**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to correctly identify, treat, resulting in worsening and non-healing of pressure ulcers for three residents (R29, R32, R81) out of five residents reviewed for pressure ulcers. Findings Include: Resident #29 (R29) Wounds were reviewed for R29. Review of the medical record reflected R29 was admitted to the facility on [DATE], with diagnoses that included chronic pain, delirium, and reduced mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R29 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Terminal Kennedy ulcers (KTU) and pressure ulcers are both types of skin breakdown, but they are different in their cause, appearance, and meaning. A pressure ulcer happens when there is prolonged pressure on one area of the skin, usually over bony parts of the body. This pressure reduces blood flow to the tissue, eventually leading to skin and tissue damage. Pressure ulcers develop gradually and are usually preventable with frequent repositioning, good nutrition, skin care, and pressure-relieving devices. The Centers for Medicare & Medicaid Services (CMS) and the National Pressure Injury Advisory Panel (NPIAP) classify pressure ulcers into stages based on how deep the damage goes, from Stage 1 (reddened, unbroken skin) to Stage 4 (deep tissue loss exposing muscle or bone) (NPIAP, 2016). KTU's, on the other hand, are a specific type of skin breakdown often seen at the end of life. They usually develop very quickly, sometimes in just a matter of hours, and are commonly found on the sacrum or coccyx area. These ulcers tend to have a distinct appearance. They can be shaped like a pear, butterfly, or horseshoe and may have a sudden dark purple or black color. Unlike pressure ulcers, Kennedy ulcers are not caused by pressure alone. Instead, they are believed to result from skin failure during the dying process, when the body is shutting down and blood is being directed away from the skin to protect vital organs (Langemo & Brown, 2006). The rapid onset and worsening of a Kennedy ulcer is often a signal that death is near, sometimes within hours to weeks. On [DATE] at 10:53 AM, R29 was observed in bed. R29's left hand was wrapped in gauze. A Nurse's Note dated [DATE] at 7:07 AM revealed On am (morning) assessment some drainage was noted coming from her (R29's) palm, staff saw that her finger nails were all inside her palm and it was cleaned and finger nails trimmed and the palm was covered with wrapped up. Wound was draining with a very foul smell. wound was cleaned and wrapped up. Review of a Hospice Note dated [DATE] stated new wound to palm of L (left) hand noted d/t (due to) hand contractures and finger nails causing skin break . Review of the Physician Orders revealed an order initiated on [DATE] and revised on [DATE] for Hand Carrot to right and left hands as tolerated. This was initiated after the development of the left palm skin wound. Further review of the Physician order's revealed an order initiated on [DATE] which stated left palm skin concern, cleanse with wound cleanser, pat dry, place AquaCell AG patch (AquaCell Ag is an antimicrobial wound dressing designed to manage wounds at risk of infection or showing signs of infection) over and cover with AquaCell foam. Wrap with Kerlix. Review of the Skin and wound tab revealed no documentation or assessment for the wound on the left palm despite the skin concern clearly being described and treated as an open wound. In an interview on [DATE] at 1:20 PM, Clinical Care Coordinator (CCC) S confirmed that R29's hands were contracted, however, had no information about the left palm wound, such as when and how it occurred, or knew any information about when the hand carrot order was implemented, despite having access to R29's medical record. CCC S stated there should have been photos and assessments for the left hand wound but had no information as to why those were not obtained. Review of the Medical Record showed no evidence of R29's Physician being notified of the left palm wound. Review of the Medical Record showed no evidence of a Change in Condition form being completed for the left palm wound. Review of the Incident report dated [DATE] revealed nursing discovered R29's fingernails inside her palm. Under the section of the Incident Report stated, people notified, only a family member for R29 was listed. No Physician was listed. Record Review revealed on [DATE], it was discovered that R29 developed a sacral wound (just above the tailbone) which was initially identified as a Stage 3 Kennedy ulcer. The wound was noted as in-house acquired. At the time, it measured 6.62 cm², with a length of 4.37 cm and a width of 1.96 cm. The wound bed was 80% epithelial and 20% slough (soft, yellow, white, or greenish dead tissue), showing no signs of granulation (new healthy tissue). Review of the sacral wound photograph in the electronic medical record can be described as an open wound with red, moist tissue. The wound bed contains yellowish slough. The wound borders appear to be irregular and macerated (skin has become soft, wet, and broken down from being in contact with too much moisture for too long), suggestive of prolonged moisture exposure. KTU's are not staged, like pressure ulcers. KTU's are identified through their characteristics rather than through a staging system. No scholarly or regulatory source supports staging KTUS. Record review revealed that on [DATE], R29's sacrum wound area had minimally decreased to 6.56 cm², with a length reduction to 4.05 cm but a slight width increase to 2.34 cm. The wound depth was recorded at 0.1 cm. PUSH (PUSH Tool, Pressure Ulcer Scale for Healing, is a standardized instrument developed by the National Pressure Injury Advisory Panel (NPIAP) to monitor the healing progression of pressure injuries over time. It assigns numerical values to three key wound characteristics: surface area (length × width), exudate amount, and tissue type present in the wound bed. The cumulative score ranges from 0 (completely healed) to 17 (severe), with higher scores indicating more severe wounds) score was 11, with 20% epithelial tissue and 80% granulation. Review of R29's sacral wound photograph on the electronic medical record revealed an open area with bright, red moist tissue, rolled wound edges, and widespread redness surrounding the wound. The wound was described as a Stage 3 [NAME] Ulcer. On [DATE], R29's sacral wound area increased to 11.11 cm² with significant length growth to 7.12 cm. Eschar (necrotic tissue) was first documented at 30%, and slough increased to 50%, suggesting tissue deterioration. PUSH score rose to 14. The wound was classified as an Unstageable (full depth of the wound bed can ' t be seen yet. This is usually because the wound is covered with dead tissue such as slough or eschar) [NAME] Ulcer. Record Review revealed on [DATE], the wound area grew slightly to 11.28 cm², though length decreased to 5.62 cm. The wound now contained 60% eschar and 40% slough. The PUSH score remained at 14. The wound was classified as an Unstageable [NAME] Ulcer. On [DATE], the area expanded to 13.63 cm². While the length further decreased to 4.14 cm, the width had grown to 4.85 cm. Slough and eschar remained stable at 40% and 60%. The wound was classified as an Unstageable [NAME] Ulcer. Review of the photograph of the wound in the electronic medical record revealed R29's wound contained eschar and areas of bright red bleeding tissue. On [DATE], the wound continued to expand, reaching 19.75 cm² with eschar increasing to 80%, signaling significant necrosis. The wound continued to be classified as an Unstageable pressure ulcer. The PUSH score was 16. The photograph depicted a bright, red wound bed and surrounding tissue area, which was a continuation of previous photographs reviewed and indicated profusion to the area, which is uncharacteristic of a KTU. On [DATE], R29's wound measured with an area of 33.87 cm², with a length of 5.59 cm and width of 8.77 cm. Granulation was first noted again at 10%, while slough and eschar accounted for 40% and 50% of the wound bed. The PUSH score maintained at 16. On [DATE], the wound assessment showed a decrease in wound area to 28.09 cm² and eschar reduced to 30%, slough remained at 40% with 30% granulation. The PUSH score maintained at 16. Per the wound assessment, the surrounding tissue was red and blanchable. On [DATE], the area increased again to 33.25 cm². Redness, inflammation, and gangrene were noted, indicating localized infection. Granulation remained at 30%, slough at 30%, and eschar increased to 40%. The wound was being described as Unstageable, however, after review of the photograph, the wound bed was visible, suggesting a depth and stage could have been documented. The wound presented as beefy red. On [DATE], R29's sacral wound area had decreased slightly to 30.09 cm². Granulation improved to 50% and eschar dropped to 20%. The wound was being described as Unstageable, however, after review of the photograph, the wound bed was visible, suggesting a depth and stage could have been documented. The wound presented as beefy red. On [DATE], the sacral wound reached its largest size at 49.28 cm², measuring 6.68 cm in length and 10.23 cm in width. Granulation increased to 70%, while slough and eschar were down to 20% and 10%. On [DATE], the wound slightly decreased to 47.94 cm², with depth reaching 3.0 cm. Epithelial tissue was documented at 30%, granulation at 50%, and slough at 20%. The PUSH score was 15. On [DATE], per the measurements documented in the medical record, R29's wound measurements implied wound improvement, with the wound area reducing to 32.86 cm², though the length increased to 7.15 cm. Depth reduced to 1.0 cm, granulation rose to 70%, and slough remained stable at 20%. The wound bed was beefy read and the wound was being classified as a Stage Four [NAME] Ulcer. On [DATE], the wound area was consistent at 32.89 cm². Granulation increased to 90%, and slough remained at 20%, indicating positive healing progress. The wound was described as stable. The PUSH score remained at 15. On [DATE], the area had decreased to 29.79 cm². Granulation was 60%, slough increased to 30%, and eschar reappeared at 10%. Undermining was documented at 3.0 cm from 7 to 3 o'clock. The PUSH score was 16. Review of the photograph in the medical record depicted a Stage 4 pressure ulcer on the sacral region with a beefy, moist wound bed. On [DATE], the area increased to 34.52 cm², and undermining extended to 3.5 cm from 8 to 4 o'clock. Granulation improved to 80% and slough decreased to 20%. On [DATE], the wound area decreased again to 28.53 cm², with a length of 4.05 cm and a width of 8.76 cm. Depth measured at 2.0 cm. Granulation tissue was at 90%, and slough had decreased to 10%. On [DATE] at 4:35 PM, a request was made to observe wound care the following day. On [DATE], Director of Nursing (DON) B reported that R29's wound care was completed overnight and that R29's wound care was scheduled during night shift. Over the 16-week period, the wound showed consistent progression and regression, a pattern uncharacteristic of a Kennedy terminal ulcer. According to the National Pressure Injury Advisory Panel (NPIAP, 2019) and [NAME] et al. (2019), Kennedy terminal ulcers are rapidly progressing wounds that develop within hours to a few weeks before death, exhibit irregular shapes (such as pear, butterfly, or horseshoe-shaped), and typically do not exhibit healing. This resident's wound demonstrates a gradual and prolonged evolution, improvement in tissue composition, and absence of significant end-of-life status, key factors that clearly align with a diagnosis of a pressure injury. Review of the Physician Order's revealed a treatment order for R29's sacral wound active since [DATE] which stated sacral wound: cleanse with wound cleaner, pat dry, crush Flagyl 500 milligram tab then apply to wound bed, moisten gauze with NS (normal saline), squeeze out excess, lightly pack wound to depth, cover with border foam dressing. Despite the