**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00146060 Based on observation, interview, and record review the facility failed to prevent accidents (falls) by not following the plan of care, for two Resident (#2, #3) out of three Residents reviewed for accidents and hazards resulting in actual harm, fractured bones resulting in decline in Activities of Daily living for Resident #3 and potential for injury for Resident #2. Findings Included: Resident #3(R3) Review of the medical record revealed R3 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), type 2 diabetes, lung cancer, unstageable sacral pressure ulcer, fibromyalgia (widespread and long term body pain), epilepsy, anemia (low red blood cells), gastro-esophageal reflux disease, hypomagnesemia (low magnesium levels in blood), hyperlipidemia (high fat content in blood), sleep apnea, right foot drop, bipolar disorder, anxiety, nicotine dependence, and history of falls. R3's medical record demonstrated she was discharged from the facility on 07/29/2024 and was re-admitted [DATE] that included new diagnoses of a closed fracture of upper end of the right tibia and a fracture of the upper end and lower end of right fibula. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2024, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During an interview on 08/07/2024 at 11:29 a.m. R3 was observed sitting up in first floor conference room. R3 explained that she had come to the facility so that she could get stronger and return home. She explained that she was in a lot of pain because of a fall which had resulted in a fracture of her right leg. R3 explained that the fall happened at the facility. R3 explained that she was being transferred from the toilet in her bathroom, with the assistance of one person, her leg gave out and she fell to the floor. R3 explained that the recent fracture of her right leg has set her back in her progress to return home. R3 also explained that it was now necessary for her to be transferred using a total mechanical lift. Review of R3's medical record demonstrated a plan of care which stated, Risk for falls r/t (related to) deconditioning, which was implemented as of 05/18/2024. R3's plan of care also stated, (Resident name) has ADL (Activity of Daily Living) deficits r/t recent hospitalization for pressure ulcer unstageable to sacrum, deconditioning, which was implemented 05/18/24. The same plan of care demonstrated an intervention that stated, Transfer: 2-person max assist, which was implemented 05/18/24 and was revised on 08/06/2024 to state Transfer: Hoyer (mechanical lift), NWB (Non-wt. bearing) on right lower extremity. Review of facility incited report demonstrated R3 had sustained a fall on 07/29/2024 at 09:00 p.m. Review of that incident report demonstrated Resident transferring from toilet to wheelchair, right leg gave out, patient fell to ground. Resident in pain ++, unable to move patient at time. Description of the incident demonstrated Physical/pain assessment, vitals, sheet placed under resident/pillow against right leg for support in non-movement, physician notified telephone message left,. Resident son notified, ambulance called. Resident transferred to (name of hospital) ED (emergency department) on stretcher, via (by) ambulance. Review of R3's hospital Discharge summary, dated [DATE], revealed R3 had presented to the emergency department for a fall from standing with a closed right tibial fracture, a closed fracture of proximal end of right fibula, and closed fracture of proximal end of right tibia. The same discharge summary revealed R3 had required open reduction internal fixation right tibia on 08/02/2024. During an interview on 08/07/2024 at 11:35 a.m. Nurse Manger (NM) I explained that she was aware of R3's fall that had occurred on 07/29/2024. NM I explained that she had investigated R3's fall. NM I explained that her investigation demonstrated that R3 was being transferred from the toilet to her wheelchair by Certified Nurse Aide (CNA) D. NM I explained that according to R3's plan of care, she was to be transferred with the assistance of 2 staff. NM I explained that CNA D did not follow the plan of care. NM I agreed that by not following the plan of care, R3 had sustained right a closed fracture of upper end of the right tibia and a fracture of the upper end and lower end of right fibula. NM I explained that staff is expected to read the plan of care and the [NAME] before providing care. NM I explained that that expectation was not followed by CNA D During a telephone interview on 08/08/2024 at 09:34 a.m. Certified Nurse Aide (CNA) D explained that she had worked at the facility for a month. CNA D explained that she was working with R3 on 07/29/2024 and was assisting her to transfer from the toilet to her wheelchair when R3's right leg gave out and R3 fell to the floor CNA D explained that she was not aware that R3 required to be transferred by 2 person max assistance . CNA D explained that she does not usually read the [NAME] of residents and only relies on what she is told about resident care from other CNA's. CNA D was asked if she was educated on the necessity of reading the [NAME] of Residents prior to providing care. CNA D explained that she was not taught to read the [NAME] prior to providing Resident care. Record review of the facility staff personnel records demonstrated Certified Nurse Aide (CNA) D was hired by the facility 06/17/2024. The personnel record of CNA D had not demonstrated a completed competency evaluation upon completion of her orientation. Resident #2 (R2) Review of the medical record revealed R2 was admitted [DATE] with diagnoses that included peripheral vascular disease (PVD), Alzheimer's disease, dementia, hypertensive kidney disease, stage 3 chronic kidney disease, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat content in blood), polyneuropathy (damage or disease affecting peripheral nerves), second degree atrioventricular block (delayed cardiac conduction in cardiac node), venous insufficiency, osteoarthritis, low back pain, depression, absence of right leg below knee. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, revealed a Brief Interview for Mental Status (BIMS) of 12 (mildly impaired cognition) out of 15. During an interview on 08/07/2024 at 01:55 p.m. R2 was observed setting up in a chair. R2 explained that he recently had a fall that had occurred in the bathroom. He explained that he needed assistance to get off the toilet and that a Certified Nursing Aide (CNA) was assisting him, and she was unable to hold him up and another CNA assisted him and lowered him to the floor. R2 explained that he was supposed to be transferred with an easy stand but that the staff did not use it at that time. R2 explained that it was a new CNA and she did not know that he was to be transferred with the easy stand. R2 explained that he did not sustain any injury. Review of R2's medical record demonstrated a physician order mechanical lift for transfers which was entered 08/08/2024. Review of R2's plan of care demonstrated . is at risk for falls r/t(relate to) spondylosis, R (right) BKA (below the knee amputation) polyneuropathy, Alzheimer's disease. R2's plan of care demonstrated an intervention EZ stand, which was entered 07/08/2024. Review of R2's [NAME] (document used by staff that are providing care of the resident) demonstrated Transfer-Mobility- Transfer EZ stand. Review of facility incident report demonstrated R2 had experience a fall on 07/29/2024 at 04:30 p.m. The report demonstrated Resident was being toileted, unable to continue standing by self-using safety bars, fell to floor. The same incident report demonstrated that R2 did not sustain any injuries. Review a provided facility summary demonstrated Certified Nurse Aide (CNA) D was assisting R2 while he was standing up holding onto the assistance bar when he was non longer able to stand. The summary then identified that CNA E arrived in the bathroom and lowered R2 to the floor. During a telephone interview on 08/08/2024 at 09:34 a.m. Certified Nurse Aide (CNA) D explained that she had worked at the facility for a month. CNA D explained that she was assisting R2 in the bathroom on 07/29/24. During the transfer from the toilet R2 was unable to stand. CNA D explained that CNA E arrived in the bathroom and observed R2 being unable to stand and asked CNA D to remove the wheelchair while CNA E lowered R2 to the floor. CNA D explained that she was not aware that R2 required to be transferred with a mechanical device called a EZ-Stand. CNA D explained that she does not usually read the [NAME] of residents and only relies on what she is told about resident care from other CNA's. CNA D was asked if she was educated on the necessity of reading the [NAME] of Residents prior to providing care. CNA D explained that she was not taught to read the [NAME] prior to providing Resident care. Record review of the facility staff personnel records demonstrated Certified Nurse Aide (CNA) D was hired by the facility 06/17/2024. The personnel record of CNA D had not demonstrated a completed competency evaluation upon completion of her orientation. During a telephone interview on 08/08/2024 at 10:31 a.m. Certified Nurse Aide (CNA) E explained that she had worked at the facility for almost a year. CNA E