wound Base: 30% granulation, 70% slough Wound Edges: Attached Periwound: Fragile, Erythema Exudate: Scant amount of Serous Wound Pain at Rest: 5 Wound: 3 Location: left buttock Primary Etiology: Pressure Stage/Severity: DTI Wound Status: Improving without complications Size: 6.5 cm x 3 cm x 0 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Intact, Fragile Exudate: None amount of None. R4's Skin and Wound Note, dated 1/28/25 documents WOUND ASSESSMENT: Wound: 1 Location: right buttock Primary Etiology: Pressure Ulcer/Injury Stage/Severity: Stage 2 Wound Status: Improving without complications. Size: 4 cm x 2.5 cm x 0 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Fragile Exudate: Scant amount of Serosanguineous Wound Pain at Rest: 5. Wound: 2 Location: sacrum Primary Etiology: Pressure Ulcer/Injury Stage/Severity: Stage 4 Wound Status: Worsening Size: 3.8 cm x 3.5 cm x 0.5 cm. Wound Base: 60% granulation, 40% slough Wound Edges: Unattached Periwound: Fragile, Erythema Exposed Tissues: Muscle/Fascia, Subcutaneous, Dermis Exudate: Heavy amount of Purulent, Serosanguineous. Wound: 3 Location: left buttock Primary Etiology: Pressure Stage/Severity: Stage 2 Wound Status: Improving without complications Size: 2 cm x 1 cm x 0.1 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Intact, Fragile Exudate: Scant amount of Serosanguineous Wound Pain at Rest: 5 PLAN: Wound # 2 sacrum Pressure Ulcer/Injury Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Silver alginate to base of the wound. 3. secure with Bordered gauze. 4. change Daily. R4's 1/2025 Physician Orders or TAR fails to document R4 being ordered or treated the change in sacrum pressure ulcer treatment of cleanse with wound cleanser, apply silver alginate to base of wound, secure with bordered gauze, and change daily that was ordered on 1/28/25. R4's Emergency Department document, dated 2/3/24 4:07 PM, documents Was called into the room by (Hospital Registered Nurse) when changing the patient's diaper, she has a deep sacral ulcer with purulent drainage present. (Hospital Physician) updated on wound and CT (computed tomography scan) abdomen and pelvis, sed (sedimentation) rate, CRP (C- Reactive Protein), vancomycin, and cefepime ordered. R4's Emergency Department Record, dated 2/3/25, documents Wound of sacral region initial encounter, Mental status has improved. Son at beside. Explained the wound will likely not heal at all given the advancement and bone involvement If there is any chance to heal this will require a diverting ostomy. Risks/benefits discussed. Code status has been addressed. Discussions with palliative hospice ongoing. As soon as determination is made, we can discuss further. R4's Hospital Record, dated 2/3/25, documents Sacral wound with infection, present on admission, s/p (symptom / plan) debridement. -Wound present on prior discharge but has certainly progressed and now with concerns of infection. - CT 5.8 x 1.6 x 2cm sacral ulceration extending from S (sacral)4-S6 containing gas and fluid and/or debris. Thin tract of gas along left side of sacrum with possible fistula and/or osteomyelitis - General surgery consulted - Continue Vanc (vancomycin)/Cefepime/Flagyl - Wound would likely require diverting ostomy for optimal healing - 2/5: Family opting to proceed with surgical intervention and hospice will follow for discussion postoperatively - 2/6: general surgery for sacral debridement and possible diverting ostomy - Wound culture with MSSA (Methicillin- resistant staphylococcus aureus), pseudomonas, continue vanc/cefepime/flagyl today. can likely de-escalate postoperatively pending findings. 3. R1's Face Sheet, print date of 2/10/25, documents R1 was re-admitted on [DATE] and has diagnoses of Type 2 Diabetes Mellitus and Dementia. R1's MDS, dated [DATE], documents that R1 is mildly cognitively impaired, requires substantial maximal assist with rolling in bed, dependent on staff for transfers, has an indwelling urinary catheter, and is always incontinent of bowel. R1's Skin and Wound Note, dated 2/5/25, documents Patient seen today for a healing stage 4 PI to his right buttock. Location: right buttock Primary Etiology: Pressure Stage/Severity: Stage 4 Wound Status: Stable Size: 0.8 cm x 0.5 cm x 0.2 cm. Wound Base: 70% epithelial, 30% granulation, 0% slough, 0% eschar. Wound # 5 right buttock Pressure Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Collagen Particles to base of the wound. 3. secure with Bordered gauze. 4. change Daily, and PRN. NEW RECOMMENDATIONS: The resident has a treatment change listed above. Please reference the recommended orders for updated treatments 2/5. On 2/8/25 at 9:18 AM, V4, Certified Nurse's Aide (CNA) and V5, CNA, entered R1's room to provide incontinent care. V4 removed R1's covers. R1 is not wearing heel protectors. R1 had a large liquid bowel movement that has leaked out of R1's incontinent brief. R1's brief was removed. V4 provided incontinent care. R1 did not have a dressing on the right buttock pressure ulcer. V4 confirmed R1 did not have a pressure ulcer dressing on the right buttock. The pressure ulcer was actively bleeding. While providing the incontinent care V4 wiped a stool soiled pre-moistened cloth over the pressure ulcer. V4 and V5 both stated that R1 should have on his heel protectors, and they placed them on him. On 2/8/25 at 10:34 AM, V9, Licensed Practical Nurse, LPN entered R1's room to provide R1's right buttock pressure ulcer treatment. V9 cleansed the wound with wound cleaner. The wound bed is red with white edges at the top. V9 measured the wound 3.2 centimeters (cm) long x 1.4 cm wide. V9 applied Hydrogel, Collagen Particles, (Silver Sulfadiazine) SSD cream, calcium alginate and a superabsorbant gauze, and then taped it securely. R1's February 2025 TAR documents, Clean with wound cleanser on right buttock hydrogel, collagen particles, SSD, calcium alginate rope, Cover with super absorbent gauze every day shift for wound care management start date of 1/8/25. This TAR fails to document and order from 2/5/25 of cleanse with wound cleanser, apply collagen particles to base of the wound, secure with bordered gauze. 4. R2's Face Sheet, Print date of 2/10/25, documents R2 was admitted on [DATE] and has diagnoses of Type 1 Diabetes and Paraplegia. R2's MDS, dated [DATE], documents that R2 is cognitively intact, requires partial to moderate assistance for bed mobility, is dependent on staff for transfers, has an indwelling urinary catheter, and an ostomy. R2's Physician Orders, dated 2/7/25, documents, SSD (Silver sulfADIAZINE) External Cream 1 % (Silver Sulfadiazine) Apply to right buttock topically in the morning for wound care management. R2's Physician Orders, dated 2/6/25, documents right buttock clean wound with wound cleanser cover wound with mixture of SSD, collagen filler and hydrogel cover with calcium alginate cover with bordered gauze every day shift for wound care management AND as needed for whenever the wound dressing comes off or dirty. R2's Physician Orders, dated 2/6/25, documents sacrum clean wound with wound cleanser cover with zinc ointment leave open to air every day shift for wound care management AND as needed after bowl movements. On 2/8/25 at 10:52 AM, V8, Registered Nurse, RN entered R2's to provide pressure ulcer treatments. V8 cleansed the sacrum pressure ulcer with wound cleanser, applied a mixture of SSD, hydrogel, collagen particles, calcium alginate, and covered the pressure ulcer with border gauze. The pressure ulcers were 5.5 cm x 4.5 cm. The wound bed was red. The upper left side of the pressure ulcer had scabs. V8 then cleansed the right buttock pressure ulcer with wound cleanser, applied a mixture of hydrogel, collagen particles, calcium alginate, and covered the pressure ulcer with border gauze. The pressure ulcer measured 3 x 1.5. There is a stitch in the middle of the pressure ulcer. The middle is indented, and the wound bed color is dark pink. V8 stated she just may have done the wrong order on the sacrum. V8 did not remove the applied a mixture of SSD, hydrogel, collagen particles, calcium alginate, and covered the pressure ulcer with border gauze. On 2/8/25 at 11:15 AM, R2 stated that she just returned from the hospital because one of the wounds needed to be cauterized because it would not stop bleeding. On 2/8/25 at 2:30 PM, V8 stated she did not use the SSD cream on the right buttock is because R2 was out. On 2/10/25 at 2:30 PM, V2, Director of Nurses, stated that she is unsure why the orders that the Wound Nurse Practitioner are not put in as orders. A pressure ulcer assessment should be done at admission, readmission, or when a pressure ulcer is found. On 2/13/25 at 11:49 AM, V13, LPN/Wound Nurse, stated a skin assessment should be done within the first two hours of admission. If a pressure ulcer is new, it will get a dressing over it, and I notify the Nurse Practitioner or the Doctor to get orders for it. I then put the order in and do the treatment. I do rounds with the Wound Nurse Practitioner. the Nurse Practitioner will go over the pressure ulcer and then what order she wants. If I am not here the floor nurse will go with the Wound Nurse Practitioner. When she changes an order, I put it in right then that way it gets put in the Physician Orders and to the Treatment Administration Record. The Wound Nurse Practitioner will send an email with the wound information and what order she wants. Sometimes it is the same and sometimes it is different. If a dressing is missing it should be replaced as soon as possible. The dressings should be done as they are ordered. On 2/19/25 at 10:48 AM, V14, Wound Nurse Practitioner, stated We are a contracted company, so we are not allowed to put in orders. The nurses here do it. I have 48 hours to turn in my report with the recommendations which are the orders, but they are called recommendations. Once they get that report, the recommendations should be entered as orders and then carried out. If a new pressure ulcer or wound develops the facility should be calling the Medical Doctor for orders. I am only here once a week so when I come next, I will then look at it. The nurses should be putting on the treatments as they are ordered. The policy Skin Management: Pressure Injury Treatment/ General Wound Treatment, dated 4/2024, documents, General Treatment Guidelines; 1. Review the physician order in the EHR (Electronic Health Record) and place all necessary supplies in treatment care. It continues, 6. Perform the treatment as ordered using proper techniques of infection prevention and control. 9. Pressure Injuries will be evaluated, and the following areas documented weekly (minimum every 7 days). Location. Size: Perpendicular measurement of the greatest extent of length and width of the injury using a disposable measuring device. Depth: insert a swab in wound and gloved finer at end, then measure in centimeters. Presence and location (based on the clock) of undermining/ tunneling/ sinus tract. exudate: type, color, odor, and appropriate amount. pain: Nature and frequency. Wound bed: color and type of tissue / character including evidence of healing (granulation tissue) or necrosis. Description of wound edges and surrounding tissue (rolled edges, redness, maceration, etc.) 10. The staff nurse will notify the Wound Nurse upon identification of skin impairment. If the Wound Nurse is not available, the staff nurse should document the open area on a Skin Screen Form and alert the health Care Provider for treatment orders. 11. When the Wound Care Team assesses the resident, they will take a picture, measure the wounds, review the orders, and update any notes and care plans as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent pressure ulcer development and failed to provide resident centered interventions, monitoring and orders for residents who were identified to be at risk for pressure ulcers and for residents with pressure ulcers for 2 of 3 residents (R1, R2) reviewed for skin impairment. This failure resulted in R1 acquiring an unstageable pressure ulcer to his/her left heel and stage 3 pressure ulcer to right buttock; R2 requiring debridement of an unstagable pressure ulcer during a hosptial stay to R2's coccyx. Findings include: 1. R1's face sheet with a print date of 10/21/2024 documented R1 has diagnoses of type 2 diabetes mellitus, sepsis, cognitive communication deficit, contracture of left knee, dementia, osteoarthritis, hypertension, and paroxysmal atrial fibrillation. R1's MDS (Minimum Data Set) dated 10/9/24 documented R1 has moderately impaired cognition. R1's MDS dated [DATE] documented R1 requires substantial to maximal assistance with bed mobility and is dependent on staff for all other mobility. R1's care plan, undated, documented R1 is at risk for pressure ulcers related to impaired mobility and incontinence. This care plan documented R1's interventions include assist and encourage resident to turn and reposition frequently, document signs and symptoms of skin break down, low air loss mattress, notify nurse of signs and symptoms of skin breakdown noted during routine care, weekly and prn (as needed) skin assessment. R1's progress note dated 8/30/24 at 10:40 AM by V10 NP (Nurse Practitioner) documented R1 developed a new stage 2 pressure ulcer to left heel. V10 documented wound size 2.5 cm x 4 cm x 0 cm, wound base 100% epithelial, wound edges attached, and exposed tissues: epithelium and dermis. R1's progress note dated 9/5/24 at 9:17 am by V10 NP documented wound left heel, primary etiology: pressure, stage/severity: stage 2, wound status: worsening, size 3 cm x 5 cm x 0 cm, wound base: 100% eschar. R1's progress note dated 9/12/24 at 10:10 AM by V10 NP documented R1's stage 2 pressure ulcer on left heel as worsening and new measurements of 4.6 cm x 4.5 cm x 0 cm. This progress note documented that R1 was experiencing pain in the heel at rest and that V10 surgically debrided that pressure ulcer during this visit. V10 documented post-debridement measurement of 4.6 cm x 4.5 cm x 0 cm. R1's progress noted dated 9/20/24 at 9:40 am by V10 NP documented R1's stage 2 pressure ulcer on left heel as unstageable. On 10/17/24 at 8:35 am R1 was observed in bed on a regular mattress lying on his back. On 10/17/24 at 11:35 am V8 LPN (Licensed Practical Nurse)/Wound Nurse and V9 LPN/former Wound Nurse were observed as they performed wound care to R1's heel. V9 stated R1's heel started out as what appeared as a bruise and that the pressure ulcer worsened and developed tunneling in the wound. V9 stated she would consider the pressure ulcer on R1's heel to be a stage 4 since it has the tunneling but she must document what the Nurse Practitioner stages the wound as, so she documented a stage 2 on the EMR (Electronic Medical Record) wound evaluation with a picture dated 9/12/24 at 3:07 pm. V9 stated that R1 is supposed to be on a low air loss mattress and she doesn't know why he isn't unless it didn't get moved when he changed rooms about a week ago. V9 stated that R1's only pressure ulcer is on R1's left heel and that R1 does not have any pressure ulcers on his backside. Surveyor then requested to observe R1's buttock region. V8 and V9 then turned R1 onto his right side revealing a large undated dressing covering R1's coccyx and partially covering R1's left buttock. V9 stated to V8 he has a wound on his bottom and a dressing over it. V8 replied no one told me. V9 then removed the dressing from R1's buttock/coccyx region revealing a large area of detached skin approximately 6 cm x 6 cm on left buttocks from what appeared to have been a fluid filled blister that had drained and an approximate 1 cm x 1 cm open area to R1's coccyx. V9 stated that R1's EMR does not document anything regarding these open areas to R1's buttock and coccyx. V9 stated that R1 does not have a treatment order for these wounds and that she would have expected the nurse to notify R1's doctor about the new pressure ulcers and get orders for a treatment. V9 stated that she expects the staff to turn and reposition R1 at least every two hours. On 10/17/24 at 11:55 am R1 stated that the staff do not turn him very often and that he was on his back all morning until the nurses changed his dressing. R1's progress note dated 10/17/24 with time of service at 12:14 pm V10 NP documented left heel stage 3 pressure ulcer, right buttock new stage 2 pressure ulcer 6 cm x 6.1 cm, and coccyx new DTI (deep tissue injury) with primary etiology as pressure measuring 1 cm x 0.6 cm. R1's progress notes orders do not documented anything regarding the pressure wounds on R1's buttock and coccyx region until V8 and V9 discovered the wounds upon the surveyor's request to observe R1's skin on R1's buttock region. R1's TAR (Treatment Administration Record) documented a new order to cleanse buttock with wound cleanser, apply calcium alginate, collagen, Silvadene, cover with bordered gauze everyday shift to promote wound healing dated 10/18/24. This treatment is not signed off as completed on 10/20/24 as ordered. R1's TAR documented an order to apply calcium alginate, collagen, Silvadene, and rolled gauze to R1's left heel daily dated 10/17/24. This treatment is not signed off as completed on 10/20/24. On 10/21/24 at 11:32 AM V2 DON (Director of Nursing) stated that she would have expected the nurse that placed the dressing on R1 to call R1's doctor and get a treatment for the pressure ulcers that were found but were not documented on R1's coccyx and buttock. V2 stated that she would have expected R1 to be on a low air loss mattress as is on his care plan. On 10/21/24 at 3:45 pm V1 Administrator stated that she would expect interventions to be in place as care planned and that R1 should have been on a low air loss mattress. V1 stated that if a treatment is not signed off on the TAR, then it was not completed as ordered. 