non healing status of the wound, the treatment order remained the same since [DATE]. R29's sacral wound persisted for approximately 16 weeks, which is inconsistent with the expected clinical trajectory of a KTU. Separately, on [DATE], second wound developed on R29's right trochanter (right hip) with an initial area of 4.13 cm² (3.77 cm in length and 1.56 cm in width). Review of the photograph in the electronic medical record revealed a dark colored closed area that presented as a suspected deep tissue injury (dark purple or deep red area, or a blood-filled blister, on skin that may feel firm, mushy, or warmer/cooler than the surrounding skin. Even though the top layer of skin may not be open, the tissue underneath is already damaged from pressure). The assessment noted a PUSH score of 11. Review of the Wound assessment dated [DATE] revealed R29's right trochanter wound area expanded dramatically to 14.02 cm², with full epithelial coverage noted and a PUSH score of 10. Clinical records indicate that a circular implanted pain pump was located under the skin in that area. The wound started to notably mirror the round shape of the underlying medical device. On [DATE], the area decreased to 10.61 cm², showing 80% epithelialization, 10% granulation, and 10% eschar. The wound continued to present in a circular shape mirroring the underlying pain pump. On [DATE], the wound expanded again to 18.7 cm², characterized by 90% slough and only 10% granulation. Review of the photograph located in the medical record revealed that the wound had opened, revealing a wound bed of eschar. The skin surrounding the wound appeared red, and the wound edges were well-demarcated (round and easy to see). Review of the wound assessment dated [DATE] revealed that R29's right trochanter wound nearly doubled in size to 35.9 cm², with tissue breakdown now consisting of 80% slough and 20% eschar. The wound had a PUSH score of 15. On [DATE], the wound had regressed to 19.17 cm², but was now 100% slough, suggesting continued necrotic progression. Review of the photograph revealed that the pain pump was now exposed. On [DATE], the wound size increased to 25.81 cm² with 40% slough. Review of the wound photograph revealed the exposed hardware, specifically a intrathecal pump (a pump that is surgically placed under the skin). A pressure ulcer developed over the surface of the implanted intrathecal pump. The wound edges were rolled and undermined, with black eschar along the margin. On [DATE], R29's wound had an area of 47.87 cm². At that time, the wound presented with 40% granulation and 60% slough. Clinical notes confirmed that the intrathecal pain pump eventually became exposed through the wound bed and ultimately dislodged and fell out of the resident's body, indicating advanced soft tissue destruction due to persistent pressure and device-related trauma. R29's right trochanter wound persisted for about 8 weeks, which is inconsistent with the expected clinical trajectory of a KTU. In an interview on [DATE] at 1:51 PM, Registered Nurse (RN) D stated that she was familiar with R29's care, including her pressure ulcers. RN D reported that she cares for R29 about two times a week under R29's hospice care. RN D reported that KTU'S typically present as a dark discoloration and deteriate rapidly. RN D reported that initially, R29's sacral and right trochanter pressure ulcers were classified as KTU's however, in retrospect, using her professional knowledge she would classify them as pressure injuries due to the long-standing nature of the wounds. In an interview on [DATE] at 11:06 AM, Physician H stated that KTU's come on very quickly and indicate that the patient is terminal with the potential to pass within days or weeks. Physician H stated that KTU's are thought to occur due to perfusion issues, skin failure, or the body shutting down. In an interview on [DATE] at 2:13 PM, Physician LL stated that KTU's were classified as [NAME] Ulcers due to the patients decline and weight loss. Physician LL also reported that [NAME] Ulcers are not stageable. Regarding treatment, Physician LL added if the ulcer is not infected we don't treat them. A review of R29's total body skin assessments revealed that every weekly assessment conducted throughout the duration of her admission consistently documented normal findings. Specifically, R29 was noted to have good skin turgor, skin color appropriate for her ethnic background, warm (normal) skin temperature, normal moisture levels, and overall skin condition described as normal. If R29 had experienced hypoperfusion and/or organ failure to a degree that impacted her skin integrity, such changes would have been reflected in the weekly skin assessments. Review of R29's Blood Pressures revealed the following: [DATE] 12:16 PM 114 / 71 mmHg [DATE] 1:19 PM 121 / 75 mmHg [DATE] 7:17 AM 110 / 78 mmHg [DATE] 2:30 PM 100 / 55 mmHg [DATE] 2:27 PM 100 / 55 mmHg Review of these blood pressure readings show evidence that R29's Mean Arterial Pressure (MAP- the average pressure in a person's arteries during one cardiac cycle. It represents the perfusion pressure delivered to the organs and tissues of the body. Unlike simple systolic or diastolic pressure readings, MAP provides a more accurate reflection of the blood flow and pressure that organs actually experience) was above the normal range of 70-100 mmHg which indicated adequate perfusion. In an interview conducted on [DATE] at 12:37 PM, Licensed Practical Nurse (LPN) D stated that physicians are primarily responsible for reviewing, staging, and initiating wound care orders. When asked whether wounds are assessed in person, LPN D explained that this is not always the case. She noted that if she encounters an issue, she may request the physician to assess the wound in person, otherwise, they typically rely on photographs and documentation in the electronic medical record. They do not round every week, she added. When asked about the process for changing wound treatments, LPN D stated that if a wound is not healing, the physician will usually consider modifying the treatment plan after approximately two weeks. Regarding R29's left palm, LPN D stated the skin was never visibly open, therefore, she did not believe it was necessary to monitor or assess the area further. Per the medical record, there was clear indication that the left palm had in fact, opened. Review of the Physician Order's revealed an order for R29's sacral wound active from [DATE] and discontinued on [DATE]. The order stated to cleanse the sacral wound with normal saline, pat dry, place AquaCell AG over the wound and cover with AquaCell dressing. As mentioned, AquaCell AG is a antimicrobial wound dressing designed to manage wounds at risk of infection or showing signs of infection. AquaCell is utilized for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4) and diabetic ulcers; surgical wounds (post-operative, donor sites, dermatological); partial-thickness (second-degree) burns . wounds that are prone to bleeding, such as wounds that have been mechanically or surgically debrided and donor sites . (https://www.woundsource.com/product/aquacel-foam-dressing). Per the manufacturer's website, AquaCell is a ConvaTec brand and stands out for its unique gelling action based on Hydrofiber technology. This property allows the dressing to absorb and lock in exudate and bacteria. It is a versatile primary wound dressing indicated for use on moderate to highly exuding chronic and acute wounds. AquaCell supports wound healing by providing a moist wound healing environment. Further review of the wound care orders for R29's sacral and right trochanter wound revealed AquaCell and AquaCell AG were utilized for R29's wound care treatments. Review of the literature provided by the facility states Setting realistic wound management goals that are situated around comfort and odor control rather than healing ([NAME] et al., 2019). Labeling these wounds as Kennedy terminal ulcers misrepresented the clinical scenario and may falsely imply unavoidability. The wound's trajectory, characteristics, and treatments support the conclusion that R29 experienced chronic, in-house acquired pressure injuries. Additionally, Kennedy terminal ulcers (KTUs) are not staged using the standard pressure injury staging system because they are considered a distinct type of skin failure related to the dying process. Unlike traditional pressure injuries, KTUs appear suddenly, often within hours to a few weeks before death, and they progress rapidly. Their unique presentation and association with end-of-life changes make them inappropriate for classification under the National Pressure Injury Advisory Panel's staging guidelines. Instead, KTUs should be described in narrative form, noting their appearance, location, size, and progression, rather than assigning a numerical stage. Applying a pressure injury stage to a Kennedy ulcer can lead to misclassification and clinical confusion (NPIAP, 2016). (https://pubmed.ncbi.nlm.nih.gov/30801349). Additionally, Accurate assessment is vital to distinguish Kennedy terminal ulcers from pressure injuries to ensure appropriate care planning and to avoid misinterpretation of unavoidable skin changes. ([NAME], S., [NAME], J., Hunt, T., [NAME], K., & [NAME], B. M. (2019). Kennedy terminal ulcers: A Scoping Review. Journal of Hospice and Palliative Nursing, 21(3), 202-208). R29 expired in the facility on [DATE]. Based on observation, interview, and record review the facility failed to correctly identify, treat, resulting in worsening and non-healing of pressure ulcers for three residents (R29, R32, R81) out of five residents reviewed for pressure ulcers Findings Include:Resident #81 (R81)Review of the medical record reflected that R81 was admitted to the facility on [DATE], hospitalized on [DATE] and was readmitted to the facility on [DATE]. Diagnoses of Dementia, Pressure-induced Deep Tissue Damage, Pressure Ulcer of Sacral region, unstageable.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] revealed R81 had a Brief Interview of Mental Status (BIMS) of 00 (unable to answer any questions) out of 15.Under section G0100, Activities of Daily Living (ADL) Assistance reveals R81 is dependent for all care. During an interview on [DATE] at 12:29 PM, R81's family member II stated that R81 developed a pressure ulcer after admission to this facility.Physician Order: Clean pressure ulcer on the coccyx with wound cleanser, pat dry apply Aquacel AG (used for managing moderate to heavily exuding wounds, including pressure ulcers, to be changed every 3-5 days for proper usage,), cover with Aquacel foam (AQUACEL® Ag Foam may be used for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4) to be changed every 3-5 days for proper usage,) and cover with bordered form every shift for Skin integrity, ordered on [DATE], discontinued on [DATE]. Record review revealed a nursing progress note dated [DATE] 1:43 PM, Nurse's Progress Note, Note Text: During routine care resident was noted to have a Pressure Ulcer on the coccyx. The nurse cleaned the area with a wound cleaner, patted dry covered with Aquacel form. Family, on call and provider were notified. A change in condition was initiated.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury- Unstageable- Sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 9.11 cm x 3.24 cm x 5.57 cm with a push score of 14 and 0% change.Record review of an Skin and Wound Evaluation dated [DATE] revealed R81's type of wound was Pressure-Kennedy terminal ulcer, unstageable due to slough and eschar, in house acquired on [DATE]. Wound measurements were 3.2cm x 5.6cm depth unknown with area 9.1cm. Granulation of 50% of wound bed filled and eschar of 50% of wound bed.