explained that she was working with CNA D on 07/29/24. CNA E explained that she was aware that R2 was on the toilet when she first arrived for her shift. She explained that she was aware that R2's [NAME] demonstrated that R2 needed a EZ-Stand for the use of transfers. CNA E explained that she had told CNA D to contact her when R2 was ready to be transferred from the toilet to the wheelchair. CNA E explained that it had been a prolonged amount of time and CNA D had not contacted her for the transfer yet, so she went to R2's bathroom. CNA E explained that when she entered the bathroom, she observed that R2 could not stand while being helped by CNA D so she asked her to move and CNA E assisted R2 to the floor. CNA E explained that an EZ-Stand was not in the bathroom and because R2 was observed falling she assisted him to the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent the development and worsening of a pressure ulcer for three (Resident #13, 24, and 45) of seven reviewed, resulting in multiple facility acquired pressure ulcers and the potential for infection and increased pain. Findings Include: Resident #13 Review of the medical record revealed Resident #13 (R13) was admitted to the facility on [DATE] with diagnoses that included hypertension, anxiety, and depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R13 was cognitively intact, did not have a pressure ulcer, and was at risk for pressure ulcer development. Review of the same MDS revealed R13 required assistance of one for most activities of daily living. On 05/21/24 at 12:56 PM, R13 was observed in her room. R13 was dressed, nicely groomed, and seated in her wheelchair. Gauze bandages were observed on both of R13's feet and heels. When queried what the purpose of the bandages were, R13 reported that she had cuts (pressure ulcers) on both of her feet. When asked how the cuts on her feet were obtained, R13 replied that the cuts (pressure ulcers) were from her heels resting on her bed for too long. R13 reported that she could not feel her feet due to a chronic peripheral neuropathy (nerve damage that often causes weakness, numbness, and pain, usually in the hands and feet) diagnosis. R13 stated that prior to the development of her pressure ulcers, she did not utilize any devices to assist with keeping her heels off the mattress for pressure reduction purposes. She stated that after staff had discovered the pressure ulcers, they offered her some boots to offload pressure from her heels, but those made her feet very sweaty. R13 stated that after the boots, the facility provided her with a foam wedge to aide in keeping her heels off the bed and she regularly utilized that. Review of an active Physician Order dated 9/8/23 reflected Monitor skin daily with care and full skin checks weekly with shower. Review of the Skin assessment task dated 4/10/24 revealed that R13 was marked for no skin issues. Review of a Shower sheet dated 4/13/24 revealed R13 had received a shower and there were no suspicious skin areas determined. Review of a Progress Note dated 4/15/2024 at 2:12 PM reflected CNA [certified nursing assistant] alerted this writer of skin issue to BIL [bilateral] heels. both heels have what appears to be pressure injuries. R [right] heel is discolored and appears to have been a blister that has popped open. the L [left] heel is discolored but not with a blister. physician and wound nurse notified to assess and set treatment. CNAs and resident were advised to elevate heels whenever in bed. heel foam dressing applied to BIL heels to alleviate possible further breakdown. Review of a Skin/Wound dated 4/16/2024 at 1:46 PM revealed Wound nurse notified of skin breakdown to bilateral heels. On assessment, left heel presents with elongated purple discoloration, consistent with deep tissue injury. Right heel presents with large, irregular shaped blister with small pinpoint opening distally, scant serosanguinous [Serosanguineous fluid is a type of wound drainage typically in response to wound damage. The drainage is typically thin and watery with a light red or pink hue] area consistent with a stage two pressure injury. Skin prep applied to intact skin of bilateral heels with foam bordered dressing to cover. Resident initially resistant to offloading heels with pillow or foam boots. With staff encouragement, resident agreeable to use pillow to offload heels or foam boots when in bed . Review of a Skin assessment dated [DATE] revealed R13's left heel was an in house acquired deep tissue injury. The left heel had an area of 0.8 centimeters (cm), length of 2.0 cm, and a width of 0.6 cm. Review of a Skin assessment dated [DATE] revealed R13's right heel was an in house acquired stage two (partial tissue skin loss with exposed dermis). The right heel had an area of 5.8 cm, length of 3.4 cm, and a width of 2.5 cm. A note at the bottom of the skin assessment stated that staff reported that R13 was resistant to change in routine such as offloading heels with pillows in bed. Review of R13's Behavior MDS dated [DATE] revealed that R13 did not have any refusals in care. Review of the Physicians Orders for R13 revealed new orders which included offloading heels at rest which was initiated on 4/15/24, achilliease (wedge) to bed of loading heels which was initiated on 4/19/24, and foam boots to bilateral heels when in bed, as tolerated with an active date of 4/26/24 and a discontinued date of 4/29/24. These orders were implemented after the development of the bilateral heel pressure injuries. Review of a Skin/Wound Note dated 4/23/2024 at 1:12 PM revealed Weekly wound assessment: Deep tissue injury to left heel presents with reduced redness, slight reduction in measurements .Right heel presents with partially ruptured blister (10% open, 90% epithelium), with light serosanguinous drainage .Resident using Achillease to end of bed to float heels, reporting comfort and ease of use . Review of a Skin/Wound Note dated 5/1/2024 at 2:31 PM revealed Weekly wound assessment: Right heel stage two presents with ruptured blister, light serous drainage, no sign of infection. Left heel deep tissue injury presents with stable measurements, epithelium intact. New scab to left heel noted with assessment. Resident reports no pain . Review of a Skin/Wound Note date 5/14/2024 1:56 PM revealed Weekly wound assessment: Left heel pressure injury presents with scabbing along achilles and small open area to heel with light serous exudate. Left heel measurements stable. Right heel pressure injury presents with slough to 90% of wound bed and 10% granulation tissue. Light serous exudate noted . Review of a Skin assessment dated [DATE] revealed R13's left heel fit the description of a Stage Two pressure ulcer. The left heel pressure ulcer had an area of 0.8 cm, a length of 0.9 cm, a width of 1.2 cm, and a depth of 0.1 cm. Review of a Skin assessment dated [DATE] revealed R13's right heel fit the description of a Stage Three pressure ulcer. The right heel pressure ulcer had an area of 3.2 cm, a length of 2.9 cm, a width of 1.4 cm, and a depth of 0.3 cm. In an interview on 05/24/24 11:16 AM, Registered Nurse (RN) F stated that she was the Wound Nurse for the facility and was familiar with R13. RN F reported that prior to the development of the bilateral heel pressure ulcers, the intervention for pressure ulcer prevention in place included a foam mattress. After the discovery of the pressure ulcers on R13's heels, an order was placed to offload her heels with foam boots initially, and then a foam wedge on the end of her bed. RN F stated that just prior to the development of the bilateral heel pressure ulcers, R13 had a health decline which caused her to stay in bed more frequently. RN F stated that she was unaware that R13 had been spending additional time in bed and would have liked to see the intervention of offloading heels in bed implemented during that time. Resident #24 Review of the medical record revealed Resident #24 (R24) was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, muscle weakness, myasthenia gravis, schizoaffective disorder-bipolar type, anxiety disorder, major depressive disorder, displaced bimalleolar fracture of left lower leg, closed fracture with routine healing, dislocation of left ankle joint, and orthostatic hypotension. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R24 was cognitively intact with a Brief Interview for Mental Status of 12, did not have a pressure ulcer, and was at risk for pressure ulcer development. Review of R24's Care Plan revealed R24 required limited assistance by one person for bed mobility and utilized the Hoyer lift for transfers. On 5/21/24 at 11:20 AM, R24 was observed in bed. R24 had an ACE wrap on his lower left extremity along with a hard boot. His left lower extremity was resting directly on the mattress. R24 was pleasantly confused and did not appear to answer questions appropriately. When asked how R24 notified staff if he needs anything, R24 held up his bed remote and stated, well I don't know, I haven't thought about that before. When asked what happened to his left leg, R24 stated oh, I don't know. They say I have a bad habit. Review of the Hospital Discharge summary dated [DATE] revealed R24 admitted to the trauma service after experiencing a fall at home resulting in a left ankle dislocation and fracture. An external fixator device (a device which consists of a metal frame and pins surgically placed into the bone to help maintain the length, alignment, and rotation of the fracture) was placed on 2/15/24. Post-operative assessments revealed that R24's left external fixator device was in place and wrapped with an ACE bandage to protect the skin from the device. R24 was able to wiggle his toes and had no visible injury. Review of the After Visit Summary dated 2/22/24 revealed orthopedic instructions which stated, non weight bearing on left lower extremity . Keep left foot elevated above heart level while at rest: only allow left foot to be in a dependent position for 10-to-15-minute intervals while up/active . Sponge bath only keeping pin sites and surrounding dressings dry . please change out dry dressings on pins daily as needed when saturated. Review of a Physician Order dated 2/22/24 revealed R24 was to maintain a non-weight bearing status on his left lower extremity. Additionally, the order stated May reinforce or replace ACE wrap as needed. Use foam cushion to elevate LLE (left lower extremity). Bed bath only. This order was discontinued on 5/17/24. Review of an After Visit Summary from a follow up orthopedic appointment on 3/1/24 revealed the following instructions: no weight bearing left lower extremity .Xeroform, Kerlix, and ace wrap to LLE. Change daily or more if drainage . apply ice to site several times per day . Review of an After Visit Summary dated 5/17/24 revealed R24 had the external fixator device removed from his left lower extremity. The post operative instructions included instructions to apply ice to the left lower extremity several times a day and to elevate the left lower extremity above heart level while at rest. In an observation on 5/21/24 at 12:36 PM, R24 was observed in bed. R24 had an ACE wrap on his lower left extremity along with a hard boot. His left lower extremity was resting directly on the mattress. R24's left foot was in a relaxed position and was observed to be tilted over and resting on the left lateral side of his foot. In a wound care observation on 05/23/24 at 10:23 AM R24 was observed in bed. R24 had an ACE wrap on his lower left extremity along with a hard boot. His left lower extremity was resting directly on the mattress. R24's left foot was in a relaxed position and was observed to be tilted over and resting on the left lateral side of his foot. Review of a Progress Note dated 5/10/2024 at 6:19 PM Some tenderness noted today when performing dressing change on LLE. Discharge noted on both medial and lateral aspects of the ankle. Used an ABD pad when bandaging today, as it looks like the hardware is being pressed into the left side of the foot, causing pain. Redness noted on tissue surrounding insertion site. Cleaned area with NS, xeroform, ABD for extra cushioning, and Curlix. Wrapped with ACE bandage . Review of a Progress Note dated 5/11/2024 3:44 PM When the nurse did the wound dressing change today, nurse found a pressure injury on the left foot which was related with the medical device .Nurse will notify the wound care nurse to evaluate the skin changes on Monday. Nurse cleansed the pressure injury with normal saline, put the pad in between the pressure injury for protection . Review of a Physician order dated 5/11/24 revealed LLE wound care: NS cleanse, Xeroform, ABD pad to lateral side of foot to protect from hardware pressing in, kerlix and ACE wrap. Change daily or more if drainage . This order was discontinued on 5/17/24. Review of the initial pressure ulcer photograph revealed a pressure ulcer on the lateral side of R24's foot that was caused from the screw and nut of the external fixator device digging into the lateral side of R24's left foot. The pressure ulcer was the same size as the screw and nut and appeared to have an indentation on the skin. The wound bed was covered with slough. Review of a Skin/Wound note dated 5/21/2024 at 1:34 PM revealed Weekly wound assessment: left lateral foot pressure injury presents with slough to ~80% of wound bed and and [sic] pink granulation tissue to remaining wound bed. Light serosanguinous drainage. Depth reduced, remaining measurements stable . Review of The Skin and Wound evaluation dated 5/21/23 revealed R24's pressure ulcer was classified as a medical device related unstageable wound. The wound had an area of 1.7 cm, a length of 1.8 cm, a width of 1.3 cm, and a depth of 0.2 cm. In an interview on 05/23/24 at 2:31 PM, Certified Nursing Assistant (CNA) T stated familiarity with R24. CNA T denied seeing a foam cushion used to elevate R24's left lower extremity when R24 had his external fixator applied. In an interview on 5/24/24 at 8:55 AM Certified Nursing Assistant (CNA) D stated familiarity with R24. CNA T denied seeing a foam cushion used to elevate R24's left lower extremity when R24 had his external fixator applied. In an interview on 5/24/24 at 09:07 AM Certified Nursing Assistant (CNA) R stated familiarity with R24. CNA T denied seeing a foam cushion used to elevate R24's left lower extremity when R24 had his external fixator applied. Review of the Kardax (portion of medical record where CNA's access care needs) revealed no instruction to elevate R24's left lower extremity. Review of the Care Plan revealed no instruction to elevate R24's left lower extremity. In an interview on 5/24/24 at 11:33 AM, Registered Nurse (RN) F stated that she was the Wound Nurse for the facility and was familiar with R24. RN F stated that she as unaware of how the medical device related pressure injury developed. RN F stated that the pressure injury should have been prevented if all preventative orthopedic instructions were implemented. RN F stated that R24 was not always compliant. Review of the Progress Notes revealed no refusals for propping R24's foot or refusals of protective ace bandage application. In an interview on 5/24/24 at 3:07 PM, Licensed Practical Nurse (LPN) E stated that she was unsure how R24's medical device related pressure injury developed. Resident #45 Review of the medical record revealed Resident #45 (R45) was admitted to the facility on [DATE] with diagnoses that included overactive bladder, cognitive communication deficit, vascular dementia, severe, with anxiety, and dysphagia. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R45 was cognitively impaired, did not have a pressure ulcer, and was at risk for pressure ulcer development. Review of the Activity of Daily Living Care Plan revealed R45 required assistance of two people for bed mobility and transferred with the use of a Hoyer. On 5/21/24 at 11:11 AM, R45 was observed lying in bed, positioned toward the left side. R45's right leg was extended straight out with pillow under her lower legs with her heel resting directly on mattress. R45's left leg was bent at the knee and her lateral leg and foot was resting directly on a pillow. A foam dressing was noted on R45's left heel. R45 did not respond when spoke to. Review of the Physician Order's revealed an active order implemented on 12/6/2023 which stated Keep LLE [left lower extremity] elevated on a pillow r/t [related to] edema. Review of a Skin/Wound Note date 4/17/2024 at 9:06 AM revealed CNA [certified nursing assistant] alerted wound nurse of skin breakdown to left heel. On assessment, small, deep tissue injury noted to medial left heel with small area of blanchable redness just superior .Foam mattress in place, pillow beneath heels (flattened), new foam boots for use in bed to be supplied . Review of a Skin and Wound Evaluation dated 4/17/24 reflected R45 had an in house acquired deep tissue injury on her left heel which had an area of 1.4cm, length of 1.7cm, and a width of 1.2cm. Review of the Care Plan revealed a focus area which stated R45 has a deep tissue injury to the left medial heel and stage two pressure injury to the coccyx related to pressure. A foam mattress intervention was implemented on 4/17/24. Offload heels at rest was implemented on 4/17/24 after the development of the deep tissue injury on the left heel. Review of a Progress Note dated 4/27/2024 at 3:19 PM revealed R45 has a 2cm open area on coccyx area . Review of the Skin and Wound assessment dated [DATE] revealed an in house acquired stage two pressure ulcer. The pressure ulcer had an area of 5.9 cm, a length of 3.7 cm, a width of 3.2 cm, and a depth of 0.1 cm. In an interview on 5/24/24 at 9:43 AM, Certified Nursing Assistant (CNA) W stated that she was familiar with R45's care needs. CNA W stated that R45 required frequent turning and repositioning. In an interview on 5/24/24 at 11:27 AM, Registered Nurse (RN) F stated that she was the Wound Nurse for the facility and was familiar with R45. RN F was notified of her left heel pressure ulcer on 4/17/24. About two weeks later, RN F was notified of the wound on the coccyx. RN F stated that R45's situation and staffing played a role in R45's development of her pressure ulcers. R45's regularly assigned CNA was on vacation causing an irregularity in R45's usual staff, which may have played a role. When asked how R45 developed a pressure ulcer to her left heel when an order for elevating her left foot was already implemented, RN F stated that the use of flat pillows may have contributed. RN F reported that she provided staff