2. R2's face sheet with a print date of 10/21/24 documented R2 has diagnoses of metabolic encephalopathy, type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema, diabetic neuropathy, dysphagia following cerebral infarction, depression, schizoaffective disorder, delusional disorders, dementia, cerebrovascular disease, Alzheimer's disease with early onset, hypertension, atherosclerotic heart disease, and chronic kidney disease. R2's MDS dated [DATE] documented R2 is severely cognitively impaired and is dependent on staff for bed mobility. R2's progress note dated 8/9/24 at 11:30 AM documented R2 has a new skin condition. Please see skin condition observation for details. R2's skin condition report dated 8/9/24 at 12:06 PM documented left buttocks open area, Kennedy ulcer in appearance. R2's skin and wound progress note dated 8/22/24 at 9:55 AM by NP V10 documented reason for visit: new skin and wound consult on current resident. It continues, wound assessment: Wound 1, location: coccyx, primary etiology: pressure, stage/severity: unstageable, wound status: new. R2's skin and wound progress note dated 9/5/24 at 8:16 AM by NP V10 documented wound 1, location: coccyx, primary etiology: pressure, stage/severity: unstageable. It continues, wound 2, location: right heel, primary etiology: pressure, stage/severity: DTI (deep tissue injury), size 1.5 cm x 2 cm x 0 cm. It continues, wound #2 right heel pressure treatment recommendations: 1. Cleanse with wound cleanser. 2. Apply skin prep to base of the wound. 3. Leave open to air. 4. Daily treatment. R2's skin and wound progress note dated 9/16/24 at 2:41 PM by NP V10 documented wound 1, location: coccyx, primary etiology: pressure, stage/severity: unstageable, size: 1.5 cm x 3 cm x 0.5 cm, wound status: stable. It continues, wound 2, location: right heel, primary etiology: pressure, stage/severity: DTI (deep tissue injury, size 1.5 cm x 2 cm x 0 cm. R2's skin and wound progress note dated 10/3/24 at 8:47 AM by NP V10 documented wound 1, location: coccyx, size 1.5 cm x 2.6 cm x 0.7 cm. Undermining from 12 o'clock to 1 o'clock, 3 cm. It continues, wound #1 coccyx pressure treatment recommendations: 1. Cleanse with wound cleanser. 2. Apply Dakins moistened fluffed gauze to base of the wound. 3. Secure the bordered gauze. 4. Change daily, and PRN (as needed). R2's skin and wound progress note dated 10/11/24 at 11:12 AM by NP V10 documented wound 1, location: coccyx, primary etiology: pressure, stage/severity: unstageable, size 3 cm x 3.2 cm x 0.7 cm, undermining from 10 o'clock to 3 o'clock. It continues, wound 2, location: right heel, primary etiology: pressure, stage/severity: stage 3, wound status: worsening, size: 0.5 cm x 0.3 cm x 0.1 cm. R2's TAR dated October 2024 documented a treatment order for R2's coccyx to cleanse with wound cleanser and apply Dakins moistened fluffed gauze everyday and night shift for wound care management. R2's October 2024 TAR does not document that this treatment was performed as ordered on the following day shifts: 10/4/24, 10/5/24, and 10/9/24. R2's TAR dated October 2024 documented a treatment order to R2's right heel to be cleansed with wound cleanser and to apply skin prep everyday shift for wound care management. R2's October 2024 does not document that this treatment was completed on 10/2/24, 10/4/24, and on 10/5/24 as ordered by R2's physician and as recommended by V10 NP for wound consultant company. R2's wound progress notes by NP V10 were reviewed and none of the progress notes by V10 documented a diagnosis of a Kennedy ulcer on R2's coccyx. R2's EMR does not document a diagnosis of a Kennedy ulcer by a Physician nor by a Nurse Practitioner. R2's progress note dated 10/12/24 at 1:20 PM documented that R2 was transferred to a local hospital. R2's hospital progress note dated 10/16/24 at 7:33 PM documented Plan #3. Left buttock decubitus ulcer. This is a deep ulcer. Doctor V15 has debrided it. Wet to dry dressing should be continued and the patient will need frequent repositioning. R2's hospital records were reviewed, and these records do not document that R2's pressure ulcer is a Kennedy ulcer. On 10/17/24 at 12:06 PM V9 stated that R2's pressure ulcer looked like it was the start of a Kennedy ulcer when it started and that is what she documented on R2's wound evaluation form. On 10/21/24 at 11:32 AM V2 DON stated that she is not sure where R2's diagnosis on a Kennedy ulcer came from. The facility's Skin Management: Monitoring of Wounds and Documentation policy dated 1/2022 documented it is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. Responsible Party: All nursing staff. General Guidelines: An evaluation of the PU/PI (pressure ulcer/pressure injury), in no dressing is present; an evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); the status of the area surround the PU/PI; the presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection; and whether pain, if present, is being adequately controlled. The facility's Skin Management: Pressure Injury Treatment/General Wound Treatment Policy dated 6/2015 documented General: The following treatment guidelines have been developed to serve as a general protocol for selecting the type of treatment or dressing to be used. It continues, an order is required for all treatment orders. Responsible Party: All nursing staff. General Guidelines: implement prevention protocol according to resident needs, sensory perception risk factor: watch for nonverbal cues, assess areas of the body that do not feel pain for openings or redness, Moisture: avoid prolonged periods of wetness, apply moisture barrier with each incontinent episode, choose treatments that do not cause skin maceration, Activity: turn and reposition as needed using a person-centered approach (minimum of every 2 hours). It continues 10. The staff nurse will notify the Wound Nurse upon identification of skin impairment. If the Wound Nurse is not available, the staff nurse should document the open area on a skin screen form and alert the health care provider for treatment orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent employee to resident abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4. This failure resulted in R2 being physically and mentally abused, causing her to feel scared and not safe in the facility. Findings include: On 6/14/24 at 6:10 AM, R2 was in her room, sitting up on the side of the bed, with purplish green bruising noted under both eyes and a bruise to her left forearm. R2 was tearful and stated that the bruising under her eyes was caused by a fall, she was feeling scared after what happened, and she was pulling a wet pad out from underneath her and when she went to put it on the floor she fell forward out of the bed. R2 stated prior to that she was sitting up in her wheelchair in her room and V12, LPN (Licensed Practical Nurse), wanted her to go to bed. R2 stated she was having pain in her feet, doesn't need much sleep and wasn't ready to go to bed. R2 stated V12 and an unknown female employee (later identified as V15, CNA, Certified Nursing Assistant), came into her room, grabbed her on the left forearm and was fighting with her in a back-and-forth motion. R2 stated V15 got into her ear and loudly yelled something like you're going to get up and get in bed. R2 stated it hurt her ear when V15 yelled in it. R2 stated then they went and grabbed the mechanical lift, put her in it and then put her in bed. R2 stated she was yelling out for someone to help her, save her. R2 stated this made her feel low class and scared. R2 stated anytime V12 wants something done, she gets V15 to help her do it. R2 stated in one way she doesn't feel safe in the facility because she was yelling for someone to help her, and no one did. R2 stated this happened last Thursday (6/6/24), she isn't sure exactly what time, but it would have been after everyone goes to bed around 10:00 PM. R2 stated she reported it to V13, LPN, either the next day or the following day. R2 stated the police came to the facility and talked to her about what happened. R2 stated she has not seen V12 or V15 since she told V13 about what happened. R2 stated she still feels scared and if she would have known something like this could happen here, she wouldn't have come here. R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteoarthritis, Weakness, Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder, Type 2 Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease, Pain in Bilateral Knees, Lumbago, Chronic Kidney Disease, Dorsalgia and Insomnia. R2's Minimum Data Set, MDS, dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status) of 15, which means R2 is cognitively intact. R2's Care Plan, dated 2/16/24, documents R2 is at risk for abuse/neglect. R2's Progress Notes by V13, LPN, document the following: 6/10/2024 9:39 PM - Resident initially said to me that she wanted to tell me something, but didn't want to if someone would get in trouble or if I would have to report it. I said depending on what it is I would have to report it. She said never mind, but eventually told me that one of the CNA's was being abusive to her. She said she was in her chair and the CNA wanted her to get up into bed, but demanded it, so she wasn't cooperating with her. The abuser tried to pull her up by her wrists and put a bruise and small cut on her left wrist. (R2) also said that the abuser yelled 3 times in her ear, you're going to get up. The resident was clearly scared to divulge the information to me. After she told me about it, I immediately notified my DON (Director of Nursing) and HR (Human Resources) manager, who notified the local Police. The police officer took both mine and (R2's) statement and left a card with the case number on it. I put the card under the DON's office door; 6/10/2024 9:42 PM - I did a skin assessment on her and she has a bruise and a small cut on her left forearm. There are no other skin issues. Will continue to monitor. The Police Report by V17, Police Officer, documents the following: Report for Incident 2024-012193, Possible Abuse, document created on 6/11/2024 @ (at) 03:59:02. On 06/10/2024, at approximately 2018 hours, I, responded to (the facility) in reference to a possible abuse complaint. On arrival, I met and spoke with (V13). (V13) advised that a resident brought an incident up to her that was concerning. (V13) stated that (R2) informed her that she has a large bruise on her left arm that she obtained from the Nurse or CNA working on the night before she went into the hospital on Friday night (06/06/2024). (R2) informed (V13) that the bruise was attained when the worker attempted to pull her up by her arms. (V13) stated that (R2) told her she was scared to talk to her about the incident and she did not want to get anyone into trouble. (V13) informed (R2) that due to the nature of the complaint, she was going to have to speak to her supervisor to report the incident. (V13) advised that after speaking with (R2), she contacted her supervisor, (V2, DON). (V13) informed (V2) of the complaint made by (R2) and (V2) then contacted the police department for a report to be created. (R2) said that she does not know the name of the Nurse or CNA working on the night of the incident, but it happened the night before she went into the hospital. (R2) stated that the nurse came into the room and told her to get up, but she did not feel like getting up at that moment, so she did not try to help the aide and the nurse in moving her. (R2) said that this made the nurse angry, so she went to get the bigger, bully, female CNA to make (R2) get up. (R2) advised that the CNA yelled into her ear 3 times that she was going to get up and this scared her. (R2) then held her left arm out and I observed a large bruise on her left arm, above her wrist, and a small cut on her wrist. (R2) advised this happened when the CNA placed one arm on top of the other and attempted to pull her up. (R2) then stated that it could have happened when the CNA grabbed her arm with her hand to pull her up. It should be noted that I observed face was due to her falling out of bed and due to falling out of bed, she was in the hospital on Friday (06/07/2024). (R2) stated that she is scared due to the situation. I took photos of the injury; they were later attached to the report. I provided (R2) with my department issued business card and told her to call the police, if a situation like the one she told me about, happened again. (V13) informed me that at this time, they did not know who was working but (V2) was working on figuring that out at this time. (V13) advised, if any additional information was obtained, the police department would be contacted. I provided (V13) with my department issued business card and report number. R2's Follow-Up Investigation Report, dated 6/14/24, documents the following: Resident was scared to report the issue but is now feeling better that she did. Resident claims that a tall woman grabbed her by the wrist and yelled in her ear that she was going to bed now - resident couldn't remember the exact date, but it happened on night shift. Resident claims she stayed up late because she doesn't sleep much, and staff kept telling her she needed to go to bed. She told them she wasn't tired yet and she just keeps requiring less and less sleep the older she gets. Then, they came in the room and forced her in bed. One grabbed her arm and yelled in her ear that she was going to bed now. Resident appeared scared to tell what happened. (V12) claims that she, (V15, CNA), and (V16, Agency CNA), put the resident to bed. She stated that they got the sit to stand and kept telling the resident she needed to go to bed because of her wound and she needed to put her legs up and get out of the wheelchair. V15 claims that she put the resident to bed in the sit to stand. (V16), states that (V15) put resident to bed while she was fighting because she didn't want too yet. (V15), told R2 she was going to bed and got the sit to stand and forced her, the nurse was in the room. The conclusion was the allegation of abuse was substantiated due to evidence collected during the investigation. The investigative evidence contains the following information: On 6/10/24, Resident claims a tall white woman grabbed her arm and yelled into her ear that she was going to bed now but she didn't know what date it happened - either 6/6 or 6/7. Resident had a bruise and small cut on her left forearm - skin assessment completed. A review of camera footage showed that (V12) and (V15, CNA) went into residents' room with a sit to stand to put resident to bed on 6/6/24 at 11:32 PM. (V12) claims that she informed resident that she needed to go to bed to put her legs up due to her wound. (V15) claims that she put resident to bed in the sit to stand. (V16) claims that the resident was fighting by kicking, hitting, and biting but (V15) still made her go to bed with the sit to stand. Resident claims she kept telling them that she didn't want to go to bed yet because she wasn't tired, and she doesn't need much sleep anymore. (V12) and (V15) were suspended immediately. (V12) was terminated on 6/13/24 on an unrelated issue. (V15), was terminated on 6/14/24 for violating resident rights to choose what time to go to bed. On 6/14/24 at 7:10AM - V3, Human Resources, stated that V12 was being terminated today for a HIPPA violation and due to an abuse investigation. On 6/17/24 at 7:55 AM, V2, Director of Nursing, DON, stated V12 and V15 were terminated due to forcing R2 into bed. The Abuse