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury- Unstageable- Sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 9.44 cm (+4%) x 5.94 cm (+83%) x 2.38 cm (-57%) with a push score of 14, with a push score of 14 and -4% change.Physician Order: Clean Pressure Ulcer on the coccyx with wound cleanser, pat dry apply aquacel AG (used for managing moderate to heavily exuding wounds, including pressure ulcers, to be changed every 3-5 days for proper usage, cover with Aquacel foam (AQUACEL® Ag Foam may be used for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4)and cover with bordered foam every evening shift every 3 day(s) for Skin integrity, ordered on [DATE] and discontinued on [DATE].Record review revealed a nursing progress note dated [DATE] 12:45 PM, Nurse's Progress Note, Note Text: Family requesting resident be sent to emergency department for ulcer to sacrum. Education given to family regarding Pressure Ulcer being a [NAME] Ulcer which is terminal and not curable. Resident sent for further evaluation on the ulcer per family request; physician notified. Transfer packet sent with bed hold policy and ombudsman information.Physician Order: Clean Pressure Ulcer on the coccyx with wound cleanser, pat dry apply aquacel AG (used for managing moderate to heavily exuding wounds, including pressure ulcers, to be changed every 3-5 days for proper usage, cover with Aquacel foam (AQUACEL® Ag Foam may be used for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4)and cover with bordered foam every evening shift every 3 day(s) for Skin integrity, ordered on [DATE] and discontinued on [DATE].Physician Order Clean Pressure Ulcer on the coccyx with wound cleanser, pat dry apply Aquacel AG (used for managing moderate to heavily exuding wounds, including pressure ulcers to be changed every 3-5 days for proper usage,), cover with Aquacel foam (AQUACEL® Ag Foam may be used for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4), and cover with bordered form every evening shift every 3 day(s) for Skin integrity AND every 24 hours as needed. Ordered on [DATE] and discontinued on [DATE].Physician Order Clean pressure ulcer on the coccyx with wound cleanser, pat dry apply Medi honey (Medi honey is used for wound care and has several benefits: Pulls moisture from wounds and reduces bacterial growth. Has an anti-inflammatory effect that speeds up healing time and reduces pain. Stimulates blood flow and oxygen release, aiding wound healing. Reduces swelling and has an antibacterial effect.Safe and effective for various types of wounds, including diabetic foot ulcers, pressure ulcers, burns, and surgical wounds. and cover with bordered form every evening shift every 3 day(s) for Skin integrity AND every 24 hours as needed, ordered on [DATE] and discontinued on [DATE].Physician Order: Kennedy terminal ulcer on sacrum: cleanse with wound cleanser, pat dry, apply Medi honey (Medi honey is used for wound care and has several benefits: not a treatment for a [NAME] Ulcer Pulls moisture from wounds and reduces bacterial growth. Has an anti-inflammatory effect that speeds up healing time and reduces pain. Stimulates blood flow and oxygen release, aiding wound healing. Reduces swelling and has an antibacterial effect. Safe and effective for various types of wounds, including diabetic foot ulcers, pressure ulcers, burns, and surgical wounds. cover with bordered form everyday shift for wound care AND as needed Ordered [DATE] 9:45AM, discontinued on [DATE].Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 5.47 cm (-42%) x 2.77 cm (+53%) x 2.92 cm (+23%) with a push score of 12 and 40% change.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 4.41 cm (-19%) x 2 cm (-28%) x 2.83 cm (-2%) with a push score of 12 and 52% change.Physician Order Kennedy terminal ulcer on sacrum: cleanse wound with wound cleanser or NS, pat dry, apply Santyl (Santyl works by breaking down damaged collagen in wounds, helping to clear away dead tissue and allowing new, healthy skin to grow) to wound bed, cover wounds with dry fluffy gauze then bordered foam dressing every day shift for wound care AND as needed. Ordered [DATE] discontinued on [DATE]. Physician Order: Kennedy terminal ulcer on sacrum: cleanse wound with wound cleanser or NS (normal saline), pat dry, apply Santyl (Santyl works by breaking down damaged collagen in wounds, helping to clear away dead tissue and allowing new, healthy skin to grow) to wound bed, cover wounds with dry fluffy gauze, skin prep, then bordered foam dressing every day shift for wound care AND as needed. Ordered [DATE], discontinued on [DATE].Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 6.21 cm (+41%) x 2.44 cm (+22%) x 3.58 cm (+26%) with a push score of 13 and 32% change.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 8.73 cm (+1%) x 2.86 cm (+8%) x 3.96 cm (+1%) deepest point .3 cm and undermining 1cm with a push score of 12 and 4% change.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 8.71 cm x 2.76 cm (-4%) x 4 cm (+1%) deepest point 1cm and undermining 1cm with a push score of 12 and 4% change.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacr

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess, monitor, document, and provide appropriate and timely treatment per professional standards of practice for one (#9) of one Residents reviewed for management of known Congestive Heart Failure (CHF-inability of the heart to pump blood efficiently, causing shortness of breath, fatigue, leg and foot swelling, and weakness), resulting in a 44 pound weight gain, shortness of breath, acute respiratory failure with hypoxia, acute pulmonary edema and acute re-hospitalization for acute exacerbation of CHF. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R9 was a [AGE] year old female admitted to the facility on [DATE] with re-admission post hospital stay 1/24/25 related to exacerbation of Congestive Heart Failure(CHF), with diagnoses that included hypertension (HTN, high blood pressure), chronic CHF, chronic kidney disease, diabetes mellitus and depression. The MDS reflected R9 had a Brief Interview of Mental Status (BIMS assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for toileting, bathing, dressing, hygiene, bed mobility, and transfers. The MDS reflected no behaviors including refusal of care. During an observation and interview on 2/12/25 at 1:10 p.m., R9 door laying in bed with very strong odor of urine in room with ( a brand name external urinary catheter system) in place on floor at the bedside. R9 was observed with noted edema in bilateral hands and legs. R9 reported they were admitted to facility at the end of November 2024 after hospital admission and re-admitted to the hospital in January 2025 related to increased swelling. R9 reported does not refuse care or weights. Review of R9 Electronic Medical Record, dated 11/26/24 through 2/12/25, reflected R9 admission weight on 11/27/24 was 356 pounds(lbs). Continued review of R9's weight summary reflected R9 weight was consistently measured by mechanical lift and reflected the following weights: 12/9/24 = 362.2 lbs.(6.2 lbs gain in 12 days) 12/27/24 = 389.5 lbs.(33.5 lbs gain in 30 days)(no documented weight between 12/9/24 and 12/27/24). 1/3/25 = 386.3 lbs. 1/8/25 = 396.1 lbs.(40.1 lbs gain in 42 days) 1/14/25 = 400.4 lbs(44.4 lbs gain in 48 days) 1/25/25 = 329 lbs(re-admission post hospital stay related to exacerbation of CHF) 1/28/25 = 357.7 lbs 2/2/25 = 364.1(35 lbs gain in 8 days) Review of R9 Hospital Discharge Summary, date printed 11/26/24, reflected, R9 had a hospital admission date 11/16/24 for Hyperkalemia (elevated potassium) and Acute Kidney Injury (AKI). The Discharge Summary reflected, AKI/hyperkalemia, baseline creatinine 1. On presentation 3.43. -Likely etiology prerenal with component of ATN[acute tubular necrosis]. Nephrology was consulted. -Lisinopril 10mg daily discontinued, Lasix 20 mg p.o.[by mouth] daily discontinued Resume Lasix after BMP check in 1 week. -Amlodipine can be added for blood pressure control if needed outpatient .NP[Nurse Practitioner] Follow up in 1 week[contact details included] . Review of R9 Hospital After Visit Summary, dated 1/26/24, reflected the following: If admitted for Heart Condition: I understand .Weighing myself daily and reporting a gain of 2-3 pounds a day/or 5-6 pounds a week to my physician is important . Review of R9 Nurse Progress, dated 11/26/2024 at 9:48 p.m., reflected, Resident arrived at the facility about 1706[5:06 p.m.] on a stretcher and staff assisted the paramedics with transfer to bed. Resident has history of HTN, diabetes type 2, acute kidney failure, CHF, Morbid Obesity, Vitamin D and B12 deficiency. Resident alert and oriented. Review of R9 Social Service Note, dated 11/27/2024 at 3:47 p.m., reflected, Patient is a [AGE] year old female, who admitted to ( facility) with an admitting dx of ACUTE KIDNEY FAILURE, UNSPECIFIED and she plans to return to her group home upon discharge. Patient made eye contact with writer and had answered all questions appropriately. Patient had scored 15/15 on the BIMS assessment, indicating her cognition remains intact. Patient is their own responsible party and is able to make decisions in their own day to day care. Review of R9 Physician Note, dated 12/10/2024 at 4:43 p.m., reflected, She was seen today for a follow up visit on nursing request for a lump in her right breast and edema of hands .No SOB [short of breath], cough, dyspnea, chest pain or other associated symptoms reported. She has been keeping her hands on pillow to raise it, which has been helping the swelling a lot. She still has the catheter to prevent her sacral area and continues to be NWB[non-weight bearing]. EXAMINATION She was comfortable in her bed, resting BP[blood pressure]:: 130/81 12/10/2024 Temp: 97.3 Pulse: 69 bpm[beats per minute] Weight: 362.9 Lbs [6.9 lbs gain since admission] Resp: 18 Breaths/minute BS[blood sugar]: 132 O2[oxygen]: 95 % . Hand edema is dependent. ACE wrap if needed, keep moving hands and keep it elevated. Check albumin with CMP[comprehensive metabolic panel] . Review of R9 Nursing Progress Notes, dated 12/30/2024 at 5:23 a.m., Resident had her call light and responded she complained of SOB asking Staff for an inhaler and she does have any order. She was reassessed after giving her 02 on 2L[liter]. V/S[vital signs] were WNL[within normal limits] BS was 95 she was given milk to help sustain BS before breakfast. Resident stated that she can breath better with the O2. The on call Dr[doctor] was tiger text and phone call was tried with no answer up this morning. But resident is filling better. Review of the Nursing Progress Notes, dated 1/5/2025 at 3:46 p.m., reflected, Resident now noted to have coarse rhonchi throughout lungs and persistent non productive cough. Current VS BP 94/65, T-98.0, Pulse-74, Resp-18 and Oxygen at 95% with 2L of oxygen in place via NC[nasal cannual]. I have administered her PRN albuterol inhaler x 2 so far today with little effect. Denies chest pain or discomfort, respirations are even and unlabored. On call provider notified of clinical condition. Awaiting direction. (No mention of R9's 30 pound weight gain in past 39 days). Review of R9 Nursing Progress Note, dated 1/5/2025 at 7:07 p.m., reflected, New orders from provider for Duo nebs via nebulizer every 6 hours x 5 days. LN[licensed nurse] notified [named family] of clinical condition. Orders entered and oncoming nurse to be notified. (No mention of R9's 30 pound weight gain in past 39 days). Review of R9's Weight Change Note, dated 1/8/2025 at 2:19 p.m., reflected, DATA: WEIGHT WARNING: Value: 396.1 Vital Date: 2025-01-08 10:14:00.0 MDS: +5.0% change over 30 day(s) [ 9.1% , 33.0 ] +3.0% change over 30 day(s) [ 9.1% , 33.2 ] +5.0% change [ 9.1% , 33.2 ] +7.5% change [ 11.3% , 40.1 ] +10.0% change [ 11.3% , 40.1 ] NOTES: Nutrition follow up: Current weight 1/8 396.1#[pounds], 1/3 386.3#, 12/27 389.5# up from 12/9 362.9#. Resident is not receiving any diuretics. She was eating very well then had SOB and was positive for covid with a cough and had a decline in oral intakes and has since recovered some and eating better. She is being treated for unstageable wound to left heel which is improving and typically she accepts liquacel well for additional protein. Will review resident in complex for weight gain. Review of