education regarding offloading, turning, and repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement timely interventions, provide appropriate supervision and ensure that staff assisted with transfers to prevent recurrent falls for two resident (Resident #70 and #547) of three reviewed for falls, resulting in a head laceration requiring emergency care and staples. Finding include: Resident #70(R70) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R70 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease, polyosteoarthritis, wedge compression lumbar fracture, spinal stenosis, radiculopathy, disc degeneration, low back pain, unsteadiness on feet, reduced mobility, repeat falls, assistance with personal care and anxiety. The MDS reflected R70 had a BIM (assessment tool) score of 13 which indicated his ability to make daily decisions was cognitively intact, and he required max assist with transfers. R70 MDS reflected no behaviors including rejection of care. During an observation and interview on 5/21/24 at 9:24 AM, R70 was observed sitting in chair with wife at side. R70 reported currently planning on surgical procedure this week and elevated pain related for need for back surgery. R70 and family reported R70 had history of falls prior to admission that contributed to current pain and had a fall at the facility on 4/15/24, three days after admission on [DATE]. R70 and family reported R70 was admitted into room toward end of hall, room [ROOM NUMBER], and door was closed and R70 called wife from cell phone to say he had fallen and hit his head on 4/15/24 and did not no how to get help. R70 family reported she had been home ill and attempted to call the facility to assist R70 but no one answered at the facility. R70 family reported called friend to go to facility an check on R70 and continued several attempts to reach facility by phone and spoke to someone who attended to R70 after several calls and R70 remaining on the floor in room. R70 family reported after staff found R70 he was transferred to the hospital related to head laceration that required several staples. R70 family reported did not want R70 to fall again so family hired one on one sitter to supervised R70 to prevent additional falls to ensure there would not be delay in needed surgical procedure because facility did not have enough staff. Review of the Nursing Progress Note, dated 4/15/2024 at 6:53 p.m., reflected, Staff was called to patient's room after receiving a phone call from patient's wife who was called by patient and stated he had fallen. Patient was observed on the floor in front of his recliner on his right side with obvious lacerations to right side of head. Patient stated I was on my way to the dining area to brush my teeth [named physician] was notified and order received to send patient to ER for further evaluation. Patient's daughter [named], called this nurse for more information, questions answered. Review of the History and Physical, dated 4/15/24, reflected, [named R70] is a [AGE] year-old man with Parkinson ' s disease with Osteoarthritis, osteopenia, history of thoracic compression fracture with history of L1 vertebral compression fracture repair by [named surgeon] and history of left femoral neck fracture on 01/15/2024 with status post ORIF by [named physician]. The patient had mechanical fall at home. The patient had x-rays shows pain on the low back and the patient was taken to the hospital. The patient was diagnosed with L4 compression fracture. The patient had kyphoplasty in setting of the Parkinson ' s disease. The patient is following with neurosurgery. The patient is stabilized. After stabilizing his condition on 04/12/2024, the patient desired to be transferred to the subacute rehabilitation at [namded facility] . Review of R70's Nurse Progress Note, dated 4/15/2024 at 10:03 a.m., reflected.Client was admitted to [named] for rehabilitation on 4/12/24. Client had a fall on 3/13. C/o back pain. Went to [named ] hospital, studies showed a L4 compression fracture. Kyphoplasty was performed on 3/27/24. Went to inpatient rehabilitation and then discharged to facility .Client is asking for a stronger pain medication with codeine. Has Ibuprofen scheduled for pain management. Has order for Tylenol PRN. BAT to ABLE. Client requires 2 person assist for transfers . Review of the N ADV Clinical admission Note dated, 4/12/2024 at 6:44 p.m Level of cognitive impairment: Alert (some forgetfulness). Mental Status Note: Known to get confused at times through the night .Safety Note: Occasionally wakes up confused during the night .Gait is unsteady. Balance is poor . Review of the Fall Risk Evaluation, dated 4/12/2024 at 5:07 p.m., reflected R70 had a high risk for falls with score of 20(>10 equals fall risk). Review of the Fall Incident/Accident Report, dated 4/15/24 at 5:30 p.m., reflected R70 had an unwitnessed fall in room with head laceration to right side of head. The reported reflected R70 was oriented to self. The provided information did no mention when the resident was last observe, toileted, or if intervention was in place or if call light was on. The reported was competed by Licensed Practical Nurse(LPN) Q. During an interview on 5/23/24 at 9:05 AM, LPN Q reported was present for R70 fall on 4/15/24. LPN Q reported was alerted to room when wife called facility by phone and there was a delay because call went to general line first. LPN Q reported eventually R70 wife spoke with Unit Manager on the phone and R70 was then found on the floor in his room with a lot of blood related to head laceration and transfer to hospital via Emergency Medical Services(EMS). LPN Q reported pressure was held to head to control bleeding and EMS transfer R70 from floor to gurney. LPN Q reported R70 returned to the facility with 7 staples that were removed 10 days later. LPN Q reported was unable to recall what other staff were present and verified completed Fall Incident Accident Report the next day because had for got to complete prior to end of shift. LPN Q reported no witness statements were part of investigation. LPN Q reported was unsure how long R70 had been on the floor before alerted by wife on phone and was unsure if investigation completed. LPN Q reported design of rehab rooms makes it difficult for residents to be seen from hall and can not physically visualize all rooms from one area. During an interview on 5/23/24 at 12:52 PM, Director of Nursing (DON) B reported no witness statements for falls including R70 and R547 falls with injury who both required hospital transfers for staples within 72 hours of admission. DON B reported recent identified need for improvement with root cause analysis and additional information gathered at the time of the falls. DON B reported IDT note should be part of fall report and progress notes. During an interview on 5/24/24 at 9:54 AM, Registered Nurse (RN) F reported was responsible for completing fall investigations at facility. RN F reported R70 had fall on 4/15/24 in room and was unable to answer how long resident was on the floor prior to staff arrival and reported R70 room was moved closer to Nurse Station after returning from the hospital for increased supervision. RN F verified R70 was at high risk for falls on admission. Resident #547 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R547 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included Hypotension(low blood pressure), history of falls including fall with traumatic subdural hematoma and craniotomy in 2023, acute rash, bilateral lower leg edema, weakness, and abnormal gait. The MDS reflected R547 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required one person physical assist with transfers. R547's MDS reflected no behaviors. During an observation on 5/21/24 at 10:17 AM, R547 was noted sitting in recliner, unable to view from hall, in room and appeared calm and able to answer questions with minimal confusion. R547 had a large border dressing over left temple area and reported was related to fall. R547's room was located at the beginning of A Hall about 7 room down from the nurse station. Review of the facility Matrix, dated 5/21/24, reflected R547 admitted to the facility on [DATE] and had a fall with injury. Request for all R547 incident/accidents(I/A) with complete investigations was sent via email to the Nursing Home Administrator(NHA) A on 5/22/24 at 3:34 PM. Received two fall with injury I/A reports for R547, dated 5/17/24 and 5/20/24, on 5/22/24 at 4:33 p.m. The provided documents included I/A report with no evidence of witness statements. Review of the facility, Fall Risk Evaluation,, dated 5/15/24, reflected R547 had a score of 14 that indicated high risk for fall. Review of the Intra Disciplinary Team(IDT) Progress Note, dated 5/16/2024 at 9:42, reflected, Client was admitted to facility for rehabilitation on 5/15/24. Went to [named] hospital on 5/10 from [named adult foster care] for generalized weakness and a rash. Also had edema to BLE[bilateral lower extremities] and increased confusion. Primary diagnosis .Metabolic Encephalopathy. Also diagnosed with Malaise, Failure to Thrive, Edema, Rash, Leukocytosis. PMH[past medical history]: Hypotension, Subdural Hemorrhage, Neurocognitive Deficits .2 Person for transfers . Review of the Physician Progress Note, dated 5/16/24, reflected, She