Policy, dated 10/2022, documents the facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain orders to treat a new pressure ulcer, to prevent deterioration of the pressure ulcer, and failed to have appropriate interventions in place to prevent new pressure ulcers from developing and keep existing pressure ulcers from getting worse for 2 of 4 residents (R3 and R4) reviewed for pressure ulcers in the sample of 11. This failure resulted in R4 developing a Stage 4 Pressure Ulcer on his right buttock. Findings include: 1. On 2/22/24 at 9:15 AM V4 (Wound Nurse) provided pressure ulcer treatment to R4's Stage 4 pressure ulcer on his right buttock. V4 stated that the wound was just discovered on 2/20/24. She stated that she has ordered a cushion for his wheelchair (w/c), and he is on an air mattress. She stated R4's pressure ulcer is on the side affected by his stroke, and he cannot feel it and she think this contributed to his not being aware he was getting a sore and not letting anyone know about it. V4 unfastened R4's adult diaper and removed the dressing from the pressure ulcer on his right buttock. The pressure ulcer was larger than a quarter and the wound base was completely covered with yellow slough. There was a moderate amount of drainage noted on the soiled dressing. R4's Face Sheet, undated, documents his diagnoses to include Cerebral Vascular Accident (CVA); Flaccid Hemiplegia Affecting Right Dominant Side; Chronic Obstructive Pulmonary Disease (COPD); Neuropathy; Aphasia; Bipolar Disorder; Schizoaffective Disorder; Major Depressive Disorder; Hypertension (HTN); and Alcohol Dependence in Remission. R4's Minimum Data Set (MDS), dated [DATE], documented that R4 was severely cognitively impaired, and he uses w/c for mobility and propels self independently. This assessment documented that R4 requires substantial to maximal assist with most Activities of Daily Living (ADLs) including transferring and toileting hygiene and requires supervision with eating and turning and positioning. According to this assessment, R4 is always incontinent of bladder and frequently incontinent of bowel. At the time of this assessment, on 1/2/24, R4 had no unhealed pressure ulcers. R4's Care Plan, dated 6/12/22, documented, Pressure Ulcer: (R4) has potential for pressure ulcers related to decreased independent mobility. Dx (Diagnosis): CVA w/right hemiplegia, incontinence. Interventions for this Care Plan include doc s/s skin breakdown, Notify MD & family prn of changes in skin status, notify nurse of any new areas of skin breakdown, redness, blisters, bruises or discoloration observed during routine care, Remind/assist as needed to reposition frequently, utilize pressure-reducing mattress, and weekly body assessment. R4's Care Plan, dated 2/15/24, documented, Skin: At risk for skin complications r/t (related to) open area on right buttocks. This Care Plan was revised on 2/21/24, documented, Skin: At risk for skin complications r/t wound on right buttock. Interventions for this care plan include: 2-22-24 (brand name protein drink) as ordered, 2-21-24 air mattress as ordered, assist and encourage resident to turn and reposition frequently, educate resident on MD (Medical Doctor) orders for wound care, educate resident on the risks of infection and poor healing r/t non-compliance, monitor area for s/s of infection: odor, drainage, color, size, observe and assess regularly, provide skin care after each incontinent episode, RD (Registered Dietician) to assess and recommend, serve diet as ordered, skin check weekly, treatment as ordered, (Wound Physician) to follow. R4's Progress Note, dated 2/14/2024 at 8:47 PM, documented, Resident has open pressure sore on right buttock. It's roughly 4cm (centimeters) x 3cm. I cleansed it with wound cleaner and put a dressing with TAO (Triple Antibiotic Ointment) on it. R4's progress notes were reviewed for 2/1/24 through 2/14/24 and there was no documentation of R4 having a pressure wound to his right buttock until 2/14/24. R4's Wound Physician Progress Note, dated 2/20/24, incorrectly documented that the Stage 4 Pressure Ulcer as a skin tear and documents and the measurements of his wound as 4cm x 1.5 cm x 0.2 cm. R4's Wound Physician Progress Note, dated 2/22/24, documented, Non-visit Progress Note: Stage 4 pressure ulcer on Right buttock, not left buttock. R4's Physician Orders, dated 2/22/24, documented, Silver Sulfadiazine External Cream 1 % (Silver Sulfadiazine). Apply to Left buttock topically every day shift for Stage 4 pressure ulcer Cleanse stage 4 pressure ulcer to left buttock with wound cleanser, apply silver sulfadiazine cream, collagen, calcium alginate, cover with boarder dressing daily until clear. There was no order for a treatment to R4's pressure ulcer before 2/20/24, after R4 was evaluated by V9 (Wound Physician) for treatment of R4's facility acquired pressure ulcer that was discovered on 2/14/24, indicating R4's pressure was untreated for 6 days. R4's Braden Scale for Predicting Pressure Sore Risk, dated 1/2/24, documented a score of 13 indicating he is at moderate risk for developing pressure ulcers. On 2/22/24 at 11:20 AM V4 (Wound Nurse) stated that she was not aware of R4's Pressure Ulcer until 2/20/24 which was the first time she observed it, along with V9 (Wound Physician). V4 stated no staff had reported to her that R4 had a pressure ulcer before that. She stated that was the first time she received orders for the treatment of the pressure ulcer. V4 confirmed the pressure ulcer is a stage 4 pressure ulcer on R4's right buttock. V4 stated she had seen the discrepancy in the physician orders and with the wound physician's progress note and stated he had documented the wrong wound location and type of wound on R4's progress note. V4 confirmed the stage 4 pressure ulcer is on R4's right buttock and it is not a skin tear. She stated she had spoken to V9 (Wound Physician), and he is going to send her a revised progress note with the correct information. On 2/22/24 at 11:25 AM V2 (Director of Nursing/DON), stated that any staff who find a pressure ulcer or other skin impairment should notify the physician immediately and have a treatment order in place, and then notify V4 (Wound Nurse), of the new wound so she can follow-up and get the resident on the list to be seen by V9 (Wound Physician). V2 stated that R4 was very resistant to care and often the Certified Nursing Assistants (CNAs) provide incontinent care over the toilet because he refuses to lay down, and that might be why they missed the pressure ulcer on his buttock. V2 stated that she does not know why the pressure ulcer was not found on his weekly skin checks before it became a Stage 4. On 2/23/24 at 10:05 AM, V2 stated that there was no documentation of weekly skin being done for R4 prior to the observation of his pressure ulcer on 2/14/24. She stated she does not know when his pressure ulcer started but does not think it would have started a Stage 4 pressure ulcer. On 2/23/24 at 12:33 PM, during phone interview, V13 (Registered Nurse/RN) stated that she received a report on 2/14/24 from a CNA who was putting R4 to bed and providing him with incontinent care that he had an open area on his buttock. V13 stated she went down to assess the wound and put a treatment on it and notified V17 (Nurse Practitioner) via a text message of the new area. V13 stated she did not receive any new orders that evening regarding R4's pressure ulcer. V13 stated that she did not notify the V2 (DON) or V3 (Assistant Director of Nursing/ADON) or V4 (Wound Nurse) of the new pressure ulcer, but did document it in his progress notes. V13 stated she has taken care of R4 again and cannot remember seeing an actual order for a pressure ulcer treatment, but stated she did put some cream on it the other day. V13 stated R4's pressure ulcer looks much worse now than when she first saw it. She stated on 2/14/24 when she first identified the pressure ulcer, it was barely a Stage 1. She stated it was an open wound but didn't look that bad. V13 stated the wound is larger and deeper now and just looks a lot worse. V13 stated she believes the protocol if you find a new pressure ulcer is to document it, put a treatment on it and notify the doctor or nurse practitioner. V13 stated she did not notify anyone else of R4's new pressure ulcer. 2. On 2/21/24 at 10:05 AM, R3 was lying in her bed on her back. She stated that she was here for rehab because she broke her ankle when she fell at home. R3 stated nobody comes to turn and reposition her in bed. She stated they did turn her one time because she put on her call light and asked them to, otherwise she does not get turned and she knows she needs to or the sore on her bottom will get worse. R3 stated that she worked in the health field for a long time and knows it is important to get pressure off her backside if she wants it to heal, but they just don't have enough staff. R3 stated that she has never told staff she does not want to be turned because she knows how important it is, but they just don't do it and she hates to bother them. She stated they got her out of bed yesterday for therapy but then put her right back in bed because the wound doctor came. R3 stated that yesterday was the first time she got out of bed since she's been here because therapy was delayed with insurance problems. On 2/21/24 at 12:05 PM R3 was laying on her back in her bed. She stated that nobody has turned her. On 2/21/24 at 1:50 PM V4 (Wound Nurse) provided pressure ulcer care for R3. Upon entering R3's room, she was lying on her back. R3 stated they had just cleaned her up because she knew V4 was going to come in and do her treatment. R3 stated she has been on her back all day except for when they turned her and cleaned her up. R3 stated her butt does hurt from lying on her back all day. She stated she has not been out of bed since yesterday when therapy got her up for a short time. V4 cleansed the stage 2 pressure ulcer on R3's left buttock. The wound was irregular shaped with dark red base. There was no treatment in place when V4 rolled R3 onto her left side to do the treatment. R3 stated, They just cleaned me up. V4 applied silver sulfadiazine cream, collagen, and calcium alginate and covered it with a foam dressing. R3 complained that the bed was very uncomfortable to lay on and felt like she had things sticking her in the back and buttocks. V4 stated they would get her an air mattress because she should have one anyway because she has a wound. V4 stated R3 was on a regular mattress right now. V4 stated when the air mattress is put on R3's bed, that will be the pressure relieving device on the bed. V4 stated R3 did not have any type of pressure relieving device on her bed right now and stated R3 should be turned and repositioned every two hours to relieve pressure off her bottom. R3 stated to V4 that she has been on her back all day except during incontinent care. V4 placed a wedge cushion under R3's left hip to relieve pressure and R3 stated that felt a lot better. On 2/21/24 at 2:05 PM, V4 asked V8 (CNA) if R3's pressure ulcer dressing came off during incontinent care and V8 stated that it had come off because R3 had been incontinent of bowel and bladder and the dressing was soiled. V8 stated R3 is not turned and repositioned every two hours because of her fractured ankle and it being so uncomfortable when she is moved for incontinent care. V4 informed her it is still important for R3 to be turned and repositioned every two hours to help her pressure ulcer heal and prevent any other pressure ulcers. R3's Face Sheet, printed 2/22/24, documented her diagnoses to include Displaced Bimalleolar Fracture of Right Lower Leg, Asthma, Type 2 Diabetes Mellitus, Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems, Non-Displaced Fracture of Neck of Left Talus, Unspecified Fall, Other Reduced Mobility, and Generalized Edema. R3's MDS, dated [DATE], documented that she was alert and oriented and she required substantial/maximal assist for turning and repositioning. The assessment further documented that R3 was dependent for all transfers and was incontinent of bowel and bladder. It continued to document that R3 was admitted with one Stage 2 pressure ulcer and has a pressure reducing device for her bed and application of nonsurgical dressings other than to feet. It documents she is not on a turning and repositioning program. R3's Care Plan, initiated 2/18/24 documented, The focus: Bed Mobility: has a self-care deficit in bed mobility r/t decreased ability to position or reposition self in bed/turn from side to side/ use side rails to move in bed/move from lying to sitting or sitting to lying position. Interventions for this care plan include Position and reposition resident in bed for comfort, joint support, and skin integrity. R3's Care Plan, initiated 2/16/24 documented, Skin: At risk for skin complication r/t blister right ankle, left gluteus present on admission pressure per wound nurse. Interventions for this care plan include Therapeutic mattress in bed and cushion in chair as appropriate. R3's Skin and Wound Evaluation, dated 2/16/24, documented that she has a stage 2 pressure ulcer on her left gluteus, middle that was present on admission. Under Additional Care this evaluation documented that R3 was to have incontinence management, mattress with a pump, moisture barrier, moisture control, positioning wedge, and turning/repositioning program. R3's Braden Scale for Predicting Pressure Sore Risk, dated 2/9/24, documented a score of 16, indicating she is at risk for developing pressure ulcers. The facility's policy, Pressure Injuries, reviewed 9/2022, documented, To prevent or reduce the incidence of pressure injuries, standards of practice should be implemented. A pressure injury may be defined as any lesions caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are important contributing factors to the development of pressure injuries. The facility's policy, Skin Management: Pressure Injury, reviewed 1/2023, documented, The following treatment guidelines have been developed to serve as a general protocol for selecting the type of treatment or dressing to be used. However, the facility recognizes that the selection of treatment protocols is individualized based on the resident condition and Health Care Provider practice patterns. Therefore, these are only guidelines and not all-inclusive. An order is required for all treatments. General Guidelines: Implement prevention protocol according to resident needs. Sensory Perception risk factor: watch for nonverbal cues, assess areas of body that do not feel pain for openings or redness. Activity: turn and reposition as needed using a person-centered approach (minimum every 2 hours), reposition in chair, provide appropriate pressure redistribution devices, teach resident to weight shift if appropriate, ensure proper body alignment. Mobility: turn and reposition as needed using a person-centered approach (minimum every 2 hours), provide appropriate pressure reducing devices. It continues, Under General Treatment Guidelines: 10. The staff nurse will notify the Wound Nurse upon identification of skin impairment. If Wound Nurse is not available, the staff nurse should document the open area on a Skin Screen Form and alert the Health Care Provider for treatment orders. Treatment Guidelines for Stage 2 Pressure Injuries: Turn and reposition as needed using a person-centered approach (minimum of every 2 hours).