R9 Weight Change Note, dated 1/15/2025 3:00 p.m., reflected, DATA: WEIGHT WARNING: Value: 400.4 Vital Date: 2025-01-14 14:23:00.0 MDS: +5.0% change over 30 day(s) [ 10.2% , 37.0 ] +3.0% change over 30 day(s) [ 10.3% , 37.5 ] +5.0% change [ 10.3% , 37.5 ] +7.5% change [ 12.5% , 44.4 ] +10.0% change [ 12.5% , 44.4 ] NOTES: Nutrition follow up: Current weight is 400.4# 1/14, 391.3# 1/13, 1/8 396.1#, 1/3 389.5#. Weights are up from 362.9# 12/9. Resident has been eating excellent at meals. Wound to her heel is healed. Will recommend to d/c liquacel supplement. MD[medical director] wanted to watch the weights when discussed at complex. (R9 had documented 44.4 pound weight gain(12.5%) in past 48 days since admission with orders for continue to monitor). Review of R9 Nursing Progress Note, dated 1/15/2025 7:27 p.m., reflected, Resident voiced c/o[complaint of] weight gain and feeling SOB O2 at 95% and v/s wnl. Edema is noted. MD made and awaiting response. Note completed by Licensed Practical Nurse (LPN) S. Review of the facility Change of Condition assessment, dated 1/15/25, reflected R9 had increased or worsening edema and shortness of breath. The assessment indicated R9 had CHF and diabetes as pertinent diagnoses and was marked for, Recently progressive or persistent minor SOB without other symptoms, OR with progressive leg edema. and, Persistent unilateral or bilateral edema. The assessment included notes that reflected, Resident voiced c/o weight gain and feeling SOB O2 at 95% and v/s wnl. Edema is noted. Review of R9 Nurse Progress Note, dated 1/16/2025 at 7:07 p.m., reflected, Resident voiced concerns r/t[related to] ring being stuck on left index finger. Resident would like ring removed if possible, discussed possibility of using ring cutter to remove. Will continue to monitor. The record had no mention of communication with physician related to continued edema or follow up from 1/15/25 Change in Condition with no documented response from Provider. Review of R9 Nurse Progress Note, dated 1/17/2025 at 7:02 p.m., reflected, Resident noted to have significant edema and weight gain. Resident's daughter in to visit and discussed with nurse and resident current clinical condition. Provider notified and all above in agreement to send resident to ED [emergency department] for eval/tx[evaluation/treatment] . During an interview on 2/12/25 at about 5:00 p.m., LPN S reported did complete Nurse Progress note on 1/15/15 about R9 edema and weight gain and completed Change in Condition Assessment and sent tiger text to physician with note waiting response at end of shift. LPN S verified did not speak with physician or receive response back prior to end of shift and reported was unsure if physician responded and verified no new orders added 1/15/25. LPN S reported facility new admission weight policy was usually to obtain weight on admission then weekly times four weeks and follow physician orders. LPN S reported would be the same for residents with CHF. LPN S reported had been off for past five days and was currently R9's nurse. LPN S verified R9 had documented refusal of physician ordered weight on 2/11/25 and verified was not aware. LPN S verified R9 primary diagnosis was CHF and verified re-admission to facility 1/24/25 post hospital admission for exacerbation of CHF. LPN S reported R9 had physician orders for weekly weights with last documented weight 2/2/25(10 days prior) of 264 pounds and verified re-admission weight was 329 lbs which indicated significant weight gain. LPN S reported if resident with CHF has over five pound gain physician should notified and documented in medical record. During an interview on 2/12/25 at 5:15 p.m., Clinical Care Coordinator Registered Nurse (CCC) R reported had worked at the facility for about two months with prior work experience on acute care hospital setting. CCC R reported was facility policy to perform admission weight on all residents then weekly to monthly depending on physician orders. CCC R reported would expect nurse to notify physician of weight gain of more than five pound for resident with diagnosis of CHF. CCC R reported nursing best practice would be to monitor resident with diagnosis of CHF weight daily especially with recent re-hospitalization for exacerbation of CHF. CCC R reported was R9's Clinical Care Coordinator and reported was not aware of R9 prior weight gain and not aware of current weight gain. CCC R reported would expect nurse to follow physician orders and verified R9 had physician order for weight on 1/10/25 that was not completed and indicated refused on 1/11/25. CCC R reported would expect nurse to continue to reapproach resident, document in medical record and report to CCC. CCC R verified was not notified of R9 weight refusal. CCC R reported would expect nursing staff to continue to reach out to physician if no response and document in medical record and inform CCC and verified was not aware physician did not respond to R9 change of condition notification. CCC R verified was unable to locate physician response in R9 EMR for 1/15/25 change in condition. CCC R verified R9 admission weight was 356 lbs on 11/27/24 with physician orders for weekly weights. CCC R reported was unsure why R9's weight was not obtained weekly but should have been. CCC R verified R9 weight on 12/27/24 was 389 lbs and verified 33 lbs weight gain in one month should have been reported to physician and documented in EMR. CCC R reported was unable to locate that R9's significant weight gain had been reported to physician. During an interview on 2/12/25 at 5:27 p.m., Director of Nursing (DON) B reported would expect new admission residents to be weighted on admission then evaluated by Registered Dietician who would decide frequency. DON B reported would expect the same with resident with diagnosis of CHF unless physician ordered otherwise including if resident had recent hospital re-admission for exacerbation of CHF. DON B reported would expect nurse to notify physician of resident weight gain of over five pounds and document in medical record. DON B reported would expect nurse to follow physician orders. Review of R9 Weight Change Note, dated 1/27/2025 at 6:58 a.m., reflected, Readmit Nutrition Assessment Diagnosis: CHF, resp failure, morbid obesity, DM, UTI, depression, CKD, HTN, hypothyroidism,GERD Medication trt for dx :novolog,senokot, duloxetine, pantprazole,levothyroxine, Lasix (40mg BID) Ht:67 Current weight: 329 # BMI:51 Usual/Desired Wt: Weight at initial admission was 356# and this increased to 400# 1/14 .Nutrition Diagnosis/Assessment:Resident was sent to the hospital with significant edema. She was noted to have chest pain,hyperkalemia, CHF exacerbation,UTI. Cardiology seen resident and noted borderline cardiomegaly with acute pulmonary edema. She was noted to have CKD stage 3B (follow potassium and fluids). She was not previously on Lasix but was started on IV Lasix and transitioned to oral. This most likely resulted in her weight loss as edema has improved. She was also started on a CPAP and UTI was treated with antibiotics. Nutrition Interventions: 1. Diet as ordered by physician-Regular (follow for need to restrict sodium or fluids) 2. Follow weights- new diuretic in place 3. Follow for TSH improvement 4. Will honor food preference 5. Monitor weight/labs/physical parameters to evaluate that diet and intake meet actual nutrition needs and resident goals . Review of R9 Physician Note, dated 2/3/2025 at 7:05 p.m., reflected, Resident was seen today for a readmission back into the facility. She was sent to the ER [emergency room] for significant edema and weight gain. The resident was complaining of chest pain and SOB. Chest X-ray revealed cardiomegaly and right side pleural effusion. She was diagnosed with HF[heart failure] exacerbation .Resident's weight has increased significantly, Check weight in 1 week[2/10/25] . Review of R9 Hospital Physician Discharge summary, dated [DATE], reflected, admission Diagnosis: Hyperkalemia, Chest Pain, Acute UTI[urinary tract infection], Acute exacerbation of CHF .CHF exacerbation, AKI(acute kidney injury), Supratherapeutic INR .Discharge Diagnoses: Principal Problem: CHF exacerbation, Active Problems: Hypoxia, Current long-term us of anticoagulant medications with history of deep vein thrombosis, HFrEF (heart failure with reduced ejection fracture), Acute pulmonary edema, Acute respiratory failure with hypoxia and hypercapnia, Acute on chronic respiratory failure wit hypoxia and hypercapnia, Mood disorder due to known physiological condition .Hospital Course .Chest pain of 1 week duration, central, gripping, 7/10, worse with leaning forward .CXR[chest X-ray significant for cardiomegaly with central vascular prominence and right-sided pleural effusion. admitted for AHRF[acute hypoxemic respiratory failure] 2/2[secondary to] HFrEF exacerbation .Rapid response called on 1/18 for hypoxia and chest pain .ABG[arterial blood gas] suggestive of respiratory acidosis. Bedside echo suggesting IVC[inferior vena cava] dilation >2; noted small pericardial effusion. Patient was started on bipap[bilevel positive airway pressure] with Lasix IV 40 mg with improvement .Due to respiratory acidosis, and acute hypoxic hypercapnic respiratory failure, patient was started on nightly CPAP[continuous positive airway pressure]. Previously on CPAP, but pt was not using at facility. Case manager spoke with facility and facility stated they will re-order CPAP. Recommend to continue nightly CPAP. Cardiology recommended lasix IV[intravenous] 40 mg BID[twice] daily until patient reached dry weight. On day of discharge transitioned to PO[by mouth] lasix 40 mg BID. Continue on hydralazine 10 mg three times daily and Toprol XL 50 mg . Review of R9 Hospital After Visit Summary, dated 1/24/25, If admitted for Heart Condition: I understand .Weighing myself daily and reporting a gain of 2-3 pounds a day/or 5-6 pounds a week to my physician is important . Review of R9 Care Plan, dated 11/27/24, reflected, CHF: Assess/Document/Report to MD PRN for any s/sx dependent edema of legs/feet, perioribtal edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, wt. gain unrelated to intake, wheezes upon auscultation, increased heart rate, leathargy, disorientation. During a telephone interview on 2/13/25 at 9:59 a.m., R9's family member T reported R9 was her own responsible party and R9 family member T was listed as emergency contact and Care Conference person. R9's family T reported had alerted nurse staff two weeks prior to Christmas of concern with R9's increased edema with no response and was present on 1/17/25 when R9 was transferred from the facility to the hospital. R9's family T reported other family member U had reported concerns of R9 increased edema to nurse staff on 1/15/25 with no follow up response. R9's family T reported on 1/17/25 had insisted R9 be sent to the hospital. R9's family T reported staff tried to tell her that 40 lbs weight gain was related to poor food intake. R9's family reported R9 had prior history of CHF with history of exacerbation requiring hospitalization prior to admission to facility with recent hospital stay between 11/16/24 and 11/26/24 diuretics placed on hold related to kidney function. During an interview on 2/13/25 at 11:18 a.m., DON B reported reviewed R9 medical record and reported completed time line. DON B reported located email communication between Registered Dietician and physician about R9 dated 1/15/25 through 1/17/25 related to possible weight gain related to poor food choices.