was seen today for admission assessment in her room. She was sitting in a chair, comfortably reports no pain, but feels concerned about her risk of falls. She is a [AGE] year-old female, who had a history of subdural hematoma last year and had a craniotomy XXX[AGE] year female with history of subdural, hematoma status post craniotomy, hypertension and falls, is admitted for skilled care after being in the hospital for worsening leg edema, contact, dermatitis, and mental status changes .Her goal is to be able to return home after improving her balance, Gait and strength .PT and OT evaluation and treatment . Review of the Incident Progress Note, dated 5/17/24 at 4:27 p.m., reflected, Staff alerted nurses to patient's room via emergency call light system, patient observed on her left side, bleeding from her head, pressure dressing applied to the laceration to the upper left side of her head. VSS, neurochecks WNL, AxO x4 at time of incident, EMS transport service arrived for transport to [named Emergency Room] for further tx, [named physician] notified, [named], patient's son, returned call and was updated on patient's incident. Review of the facility I/A Fall with Injury Report, dated 5/17/24 at 4:35 p.m., reflected R547 was alert and oriented and had an unwitnessed fall coming out of bathroom and found in doorway of room bleeding from left temple area. The report did not mention when resident was last observed or if call light was on at the time of the fall. The reported reflected, Upon return from ED and IDT review: intervention to education on importance of call light use. AXOx4, able to demonstrate use of call light and understanding of when to use. Review of the Baseline Care Plan(BLCP) Summary, dated 5/15/24, reflected R547 fall prevention measure in place that included, oriented to room, encouraged use of call light, and ensure items in place/reach. The BLCP included interventions that included one to two persons assist with toileting, transfers and two person assist with bed mobility. The BLCP indicated R547 used a wheelchair for mobility and included, Fall Risk under other care plan considerations. Review of the facility Working Schedules, dated 5/17/24, reflected 2 nurses and 3 cna staff for 45 rooms on first floor including one cna call in. During an interview on 5/24/24 at 9:00 AM, Licensed Practical Nurse (LPN) Q reported was R547 nurse on 5/17/24 at the time of the fall. LPN Q reported R547 had self transferred to bathroom and fell in room coming out of bathroom and hit head and was found in doorway with laceration to left temple with a large pool of blood on floor. LPN Q reported pressure was held to head to control the bleeding and vitals taken and EMS transferred R547 off the floor to the Emergency Room. LPN Q was unsure when resident last observed prior to fall or if call light was on. LPN Q reported R547 returned to the facility with 7 to 8 stable to left side of head and reported was very concerned post fall related to history of fall with subdural hematoma and craniotomy and decision to send R547 directly to hospital for follow up. LPN Q reported was unable to recall other staff present. LPN Q reported unfortunately the facility layout had a poor design for rehab because not able to physically be in view of all rooms from any one location. LPN Q reported rehab unit with several new admissions and with large turn over rates. LPN Q reported poor decision to place new residents with high acuity and high risk for falls at end of unit with less foot traffic because increases the risk for residents who need more supervision. LPN Q reported example of current resident in furthest end of hall(not visible from main nurse station) was new admission post hospital admission for respiratory failure, extubated the day prior, with confusion and high risk for falls. Review of the Nursing Progress Note, dated 5/20/2024 2:10 PM, reflected, CNA alerted this writer to resident's room. resident had fallen when ambulating from the BR back to room, hitting head on the floor. CNA was present and witnessed fall but unable to stop fall. resident remained alert and talking to staff. laceration to L temple area. resident assisted up to w/c. laceration cleansed with NS and dry dressing applied. vitals obtained and are wnl, no other injuries observed and pain denied. staff will continue to monitor. Review of the facility I/A Fall with Injury Report, dated 5/20/24 at 1:30 PM, reflected, CNA alerted this writer to resident's room. resident had fallen when ambulating from the BR[bathroom] back to room, hitting head on the floor. (Same type of fall as on 5/17/24) resident was walking with walker. CNA was present and witnessed fall but unable to stop fall. resident remained alert and talking to staff. laceration to L temple area. The report reflected, IDT review of fall: intervention to encourage non-slip footwear when up, as patient had removed shoes. Continue with therapy efforts to address gait impairments (has crisscross step patterns). The report did not mention the last time R547 was observed prior to the fall, last toileted, if the call light was on or off or if gait belt had been used during the transfer. Review of the Care Plans, dated 5/17/24 through 5/20/24, reflected no new interventions post 5/17/24 fall that required hospital visit and several staples to left temple area related to laceration. Review of the Progress Notes, dated 5/17/24 to 5/20/24, reflected no mention of follow up fall documentation. During an interview on 5/24/24 at 9:54 AM, Registered Nurse(RN) F reported was responsible for fall investigations along with Director of Nursing(DON) B and also verify appropriate interventions in place. Reported R547 had history of fall upon admission on [DATE] and had unwitnessed fall on 5/17/24 post self transfer that caused left head laceration and staples. RN F reported intervention was to remind R547 to use call light. RN F was unable to answer if that same intervention was effective prior to the 5/17/24 fall. RN F reported staff were expected to document fall Progress Note every shift for 3 days post fall and verified R547 did not have any post fall progress notes in the medical record and was unsure why. RN F reported R547 had additional fall with similar situation and hit head that caused another head laceration on 5/20/24(3 days after prior fall with head laceration, hospital transfer and staples). RN F verified R547 did not have any new interventions added to the fall care plan after the 5/17/24 fall with injury and should have. RN F verified nurse staff had indicated post fall charting had been completed in the Treatment Administration Record after the 5/20/24 fall but was unable to locate complete post fall charting every shift for 3 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00139554 Based on interview and record review, the facility failed to provide timely cardiopulmonary resuscitation (CPR) per the standards of practice and according to facility policy for one (Resident #2) of two reviewed for emergency resuscitation, when Resident #2 was found unresponsive without pulse or respiration with a 1 hour 58-minute delay prior to the initiation of CPR with the deficient practice resulting in death for Resident #2. Findings include: Review of the medical record revealed that Resident #2 (R2) was admitted to facility [DATE] with diagnoses including secondary malignant neoplasm of prostate, severe protein-calorie malnutrition, paranoid schizophrenia, and anemia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 6 (severe cognitive impairment). Section G of the same MDS revealed that R2 required one-person limited assist for bed mobility, supervision for toilet use, and was independent with eating after set up. Review of a second MDS dated [DATE] reflected that R2 deceased while at the facility. Review of R2's medical record completed with the following findings noted: Order dated [DATE] at 9:33 AM stated, Full Code (CPR) [cardiopulmonary Resuscitation]. Multidisciplinary Care Conference form dated [DATE] stated, .