Based on interview and record review the facility to monitor and prevent weight loss for one of two residents (R48) reviewed for weight loss in the sample of 33. This failure resulted in R48 having a slow insidious weight loss from March 2023 through July 2023 and a 12% weight loss since January 2023. Findings include: R48's admission Record Sheet, printed on 8/1/23, documented R48 had diagnoses of Dysphagia following other Cerebrovascular Disease, Moderate Protein-calorie Malnutrition, Cerebral Infarction. R48's Care Plan initiated on 10/12/22, documented Tube feeding: Resident is a risk for complications of g-tube r/t dysphagia from CVA (stroke). R48's Care Plan Intervention, dated 10/19/22 documented monitor weights and labs as ordered and notify dr (doctor) of sig (significant) wt (weight) changes. R48's Electronic Health Record (EHR) documented R48 weighed 264.5 pounds (lbs.) on 11/25/22. R48's Physician Order, dated 12/15/22 documents Every shift Osmolite 1.2, 68ml (milliliter)/hr (hour). R48's EHR documented R48 weighed 255 pounds (lbs.) on 12/27/22, a 9 lb. weight loss in one month. R48's Dietary Nutrition at Risk Follow up dated 1/24/23 documents increase tube feeding to 68ml. R48's currently tube feeding order was Osmolite 1.2 68ml/hr and did not change. R48's EHR documented R48 weighed 245.5 lbs. on 1/31/23, a 9.5 weight loss in one month and 19 lbs. in two months. R48's Physician Order dated 2/21/23 documents Osmolite 1.2 320ml bolus every 4 hours. R48 remained NPO (nothing by mouth) at the time. R48's Nurses Note 2/21/23 Pt (patient) has had no issues with her g-tube. All medications, feedings, and flushes have flushed well. R48's EHR documented R48 weighed 248 lbs. on 2/28/23. R48's Dietary Nutrition at Risk Follow up dated 2/28/23 discontinue continuous feeding and started bolus. R48's Physician Orders dated 3/1/23 documented Osmolite 1.2, 320ml bolus q 4 hours. R48's March and April 2023 Physician's Order Sheet documents Osmolite 320ml Q 4hrs. R48's POS dated 5/5/23 documents Regular diet mechanical soft texture nectar thick liquids. R48's Physician Order Sheet (POS) dated 5/5/23 documents Enteral Feed Osmolite 1.2 320ml TID if resident eats less than 50% Enteral Feed. R48's Dietary Nutrition at Risk Follow up dated 5/5/23 Patient wants to eat will inquire about speech therapy. R48's Care Plan, revised 5/6/23, documented Tube feeding dc'd (discontinued) tube for free water flushes has been upgrade to mech altered diet and thickened liquids, wt. loss. The Interventions dated 5/5/23 documented diet as ordered mech altered with thickened liquids 5/5/23. R48's EHR documented R48 weighed 249.4 lbs. on 5/19/23. R48's Physician Order Sheet (POS) dated 6/1/23 documents regular diet puree texture nectar thick liquids. R48's EHR documented R48 weighed 237.4 lbs. on 6/5/23 which was over a 10 lb. weight loss in one month. There was no documented assessment to address R48's weight loss and there were no interventions to address this weight loss. On 7/26/23 documentation was requested as to how the facility was documenting if R48 was eating less than 50%. This was never provided. R48's EHR documented R48 weighed 235.6 lbs. 7/6/23 and then 215.8 lbs. on 7/27/23 which is a 20 lb. weight loss. R48's Nurse's Note dated 7/25/23 documents R48 noted with a 20-pound weight loss, and she remains on a pureed diet with nectar thick liquids. On 7/26/23 at 1:00 PM V24 Director of Nursing (DON) from another facility stated We reviewed her chart on 7/25/23, and a note was sent to the dietician for her case to be reviewed. She (R48) has had a 20-pound weight loss from January to July. R48's Dietary Evaluation dated 11/15/22 documents Current ht (height): 63 and wt. (weight): 264.5#; BMI 46.8 Wt. hx: 11/9 and 11/11 264.5# 10/19 277# 9/26- 296# 9/6- 292# 8/25- 290.5# 7/15- 268# 6/16- 251# 5/18- 246.5. Tube feeding Osmolite 1.5 continuous feeds at 55ml/hr provides total of 1320ml of feeding: 1980kcalorie (cal)/day and 82.8 g protein (PRO)/day. EEN: Calories: 2400-2770kcal/day (20-23kcal/kg (kilograms) BW body weight)) for weight moderation/maintenance Protein: 96-120g pro/day (0.8-1.0g/kg BW). Significant change of status/readmission assessment. hospitalized 9/28-10/12/22 following CVA; returned on tube feeding d/t difficulty swallowing while in hospital. hospitalized again 10/24-11/9/22. Current ht: 63 and wt: 264.5#; BMI( basic metabolic index) 46.8. Resident had been triggering for significant weight gains just prior to CVA; now triggering for loss. Current tube feeding order: Osmolite 1.5 continuous feeds at 55ml/hr provides total of 1320ml of feeding; 1980kcal/day and 82.8 g pro/day. This order meets needs for weight moderation, as resident had previously displayed multiple triggers of significant weight gains. Resident tolerating tube feeding well at this time. Speech therapy will be working with resident to reinstate PO intake. Will continue on weekly weights while on tube feeding. Will continue to monitor and adjust tube feeding as necessary. On 8/1/23 at 1:45 PM V26 Registered Dietician stated, You know I'm trying to recall we had a different company now. I took over in March. She was a tube feeding then. I don't have access to her stuff. I think she lost weight from her hospitalizations. I usually put my recommendations in forms. The facility Policy entitled Weight Change Policy 9/2022 documents it is the policy of this facility to monitor the nutritional status of all residents, including all significant or trending patterns of weight change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify a resident's family representative and physician of changes in condition for 2 of 3 residents (R40, R71) reviewed for changes in condition in the sample of 36. This failure resulted in R40's psychiatric decline and R71's exacerbation of heart and lung issues resulting in hospitalization. Findings include: 1. On 9/6/22 at 10:54 AM, R40 was sitting in the recliner in her room with her eyes closed. R40 was able to state her name but then had slurred, mumbled speech when answering questions, and was very difficult to understand. She stated she has only been in the facility a couple of days and had moved here because the last facility she lived in told her she had to leave because the administrator didn't want her there. R40 kept nodding off to sleep but would wake to try to answer questions. She appeared very lethargic and drowsy. Her hair was uncombed and general appearance disheveled. R40's Face Sheet documents her diagnoses to include Anxiety Disorder, Schizophrenia, Schizoaffective Disorder and Bipolar Disorder. R40's Minimum Data Set (MDS) dated [DATE] documents she was admitted to the facility on [DATE] and is alert and oriented. It also documents she did not have any delusions , hallucinations, or behaviors during that assessment period. R40's Care Plan dated 4/14/21 documents, Medication: (R40) uses antianxiety medications related to anxiety disorder. Is at risk for side effects. Interventions for this Care Plan include anti-anxiety medication as ordered. R40's Care Plan dated 4/16/21 documents, Behavior: (R40) has a history of anxiety and self-isolation. At risk for alteration in mood. Diagnosis: Anxiety, Schizophrenia. Interventions for this care plan include medications as ordered. R40's Care Plan dated 9/3/22 documents: Elopement: At this time (R40) is experiencing delusions and hallucinations related to her mental illness. Interventions for this care plan include: 1:1 with staff as needed; 15-30 minute checks as needed; allow concerns to be expressed; encourage resident to keep busy with activities; MD notification as needed. R40's Physician Orders dated Physician Order Summary dated 9/7/22 documents the following orders: Clozapine (antipsychotic medication) 100 mg by mouth at bedtime with start date 6/8/21 and Clozapine 50 mg by mouth in the morning with a start date of 9/3/22. R40's Physician Orders also included an order for Lorazepam (antianxiety medication) 0.5 mg 1 tablet by mouth two times a day with a start date of 6/8/21, but no discontinue date. Review of R40's Progress Notes dated 6/1/22 to 9/7/22 document she missed 18 doses of Lorazepam 0.5 mg which was ordered to be given twice a day for anxiety. All the missed doses of Lorazepam occurred between 6/20/22 and 7/26/22. On R40's Medication Administration Record (MAR) starting on 7/27/22, R40's Lorazepam was on hold by the physician, but there was no order on R40's Physician Order Sheet documenting an order to put Lorazepam on hold and no documentation in R40's Progress Notes documenting a physician had put R40's Lorazepam on hold on 7/27/22. R40's Progress Notes document she did not receive her Clozapine 100 mg which was ordered to be given at 8:00 PM every night, on 8/6/22, 8/19/22 or 8/20/22. R40's Drug Record Book dated 6/1/22 to 9/30/2022 documents her Clozapine 100 mg was reordered on 8/27/22 and notes on that date, out, please send asap (as soon as possible). Review of R40's Progress Notes dated 6/1/22 to 9/7/22 does not document any behaviors until 9/4/22 at 4:46 AM when it documents, most of evening and night, resident up yelling and screaming. Very confused and talking about people and things from the past. no distress noted. Will continue to monitor. There was no documentation that family or physician was notified of R40's change in condition. R40's Progress note dated 9/3/22 at 8:52 AM documents, Resident very restless, walking from her room to nurses station to front lobby. Voicing delusional thoughts and difficult to redirect. Told this nurse, You are a bad nurse, you don't have any facts. I no longer live here. I was in Australia all last week. Resident's family reports that resident refusing to take their phone calls and denied knowing who her sister is when she came to see her this AM. V24 (Psychiatric Nurse Practitioner) aware of above. New order received. Resident placed on 15-minute checks for safety. On 9/8/22 at 9:30 AM, V2 (Director of Nurses/DON) provided R40's psychiatric progress notes dated 4/27/21, 2/4/22 and 5/25/22. She included a handwritten note that documents, (R40) verified with NP (Nurse Practitioner) 9/7 at 5:28 PM that R40 was last seen May 2022 and was not seen in June or July (did not mention August). The note documents she will see this month. May call (V24) to discuss. On 9/7/22 at 2:36 PM, V18 (LPN) stated R40 was moved yesterday. She stated R40 had been having some kind of psychosis V18 stated on the past Thursday, September 1st, R40 was delusional and saying that she needed to go to Washington DC, and she thought her sister had committed suicide and that her roommate had gotten inside her head and stolen all her memories and deleted them. V18 stated she did not know anything about R40 having fallen recently. On 9/7/22 at 2:38 PM, V19 (LPN) stated she was here last Thursday (September 1st) and saw changes in R40's behaviors. She stated R40 had missed one of medications for a couple of days because of problems with pharmacy, something about them not getting the order, or it was outdated. V19 stated today R40 was doing a lot better, but last night when she worked R40 was still not the same but did finally remember V19's name. V19 stated if they don't have a resident's medication, they notify the pharmacy to see what is going on. V19 stated if the medication is not a psych med, they notify the MD's nurse practitioner, but if it is a psych med, they notify V24 (psych nurse practitioner). On 9/7/22 at 2:45 PM, R40 was sitting in her room. Her speech was clear, and she was awake and alert. R40 stated, I couldn't sleep because I didn't have my medicine. They kept telling me it didn't come in from pharmacy. I haven't been sleeping good for 4 or 5 weeks, and I wasn't getting enough to eat. I felt like they were punishing me because (V1) doesn't want us to have Resident Council meetings and it's our right. I felt bullied by her. I am the resident council president and I have to look out for the residents here. She stated her parents are not her guardians, her husband is . She stated, You know, he is Hawkeye on MASH. She stated she goes out on Saturdays with her sister to eat and shop. She stated they wouldn't let her husband take her out. R40 stated she talks to her brother a lot on the phone, but he doesn't live around here. On 9/7/22 at 3:05 PM, V2 (DON), stated the facility had some problems with the pharmacy at the beginning of August when they went to a new system. She stated they went from the card system to having medications in individual plastic rolls, except high acuity medications, which were still on cards. V2 stated the first couple of weeks after the change they had a lot of problems because the pharmacy thought they still had the high acuity medication cards, but they had sent everything to the pharmacy and then did not get the high acuity meds back with the other meds. V2 stated R40 did miss her Clozapine 50 mg on September 3 but did get it as soon as it came in on September 4. V2 stated R40 had started getting a little manic, and the psychiatric nurse practitioner had ordered her to have Clozapine 50 mg every morning in addition to her current dose of Clozapine 100 mg at HS. V2 stated R40's brother had called and asked about her missing some medication. V2 stated he talked to V1 (Administrator) but she was unable to give him any information because he was not on R40's contact list. V2 stated when R40 had behaviors last week she had contacted R40's parents and sister on Thursday, August 1st and asked them to come and see her and help figure out what was going on with R40. V2 stated they came to see R40 on Saturday. V2 stated R40's sister does not see her often; she has only seen her visit a couple of times in the last year. V2 stated R40's parents are her guardians, but they are elderly and don't hear well so when staff call them, if they can't hear what is being said, they hang up. V2 stated R40's parents and sister have left specific instructions that they are not to give her brother any information regarding R40; he is to call either her parents or sister and they will let him know what they want him to know. V2 stated I called R40's sister and parents to inform them of her behaviors last week. I can show you on my cell phone where I called them. V2 then looked through her cell phone and stated, I must have used (V1's) cell phone because I can't find it on my phone. V2 stated when a medication is missed, if it is a psych med, they notify the psychiatrist because the medical doctor and his nurse practitioner will not do anything with psych meds. She stated the nurse usually notifies V24, the psychiatric nurse practitioner, with any psyche issues. She stated she does not think the psychiatrist has been in the facility for several months. On 9/7/22 at 3:50 PM, V16 (R40's brother) during phone interview, stated he had not talked to R40 about her missing medications, because he was on a zoom call when she tried to call him, but R40 had notified his niece, who is in medical school, by text, stating that she had missed some of her medication and was not sleeping. V16 stated R40, in her text message to his niece, stated the facility was giving her Melatonin and it was not helping her to sleep, and was asking if there was anything else that would help. V16 stated he called and tried to ask the administrator (V1) about R40 having missed medications, and she told him she is dealing with a state survey and has a funeral to attend and did not have time to talk to him. V16 stated he tried to set up a better time to discuss R40 but (V1) told him he was not on her contact list so she would not be able to talk to him. V16 stated he then asked if his sister (V17) could call and make the appointment and was told yes, she could. V16 stated R40's text to his niece indicated she had missed her medication for about a week. He stated R40 had been doing very well with no psychiatric setbacks for about 17 years and was usually very alert and oriented and well organized. V16 stated he had called and informed his sister about the text message R40 had sent to her niece about missing medication, so she went to see her on Saturday, which was the usual routine, and R40 was not her normal self. V16 stated he did not know of any falls or injuries that had occurred as a result of R40 not receiving all her medication, but he feels she has had a mental set back as noted by her change in behaviors and her lack of sleep. V16 stated he is worried about the facility retaliating against R40 because the family is complaining, but he stated he just wants to know what medication was missed, why it was missed and what is being done about it, so it doesn't keep happening because he knows her medications are very important to her stability mentally. On 9/7/22 at 5:15 PM, V17 (R40's sister) during a phone interview, stated she comes in every Saturday and takes R40 out of the facility for the day and they usually have lunch or dinner with their parents. V17 stated R40 is very alert and oriented and runs the Resident Council at the facility, and if she feels like she or any of the other residents are being mistreated, she will say something about it. V17 stated R40 usually calls her during the week to talk about what they are going to do on the Saturday when she comes to get her, but R40 did not call her last week, which was very unusual for R40. V17 stated nobody from the facility called her last week to tell her about R40 having behaviors, but when she arrived at the facility that Saturday morning, September 3, a staff met her at the door and stated she had meant to call her and warn her that R40 was having a lot of behaviors and was not acting like herself. V17 stated they told her R40 was yelling and cursing at the staff. She stated she went to R40's room and R40 yelled for her to get the f*#% out. V17 stated nobody from the facility had notified her or R40's parents that R40 was