(40 lbs in 48 days since admission). DON B was asked if information was documented in R9 medical record and DON B responded, no, staff could do better about documentation. DON B reported was unsure if weight alerts existed and reported was unsure why staff did not receive weight alert for R9 33 pound gain from admission to 12/27/24. DON B reported staff document by exception only and reported would expect staff to complete assessment for weight gain but only document if abnormal. DON B reported if residents refuse care would expect staff to document if resident was educated on possible outcomes of choices. DON B reported if resident requests to go to hospital facility would send them. DON B reported would provided timeline of information. No timeline was received prior to to survey exit. During a telephone interview on 2/13/25 at 12:13 p.m, R9 family U reported was present at facility visiting R9 on 1/15/25 and reported to LPN S concern with R9 increased edemas, and shortness of breath. R9's family U reported LPN S had reported R9 had 40-50 pound weight gain since admission and reported was not aware of any follow up. R9's family U reported returned to visit next day on 1/16/25 and again reported concern to nursing staff related to R9's increased edema and shortness of breath and R9's reported concern of needing wedding band cut off because hands were so swollen. R9's family U reported R9 had not removed wedding band in over 20 years and was upset as husband had recently past away. R9 family U reported other family T arrived the next day on 1/17/25 and insisted R9 be sent to the hospital and reported was told by hospital medical staff that R9 would not have made it if they had waited much longer to be treated. During an interview on 2/13/25 at 2:12 p.m., LPN L reported CCC has schedule of monthly resident weights for first week of month and reported otherwise order was located on Medication Administration Record. During a telephone interview on 2/13/25 at 3:51 p.m., Registered Dietician (RD) D reported she monitored R9 weekly weights and alerts go to her and she documented in progress notes. RD D reported had communicated with physician 1/15/25 about 44 lbs gain since admission who wanted to continue to monitor R9 weight. When asked if she had received weight alert on 12/27/24 for R9's 33.5 lbs gain in 30 days RD D reported she must have and reported she must have cleared the alert and was unable to answer why and verified was not able to located in R9's EMR and should have been reported to physician and documented. RD D reported R9's weight on 1/25/25 at re-admission was not an accurate weight after comparing to hospital discharge weight and re-weight was completed on 1/28/25 as 357.7. Review of the facility, CHANGE OF CONDITION - RESIDENT PHYSICIAN/NP NOTIFICATION policy, dated 10/29/14, reflected, POLICY: The attending physician /physician extender or on-call physician/physician extender will be notified with changes in a resident ' s condition or health status .PROCEDURE: 1. Seven (7) days a week, attending physicians or physician/NP on call is to be notified of all condition or health status changes .Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received . A policy/procedure was requested, but not received by the conclusion of the survey, pertaining to monitoring of Residents with CHF.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers to intake MI00145124. Based on observation, interview and record review, the facility failed to competently assess and monitor for changes in condition and notify the physician of pertinent findings in a timely manner for 2 residents (Resident #103 and Resident #104) resulting in the potential for and actual harm from unrecognized, clinically significant changes in condition and uncontrolled pain. Findings: Resident #103(R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included aftercare arthroplasty right hip removal prosthesis and insertion of antibiotic spacer post hip infection, muscle weakness, need for assistance with person care, cardiomyopathy, hypertension (high blood pressure), anemia, atrial fibrillation, and congestive heart disease. The MDS reflected R103 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required partial to moderate assist with transfers. During a telephone interview on 6/26/24 at 3:19 p.m. complainant C reported Certified Nurse Aid(CNA) D was very rough with R103 during a transfer on 5/9/24 around 7:30 p.m. and threw legs into bed followed by extreme pain. Complainant C reported R103 was post right hip reconstruction surgery on 4/25/24 and surgical follow up appointment on 5/8/24. Complainant C reported R103 was sent to the emergency room after X-ray showed right hip dislocation on 5/10/24 and returned to the facility on 5/11/24 around 2:00a.m. Complainant C reported facility ran out of pain medications and R103 went over 24 hours without. Complainant C reported R103 was seen by surgeon on 5/16/24 and sent to the hospital for emergency surgery related to damaged right hip and hardware was removed and unable to replace hardware for six months. Review of the Orthopedic Physician Consult, dated 5/8/24, reflected R103 was seen in the office for a two week post-operative right total hip arthroplasty revision removal prosthesis and insertion antibiotic spacer. The consult note reflected R103 had a current pain scale of 4/10 and indicated since the last office visit the pain had become better for the patient and decrease since surgery on 4/25/24. The note reflected the surgical incision demonstrated acceptable healing and no drainage. Continued review of Consult reflected X-ray of hip with Remedy long femoral stem hemiarthroplasty with was well aligned. Review of the Orthopedic Center X-Ray Report, dated 5/8/24, reflected R103 had X-Ray 73502-hip, unilat, 2-3 views Right completed. The report reflected, Hip/Pelvis X-ray: Remedy long femoral stem hemiarthroplasty. Well aligned. Review of R103's Physician Note, dated 5/10/24 at 2:44 p.m., reflected, Note Text: In today for an urgent visit on his request for pain in his right hip after he was transferred into the bed, and he fears that he might have dislocated his hip. He is a [AGE] year-old man with history of osteoarthritis, atrial fibrillation, and GERD. He is admitted for skilled care after he developed infection in his right hip prosthesis. The right hip was replaced initially in 2018. It was later replaced due to chromium toxicity two years ago. He had a fall recently and that required revision of the hip, but later developed prosthesis infection and was admitted for skilled care. He is currently receiving IV abx. He had a wound clinic follow up appointment and his wound back[vac] has been removed. He reports that last night, while being transferred into the bed nursing aid lift his leg to transfer him in the bed. He feels that right after the transfer, he developed significant pain in his right leg and his right leg appears externally rotated. His wife is also present and concerned if it has dislocated. Is it recent lab labs reviewed and currently his Vancomycin is being held based on his trough levels. He reports pain seven out of 10 currently, worse with slight movement. He requesting if a stronger pain medication can be given to him until the x-ray is done. Nursing staff, but also interviewed to complete this assessment .PLAN - [AGE] year old man with infection of prosthetic right hip, IV antibiotics status I& D developed worsening pain with extra rotated right tip after transferring into the bed - X ray right to rule out dislocation - is assessed. Increase PRN and Norco to every four hours - awaiting x-ray of hip, if this[dis] location is confirmed will transfer to emergency room for orthopedic intervention, if recommended - family, including wife and granddaughter was explained the care plan in detail and they agreed - nurse will call as soon as the stat x-ray report are available. Care plan is discussed with the nurse and nursing Director. Review of of R103 Nurse Progress Notes, dated 5/10/2024 at 4:47 p.m., reflected, Received STAT x-ray results and reviewed with [named physician]. Noted dislocation of spacer/femur. Physician gave order to send resident to ED with hope he can be seen by ortho to have the hip reset. Daughter and wife updated on resident's status and notified of order to transfer resident. Will send to [named hospital], which is where resident was originally treated . Review of the Physician orders, dated 5/9/24 through 5/10/24 reflected no evidence of order for STAT X-ray for R103 on 5/10/24. Review of R103 Radiology Results Report, dated 5/10/24 at 3:06 p.m., reflected, Conclusion: 1. Post right hip with superior dislocation of the prosthetic femur. Suspected additional underlying malrotation. Correlate with prior imaging. 2. Questionable minute fracture deformities at the acetebular fossa versus expected postsurgical change . Review of the Hospital Records, date 5/10/24 through 5/11/24, reflected R103 was seen in the Emergency Department on 5/10 at 6:21 p.m. The record reflected, Chief Complaint: Pt comes from [named facility] after right hip sx[surgery] in April, last night staff threw his legs into bed and pt had significant pain, x-ray was obtained today showing R femur dislocation . Continued review of the ED Note Physician/Provider, dated 5/10/24 at 7:19 p.m., reflected, History of Present Illness: [named R103] a [AGE] year-old man with past history of right hip replacement complicated by infection presented to ED today wit complaint of right hip pain. The patient's wife and daughter were at bedside and provided additional history. The patient and his family state that nurses in the facility center were trying to put him in bed when they pulled his right leg out and the hip got dislocated .The patient and his wife did note that they are concerned that there was a caregiver abuse at the patients SAR that resulted in dislocation of the hip. They already spoke with the manager of the SAR and the nurse responsible has been placed on leave. They also made a police report. Review of R103 Nurse Progress Note, dated 5/11/2024 5:22 p.m., reflected, Resident has been pleasant and cooperative with cares. A/Ox4. VSS. Skin W/D. Takes medications as ordered. Has taken one PRN pain medication for pain in right hip. Has been resting in bed most of shift with call light in reach and safety maintained. Skin well approximated at S/P surgical site. No noted S/SX of infection present. Attends therapy per recommendations. Able to verbalize wants and needs. Needs met at this time. Review of R103 Nurse Progress Notes, dated 5/14/2024 at 7:55 a.m., reflected, spoke with resident's daughter who shared concerns about resident's pain management and hydration .Resident's daughter also expressed that she feels like his current rx for Oxycodone 5mg q4h prn is not enough to management resident's current pain level and requested that nurse asked the Dr for fentanyl patches for resident. Nurse spoke with resident and encouraged fluids through PM/midnight shift and offered OTC pain management which resident accepted. Dr notified . Review of the Physician Progress Note, dated 5/14/2024 at 11:10 a.m., reflected, Resident is a [AGE] year old male who was seen today for a follow-up of pain and need for fluids. He was admitted into the facility for rehab following a revision of his hip post fall. He was also treated for an infection of his prosthesis in the hospital. The attending visited with the resident on the 10th of May for pain and pain medications were increased. The notes reviewed and the daughter is concerned that the resident is not receiving adequate hydration and is requesting IV fluids. She also feels that the pain regimen is not covering his pain and she is requesting fentanyl patches. Spoke with the nurse and she reported that the resident does drink independently and does not feel he needs more fluids, but labs were ordered. Visited with the resident at bedside with the family present. The resident reported that he does have a lot of pain, but feels the oxycodone does provide him with relief. I spoke with him about the plan for the oxycodone and we also talked about adding a lidocaine patch in addition and both he and his family agreed. I spoke with the resident about his fluid intake. He said that he doesn ' t drink very much because he doesn ' t like the water, but has been drinking Gatorade. I let him know because of his history, we will check his labs first and go from there. I also let him know that I had the nurse to consult