(R2's name) was to be admitted with hospice following his hospitalization. Family declined. Hospice nurse present and gave additional options for support with chronic disease. Family is electing to enroll (R2's name) in palliative care [specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness]. Transfer/Discharge Report dated 1 Sep, 2023 ([DATE]) indicated within section titled Other Information, R2's Advance Directive as Full Code (CPR). Progress Note dated [DATE] at 7:52 AM completed by Registered Nurse (RN) H stated, Resident passed away during night shift and found during shift change around 7am. Resident body was cold with no pulse or respiration. Floor manager (Licensed Practical Nurse/Nurse Manager D's name) contacted and instructed to call Hospice. Hospice nurse (nurses name) contacted and he stated thatresident [sic] is transitioning to palliative care under (name of company) care. Night nurse aware. Progress Note dated [DATE] at 10:27 AM completed by RN H stated, DON (Director of Nursing B's name) instructed to start CPR on resident due to Full code states [sic]. Around 0900 [9:00 AM] CPR started on resident, CPR completed between (DON B's name), Night nurse (LPN O's name), and day time nurse (RN H's name). EMT [Emergency Medical Technician] arrived and take [sic] over CPR and announced death at 0924 [9:24 AM]. Order Note dated [DATE] at 12:11 PM completed by RN H stated, Okay to transfer resident body to funeral home .Resident body transfer to (name of funeral home) at 1145 [11:45 AM]. In an interview on [DATE] at 10:25 AM, CNA (Certified Nurse Aide) F stated that she had arrived to assigned unit at approximately 7:15 AM on [DATE], was informed by night shift CNA G that R2 had passed away that morning, and upon completion of report with CNA G was approached and informed by RN H that R2's postmortem care (care provided after death including a bed bath, clean gown, and positioning) could be completed. CNA F stated that at least a good hour after she had completed R2's postmortem care, a code alarm was activated, she entered R2's room, observed RN H at bedside, exited room and obtained crash cart. CNA F stated that R2 had a bracelet on his right wrist that indicated that he was a DNR (Do Not Resuscitate) but that she had heard discussion among the nurses that morning that R2 was really a full code. In a telephone interview on [DATE] at 2:03 PM, CNA G confirmed familiarity with R2 and that she was his assigned CNA from [DATE] at 11:00 PM to [DATE] at 7:00 AM. CNA G stated that R2 was incontinent of both bowel and bladder, required one-person extensive assist for incontinency care and repositioning, and therefore checked on him every 2 hours. CNA G stated that she initially entered R2's room at approximately 11:30 PM on [DATE] at which time he was awake, followed commands to assist with turning, completed a brief check for incontinency and assisted R2 to reposition. CNA G stated that she checked on R2 again at approximately 1:30 AM, completed incontinency care as he had a loose bowel movement and that he remained alert. Per CNA G, R2 was checked on again at approximately 3:30 AM at which time he remained alert, she elevated head of bed, provided sip of water, and then repositioned him so that he seemed comfortable. Per CNA G, sometime after 5:00 AM R2's roommate activated call light to complain that R2 was being loud. CNA G stated that R2 was awake at that time, that he followed commands to assist her with checking his brief but that he was moaning and seemed uncomfortable. CNA G stated that upon completion of care she exited room, updated Licensed Practical Nurse (LPN) O that R2 was moaning and seemed to be in pain and that LPN O stated that she would check on him. CNA G stated that she then proceeded to the other end of the hall and had no further contact with R2. CNA G stated that at approximately 7:05 AM, day shift RN H approached her, stated that R2 was unresponsive but provided no further direction prior to walking away to find LPN O. CNA G stated that at approximately 7:15 AM, she gave report to CNA F and left unit. In a telephone interview on [DATE] at 10:44 AM, RN H stated that she had been employed at the facility for 10 years but was terminated from her position because of the [DATE] occurrence with R2. RN H stated that she arrived to unit on [DATE] at approximately 6:55 AM, clocked in, proceeded to complete unit rounds at which time she observed R2's door to be closed. RN H stated that upon entering room, observed R2's privacy curtain to be halfway closed around his bed and upon approach observed R2 to be without respirations, his mouth to be open, no pulse could be detected, and his body was cold to touch. RN H stated that R2 had a DNR bracelet on his right wrist and assumed that as R2's privacy curtain was partially closed, and the room door had been closed that staff had prior awareness of R2's passing. RN H stated that after approximately 3-4 minutes she exited room, located night shift nurse (LPN O), and as LPN O denied prior awareness of R2's passing, reentered room with LPN O and both confirmed that R2 was without pulse or respirations. RN H stated that LPN O denied need for assist with contacting R2's physician and family for further instruction and therefore RN H stated that she sat in the nursing office to check her emails at which time she received a call from Licensed Practical Nurse/Nurse Manager (LPN/NM) D, informed her that R2 had passed away during night shift at which time RN H stated that LPN/NM D provided guidance to contact hospice as she believed that he had recently been admitted to hospice services. RN H stated that sometime between 7:40 AM and 7:50 AM, she relayed to LPN O that hospice should be contacted, dialed hospice number, placed call on speaker and that the hospice nurse informed them that that because of religious reasons, R2 was under palliative/comfort care and not hospice care. RN H stated that she still believed that R2 was a DNR and did not check R2's medical record to verify code status. RN H stated that LPN O again denied need for assistance addressing R2's death, provided her with the medication cart keys, they completed narcotic count together, and that she then began morning medication pass. RN H stated that sometime after 8:00 AM, Director of Nursing (DON) B approached her at medication cart, informed her that R2 was a Full Code and that CPR needed to be initiated. RN H stated that was the first knowledge she had of R2's full code status, and upon verifying full code status in R2's medical record, expressed concern to DON B regarding initiation of CPR as was unknown when R2 passed away as he had clearly been deceased at 6:55 AM, upon her arrival to unit, as his body was already cold. RN H stated that she was next approached by NHA A sometime after 8:30 AM, and that she then entered R2's room with LPN O and DON B and that she initiated chest compressions and DON B placed AED (Automatic External Defibrillator) and provided rescue breaths. RN H stated she then received a return call from R2's spouse, that LPN O assumed chest compressions, and she exited room to take call. RN H stated that she informed R2's spouse of his passing and that CPR had been initiated, reentered room, and as DON B inquired whether spouse wished CPR to continue, recontacted spouse and as spouse confirmed desire for ongoing CPR, reentered room and informed the EMT, now present in R2's room, of spouse's desire that R2 receive continued CPR. Upon conclusion of telephone interview, RN H stated that as R2 was a cancer patient, there had been talk that he had enrolled in hospice, and as he had a DNR wrist band in place, she thought that he was a DNR and therefore never thought to verify R2's code status in his medical record upon finding him unresponsive at 6:55 AM and unfortunately did not know that he was actually a full code until informed by DON B after 8:00 AM. In a telephone interview on [DATE] at 12:57 PM, LPN O stated that [DATE] was the first time that she had worked with R2, that she started her shift at 7:00 PM on that date, received report from day shift nurse that R2 was declining, and initially entered R2's room between 8:00 and 8:30 PM for medication pass. LPN O stated that R2 was easy to awaken upon room entry, that he was alert and responded to questions with pain denied, and that his extremities were warm to touch. Per LPN O, R2 was resting in bed and not noted to be in any distress when she next checked on him between 1:00 and 2:00 AM. LPN O stated that at approximately 6:00 AM, CNA G reported to her that R2 was making noise but that she did not ask any additional questions, did not ask CNA G to obtain R2's vital signs, and did not check on R2 at that time as it was her plan to complete an assessment and discuss R2's status with the day shift nurse once she arrived. LPN O further stated that she thought R2 was receiving hospice care as he had terminal prostate cancer and therefore assumed that he was a DNR and that it never crossed her mind to verify his code status in his medical record. LPN O stated that as she was completing her shift at the medication cart, day shift RN H approached her and stated that R2 had passed. LPN O stated that she proceeded to room and upon assessment verified that R2 was not breathing and stated that it appeared that he had been gone for approximately 20 to 25 minutes due to skin coloring and coolness. LPN O stated that she then returned to medication cart, texted night RN/Former Nurse Supervisor (RN/FNS) C at approximately 7:15 AM to inform that R2 had passed and to inquire about the protocol at that point. LPN O stated that RN/FNS C did not text back right away, that she and RN H updated hospice nurse regarding R2's passing, at which time they were informed that R2 had not been admitted to hospice as family had declined. LPN O stated that she then referenced facility report sheet and noted that R2 was indicated to be a full code. LPN O stated that RN/FNS C also texted back at about the same time, confirmed that R2 was a full code and that compressions should be initiated and 911 called. LPN O stated that although she had confirmed R2 to be a full code, had received direction to start compressions and call 911, that she did not activate a code, start compressions, or call 911 as thought that it was too late to initiate CPR as it had been over 30 minutes since the time that R2 was first noted to be unresponsive. LPN O stated that as she was trying to tie up loose ends with R2 including offering to call family, physician, and assuring