not receiving all of her medications. V17 stated her brother had called her with concerns because their niece had received a text message from R40 last week, telling her R40 was not getting her medications and could not sleep and wanted to know if she could tell her something that would help her because the Melatonin the facility was giving her was not working. V17 stated R40 knew her own medication very well and sometimes when she went on home visits, R40 would catch that they had forgotten to send one of her medications and would call up and tell them she needed it. V17 stated no one had given any directive to the facility to not release any information to R40's brother regarding her care. V17 stated he is not on her list because he lives out of state and it is easier to get in touch with her or her parents, but there is no reason he cannot call with concerns about her care. She stated R40 speaks to her brother on the phone often. V17 stated she feels the facility owes them an apology and an explanation of why some of R40's medications were missed and why they had not been informed of this or R40's change in behaviors and overall condition. V17 stated R40 has not had a psychotic break like this since 2005, and when it happened back then, it caused her to have to be institutionalized. V17 stated she knows R40 not receiving her medications could be very detrimental to her mental health. On 9/8/22 at 10:35 AM, V2 (DON), stated, I don't do medication error reports when medications are missed, only when the wrong medication is given. We don't do a medication error report, but we notify the doctor when a medication is missed. If the doctor was notified of the missed medication it is documented in the eMAR (Electronic Medication Administration Record) documentation progress notes. V2 stated she would expect physician orders to be followed and medications to be given as ordered. On 9/8/22 at 2:00 PM, V24 (Psychiatric Nurse Practitioner) stated the facility does sometimes send a fax or calls the office when a resident's medication is not available. V24 stated she was surprised when the nursing staff called about R40 having behaviors this past weekend. V24 stated staff reported to her that R40 was in the midst of the delusion of having a famous husband and was trying to run out of the facility to meet him. V24 stated she does not recall anyone reporting R40 missing 18 doses of Lorazepam in July 2022 because that would have been pretty significant. V24 stated she would think the facility would contact the pharmacy right away and figure out what was going on so R40 would get her medications as ordered. V24 stated there is no reason R40 should have missed 18 doses of her Lorazepam without the facility doing something about it. V24 stated she does not think that is related to R40's behaviors this past weekend, as R40 had been complaining of being tired and her Lorazepam would have made her drowsier, not caused her to have behaviors. V24 stated they had been decreasing R40's Clozapine gradually over the past year, so missing a dose may cause her to have changes in her behaviors for a couple of days following the missed dose, but the missed dose a couple of weeks ago probably would not have affected R40's behaviors this past weekend. V24 stated she knows R40 very well and has been treating her for the past 5 years and stated R40 is normally very alert and oriented and is aware of her own care. V24 stated she would not be surprised if R40 remembers meetings she had 2 or 3 years ago. V24 stated she does not know what would have caused R40's behaviors last weekend but she did give an order to add Clozapine 50 mg QAM because they had decreased her dose quite a bit. On 9/8/22 at 7:00 PM, R40 was sitting in her room waiting on her medication and snacks. R40 stated she is feeling a lot better. R40 was noticeably more alert, and her speech was clearer than during previous encounters with her during the survey. She remembered this surveyors name. She stated she had missed her nighttime dose of Clozapine 3 nights last week and it was horrible. R40 stated, The didn't give me my Clozapine for 3 days and I couldn't sleep. I begged them to give me my meds and they told me pharmacy didn't bring them yet. I asked them to call my doctor and they told me they couldn't because he was on vacation. It was terrible. I felt like my eyelids wouldn't close. I cried because I knew I wasn't right, but I didn't know what to do. On 9/8/22 at 7:20 PM, during an off-hours portion of the survey, V19 (Licensed Practical Nurse/LPN) stated the facility is still using the same pharmacy since changing owners, but they reorder residents' medications differently. V19 stated they reorder a resident's medication through the electronic medical record but several times the medication has been reordered it doesn't show up with the delivery. V19 stated this has happened with R40's Clozapine more than once, but she knows she missed some doses last week, but doesn't know how many because she doesn't always work on the same hall. V19 stated she felt very bad about what R40 went through last week and the beginning of this week. V19 stated R40 got so bad mentally that she did not even know V19's name, and she stated R40 usually recognizes all the staff and her fellow residents. V19 stated R40 was upset because she was afraid her changes were part of her illness and was afraid, she was getting worse, but V19 stated she reassured R40, when she was able to understand again, that her mental changes and behaviors were not her fault, and that it was the facility's fault because they did not get her Clozapine ordered on time. V19 stated she has worked with R40 for over a year, and this is the first time she has seen her have behaviors like these, and not recognize staff. V19 stated when R40 had missed doses of her Clozapine in the past it did not affect her this bad. V19 stated she talked to R40's sister when she came in and she told V19 that R40 had behaviors similar to these back in 2009 and that is what caused her to be institutionalized. On 9/9/22 at 8:45 AM, V31 (Pharmacist) stated R40's Clozapine 50 mg was ordered and processed on 9/2/22 and should have been delivered on 9/3/22. V31 stated she could not tell when R40's Clozapine 100 mg was ordered, but all the orders she has are old. V31 stated she could not tell exactly when the last Clozapine 100 mg was last sent to the facility and would have to check with someone else and will return call. On 9/9/22 at 12:00 PM, V31 (Pharmacist) stated they did receive the facility's request for a refill of her Clozapine on 8/27/22 but it was not sent because they needed a lab that is required before they can send Clozapine. V31 stated her records show the pharmacy has not refilled R40's Clozapine 100 mg since April 2022. V31 stated since April 2022, the only Clozapine that has been sent to facility for R40 was Clozapine 50 mg for her new order received on 9/2/22 for Clozapine 50 mg one every morning. On 9/9/22 at 12:15 PM, V2 (DON) and V23 (ADON) stated they were not aware R40 did not receive her Clozapine 100 mg from 8/27/22 until her Clozapine 50 mg was delivered on 9/4/22. V23 stated, I am the one who wrote on the order that we were out of (R40's) Clozapine and to please send it out. Both V2 and V23 stated they have given R40 her medications when they have worked the floor since April 2022, and they feel like she had her Clozapine 100 mg when they gave her medications. On 9/9/22 at 1:37 PM, V24 (Psychiatric Nurse Practitioner) during phone interview, stated R40 having missed her Clozapine 100 mg QHS would have directly caused her to have experience her changes in mental status resulting in her psychosis she experienced starting on 9/2/22 and she is continuing to have some psychosis. V24 stated R40 will most likely require a higher dose of Clozapine to get back to her baseline and it might take a while. V24 stated she will be assessing R40 next week and will be contacting the DON to get an update on R40. V24 stated it is very sad that R40 is going through this because she was doing so well and was very active in the facility before last week. 2. R71's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Acute Exacerbation, Major Depressive Disorder, Anxiety Disorder, Essential Hypertension, Primary Pulmonary Hypertension, Chronic Atrial Fibrillation, Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure (CHF), Chronic Respiratory Failure with Hypoxia and Personal History of Pulmonary Embolism. R71's Progress Notes dated 8/24/2022 at 4:36 PM documents, resident admitted to (local hospital) with dx (diagnosis) of exacerbation of COPD and acute CHF. R71 had an additional Progress Note dated 8/24/2022 at 4:36 PM which documents, resident sats (saturates) at 95% on 2.5L (liters) O2 (oxygen) states she feels SOB (short of breath), abdominal breathing observed, wheezing auscultated. pulmonologist NP (Nurse Practitioner) here to see and assess resident, new orders received of daliresp 500 mcg ( micrograms) and breo ellipta inhaler that were just ordered and not available from pharmacy at this time. medical NP here to see and assess resident ordered to be sent to ER (emergency room) per 911 for respiratory distress. EMS (Emergency Medical Services) arrived approx (approximately) 1305 (1:05 PM) to take over tx (treatment). Review of R71's Progress Notes dated 8/16/22 to current (9/9/22) includes documentation of R71's medications that were not available on these dates. There is no documentation that the facility notified the physician or nurse practitioner of the missed doses of medications on these dates: 8/17/22: Protonix, Propranolol, Potassium Chloride, and Spiriva were not available 8/18/22: Propranolol and Dicyclomine were not available 8/19/22: Cardizem, Dicyclomine, Flonase, Furosemide, Guaifenesin, Isosorbide, Lisinopril, Protonix, Propranolol, Potassium Chloride, Vitamin D, and Spiriva were not available. 8/21/22: Spiriva was not available 8/22/22: Cardizem was not available (R71 was hospitalized at local hospital 8/24/22 to 8/25/22 with diagnosis of COPD Exacerbation and CHF) 8/26/22: Guaifenesin, Cardizem, Prednisone, Furosemide was not available 8/29/22: Spiriva was not available 8/31/22: Spiriva was not available 9/1/22: Incruse Ellipta not available 9/3/22: Breo Ellipta not available 9/7/22: Incruse Ellipta not available. R71's Hospital Discharge summary dated [DATE] documents her admitting diagnoses were Acute Congestive Heart Failure and COPD with Acute Exacerbation. On 9/9/22 at 12:37 PM R71 stated she does not know why she did not get her medications when she was first admitted and thinks that was the reason she had to go back to the hospital. R71 stated it scares her when she doesn't get her medications because she has heart and breathing problems. She stated the nurses said it was not their fault that her medications were not here; it was because of pharmacy. On 9/9/22 at 12:40 PM, V38 (Pulmonary Nurse Practitioner) stated she was not notified by the facility that R71 was not receiving her medications as ordered. After reviewing the medications R71 had missed since her admission on [DATE] until 9/7/22, V38 stated R71 having missed those medications definitely would have caused her to have an exacerbation of her COPD and CHF and caused her to be sent to the hospital. V38 stated she had seen R71 on 8/24/22, the day she was sent to the hospital, and noted she was short of breath, but she had just finished with therapy, so she thought R71 was just needing to recover from that. V38 stated the Primary Nurse Practitioner called her later that day and told her R71 was continuing to be short of breath and lethargic and they made the decision to send her to the emergency room for evaluation. V38 stated the facility did not notify her that R71 was not receiving all of her medications and that would have absolutely been something they should have reported to her so she could follow up with the pharmacy to determine the estimated time of delivery of the medications. She stated R71's diuretics and inhalers are very important medications for her to receive because of her COPD and CHF diagnoses. The facility's policy, Change in Resident's Condition with the review date of 9/2022, it documents, General: It is the policy of the facility, except in medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: it continues, b. There is a significant change in the resident's physical, mental, or emotional status. and e. It is deemed necessary or appropriate in the best interest of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview and record review the facility failed to provide adequate supervision, assess, and investigate for the root cause of falls, and implement progressive interventions to prevent further falls for 1 of 4 residents (R42) reviewed for accidents in the sample of 36. This failure resulted in R42 having 32 falls from 1/2022 through 9/8/2022, 6 of which required R42 to be transported to the emergency room for right knee fracture, right hand fracture, staples to R42's head, and 2 concussions. B. Based on observation, interview and record review the facility failed utilize safe equipment to propel residents for 1 of 4 residents (R2) reviewed for safe equipment to provide locomotion in the sample of 36. Findings include: A. R42's Undated Face Sheet documents she was admitted to the facility on [DATE]. R42's Face Sheet documents diagnoses of history of falling, cerebral palsy, difficulty walking, seizures, schizoaffective disorder and bipolar disorder. R42's Referral form from a local group home, dated 6/7/2021 documents she was at risk for falls. The referral form documents R42 ambulated with a wheeled walker with minimum assist of 2 staff for balance, weakness, and safety. The Referral Form documented R42 needed assistance with ADLs (activities of daily living). The Referral Form documented interventions in place included call light within reach, bed in lowest position, bed wheels locked and a bed alarm. The Referral Form documented the group home staff documented R42 whereabouts every 2 hours. R42's admission Fall Risk Assessment, dated 6/15/2021 documents she was high risk for falls. The Fall Risk Assessment documented she had 3 or more falls in the last 3 months, assess the resident's gait/balance, have him or her stand on both feet without holding onto anything; walk straight forward; walk through a doorway; and make a turn: N/A not able to perform function adequate vision and intermittent confusion. R42's medical record documented R42 had falls on following dates with no major injuries: 1/20/2022 no injury, 2/4/2022 no injury, 2/11/2022 no injury, 2/4/2022 laceration to nose, 2/16/2022 no injury, 2/22/2022 abrasion right knee, 2/23/2022 no injury, 2/26/2022 no injury, 3/6/2022 no injury, 3/8/2022 no injury, 3/9/2022 no injury, 3/10/2022 no injury, 3/13/2022 no injury, 3/15/2022 no injury, 3/18/2022 no injury, 3/19/2022 blood coming from her nose, large hematoma to left eye, bruise on right wrist, 3/31/2022 no injury, 5/20/2022 no injury, 5/22/2022 no injury, 5/23/2022 no injury, 5/28/2022 no injury, 6/5/2022 steri-strips right forehead, 6/14/2022 no injury, 6/22/2022 no injury, 6/23/2022 no injury, 6/29/2022 no injury, 7/26/2022 no injury, 7/28/2022 no injury, 7/30/2022 no injury, 8/21/2022 abrasion to left knee and elbow and 8/23/2022 bruise right side of face and lump on right forehead. R42's Quarterly Minimum Data Set (MDS), dated [DATE] documents she is alert and needs supervision/setup help only with bed mobility, transfers, personal hygiene and walk in room. Independent/setup help only with locomotion on and off unit. R42's MDS documents R42 requires staff dressing limited assist with one-person physical assist for dressing, and extensive assistance one-person physical assist with toileting. R42's MDS documents R42 is not steady, but able to stabilize without staff assistance for moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet, surface-to-surface transfer (transfer between bed and chair or wheelchair). R42's MDS documents R42 utilizes a walker and wheelchair. R42's MDS documents R42 had 4 falls including 2 with no injury and 2 with injuries except major. R42's Nurse's Note, dated 1/11/2022 at 6:26 AM documents R42 fell in room between bed and dresser. The Nurse's Note documented R42 busted her head-on right-side ear level. R42's Nurse's Note documented she was able to move extremities and sat herself up. The Nurse's Note documented R42 stated she don't want to be on this covid unit and wait until her family hears about her being on unit. R42's Nurse's Note documented at 6:45 AM Emergency Medical service (EMS) called and R42 left facility to local hospital via ambulance at 7:00 AM. The Nurse's Note documented R42's sister was called, and the Assistant Director of Nurses (ADON) was notified and called report to local hospital. R42's Hospital Paperwork, dated 1/11/2022, documents reason for visit was a fall. R42's Hospital Record documented R42 had diagnoses of fall, closed nondisplaced fracture of right patella (knee), concussion with loss of consciousness of 30 minutes or less and acute cystitis (inflammation of the bladder) without hematuria (bloody urine.) R42's Care Plan, dated 1/11/2022 documents post fall intervention cardiologist consultation as she allows. The Care Plan did not document any staff interventions to provide R42 with increased supervision. R42's Nurse's Note, dated 1/15/2022 at 5:11 PM, documents took residents out to smoke at 4:00 PM. The Note documented Upon entering building heard resident scream. 