dietary for additional fluids with his IV ABX and to continue to drink what he likes. The resident does see ortho tomorrow. He has not been working with PT because he had to go back to the hospital because his hip popped out and he has been in a lot of pain .Plan: 1. Right hip pain 2. Dehydration Receiving oxycodone 5mg QID and PRN q 6 hours. Had the nurse split up order and new C2 completed Has ibuprofen as needed for breakthrough pain, will continued Added lidocaine patch to right hip q 24 hours BMP ordered to check hydration status. Consult dietary for possibly fluids with ABX, continue to encourage fluids Plans discussed with the nurse . Review of the Medication Administration Note, dated 5/15/2024 at 12:36 p.m., reflected R103 was sent to hospital from doctors appointment. Review of the Hospital Discharge summary, dated [DATE], reflected R103 was admitted [DATE] and taken to the Operating Room for an open irrigation and debridement of his right hip and removal of antibiotic spacer. Patient has no hip prosthesis in. The Summary included, Discharge Diagnosis and Plan: 1. Infection of right prosthetic hip joint .Pt is to remain nonweightbearing on his rt lower extremity as he has no hip joint currently. PT Must work with patient today to at least stand and transfer and get him off his pack so as not to develop bed sores .Will leave incisional drain on for another 10 days and DC sutures in 3 weeks post op .cefepine 2g and vacomycin .for total of 4 weeks .end date at 6/17/24 .Dislocated hip .heart failure .cardiomyopathy .atrial fibrilation .anemia . Review of the Nursing Schedules, dated 6/27/24, reflected CNA D was working South Hall(rehab unit) at 3:00 p.m. During an interview on 6/27/24 at 9:59 a.m. CNA E reported had worked at the facility for about 10 years and often on the rehab unit. CNA E reported facility did not provide any training related to post operative hip precautions including transfers with exception to follow kardex. CNA E reported worked with R103 on 5/10/24 on day shift. CNA E reported R103 had reported he could not get out of bed that morning for group therapy related to elevated pain and stated, was not like him. CNA E reported he always participated in therapy and had not seen him in that much pain in past. CNA E reported R103 told her about incident night prior(5/9/24) with staff assisted transfer being rough with extreme pain and reported wife and daughter were very upset. CNA E reported had informed nurse because allegation of rough care. CNA E reported prior to 5/10/24 R103 was doing well with controlled pain and staff knew to be careful related to new hip surgery. Nursing Home Administrator(NHA) A provided three abuse allegations investigations on 5/27/24 at 10:18 a.m. including one for R103, dated 5/10/24 at 4:45 p.m. Review of the Facility Reported Incident(FRI), dated 5/10/24 at 4:45 p.m., reflected NHA A submitted FRI for R103 on 5/10/24 at 5:51 p.m.(for incident that occurred 5/9/24 at 7:00 p.m.) The Incident Report included, Incident Summary: Residents family alleges nurse aid was rough when transferring residents' legs into bed. Nurse Aide has been suspended pending investigation . The FRI reflected there was no witnesses.(investigation reflected R103 wife was present at time of incident on 5/9/24). The FRI included investigation notes that reflected, 5/10/24(no time): [named R103 wife] interview with [named Director of Nursing(DON) B]. I [name DON B] was called to room regarding concern with CNA from the night before. The wife and daughter were in the residents room. I introduced myself and asked the resident and family what had occurred the previous night. The residents wife and daughter reported they had concern with an employee named [named CNA D] .who seemed to have an attitude the previous night when she came in to answer the call light. Family stated, [named CNA D]came in and asked what was needed. [Named R103] said he needed to get up and get into bed. The wife stated she told [named CNA D] that R103 wanted to do as much as he could without assistance, and the aide would need to take her time because of the situation with his hip. The wife stated [named R103]was able to stand up slowly, turn around, and sit slowly on the edge of the bed. At that point the aide asked if he needed help getting his legs into bed, and he said yes. The aide grabbed the residents ankles, counted to 3 and swung his legs up into bed quickly. The wife reported her husband then yelled out in pain. The wife the stated she couldn't believe what just happened, because she had told the CNA to go slowly. Continued review of the FRI investigation notes reflected, 5/10/24(no time): [named R103] and [named R103 wife] interview with [named NHA A]. DON requested that I speak with the family. I went down to the room to speak with the wife and daughter. They stated the previous night they were upset with how a CENA transferred [named R103] into bed. [named wife] lead off with the aide already had a bad attitude .[named R103 wife] explained how the transfer happened, included that the aide counted to three and then quickly lifted his legs onto the bed. [named R103 wife] states that she thought that it could almost be intentional during initial interview but seemed unsure. Continued review of the FRI investigation notes reflected, 5/10/24(no time): [named R103] and [named R103 wife]Second interview with [named DON B]. This writer notified wife and daughter that resident hip was dislocated per the x-ray, the physician was notified, and was ordering [named R103] to be transferred to the hospital . Continued Review of the FRI investigation notes reflected, 5/10/24(no time): [Named CNA D] .I entered the room as the call light was on and I went to check on the resident. The resident requested to be put in bed, after I transferred him to the bed, he requested that I put his legs up. I counted to three and then picked his legs up to transfer them onto the bed. After the transfer, the resident made a grunting noise and stated that his leg hurt, I then notified the nurse that he was in pain .5/14/24: [named CNA F] Sometimes I think that she needs to slow down to show the residents more empathy .The family member reported the situation to me, I then notified the nurse .5/17/24: [named Registered Nurse(RN) H] I do feel that she should slow down at times when providing care . During an interview on 6/27/24 at 12:25 p.m., Physical Therapy staff(PT) I reported had worked at the facility for about five months and was not involved in training staff including hip precautions. PT I reported post hip precautions included no hip flexion over 90 degrees, no abduction and need for careful staff assist with transfers if residents request with support of both ankles at same time to keep body alignment. PT I reported had worked with R103 prior to 5/9/24 incident and reported had been progressing well with therapy including short ambulation with use of walker. PT I reported after 5/9/24 R103 was unable to get out of bed related to uncontrolled pain so only able to perform limited range of motion exercises until discharged [DATE]. PT I reported completed one on one education with CNA D post incident with R103 that included safe transfer with hip precautions on 5/21/24. Review of the Physical Therapy Treatment Encounter, dated 5/6/24 through 5/14/24, reflected R103 was progressing toward goals and compliant with treatment 5/6/24 through 5/9/24 with noted ambulation with 2 wheel walker 5 feet on 5/9/24 at 12:48 p.m Review of therapy on 5/13 and 5/14 reflected pain with leg immobilize in place with sessions in bed. During an interview on 6/27/24 at 12:48 p.m., Licensed Practical Nurse(LPN) G reported nurse expected to report assess resident if staff report change of condition to nurse and report to physician in document on change of conditions documents or progress notes. LPN G reported if CNA staff report resident with increased pain, nurse expected to assess resident first then determine what options available for pain control and if no medication or treatments available or pain not controlled to contact physician and document. LPN G reported expect that pain medications should be available within no more than 4 hours from pharmacy if narcotics orders. LPN G reported worked day shift on 5/9/24 and was giving report to RN H about 7:00 p.m. when CNA staff reported R103 had requested pain medications. LPN G reported during day shift R103 pain was controlled and was able to go outside with family and participate in therapy. LPN G reported worked next on 5/11/24 and 5/12/24 and R103 did not get out of bed related to increased pain. LPN G reported investigation was completed. LPN G reported if residents have increased uncontrolled pain nurse should assess and notify physician and document. During an interview on 6/27/24 at 1:30 p.m., CNA J reported had worked at the facility over three years. CNA J reported if change in resident baseline with either oral intake of resident reports of pain expected to report to nurse and reported not able to document that information as CNA. CNA J reported knows how to care for residents by following the Kardex. Review of the Physician orders, dated 5/9/24 through 5/10/24, reflected R103 had orders that included Oxycodone 5mg every 6 hours as needed for pain and Tylenol 1000mg every 6 hours as needed for pain. Review of the Electronic Medical Record(EMR), dated 5/9/24 through 5/10/24, reflected R103 requested as needed Oxycodone 5mg on 5/19/24 at 4:06 pm for pain 5/10 on pain scale and with effective pain control at 6:55 p.m. of 2/10 on pain scale. R103 was given as needed dose of Tylenol for patient complaint of 8/10 on pain scale at 7:38 p.m. R103 was given as needed dose of Oxycodone 5mg for R103 complaint of severe pain. R103 was given additional dose of Tylenol 1000mg on 5/10/24 at 1:17 a.m. related to prior Tylenol and Oxycodone dose ineffective with pain 7/10 on pain scale. R103 was administered as needed dose of Oxycodone 5mg 5/10/24 at 4:10 a.m. related to R103 report of pain 7/10 on pain scale. R103 requested additional as needed dose of Oxycodone 5mg on 5/10/24 at 10:32 for pain of 6/10 on pain scale and requested increased pain medication when seen by physician.(order changed from Oxycodone 5mg every 6 hours to every 4 hours on 5/10/24 at 11:45 a.m.). Continued review of the EMR reflected no mention of nursing assessment of R103 post reported incident at 7:00 p.m.(including right hip physical assessment/positioning) or no evidence of physician notification of change in pain level.(prior to reported incident R103 pain level documented between 0 to 6 on pain assessment). During an telephone interview on 6/27/24 at 4:09 p.m., LPN K reported R103 was a pleasant man with a pleasant family. LPN K reported worked on 5/10/24 with R103 after family reported concerns about R103 right hip pain. LPN K stated, Resident was in excruciating pain. LPN K reported R103 was assessed by physician on 5/10/24 who suspected R103's right hip was dislocated. LPN K reported R103's wife did not want to wait for X-ray to arrive and DON B was notified and shortly after mobile X-ray arrived. LPN K reported even with changes in R103 pain medications pain was no controlled and X-ray came back positive for dislocation and R103 was transferred to the hospital. During an interview on 6/27/24 at 4:51 p.m., CNA L reported had worked at the facility for about one year and worked with R103 on the evening on 5/9/24 from 11:00 p.m. through 6:30 a.m. CNA L reported R103 told her was transferred into bed with staff assist and transfer did not go right. CNA L reported later that night attempted to change R103 and he refused care because hip was, in bad condition and hurting really bad. CNA L reported R103 reported did not want to end up in hospital with worse injury. CNA L reported to to Registered Nurse(RN) H. During an interview on 6/27/24 at 5:10 p.m. LPN M reported was not present for at time of R103 incident on 5/9/24. LPN M reported R103 was alert and oriented and able to make needs known. LPN M reported worked 5/14/24 when R103 daughter reported concerns that R103 pain medications were not controlling pain and reported had notified physician. LPN M reported R103 did not return after orthopedic appointment the next day. LPN M reported if CNA staff reported to her that resident with recent post hip replacement complained of increased pain with transfer would assess resident, notify NHA and Physician because possible allegation of abuse. During an interview on 6/27/24 at 5:20 a.m., CNA D reported worked with R103 on second shift on 5/9/24. CNA D reported R103 used call light and report she answered call light on 5/9/24 around 7:00 p.m. CNA D reported R103 was sitting in a wheelchair with left side against the bed and stood up with use of walker and pivoted to turn and sit on edge of bed without assist. CNA D reported R103 requested assistance to get legs into bed. CNA D reported she lifted R103 ankles after counting to 3 to the bed and R103 made a noise that made her think he was in pain.(CNA D acted out wheelchair position and had reported did not move wheelchair to place legs in bed, however wheelchair would have been in the way to pivot legs in bed with smooth motion. CNA D changed story and reported maybe she did move wheelchair prior to assisting R103 position legs in the bed.) CNA D reported R103 requested pain medication, CNA D reported to LPN G and RN H during shift report at around 7:00pm that after transferring R103 to bed R103 complained on increased right hip pain(surgical hip) and requested pain medications. CNA D reported R103 pressed his call light three additional times in next 45 minutes to ask for pain medications related to elevated pain. CNA D reported to RN H again that R103 requested pain medication. CNA D reported after R103 got pain medications did not hear from him again during the shift that ended at 11:00 p.m. CNA D reported R103 was a one person assist with transfers and had not received specific teaching related to post hip precautions but now after incident they have a binder at the nurse station with post hip precautions. CNA D reported hip precautions were not on R103 kardex at the time but now have been added after incident. CNA D reported worked 5/10/24 first shift 7:00 a.m. to 3:00 p.m. and was questioned at the end of the shift about R103 transfer on 5/9/24 evening. CNA D reported was later called by Human Resources and informed she would be on suspension pending investigation and was off for about two weeks. CNA D reported received education from PT I prior to return to work. During an observation on 6/28/24 at 9:45 a.m. observed transfer precautions binder located at the south nurse station included post hip precautions. During a telephone interview on 6/28/24 at 11:01 a.m., CNA F reported had worked second shift on 5/9/24 at the time of the incident around 7:00 p.m. with R103. CNA F reported R103 was very upset and dis-[NAME], R103 wife was upset because R103 had requested assistance from another CNA to transfer into bed. CNA F reported wife was angry because she asked CNA D to be genital because of recent hip surgery and CNA D quickly transferred legs on bed and caused R103 immediate pain in right hip. CNA F reported consoled R103 and wife and reported to RN H that R103 complained of immediate right hip pain after CNA D transferred him. CNA F reported R103 was a pleasant man who was alert and oriented and was clearly in severe pain after incident related to reported pain, significant facial grimacing, and stated, looked like he was in pain because he was board stiff. CNA F reported worked with R103 in the past and pain was controlled and would go outside in wheelchair with family or to Dining Room but not after incident, he remained in bed. During a telephone interview on 6/28/24 at 11:30 a.m., RN H reported had worked with R103 on 5/9/24. RN H reported was told by CNA D had pain after transfer from wheelchair to bed. RN H reported R103 had recently received as needed Oxycodone for pain so was not due at that time so gave as needed dose of Tylenol. RH H spoke with R103 who reported pain was, pretty high and reported CNA D staff was rough and moved little too fast when assisting with transfer. RN I reported he then spoke with CNA D about R103 complaint. RN I verified did not document in the medical record about the reports from staff of R103 increased pain during transfer. RN I later learned from someone else that R103 right hip was dislocated and had to be transferred to the hospital. RN I reported did not contact physician or assess R103 right hip including palpation or observe for external rotation. RN I continued to administer as needed pain medication through out night shift. RN I reported did not report incident as allegation of abuse because did not think CNA D intended to hurt R103. During an interview on 6/2824 at 12:08 p.m., Physician Medical Director(MD) N reported had been the Medical Director at the facility for several years. MD N reported did not receive call from the facility on 5/9/24 related to R103 pain post staff assisted transfer around 7:00 p.m. MD N reported staff requested R103 to be seen on 5/10/24 and reported was unsure when. MD N reported ordered x-ray to rule out dislocation. MD N reported x-ray came back positive for dislocation and order to send R103 to the hospital. MD N reported did not feel staff deliberately caused injury. MD N reported would expect nurse to give ordered medication. MD N was queried if he would expect nurse to call if aware of knowledge that R103 reported rough transfer followed by increased pain. MD N reported was not able to answer that question. MD N reported assessed R103 on 5/10/24 and wife and daughter were upset after increased pain related to transfer night prior. During a telephone interview on 6/28/24 at 1:07 p.m., R103 wife O reported was present on 5/9/24 and observed CNA D assist R103 transfer to bed around 7:00 p.m. that caused R103 immediate pain. R103 wife O reported she had been outside with R103 for about one hours prior to both returning to R103 room and used the call light to assist R103 into bed. R103 wife O reported CNA D entered the room alone. R103 wife O reported told CNA D R103 needed two people to transfer and CNA D responded, they were busy, and R103 reported he would try. R103 wife O reported took several minutes but R103 stood from wheelchair and sat on bed slowly. R103 wife reported told CNA D needed to be very careful and CNA D asked if R103 needed help with legs and R103 reported yes. CNA D grabbed both legs near heels and threw R103's legs on the bed and R103 screamed in pain. R103 wife O told CNA D she could not believe she just did that and told R103 wife O she would tell the nurse what had happened. R103 wife O reported did not see CNA D prior to leaving for the evening. R103 wife O reported also went to nurse desk and reported to nurse what had happened to R103 and need for pain medications prior to leaving on 5/9/24. During a telephone interview on 6/28/24 at 1:28 p.m., R103 reported recalled very clearly what happened on 5/9/24. R103 reported had reconstructive surgery on right hip after complications including infection on 4/24/25. R103 reported admitted to facility on 5/3/24 and had been working with therapy and progressing well with good pain control around 4/10 on pain scale. R103 reported on 5/9/24 CNA D assisted him into bed. R103 reported was sitting on side of bed and stated, she tossed my legs onto bed. R103 reported it cause him so much pain at 10/10 he could not even say what happened next. R103 stated, I was trying to keep it together. R103 reported RN H asked about pain several times during the night and reported told RN H CNA D threw R103 legs in bed. R103 reported CNA D came in room after R103 told RN H what had happened and CNA D apologized and asked, how should I have done that? R103 reported did not assess R103 right after the incident or move the covers to observe right leg. R103 reported told everyone he could what happened because he was in so much pain and worst pain he had ever been in and reported everyone knew what had happened. R103 reported no relieve from pain medications and remained 10/10 on pain scale through the night and next day. R103 reported daughter called the physician who came right in and ordered an X-ray that took about four hours to arrive and was later sent to the hospital. During a telephone interview on 6/28/24 at 1:48 p.m., R103 daughter C reported she called Physician Medical Director N on 5/10/24 at about 10:30 a.m. and informed him of transfer on 5/9/24 evening that caused uncontrolled pain to R103 post operative right hip. R103 daughter C reported MD N came to assess R103 right away and was mad and suspected hip was dislocated. R103 daughter C reported at least four hours before mobile X-ray arrived[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 (R15) Review of the admission Record reflected R15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis which included mood disorder, anxiety disorder, diverticulosis (a condition where small pouches form in the walls of the large intestine), chronic respiratory failure, and pain in left shoulder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/17/24, reflected R15's Brief Interview for Mental Status (BIMS) was scored 15 out of 15, indicating cognitively intact. Review of the same MDS reflected R15 was experiencing pain almost constantly. Review of the Physician Order's revealed R15 was prescribed Oxycodone HCl 5 milligrams (mg) (a opioid containing medication) as needed for pain. The order was activated on 4/18/24. Review of the May Medication Administration record revealed R15 was administered the Oxycodone 5mg two to four times daily. Review of the June Medication Administration record revealed R15 was administered the Oxycodone 5mg two to three times daily. According to the National Center for Biotechnology Information website, opioid drugs affect receptors in the gastrointestinal (GI) tract. These receptors control the contraction of the muscles in the GI tract which leads to a decrease in gastrointestinal motility. Review of a Nurses Note dated 5/25/2024 at 12:32 PM revealed Resident [R15] complaining of constipation. Refused MOM (milk of magnesia). Agreed to take Bisacodyl 5mg (laxative tablet) one tablet today and one tonight. Review of an Alert Note dated 5/26/24 at 12:20 PM revealed R15 had a bowel movement. Review of the Physician's Orders revealed a new order for Senna Plus Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth in the morning for constipation. Review of the Bowel Task revealed R15 did not have bowel movement 5/30/24 through 6/4/24 and 6/6/24 through 6/11/24. Review of the May and June Medication Administration Records revealed that no as needed constipation relief medications were offered, refused or administered to R15. Review of the Progress Notes revealed no indication that R15 was offered and refused the as needed constipation relief medications. In an interview on 06/13/24 05:14 PM, Director of Nursing (DON) B stated that the Bowel Protocol should be initiated after a resident does not have a bowel movement after nine shifts. The nurse would initiate the as needed standing orders and administer according to Physician instructions. If the medications do not provide relief, the physician should be notified. DON B reviewed the medical record and confirmed the absence of bowel movements for R15 and the absence of the constipation relief medication being ordered or offered. Based on observation, interview, and record review, the facility failed to provide timely, appropriate care and services to meet the needs of three of 27 residents reviewed for quality of care (Resident #11, Resident #15 and Resident #121), from a total of 27 sampled residents, resulting in these residents potentially not receiving adequate and/or appropriate care required for them to maintain or achieve their highest practicable physical well-being. Findings Include: Resident #11 (R11) Review of the medical record