4:05 PM entered room resident lying face down on floor. Assessed resident she has hematoma on right eye, laceration on nose, and swollen right wrist. Resident was laughing and stated she was upset over TV not working. 4:15 PM Called 911. B/P (blood pressure) 158/92, T (temperature) 97.8, P (pulse) 94, O2 (oxygen saturation) 98% RA (room air), R (respiration) 24. 4:35 PM EMS arrives and picks up resident going to local hospital. 4:40 PM DON (Director of Nurses) called, 4:45 PM NP (nurse practitioner) called, 4:50 PM POA (power of attorney) called. R42's Nurse's Note, dated 1/15/2022 at 8:19 PM documents, R42 returned to facility from local hospital. The Note documented Resident RT (right) orbital/eye swollen shut, purple in color. Sutures noted to RT eyebrow. RT hand had splint and wrapped. Resident has nasal fracture, metacarpal bone fracture, metacarpal neck, 2nd thru 5th. Eyebrow laceration which was sutured. Orders to f/u (follow up) with physicians Resident was alert and not complaining of any pain. Resident assisted into her bed and instructed her to use call light for assistance. R42's Hospital Paperwork, dated 1/15/2022, documents reason for visit, fall. The Hospital records documented Diagnoses metacarpal (hand) bone fracture, metacarpal neck, 2nd through 5th, nasal fracture and facial laceration. R42's Care Plan, dated 1/15/2022 documents post fall intervention discuss behaviors with her as she allows, moved closer to the nurse's station, referred for cardiologist re-visit and seen by cardiologist. R42's Medical Practitioner Late Entry Note (Physician/NP), dated 1/18/2022 at 9:51 AM documents Will continue to monitor falls and attempt to gather additional information from the patient about the falls. Will order tilt table test to assess for syncope Continue to monitor. R42's Medical Practitioner Late Entry Note (Physician/NP), dated 2/22/2022 at 7:18 AM, documents Tilt table test for syncope pending, most recent fall occurred on 2/20/2022, no loss of consciousness reported. Continue to monitor. R42's Medical Practitioner Late Entry (Physician/NP), dated 3/8/2022 at 10:53 AM, documents Unable to obtain tilt table test due to no local hospitals performing them. R42's Nurse's Note, dated 4/12/2022 at 12:04 PM documents Call to local hospital ER (emergency room) to check up on res. Received info that res has closed nasal FX (fracture) but stable. Blood work pending and res to be discharged back to facility at that time. R42's Hospital After Visit Summary, dated 4/12/2022 documents R42 fell and sustained closed fracture of nasal bone. R42's Hospital Paperwork, dated 4/12/2022, document diagnoses of fall, closed fracture of nasal bone and syncope. R42's Nurse's Note, dated 4/12/2022 has no documentation R42 fell or that she was transferred to the hospital. R42's Care Plan, dated 4/12/2022 documents post fall intervention out to ER for evaluation. Referred to ENT (ear/nose and throat physician). R42's Medical Practitioner (Physician/NP) Late Entry Note, dated 4/19/2022 at 5:29 AM documents Since last visit, patient has had an additional fall which required hospitalization and surgery for a nasal fracture. R42's Nurse's Note, dated 4/19/2022 at 6:15 PM documents R42 was found face down in room by bed. The Note documents R42 was bleeding from nose and lump to front mid forehead. The Note documented Resident c/o (complaint of) pain to right arm during ROM (range of motion). NP notified and ordered resident to be sent to ER for eval and tx (treatment.) Resident agreed to go to ER after three attempts. Family called to make aware with no answer. Message left to call facility back. EMT arrived at approximately 6:10 PM to transport resident. R42's Hospital After Visit Summary, dated 4/19/2022, documents she sustained a closed fracture of nasal bone and a right forearm contusion. R42's Hospital Paperwork, dated 4/27/2022 documents chart review pt (patient) presented to hospital on 4/19/2022 for evaluation after a fall. Imaging showed bilateral mildly displaced nasal bone fractures. R42's Care Plan, dated 4/19/2022 documents post fall intervention ER visit with f/u (follow up) radiology as indicated. No injuries noted. The Care Plan documented Camera review completed. Resident stood fell forward bending at knees prior to falling to floor. No hazards or issues observed. Lost balance when she stood up quickly from seated position on bed. Education provided on carefully/slowly changing positions. Resident agreed to allow staff to attempt to set up neurology apt (appointment). Resident agrees to hospital. R42's Nurse's Note, dated 4/27/2022 at 12:20 PM documents Heard res yelling out and noted her laying face down in her BR (bathroom) in front of her toilet with her pants halfway up. Large pool of blood under res head. Pressure held to laceration to R (right) hairline and position safely maintained. Call to 911. NP, DON and res family notified of above. R42's Hospital ED report, dated 4/27/2022 documents Resident arrived via EMS from nursing home for evaluation after a fall today. Pt (patient) states she was using the bathroom and when she was trying to pull up her pants, she had a syncopal (to faint) episode in which she fell forward, hitting her head on the ground. Pt states she 'blacked out' for 2-3 seconds. She notes a laceration to the anterior aspect of her scalp and states she noted blood on the floor of her home. She states her roommate called EMS (emergency medical services). The Record documented R42 received 6 staples to scalp. R42's Care Plan, dated 4/27/2022 documents post fall intervention out to ER laceration to forehead treated. Refused therapy screen and orthostatic v/s (vital signs) refused. Continue at risk interventions, evaluate cause of falls, neuro checks per policy and staples to right scalp. The Care Plan did not address R42's need for increased supervision. R42's Nurse's Note, dated 5/7/2022 at 4:38 PM documents Called to room by CNA (Certified Nurse's Aide). Resident noted on floor beside bed in prone position bleeding noted from scalp wound above middle of forehead. states 'don't know what happened I blacked out.' Pressure dressing applied refused vitals to be taken refused neuro checks ambulance called. R42's Nurse's Note, dated 5/7/2022 at 9:25 PM documents Hospital ER called resident is returning dx concussion and with staples. R42's Hospital Paperwork, dated 5/7/2022 documents Patient presenting via EMS for syncope and ground level fall. Prior to presentation patient states that she got up, lost consciousness and woke up on the ground. Per EMS report patient fell down on her knees then fell headfirst into the tile floor. Patient regained consciousness within seconds. Was alert oriented immediately afterwards. Apparently, patient has a long history of syncope. Additionally, patient had staples removed from her forehead today no which were used to fix an injury due to a similar event about a week ago. She lacerated her head in the same place. Hemostatis noted. ED provider notes documents there is a vertical laceration on the right side in the hairline extending into the forehead measuring approximately 7 cm (centimeters.) 6 staples were used to suture the laceration. R42's Nurse's Note, dated 5/7/2022 at 10:50 PM documents Resident returned from hospital via ambulance. Ambulated to bed with 2 assist. Resident refused to have vital signs taken. Staples intact to left upper forehead. Small trickle of blood noted. Paramedics stated they attempted to wipe her face, but she refused. She also refused from me. Resident denies headache or dizziness. Resident is able to move all extremities. Call light within reach. R42's Care Plan, dated 5/7/2022 documents post fall intervention IDT (interdisciplinary team) review completed and w/c seat dumped to provide for safety. The Care Plan documents the following interventions: Encourage her to leave her door open so we can observe her, neuro checks as she allows, out to ER, review camera footage for cause of fall and wheelchair dumped. R42's Medical Practitioner (Physician/NP) Late Entry Note, dated 5/17/2022 at 12:41 PM documents patient continues to have falls, cardiac work-up has been negative, continue to monitor. R42's Medical Practitioner (Physician/NP) Late Entry Note, dated 6/14/2022 at 7:53 PM documents Patient continues to have falls, cardiac work-up has been negative, continue with Midodrine 5 mg (milligrams) PO (by mouth) 3 times a daily to prevent orthostatic hypotension and continue to monitor. Observation of R42's room on 9/8/2022 at 2:00 PM showed quarter side rails on her bed, nonskid strips on the side of the bed located toward the door. On 9/7/2022 at 3:30 PM R42 stated she doesn't know why she keeps falling, she just blacks out. R42 stated she lets staff assist her with care and she doesn't ambulate on her own. R42 stated she walks with a walker with assistance of staff. R42 stated she goes to the bathroom in her room independently. R42 stated she hasn't changed rooms or wheelchairs recently. She wears a padded headband to protect her head when she falls. R42 stated she's never fell out of bed. On 9/7/2022 at 1:00 PM V19 (Licensed Practical Nurse/LPN) stated (R42) just keeps falling and there is nothing we can do about it. She refuses assistance. On 9/8/2022 at 12:20 PM V5, (Registered Nurse/RN) stated (R42) has probably set a record for falls. (R42) seems to fall a lot in her bathroom after having a large bowel movement and she has educated her to stand up slowly and hold onto the grab bar after when getting up. (R42) has no safety awareness. She recalled she removed staples from (R42's) forehead in May 2022 and the same day she fell again and had to get staples again in the same place. On 9/9/2022 at 9:52 AM V33 (Nurse Practitioner/NP) stated she wouldn't answer questions regarding why R42 has had so many falls. V33 stated to talk to V32, R42's Physician. V33 stated she expected the facility to follow the fall policy and to have progressive interventions after each fall because that is the expectation. On 9/9/2022 at 10:07 AM V32 stated he have to look at (R42's) medical record to see what the medical reason why she is falling so much. V32 stated he was aware (R42) having a lot of falls, he expected staff to document the falls and to follow the facility's fall policy and to have progressive interventions in place after each fall. On 9/9/2022 at 11:40 AM V36 (Physical Therapist/PT) stated she started working at the facility in March 2022. V36 stated (R42) is a very difficult resident because she falls a lot, and no one knows what the medical cause. (R42) is alert and propels herself in her wheelchair. Her understanding was (R42) falls in her bathroom a lot. (R42) has received PT and occupational therapy (OT) when she is willing to participate. On 9/7/2022 at 2:00 AM V2 (Director of Nursing/DON) stated she has a line listing of all R42's fall with interventions the facility put in place after each fall. V2 stated (R42) has fell 32 times in 2022. V2 stated she doesn't know why R42 falls so much; it could be behavioral she may throw herself out of her wheelchair. V2 stated (R42) refuses ADL care from staff and she doesn't want assist with anything. She self-propels about the facility in a wheelchair. She falls a lot in her bathroom. Staff placed a camera in her room, and she reviews it for post fall assessment (R42) often stands up and falls. On 9/8/2022 at 2:00 PM V1 (Administrator) stated she knew R42 called 911 many times and had multiple times prior to being admitted to the facility. V1 stated staff have done everything they felt they can for R42. She didn't know what else to do to stop R42 from falling. The facility's Fall Prevention and Management Policy, revised 10/2018, documents This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Upon admission a fall risk evaluation will be completed on admission, readmission and quarterly, significant change and after each fall. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP (Individualized Service Plan) with interventions implemented to minimize fall risk. Evaluate the resident for any injury and notify the physician and emergency contact. Complete a fall incident report in the PCC (Point Click Care) risk management portal. A fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less than 10 indicates at risk for fall. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. Complete the follow-up monitoring from every shift for 72 hours. All incident and accident with serious physical injury will be reported to IDPH (Illinois Department of Public Health) within 24 hours. A full written investigative report is required by IDPH within five (5) days of the incident. B. R2's Face sheet documents on 9/6/2022 a weight of 288 pounds. On 9/7/2022 at 10:32 AM, R2 was in a large shower chair on the VVV hall and was being pushed by V22 (Certified Nursing Assistant/CNA), and V27 (Maintenance Director). V27 was bending over and was grabbing the bottom of the chair and was pulling R2 down the hallways while bending down the entire time all the way down from the VVV-hall to the end of the YYY-hall. The large shower chair did not have any wheels in the front of the chair and the white pipes where the wheels had detached were brown in color and there were two wheels on the back of the chair. On 9/7/2022 at 10:39 AM, V27 stated, The wheels are no longer on the chair because they rusted out or rather the bolt broke. I am looking into fixing it. On 9/27/2022 at 11:01 AM, R2 stated, The shower chair has been broken for several weeks and it has been like that for a while now with the missing wheels. On 9/8/2022 at 4:02 PM, V2 (Director of Nursing) stated, I would not expect any staff to transfer residents in shower chairs down the hall with no wheels in the front or not in working order. I heard about the chair not having wheels yesterday. The Fall Prevention Policy dated May 2015 documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to assess, monitor, and implement progressive interventions to prevent weight loss for one of one resident (R62) reviewed for nutritional needs and the sample of 36. This failure resulted in R62 having a significant weight loss of 24 pounds (lbs. and/or 12.9%) in six months. Findings include: On 09/06/2022 at 12:23 PM R62's head of bed was up 30 degrees for lunch. V14 (Certified Nurse Assistant/CNA) did not raise the head of the bed up any further for R62 to eat his lunch. R62 was frail, thin, and pale. R62's bedside table was approximately six feet away from his bed. A water cup and the lunch meal were sitting on the bedside table. The bedside table was out his reach. R62's lunch consisted of two hamburgers on a bun, potato chips, brownie, and milk in a carton with a straw. V14 handed R62 his hamburger which she had broken apart in quarter sizes. V14 handed R62 a quarter size of his hamburger each time she handed the hamburger to R62 until R62 consumed both hamburgers. V14 gave him a drink of milk. V14 stated, He won't eat his chips. R62 stated, I will eat my chips. V14 handed him his chips, and she laid some chips on his bed where he picked the chips up and ate them. V14 handed the milk to R62, and he drank 100% of his milk. V14 stated He won't eat the brownie he doesn't like the consistency or texture. Immediately R62 stated, I will eat my brownie. I like brownies. V14 then handed him his brownie and he ate the brownies. No fluids were offered after R62 ate his brownie. There were no noted house supplements, or ice cream on his meal tray. R62 stated Thank you each time he was handed his hamburger, chips, and milk. At the end of the meal V14 stated, I better raise the head of the bed up more. She then raised the head of bed to 45 degrees. On 9/08/2022, at 11:30 AM R62 was up in his tilted back wheelchair sitting in the dining room for lunch. R62's meal tray consisted of two hamburgers, potato chips, brownie, ice cream, 8-ounce glass of water. R62 was not given his house supplements, health shake, or milk that was documented on his meal ticket. V14 tore one hamburger apart and handed the torn hamburger to R62. He proceeded to eat the hamburger and ate 100% of the first hamburger, then R62 picked up the second hamburger that had not been torn or cut apart. R62 ate 100% of his hamburger. V14 handed him a cup of water. R62 drank 100% of his water. R62 then picked up his potato chips and started to eat the chips. He ate 100% of the chips. V14 went to get R62 a glass of (flavored drink) then handed him his (flavored drink) he drank 100% of his (flavored drink) without a straw. V14 fed R62's ice cream at times to him. At times, R62 would feed himself the ice cream, he was using a plastic spoon which he had difficultly scooping up the ice cream from the cup, he ate 100% of his ice cream. R62 stated, I am still hungry, he was supposed to have gotten hot dogs for lunch. (R62) stated, I would like to have hot dogs. V14 stated, we are out of hot dogs, she offered a peanut butter and jelly sandwich. They brought him a peanut butter and jelly sandwich. R62 picked up the sandwich and ate 100% of his sandwich. No other fluids were offered after he ate the peanut butter and jelly sandwich. No house supplements, health shake was noted on the meal tray. V14 stated, We are done, and wheeled R62 out of the dining room. R62's weights were reviewed and documents on Physician Order Sheet (POS) the following weights: 12/06/2021 at 185 pounds (lbs.), 1/6/2022 at 182 lbs., 2/4/2022 at 174 lbs., 3/7/2022 at 175 lbs., 5/1/2022 at 161 lbs., and 9/6/2022 at 158 lbs. There were no weights for R62 documented for the following months 04/2022, 06/2022, 07/2022, and 08/2022. From 12/2021 through 5/1/22, R62 experienced a 24 lbs. (12.9%) weight loss. R62's Minimum Data Set (MDS) dated [DATE], documents a BIMS score of 99, severely impaired cognition. R62's MDS documents he is totally dependent upon staff for eating. The MDS did not document R62 had a weight loss. The MDS documented R62's weight as 161 lbs. R62's Note Text Nutrition Assessment Weight Warning written by V40 (Registered Dietician), dated, 03/07/2022, document R62's current body weight was 175 lbs. The Note documented R62's weight indicates stability in the last two months, but overall loss as previously noted. The Note documented the following dates and weight history: 2/4/2022 176 lbs. 12/6/2021 185 lbs., and 9/3/2021 200 lbs. indicating a 12% loss of weight. The Note documented R62 remains on regular thin liquids with milk all meals, ice cream with lunch/dinner. Intake >/=50% now, improved. The Note documented a (nutritional supplement ice cream) and (nutritional supplement drink) previous added, but reported to refuse (nutritional supplement drink), appropriate to discontinue. The Note documented reported improved intake and self-assist when finger type foods offered, stability at current weight desired. The Note documented to recommend discontinue (nutritional supplement ice cream) as ordered, continue ice cream for lunch/dinner, discontinue (nutritional supplement drink) as ordered refusing and overall, with improved intake at meals, offer finger type foods, when possible, monitor weight, will follow. There was no documentation a Physician's Order (PO) was obtained regarding the recommendation made by the dietician on 3/7/22 for ice cream at lunch and dinner and finger type foods when possible. R62's Physician Order Sheet (POS) dated, 05/01/2022, documents Regular diet, regular texture, Thin liquids consistency. GI soft, house supplement with all meals for diet order. R62's form, (Requests for Diet Change) dated, 05/04/2022, documents add super cereal and fortified pudding at lunch. Will follow. There was no documentation noted in Physician Orders Sheet (POS) for fortified cereal and fortified pudding at lunch. R62's Dietary Notes dated 08/01/2022, documents Nutrition assessment: Resident with unintentional weight loss related to hospitalizations, inadequate oral intake, as evidenced by 15 lbs. weight loss in 6 months, 8.5 %. Recommend: continue soft diet as tolerated, monitor swallowing, add house supplement with meals, obtain a new weight (last weight taken 5/1/2022), encourage PO (by mouth) intake and offer snacks, will monitor tolerance to supplements, PO intakes, and weight. R62's Care Plan dated 09/06/2022, documents (R62) is at risk for complications with weight and nutrition r/t (related to) need max assist -total assist with eating most of the time now. R62's Care Plan Goal documented R62 will consume adequate nutrition and weight to remain stable throughout next review. R62's Care Plan interventions, dated 9/6/22, document assist feed resident with meals as needed, document signs and symptoms of chewing/swallowing problems, monitor weight and labs, notify MD, RD, of any significant weight changes, offer substitutes for uneaten foods, RD to assess and recommend as needed, serve diet as ordered. R62's Meal ticket dated, 09/09/2022, documents, breakfast diet regular, diet texture regular, needs up for all meals NAS (No added salt), high protein meals. Soft food, resident has no teeth. Adaptive equipment paper products. Lunch diet regular, diet texture regular, needs up for all meals NAS high protein meals. Soft foods, resident has no teeth. Supper documents diet regular, diet texture regular, needs up for all meals NAS high protein meals, soft foods, resident has no teeth. On 09/09/2022 at 9: 04 AM, V4 (Dietary Manager) stated, (R62) was asked what he wanted for lunch this morning for 09/09/2022. V4 said, (R62) requested two grilled cheese sandwiches. (R62) wants what is on the regular menu for supper V4 (Dietary Manager) stated, (R62) did not get his hot dogs yesterday for lunch that he requested because we ran out of hot dogs and it will be several days before the hot dogs will be delivered, so, we just gave him hamburgers. V4 stated, (R62) told me during lunch he really wanted the hot dogs. On 09/09/2022 at 9:10 AM V4 gave surveyor another meal ticket that R62 did not have on his table yesterday for 09/08/2022 that did not match up with the meal ticket given to surveyor this morning. meal ticket. R62's meal ticket documented on 9/8/2022 needs up for all meals, NAS, House Supplements with all meals, Health Shake 8 fl ounces, Milk 8 fluid ounces, and Ice Cream for lunch and dinner. V4 stated, They changed these meal tickets last night in the office. On, 09/06/2022 at 10:02 AM, V3 (Registered Nurse/RN), stated, We feed (R62) in his room we don't get him up because he fights the staff, and curses staff. On 09/06/2022 at 10:30AM, V2 (Director of Nursing/DON), stated, We had (R62) losing weight because he was too big. On 09/08/2022 at 2:00PM, V2 stated, Not sure why (R62's) weights were not done during the months of April, June, July, and August of 2022. V2 stated, not sure what happened. On 09/08/2022 at 2:10PM, V2 said, I would expect the staff to be checking the meal tickets before giving the tray to the resident to make sure the correct diet was being served. V2 stated, I would expect the staff to give what is ordered, or on the meal tickets for any supplements. On 09/09/2022 at 11:48 AM V40 (Dietician) said, (R62's) weight loss was significant. V40 stated she not aware that four months of weights were not gotten. V40 stated that she would expect what is recommended on the nutrition assessment and signed off by the MD to be followed. V40 stated she would expect the meal tickets to be correct based on the diet orders, and any supplements be given and on the meal tickets. V40 stated she expect R62 having a weight loss a monthly weight be gotten, and sometimes more often. V40 stated I haven't been to that facility since July 2022. Weight Change Policy review date, 09/2022 documents General: It is the policy of this facility to monitor the nutritional status of all residents, including all significant or trending patterns of weight change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents are free from significant medication errors for two of 7 residents (R40, R71) reviewed for medication in the sample of 36. This failure resulted in R40 experiencing acute psychotic episode due to not receiving her antipsychotic medication as ordered, and R71 being hospitalized with an exacerbation of her COPD (Chronic Obstructive Pulmonary Disease) and CHF (Congestive Heart Failure) after not receiving her cardiac and respiratory medications. Findings include: 1. On 9/6/22 at 10:54 AM, R40 was sitting in the recliner in her room with her eyes closed. R40 was able to state her name but then had slurred, mumbled speech when answering questions, and was very difficult to understand. She stated she has only been in the facility a couple of days and had moved here because the last facility she lived in told her she had to leave because the administrator didn't want her there. R40 kept nodding off to sleep but would wake to try to answer questions. She appeared very lethargic and drowsy. Her hair was uncombed and general appearance disheveled. R40's Face Sheet documents her diagnoses to include Anxiety Disorder, Schizophrenia, Schizoaffective Disorder and Bipolar Disorder. R40's Minimum Data Set (MDS) dated [DATE] documents she was admitted to the facility on [DATE] and is alert and oriented. It also documents she did not have any delusions, hallucinations, or behaviors during that assessment period. R40's Care Plan dated 4/14/21 documents, Medication: (R40) uses antianxiety medications related to anxiety disorder. Is at risk for side effects. Interventions for this Care Plan include anti-anxiety medication as ordered. R40's Care Plan dated 4/16/21 documents, Behavior: (R40) has a history of anxiety and self-isolation. At risk for alteration in mood. Diagnosis: Anxiety, Schizophrenia. Interventions for this care plan include medications as ordered. R40's Care Plan dated 9/3/22 documents: Elopement: At this time (R40) is experiencing delusions and hallucinations related to her mental illness. Interventions for this care plan include: 1:1 with staff as needed; 15-30 minute checks as needed; allow concerns to be expressed; encourage resident to keep busy with activities; MD (medical doctor) notification as needed. R40's Physician Orders dated Physician Order Summary dated 9/7/22 documents the following orders: Clozapine (antipsychotic medication) 100 mg by mouth at bedtime with start date 6/8/21 and Clozapine 50 mg by mouth in the morning with a start date of 9/3/22. R40's Physician Orders also included an order for Lorazepam (antianxiety medication) 0.5 mg 1 tablet by mouth two times a day with a start date of 6/8/21, but no discontinue date. Review of R40's Progress Notes dated 6/1/22 to 9/7/22 document she missed 18 doses of Lorazepam 0.5 mg which was ordered to be given twice a day for anxiety. All the missed doses of Lorazepam occurred between 6/20/22 and 7/26/22. On R40's Medication Administration Record (MAR) starting on July 27, 2022, R40's Lorazepam was on hold by the physician, but there was no order on R40's Physician Order Sheet documenting an order to put Lorazepam on hold and no documentation in R40's Progress Notes documenting a physician had put R40's Lorazepam on hold on 7/27/22. R40's Progress Notes document she did not receive her Clozapine 100 mg which was ordered to be given at 8:00 PM every night, on 8/6/22, 8/19/22 or 8/20/22. R40's Drug Record Book dated 6/1/22 to 9/30/2022 documents her Clozapine 100 mg was reordered on 8/27/22 and notes on that date, out, please send asap (as soon as possible). Review of R40's Progress Notes dated 6/1/22 to 9/7/22 does not document any behaviors until 9/4/22 at 4:46 AM when it documents, most of evening and night, resident up yelling and screaming. Very confused and talking about people and things from the past. no distress noted. Will continue to monitor. There was no documentation that family or physician was notified of R40's change in condition. R40's Progress note dated 9/3/22 at 8:52 AM documents, Resident very restless, walking from her room to nurses station to front lobby. Voicing delusional thoughts and difficult to redirect. Told this nurse, You are a bad nurse, you don't have any facts. I no longer live here. I was in Australia all last week. Resident family reports that resident refusing to take their phone calls and denied knowing who her sister is when she came to see her this AM. (V24 Psychiatric Nurse Practitioner) aware of above. New order received. Resident placed on 15-minute checks for safety. On 9/8/22 at 9:30 AM, V2 (Director of Nursing/DON) provided R40's psychiatric progress notes dated 4/27/21, 2/4/22 and 5/25/22. She included a handwritten note that documents, (R40) verified with NP (Nurse Practitioner) 9/7 at 5:28 PM that (R40) was last seen May 2022 and was not seen in June or July (did not mention August). The note documents she will see this month. May call (V24) to discuss. On 9/7/22 at 2:36 PM, V18 (Licensed Practical Nurse/LPN) stated R40 was moved yesterday. V18 stated R40 had been having some kind of psychosis. V18 stated on the past Thursday, September 1st, R40 was delusional and saying that she needed to go to Washington DC, and she thought her sister had committed suicide and that her roommate had gotten inside her head and stolen all her memories and deleted them. V18 stated she did not know anything about R40 having fallen recently. On 9/7/22 at 2:38 PM, V19, LPN, stated she was here last Thursday (September 1st) and saw changes in R40's behaviors. V19 stated R40 had missed one of medications for a couple of days because of problems with pharmacy, something about them not getting the order, or it was outdated. V19 stated today R40 was doing a lot better, but last night when she worked R40 was still not the same but did finally remember V19's name. V19 stated if they don't have a resident's medication, they notify the pharmacy to see what is going on. V19 stated if the medication is not a psych med, they notify the MD's nurse practitioner, but if it is a psych med, they notify V24 (psychiatric nurse practitioner.) On 9/7/22 at 2:45 PM, R40 was sitting in her room. Her speech was clear, and she was awake and alert. R40 stated, I couldn't sleep because I didn't have my medicine. They kept telling me it didn't come in from pharmacy. I haven't been sleeping good for 4 or 5 weeks, and I wasn't getting enough to eat. I felt like they were punishing me because V1 (Administrator) doesn't want us to have Resident Council meetings and it's our right. I felt bullied by her. I am the Resident Council President and I have to look out for the residents here. She stated her parents are not her guardians, her husband, (television actor) is. She stated, You know, he is Hawkeye on MASH. She stated she goes out on Saturdays with her sister to eat and shop. She stated they wouldn't let her husband take her out. R40 stated she talks to her brother a lot on the phone, but he doesn't live around here. On 9/7/22 at 3:05 PM, V2 (Director of Nursing /DON), stated the facility had some problems with the pharmacy at the beginning of August when they went to a new system. V2 stated they went from the card system to having medications in individual plastic rolls, except high acuity medications, which were still on cards. V2 stated the first couple of weeks after the change they had a lot of problems because the pharmacy thought they still had the high acuity medication cards, but they had sent everything to the pharmacy and then did not get the high acuity meds back with the other meds. V2 stated R40 did miss her Clozapine 50 mg on September 3 but did get it as soon as it came in on September 4. V2 stated R40 had started getting a little manic, and the psychiatric nurse practitioner had ordered her to have Clozapine 50 mg every morning in addition to her current dose of Clozapine 100 mg at HS. V2 stated R40's brother had called and asked about her missing some medication. V2 stated he talked to V1 (Administrator), but she was unable to give him any information because he was not on R40's contact list. V2 stated when R40 had behaviors last week, she had contacted R40's parents and sister on Thursday, August 1st and asked them to come and see her and help figure out what was going on with R40. V2 stated they came to see R40 on Saturday. V2 stated R40's sister does not see her often; she has only seen her visit a couple of times in the last year. V2 stated R40's parents are her guardians, but they are elderly and don't hear well so when staff call them, if