reflected R11 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Acute and Chronic Respiratory Failure with Hypoxia, Muscle Weakness, Chronic Obstructive Pulmonary Disease, Acute on Chronic Systolic (congestive) Heart Failure, Hemiplegia and Hemiparesis following Cerebral Infarction (stroke) affecting the right side and Peripherial Vascular Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2024, revealed R11 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R11 requires assistance with care provided for his lower extremities. During an interview and observation on 06/12/24 at 08:12 AM, R11, stated he wanted to go to the hospital because he was short of breath, he also stated the nurse working that shift checked his vital signs including the O2 sats. He stated that he ended up calling 911 to come and get him, because the facility did not help get him transferred to the hospital. R11 stated the EMS called the facility to see if he really needed to be transferred because he had called 911 before. R11 stated he finally was sent out to the hospital and was admitted on [DATE] through 04/25/24. Record review revealed R11 was admitted to the hospital on [DATE] due to acute hypoxic respiratory failure and decompensated ejection fraction (heart failure with reduced ejection fraction) as well as lower extremity cellulitis. R11 required increased oxygen requirements of 4 liters per minute (lpm) with a baseline of 2 lpm. R11 received IV diuresis (kidneys filter too much fluid from the body) and oxygen requirements helped with dyspnea (shortness of breath) and peripheral edema (accumulation of fluid causing swelling). On-call provider was notified on 04/14/24 at 02:44 AM and no new orders received. On 06/14/24 at 08:40 AM During an Interview with Clinical Care Coordinator (CCC) D Stated they had checked his vitals, a provider came in and checked him, checked his lungs, O2 sat's. Provider went to nurses' station to writer orders, the emergency Medical Service (EMS) walked by the station to pick him up. R11 stated he wasn't feeling well, she called provider came in and assessed him. CCC D stated she did not see a progress note for the provider on 04/14/24. CCC D stated she was standing there with provider during his assessment and the orders given. CCC D stated unfortunately, he did not put in a progress note. During an interview on 06/14/24 at 02:18 PM, CCC D stated she had called the provider regarding the hospital visit with no progress note. CCC D stated R11 had went out to the hospital on [DATE] first, and that was the visit that provider stated he saw the resident. Provider looked through his draft notes and he found his note and scanned it in the medical record. Resident #121(R121) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R121 was a [AGE] year old male admitted to the facility on [DATE], with recent re-admission post new onset diabetes mellitus on 4/4/24 with prior diagnoses that included traumatic brain injury with left craniotomy, pelvic fracture, hypertension (high blood pressure), diabetes insipidus, seizure disorder, hypopituitarism, hypothyroidism, speech and language deficits following brain injury, weakness, difficulties walking and depression. The MDS reflected R121 a BIM (assessment tool) score of 7 which indicated his ability to make daily decisions was severely impaired. The MDS reflected R121 had no behaviors including rejection of care. During a telephone interview on 6/11/24 at 11:59 a.m., R121's father and Durable Power of Attorney (DPOA) Z verified was R121 responsible party. R12's DPOA Z reported concerns that facility did not notify him of changes in R121 care at times. R121's DPOA Z reported on 3/29/24, when R121 was transferred to the hospital R121 DPOA Z had requested R121 be transferred to the hospital on day shift related to change in condition several times. R121 DPOA Z reported he noticed the change in R121 condition during a visit and informed the day shift nurse several times who reported the physician had not returned their call. DPOA Z reported had asked for R121 to be sent to hospital at 3:00 p.m. and did not receive return call from the facility until 11:00 p.m. informing him R121 was being transferred to the hospital. DPOA Z reported was very upset because he had requested R121 be sent around 3:00 p.m. and should not need to wait for physician if he was the responsible party. DPOA Z reported R121 blood sugar was over 900 when he arrived to the hospital which was dangerously high and should have been sent much earlier. DPOA Z reported elevated blood sugar was new for R121 but staff should have recognized that he looked ill on the day shift during his visit and listened when he requested R121 be sent to the hospital several times. Review of the Physician Discharge summary, dated [DATE](43 days after hospital admission 8/15/23), reflected R121 had discharge diagnoses that included hypernatremia, diabetes incipidus, head trauma, intraparenchymal hematoma of brain due to trauma, central hypothyroidism, anemia, mixed origin delirium and traumatic brain injury. Continued review reflected, Hospital Course: [AGE] year mal who was admitted to [named hospital] on 7/31/23 to trauma services .Hyperglycemia and A1c of 5.9[elevated], started on insulin gtt[drip], transitioned to subcutaneous . Review of R121's History and Physical, dated 8/15/23, reflected, Assessment and Plan .Hyperglycemia Hemoglobin A1C 8/11/23 5.9(H) .comment: increased risk for diabetes .Levemir 43 units BID . Review of the facility History and Physical, dated 9/27/23, reflected, History of Present Illness: The patient had significant head injuries. The patient was admitted to the prolonged hospitalization, ventilation, PEG tube placement, multi specialty intervention. Later, the patient is stabilized. After stabilizing his condition today on 09/27/2023, the patient desired to be transferred to the subacute rehabilitation .Past Medical History: Including acquired problems in the hospital including status post craniotomy,hypernatremia, hypokalemia, central hypothyroidism, hyperglycemia,thrombocytosis, respiratory failure,status post tracheostomy,craniotomy, multiple surgical intervention, status post EGD with PEG tube placement, head trauma,motor vehicle non-traffic accident injury, traumatic subdural hematoma,occipital skull fracture, thrombosis of superior sagittal sinus, GI bleed,status post PRBC transfusion Review of R121 Nutritional Note, dated 12/28/2023 at 8:03am, reflected, DOCUMENT CHANGES IN DIET, INTAKE AND HYDRATION STATUS,PERTINENT LABS::QUARTERLY:Nutrition Note Ht: 70 Current weight:222.8 # BMI:32 Resident has triggered for significant weight gain X 1 month. Weight increased from 193#. Resident has made tremendous improvements since admission. He came in NPO with tube feeding and then started an oral diet with was upgraded and now he has no tubefeeding and weight has increased. Diet is Regular, regular texture, thin liquids- large portions . Review of the Weight Change Notes, dated 3/8/24, for R121, reflected, March weight is 265# 3/6, resident continues to gain weight. Weight 2/26 260#, 2/20 256.6#, 2/13 251# . Review of the Nutritional Note, dated 3/21/2024 at 10:37am, for R121, reflected, Nutrition followup .Residents oral intakes continue to increase. This morning resident ate100% of breakfast and then told aid that he didn't eat. They knew he did eat and encouraged him to just tell them that he wanted more to eat. He then did ask for more so aid got him more to eat this morning. PM aid reported that he ate dinner and had 2 sloppy joes with bag of chips and did snack during the night. Aid did report that his weight gain is impacting how his clothes are fitting. Will review this again with MD to discuss any changes that could be made to meds. Review of R121 Nutritional note, dated 3/29/2024 at 7:39am, reflected, INTAKE AND HYDRATION STATUS,PERTINENT LABS:: QUARTERLY:Nutrition Note Ht:70 Current weight:265 # BMI: 38 Resident has had 10% weight increase X 1 month and 23% weight gain from 6 months ago. Resident had weight gain from 200-231# Sept to Feb. Resident then had bone flap replaced 2/5 and since that time weight has increased to 265#. Over this past month he is constantly hungry, asking for food, snacking all day resulting in significant weight gain .Discussed this with team and it was also stated that since bone flap replaced his behaviors have changed resulting in more anger and trashing his room . Review of the Provider Notes dated 9/2023 through 3/29/24 with no mention of weight gain mentioned or addressed. Continued review of the Provider notes with no mention of glucose monitoring related to history of documented hyperglycemia. Review of the Nursing Progress Notes, dated 3/30/24 at 1:23 a.m., for R121, reflected, Resident had a fall earlier today, noted the resident was sleepy and drowsy during the bedtime med pass, about 9pm resident had a right-side weakness, and activity level was below his baseline. Family members were notified and requested him to be sent out. Resident sent out a few minutes to 11pm. resident was tachycardiac and could not feed himself which he normally does. Dr and on call supervisor were notified. Resident transferred out to [named] Hospital with all the paperwork and documentation relating to ombudsman and bed hold policy.(last documented Nursing Progress Note was dated 3/18/24). Review of the Fall Incident/Accident Report, dated 3/29/24 at 2:20p.m., reflected R121 had an unwitnessed fall in the room and was found by aide laying on floor face down. The report reflected R121 was unable to give description. The reported reflected immediate action that was taken included,Resident was assessed for injuries none were noted, neuros were initiated, DON and family notified. The report appeared incomplete with no documentation under pain, mental status, mobity or predisposing factors were blank. (No evidence that investigation or follow up was provided as requested including neurological assessments.) Review of the Electronic Medical Record(EMR), dated 3/29/24, reflected no evidence of neurological checks as indicated on Fall Report until 8:00p.m. on 3/29/24.(Fall was at 2:20p.m.) Further review of the EMR reflected no evidence pain assessment or vitals signs post fall. Review of the SBAR Communication Form and Progress Notes for Change of condition, dated 3/29/24, reflected nurse had notified physician at 8:00 p.m. of R121 decreased level of consciousness. Review of the Nursing Home to Hospital Transfer Form, dated 3/29/24, reflected R121 report was called to the hospital at 12:00 a.m. and the form was completed by DON B on 4/1/24. Review of the Hospital Discharge summary, dated [DATE], reflected R121 was admitted on [DATE] at 12:22a.m. The summary reflected, admission Diagnosis DKA (diabetic ketoacidosis) .Hyperosmolar hyperglycemic state .HPI, as per admitting provider .On arrival to the ED, stroke team was called to evaluate the patient .Lab work was remarkable for .glucose (985) .He was treated with 2 L normal saline, given a dos of ceftriaxone and placed on an insulin drip according to the e DKA HHS protocol. He was admitted to the ICU for further treatment and management of AMS [altered mental state] likely from hyperglycemia. Hospital Course: Patient is a [AGE] year-old gentleman with TBI and a resident at a nursing home who comes to the hospital with altered mental status and lethargy. Found to have finding concerning for HHS[hyperosmolar hyperglycemic syndrome]. A1c 9.5. 2 months ago was 5.4. Started on aggressive IV fluids and insulin regimen subcutaneously .New onset diabetes likely due to autoimmune diabetes . Attempts were made to contact all day shift staff and transferring nurse (8 staff members) with no answer and no return calls. During an interview on 6/14/24 at 2:03 PM, Facility Nurse Consultant U verified no physician or provider notes were located that mentioned knowledge of R121 significant weight gain prior to change of condition and transfer to the hospital with blood sugars greater than 900 on 3/29/24.