they can't hear what is being said, they hang up. V2 stated R40's parents and sister have left specific instructions that they are not to give her brother any information regarding R40; he is to call either her parents or sister and they will let him know what they want him to know. V2 stated, I called (R40's) sister and parents to inform them of her behaviors last week. I can show you on my cell phone where I called them. V2 then looked through her cell phone and stated, I must have used (V1's) cell phone because I can't find it on my phone. V2 stated when a medication is missed, if it is a psych med, they notify the psychiatrist because the medical doctor and his nurse practitioner will not do anything with psych meds. V2 stated the nurse usually notifies V24 (psychiatric nurse practitioner) with any psych issues. V2 stated she does not think the psychiatrist has been in the facility for several months. On 9/7/22 at 3:50 PM, V16 (R40's brother) during phone interview, stated he had not talked to R40 about her missing medications, because he was on a zoom call when she tried to call him, but R40 had notified his niece, who is in medical school, by text, stating that she had missed some of her medication and was not sleeping. V16 stated R40, in her text message to his niece, stated the facility was giving her Melatonin and it was not helping her to sleep, and was asking if there was anything else that would help. V16 stated he called and tried to ask the Administrator (V1) about R40 having missed medications, and she told him she is dealing with a state survey and has a funeral to attend and did not have time to talk to him. V16 stated he tried to set up a better time to discuss R40 but (V1) told him he was not on her contact list so she would not be able to talk to him. V16 stated he then asked if his sister (V17) could call and make the appointment and was told yes, she could. V16 stated R40's text to his niece indicated she had missed her medication for about a week. V16 stated R40 had been doing very well with no psychiatric setbacks for about 17 years and was usually very alert and oriented and well organized. V16 stated he had called and informed his sister about the text message R40 had sent to her niece about missing medication, so she went to see her on Saturday, which was the usual routine, and R40 was not her normal self. V16 stated he did not know of any falls or injuries that had occurred as a result of R40 not receiving all her medication, but he feels she has had a mental set back as noted by her change in behaviors and her lack of sleep. V16 stated he is worried about the facility retaliating against R40 because the family is complaining, but he stated he just wants to know what medication was missed, why it was missed and what is being done about it, so it doesn't keep happening because he knows her medications are very important to her stability mentally. On 9/7/22 at 5:15 PM, V17 (R40's sister) during a phone interview, stated she comes in every Saturday and takes R40 out of the facility for the day and they usually have lunch or dinner with their parents. V17 stated R40 is very alert and oriented and runs the Resident Council at the facility, and if R40 feels like she or any of the other residents are being mistreated, she will say something about it. V17 stated R40 usually calls her during the week to talk about what they are going to do on the Saturday when she comes to get her, but R40 did not call her last week, which was very unusual for R40. V17 stated nobody from the facility called her last week to tell her about R40 having behaviors, but when she arrived at the facility that Saturday morning, September 3, a staff met her at the door and stated she had meant to call her and warn her that R40 was having a lot of behaviors and was not acting like herself. V17 stated they told her R40 was yelling and cursing at the staff. V17 stated she went to R40's room and R40 yelled for her to get the f*#% out. V17 stated nobody from the facility had notified her or R40's parents that R40 was not receiving all of her medications. V17 stated her brother had called her with concerns because their niece had received a text message from R40 last week, telling her R40 was not getting her medications and could not sleep and wanted to know if she could tell her something that would help her because the Melatonin the facility was giving her was not working. V17 stated R40 knew her own medication very well and sometimes when she went on home visits, R40 would catch that they had forgotten to send one of her medications and would call up and tell them she needed it. V17 stated no one had given any directive to the facility to not release any information to R40's brother regarding her care. V17 stated he is not on her list because he lives out of state and it is easier to get in touch with her or her parents, but there is no reason he cannot call with concerns about her care. She stated R40 speaks to her brother on the phone often. V17 stated she feels the facility owes them an apology and an explanation of why some of R40's medications were missed and why they had not been informed of this or R40's change in behaviors and overall condition. V17 stated R40 has not had a psychotic break like this since 2005, and when it happened back then, it caused her to have to be institutionalized. V17 stated she knows R40 not receiving her medications could be very detrimental to her mental health. On 9/8/22 at 10:35 AM, V2 (DON) stated, I don't do medication error reports when medications are missed, only when the wrong medication is given. We don't do a medication error report, but we notify the doctor when a medication is missed. If the doctor was notified of the missed medication it is documented in the eMAR (Electronic Medication Administration Record) documentation progress notes. V2 stated she would expect physician orders to be followed and medications to be given as ordered. 9/8/22 at 2:00 PM, V24 (Psychiatric Nurse Practitioner) stated the facility does sometimes send a fax or calls the office when a resident's medication is not available. V24 stated she was surprised when the nursing staff called about R40 having behaviors this past weekend. She stated staff reported to her that R40 was in the midst of the delusion of having a famous husband and was trying to run out of the facility to meet him. She stated she does not recall anyone reporting R40 missing 18 doses of Lorazepam in July 2022 because that would have been pretty significant. She stated she would think the facility would contact the pharmacy right away and figure out what was going on so R40 would get her medications as ordered. V24 stated there is no reason R40 should have missed 18 doses of her Lorazepam without the facility doing something about it. She stated she does not think that is related to R40's behaviors this past weekend, as R40 had been complaining of being tired and her Lorazepam would have made her more drowsy, not caused her to have behaviors. V24 stated they had been decreasing R40's Clozapine gradually over the past year, so missing a dose may cause her to have changes in her behaviors for a couple of days following the missed dose, but the missed dose a couple of weeks ago probably would not have affected R40's behaviors this past weekend. V24 stated she knows R40 very well and has been treating her for the past 5 years and stated R40 is normally very alert and oriented and is aware of her own care. V24 stated she would not be surprised if R40 remembers meetings she had 2 or 3 years ago. V24 stated she does not know what would have caused R40's behaviors last weekend but she did give an order to add Clozapine 50 mg QAM because they had decreased her dose quite a bit. On 9/8/22 at 7:00 PM, R40 was sitting in her room waiting on her medication and snacks. R40 stated she is feeling a lot better. R40 was noticeably more alert, and her speech was clearer than during previous encounters with her during the survey. She remembered this surveyors name. She stated she had missed her nighttime dose of Clozapine 3 nights last week and it was horrible. R40 stated, The didn't give me my Clozapine for 3 days and I couldn't sleep. I begged them to give me my meds and they told me pharmacy didn't bring them yet. I asked them to call my doctor and they told me they couldn't because he was on vacation. It was terrible. I felt like my eyelids wouldn't close. I cried because I knew I wasn't right, but I didn't know what to do. On 9/8/22 at 7:20 PM, during an off-hours portion of the survey, V19 (Licensed Practical Nurse/LPN) stated the facility is still using the same pharmacy since changing owners, but they reorder residents' medications differently. V19 stated they reorder a resident's medication through the electronic medical record but several times the medication has been reordered it doesn't show up with the delivery. V19 stated this has happened with R40's Clozapine more than once, but she knows she missed some doses last week, but doesn't know how many because she doesn't always work on the same hall. V19 stated she felt very bad about what R40 went through last week and the beginning of this week. V19 stated R40 got so bad mentally that she did not even know V19's name, and she stated R40 usually recognizes all the staff and her fellow residents. V19 stated R40 was upset because she was afraid her changes were part of her illness and was afraid, she was getting worse, but V19 stated she reassured R40, when she was able to understand again, that her mental changes and behaviors were not her fault, and that it was the facility's fault because they did not get her Clozapine ordered on time. V19 stated she has worked with R40 for over a year, and this is the first time she has seen her have behaviors like these, and not recognize staff. V19 stated when R40 had missed doses of her Clozapine in the past it did not affect her this bad. V19 stated she talked to R40's sister when she came in and she told V19 that R40 had behaviors similar to these back in 2009 and that is what caused her to be institutionalized. On 9/9/22 at 8:45 AM, V31 (Pharmacist) stated R40's Clozapine 50 mg was ordered and processed on 9/2/22 and should have been delivered on 9/3/22. She stated she could not tell when R40's Clozapine 100 mg was ordered, but all the orders she has are old. She stated she could not tell exactly when the last Clozapine 100 mg was last sent to the facility and would have to check with someone else and will return call. On 9/9/22 at 12:00 PM, V31 stated they did receive the facility's request for a refill of her Clozapine on 8/27/22 but it was not sent because they needed a lab that is required before they can send Clozapine. V31 stated her records show the pharmacy has not refilled R40's Clozapine 100 mg since April 2022. V31 stated since April 2022, the only Clozapine that has been sent to facility for R40 was Clozapine 50 mg for her new order received on 9/2/22 for Clozapine 50 mg every morning. On 9/9/22 at 12:15 PM, V2 (DON) and V23 (ADON) stated they were not aware R40 did not receive her Clozapine 100 mg from 8/27/22 until her Clozapine 50 mg was delivered on 9/4/22. V23 stated, I am the one who wrote on the order that we were out of (R40's) Clozapine and to please send it out. Both V2 and V23 stated they have given R40 her medications when they have worked the floor since April 2022, and they feel like she had her Clozapine 100 mg when they gave her medications. On 9/9/22 at 1:37 PM, V24 (Psychiatric Nurse Practitioner) during phone interview, stated R40 having missed her Clozapine 100 mg QHS would have directly caused her to have experience her changes in mental status resulting in her psychosis she experienced starting on 9/2/22 and she is continuing to have some psychosis. V24 stated R40 will most likely require a higher dose of Clozapine to get back to her baseline and it might take a while. V24 stated she will be assessing R40 next week and will be contacting the DON to get an update on R40. V24 stated it is very sad that R40 is going through this because she was doing so well and was very active in the facility before last week. 2. R71's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Acute Exacerbation, Major Depressive Disorder, Anxiety Disorder, Essential Hypertension, Primary Pulmonary Hypertension, Chronic Atrial Fibrillation, Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure (CHF), Chronic Respiratory Failure with Hypoxia and Personal History of Pulmonary Embolism. R71's Progress Notes dated 8/24/2022 at 4:36 PM documents, resident admitted to (local hospital) with dx of exacerbation of COPD and acute CHF. R71 had an additional Progress Note dated 8/24/2022 at 4:36 PM which documents, resident sats (saturates) at 95% on 2.5L (liters) O2 (oxygen) states she feels SOB (short of breath), abdominal breathing observed, wheezing auscultated. pulmonologist NP (Nurse Practitioner) here to see and assess resident, new orders received of daliresp 500 mcg ( micrograms) and breo ellipta inhaler that were just ordered and not available from pharmacy at this time. medical NP here to see and assess resident ordered to be sent to ER (emergency room) per 911 for respiratory distress. EMS (Emergency Medical Services) arrived approx (approximately) 1305 (1:05 PM) to take over tx. Review of R71's Progress Notes dated 8/16/22 to current (9/9/22) includes documentation of R71's medications that were not available on these dates. There is no documentation that the facility notified the physician or nurse practitioner of the missed doses of medications on these dates: 8/17/22: Protonix, Propranolol, Potassium Chloride, and Spiriva were not available 8/18/22: Propranolol and Dicyclomine were not available 8/19/22: Cardizem, Dicyclomine, Flonase, Furosemide, Guaifenesin, Isosorbide, Lisinopril, Protonix, Propranolol, Potassium Chloride, Vitamin D, and Spiriva was not available. 8/21/22: Spiriva was not available 8/22/22: Cardizem was not available (R71 was hospitalized at local hospital 8/24/22 to 8/25/22 with diagnosis of COPD Exacerbation and CHF) 8/26/22: Guaifenesin, Cardizem, Prednisone, Furosemide was not available 8/29/22: Spiriva was not available 8/31/22: Spiriva was not available 9/1/22: Incruse Ellipta not availabel 9/3/22: Breo Ellipta not available 9/7/22: Incruse Ellipta not available. R71's Hospital Discharge summary dated [DATE] documents her admitting diagnoses were Acute Congestive Heart Failure and COPD with Acute Exacerbation. On 9/9/22 at 12:37 PM, R71 stated she does not know why she did not get her medications when she was first admitted and thinks that was the reason she had to go back to the hospital. R71 stated it scares her when she doesn't get her medications because she has heart and breathing problems. She stated the nurses said it was not their fault that her medications were not here; it was because of pharmacy. On 9/9/22 at 12:40 PM, V38, Pulmonary Nurse Practitioner, stated she was not notified by the facility that R71 was not receiving her medications as ordered. After reviewing the medications R71 had missed since her admission on [DATE] until 9/7/22, V38 stated R71 having missed those medications definitely would have caused her to have an exacerbation of her COPD and CHF and caused her to be sent to the hospital. V38 stated she had seen R71 on 8/24/22, the day she was sent to the hospital, and noted she was short of breath, but she had just finished with therapy, so she thought R71 was just needing to recover from that. V38 stated the Primary Nurse Practitioner called her later that day and told her R71 was continuing to be short of breath and lethargic and they made the decision to send her to the emergency room for evaluation. V38 stated the facility did not notify her that R71 was not receiving all of her medications and that would have absolutely been something they should have reported to her so she could follow up with the pharmacy to determine the estimated time of delivery of the medications. She stated R71's diuretics and inhalers are very important medications for her to receive because of her COPD and CHF diagnoses. The facility's policy, Medication Administration with date reviewed of 3/2022, documents, General: All medications are administered safely and appropriately to aid residents to overcome illnesses, relieve and prevent symptoms and help in diagnosis. It continues, 26. If medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain from the contingency or convenience box. 27. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on situation), and a note should reflect the situation in the resident's medical record.