postmortem care had been completed, DON B and then Nursing Home Administrator (NHA) A arrived to unit and took over. LPN O stated that she reentered R2's room well after 8:00 AM to assure that R2 was presentable, that postmortem care had been completed, and that room was tidy when she noted RN H at R2's chest starting compressions and DON B placing the AED. LPN O stated that she stood by to offer assistance at which time DON B instructed her to assume chest compression which she did until EMS (Emergency Medical Services) arrived. Upon conclusion of telephone interview, LPN O stated that in retrospect she should have checked the report sheet provided to her by the off going nurse on [DATE] at 7:00 PM that indicated that R2 was a full code but reiterated that as she thought R2 was receiving hospice care as had terminal prostate cancer, assumed that he was a DNR and that verifying R2's code status in his medical record never crossed her mind. In a telephone interview on [DATE] at 4:16 PM, Registered Nurse/Former Night Supervisor (RN/FNS) C stated that she was the assigned nurse on the first floor of the facility on the night shift of [DATE]. RN/FNS C stated that as she was providing report to the day shift nurse at approximately 7:30 AM on [DATE], she received a text from LPN O that R2 had passed away. RN/FNS C stated that she did not respond to the text as she had been in the middle of report, finished report, left facility and that approximately 10 to 15 minutes later texted LPN O back to inquire about R2's code status. RN/FNS C stated that LPN O texted right back stating that he was a full code and that she then replied that if he was a full code that compressions must be started and 911 called. RN/FNS C stated that LPN O did not respond following the directive to initiate compressions. RN/FNS C stated that she called DON B at approximately 7:50 AM on [DATE], informed her that she had been notified that R2 had passed away, had initially thought that he was a DNR but had since confirmed with LPN O that he was a full code, but that LPN O had not responded to the final text and was not certain that CPR had been initiated. In an interview on [DATE] at 2:31 PM, Director of Nursing (DON) B stated that the expectation upon observing a resident to be unresponsive would be to first verify code status via the EMR (electronic medical record) and that if an individual was determined to be a full code, code blue would be activated within that resident's room, CPR would be initiated, and crash cart and AED obtained. DON B confirmed familiarity with R2, stated that on [DATE] at approximately 8:11 AM was notified by RN/FNS C that R2 had expired, that he was a full code, and that she was not sure that CPR had been initiated. DON B stated that she was enroute to facility at that time, arrived to facility at approximately 8:20 AM, went to unit, did not observe CPR in process, discussed with RN H and LPN O for better understanding of situation, referenced R2's chart with full code status verified and directed RN H and LPN O to start CPR. DON B stated that as she was under the impression that RH H and LPN O were going to initiate CPR, called Nursing Home Administrator A to notify of situation. DON B stated that RN H had not initiated CPR, disputed decision that CPR should be initiated as in her view R2 was deceased , cold, and too much time had passed and that she could not understand the rationale as to why CPR would now be initiated. DON B stated that R2's physician was called at 8:40 AM, advised of situation, and that he provided order to initiate CPR. DON B stated that RN H was again advised to initiate CPR, that RN H remained hesitant as stated that R2's spouse knew he was end of life and would not want CPR initiated. DON B stated that she then called spouse and left message at approximately 8:45 AM, instructed RN H again to start CPR and that she called 911. DON B stated that she then entered R2's room at 8:53 AM, observed RN H to begin chest compressions and that she applied AED and provided rescue breaths. Upon conclusion of interview, DON B stated that in hindsight she would have initiated CPR after arriving to unit and validating R2's full code status at approximately 8:25 AM but that as R2 had initially been observed without pulse or respirations at 6:55 AM, did not believe that the outcome would have been any different. In an interview on [DATE] at 3:30 PM, Nursing Home Administrator (NHA) A stated that code status was reviewed with each resident/family at admission, code status order was written, and that when a resident was determined to be unresponsive, code status would be checked in the EMR, CPR initiated for a full code, and the in-room code activated. NHA A stated that R2's hospital referral information had indicated that he was a DNR and was receiving hospice services but upon admission to facility, spouse had changed her mind, declined hospice services and that R2 was a full code. NHA A stated that she received a call from DON B on [DATE] at approximately 8:35 AM, was updated regarding confusion over R2's code status, and informed DON B that if R2 was a full code that CPR must be initiated, and EMS called. NHA A stated that she arrived to the unit at approximately 8:50 AM, observed DON B to be on the phone with R2's physician, and RN H at the medication cart. NHA A stated that DON B confirmed R2's full code status with her and that she then notified RN H that R2 was a full code, and that CPR must be initiated. NHA A stated that she obtained the crash cart and that DON A, RN H, and LPN O entered R2's room and initiated CPR. NHA A confirmed that R2 was initially noted to be unresponsive at 6:55 AM but that CPR was not initiated until 8:53 AM and that the expectation would have been that when R2 was initially noted to be unresponsive at 6:55 AM, that his code status should have been verified in the EMR, CPR initiated, code activated, and EMS called. According to the American Heart Association, CPR-or Cardiopulmonary Resuscitation-is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest .Out-of-hospital Chain of Survival .Recognition of cardiac arrest and activation of the emergency response system, Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, Rapid defibrillation, Advance resuscitation by Emergency Medical Services . (https://cpr.heart.org/en/resources/cpr-facts-and-stats/) Review of the facility policy (in place at the time R2 was observed to be unresponsive) titled CPR dated [DATE] stated, Policy: Upon admission a Scope of Treatment declaration specifying administration or withholding CPR interventions will be completed for each resident. It is the guiding principle of (name of facility) to respect each individual's informed decision regarding advance directives and code status. (Name of facility) ensures that there is at least one qualified American Heart Association (AHA) certified person capable of carrying out cardiopulmonary resuscitation (CPR) in the facility at all times. (Name of facility) must provide basic life support including, initiating CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the resident's advance directives .CPR will be initiated for residents who have requested CPR .Procedure .The admitting nurse will write a physician order indicating code status preference .4. In the event a resident goes/is found unresponsive and upon a thorough circulation, airway and breathing assessment determines that there is no pulse or respiratory activity AND the resident is declared a full-code status or code status unknown that staff member will activate/announce a code blue . During onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1) Investigation initiated immediately. 2) All residents with full code status have the potential for being affected. 3)All residents currently in facility had code status reviewed and verified the code status matched the order. 4) All residents currently in facility were reviewed for the presence of any wristbands, any found were removed. 5) Nurses involved were immediately provided with verbal education regarding the initiation of CPR. 6) All nurses on duty were reeducated on CPR, following code status orders, and actions when a resident is found unresponsive. 7) Every nurse was educated at the beginning of the shift there after. 8) The Code Status Protocol Policy was reviewed and revised. 9) Mock code drill performed on 9-6-23. Monitoring to ensure compliance: 1) Mock code drills to continue weekly x4, then monthly x3. Results presented at QAPI for review and improvement opportunities. 2) All newly admitted residents will be evaluated for wristbands at admission and any found will be removed. 3) Accuracy of code status for new admissions will be audited weekly x4, then monthly x 3. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00132620 Based on observation, interview, and record review, the facility failed to ensure appropriate monitoring of blood glucose (sugar) levels and ensure insulin was administered according to physician's orders for one (Resident #494) of 20 reviewed for quality of care, resulting in insulin not being administered per physician's orders and hospitalization. Findings include: Review of the medical record revealed Resident #494 (R494) admitted to the facility on [DATE] with diagnoses that included atrial flutter, acute kidney failure, hypo-osmolality and hyponatremia, type 2 diabetes, congestive heart failure, epilepsy, anxiety, and long term use of insulin. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/22 revealed R494 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R494 was transferred to the hospital on [DATE] and did not return to the facility. In a telephone interview on 3/7/23 at 11:38 AM, Family Member (FM) I reported R494 was admitted to the facility with a Freestyle continuous glucose monitor, but that the facility was not familiar with the device so staff used the facility's glucometers to monitor R494's blood sugar levels. FM I reported R494 was sent to the hospital on [DATE] and when she checked R494's Freestyle glucose monitor, R494's blood sugars had been 600 all weekend. FM I reported when R494 arrived to the hospital, her blood sugar level was over 1000. A Freestyle Libre includes a small sensor applied to the back of the upper arm with a small tip that is inserted just under the skin. The sensor continuously measures and stores glucose readings. A smartphone app is used to track glucose levels. (https://www.freestyle.[NAME]/us-en/what-is-cgm.html) Review of the Clinical admission Evaluation dated 10/25/22 revealed R494 had a glucose meter patch to posterior left arm (placed 10-23 and good for 2 weeks, family to provide replacement) .Declared valuables on admit: Glucometer and charger . Review of the Physician's Order dated 10/25/22 revealed Okay to use client's glucose meter (Freestyle Libre) to monitor blood glucose. Ensure device is charged at night. There was no order to change the monitor after 14 days. The Physician's Order dated 10/25/22 revealed Humalog (short acting insulin) 5 units was to be given before meals for blood sugars of 100-150. If the blood sugar was over 150, the sliding scale was also to be administered. The Physician's order dated 10/25/22 revealed R494's Humalog sliding scale was as follows: 0-200 (blood sugar level) = 0 units (of Humalog) 201-250 = 2 units before meals 251-300 = 4 units before meals 301-350 = 6 units before meals 351-400 = 8 units before meals 401+ Call physician There was no documentation regarding the discrepancy of the scheduled Humalog order indicating the sliding scale started for levels over 150 and the order for sliding scale Humalog starting for levels over 200. On 10/29/22, R494's Lantus (long-acting insulin) was changed from 17 unit daily to 19 units daily. Review of the facility's mealtime provided at survey entrance revealed breakfast was served between 8:00 AM-9:15 AM, lunch was served between 12:00 PM-1:15 PM, and dinner was served between 5:00 PM-6:15 PM. Review of the Medication Administration Records (MARs) revealed R494's blood sugar checks and Humalog insulin was schedule for 7:30 AM, 11:30 AM, and 4:30 PM. The Lantus was scheduled to be administered daily at 9:00 AM. Review of R494's Blood Sugar Summary and MARs revealed the following documented: On 11/5/22 at 12:03 PM, R494's sugar was 243. This was recorded on the MAR in the section for 7:30 AM. On 11/5/22 at 2:18 PM, R494's sugar was 364. This was recorded on the MAR in the section for 11:30 AM. On 11/5/22 at 5:49 PM, R494's sugar was 231. This was recorded on the MAR in the section for 4:30 PM. On 11/6/22 at 8:22 AM, R494's sugar was 253. This was recorded on the MAR in the section for 7:30 AM. On 11/6/22 at 12:30 PM, R494's sugar was 198. This was recorded on the MAR in the section for 11:30 AM. On 11/6/22 at 6:14 AM, R494's sugar was 266. This was recorded on the MAR in the section for 4:30 PM. On 11/7/22 at 07:48 AM R494's sugar was 380. Review of the Location of Administration Report revealed the following late insulin administration times: On 10/29/22 the two Humalog doses (routine and sliding scale) scheduled for 7:30 AM were given at 9:54 AM and 9:55 AM. On 10/29/22 the two Humalog doses scheduled for 11:30 AM were given at 12:52 PM and 12:53 PM. On 10/30/22 the two Humalog doses scheduled for 11:30 AM were given at 12:59 PM and 1:01 PM. On 11/1/22 the two Humalog doses scheduled for 7:30 AM were given at 9:08 AM. On 11/1/22 the two Humalog doses scheduled for 4:30 pm were given at at 5:52 PM and 6:00 PM. On 11/5/22 the two Humalog doses scheduled for 7:30 AM were given at 11:39 AM and 12:04 PM. On 11/5/22 the Lantus scheduled for 9:00 AM was given at 11:27 AM. On 11/5/22 the two Humalog doses scheduled for 11:30 AM were given at 2:18 PM and 2:20 PM. On 11/5/22 the two Humalog doses scheduled for 4:30 PM were given at 5:49 PM. On 11/6/22 the two Humalog doses scheduled for 7:30 AM were given at 8:22 AM and 8:24 AM. On 11/6/22 the two Humalog doses scheduled for 4:30 PM were given at 6:14 PM and 6:16 PM. There was no documentation as to why R494's blood sugars were checked, and insulin administered after scheduled mealtimes. Review of the laboratory results dated [DATE] at 6:04 AM revealed R494's blood glucose was a critically high level of 756 mg/dL (milligrams per deciliter). Normal values were 70-100 mg/dL. The facility's documented blood sugar level on 11/7/22 at 7:48 AM was 380. Review of the Progress Note dated 11/7/23 at 9:29 AM revealed Notified MD [physician] observed patient having Altered mental status symptoms. Ordered to sent [sic] patient out to hospital .Patient left facility at 9:25 AM . The laboratory called the facility on 11/7/22 at 11:51 AM (after R494 transferred to the hospital) to report the critically high laboratory results. There was no documentation as to why there was such a large discrepancy between the laboratory sample that was drawn at 6:04 AM and the facility's level that was checked at 7:48 AM. Review of R494's hospital records dated 11/7/22 revealed R494 was admitted to the hospital for HHS (Hyperosmolar hyperglycemic state)/DKA (Diabetic Ketoacidosis). The hospital records revealed Vital signs in ED include temperature 36.5 (Celsius), heart rate 59, respiratory to 25, blood pressure initially of 94/45 then improved to 128/50 and oxygen saturation at 98% on 3 L nasal cannula (No O2 at home) .blood glucose of >999 .transferred to the ICU for management of insulin drip . High anion gap metabolic acidosis .likely secondary to combination of HHS, starvation ketoacidosis, lactic acidosis. Patient presents from [name of facility] where patient may not have been given timely medication and may have developed HHS with acute encephalopathy leading to starvation ketoacidosis .upon arrival glucose reading was >999. According to the Centers for Disease Control and Prevention (CDC), .Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening .DKA develops when your body doesn ' t have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body .Causes of DKA Very high blood sugar and low insulin levels lead to DKA. The two most common causes are .Illness .Missing insulin shots, a clogged insulin pump, or the wrong insulin dose . (https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html) According to the Cleveland Clinic, Hyperosmolar hyperglycemic state (HHS) is a life-threatening complication of diabetes - mainly Type 2 diabetes. HHS happens when your blood glucose (sugar) levels are too high for a long period, leading to severe dehydration and confusion. HHS requires immediate medical treatment. Without treatment, it can be fatal. (https://my.clevelandclinic.org/health/diseases/21147-hyperosmolar-hyperglycemic-state#:~:text=Hyperosmolar%20hyperglycemic%20state%20(HHS)%20is%20a%20life%2Dthreatening%20complication,treatment%2C%20it%20can%20be%20fatal.) The Progress Note dated 11/8/22 revealed Writer and additional manager called and spoke with client's daughter about questions and concerns that were raised after her mother was sent out to the hospital .daughter had requested her coat and freestyle libre [glucose monitor] be sent with her to the ED [Emergency Department]. Daughter had asked for clarification on blood sugar checks throughout the weekend. Writer reviewed numbers that were documented .Client's daughter stated that her freestyle Libre was reading high throughout the weekend. Writer informed daughter that when there was a question about the accuracy of the Freestyle libre the nurses checked a finger stick for blood sugar levels and treated per order with insulin. Writer also reviewed labs that were drawn on day of hospitalization. In an interview on 3/7/23 at 2:20 PM, RN/Unit Manager (UM) F reported she spoke with R494's daughter on 11/8/22. UM F reported if she remembered correctly, the nurse was double checking R494's sugar levels with the facility's glucometer because the nurse questioned the accuracy of the Freestyle Libre. UM F stated our numbers differed from what the Freestyle said. UM F reported on 11/4/22 R494's laboratory drawn glucose level was 392 and on 11/7/22, it was 756. UM F reported R494's Humalog insulin was scheduled before meals at 7:30 AM, 11:30 AM, and 4:30 PM, but staff had an hour window either way, indicating the insulin could be given as early as 6:30 AM, 10:30 AM, and 3:30 PM or as late as 8:30 AM, 12:30 PM, and 5:30 PM. When asked about the accuracy of the facility's glucometer and quality controls, UM F reported quality controls on glucometers were performed weekly on midnights. UM F reported the logs were kept in the controlled substance sign out books. UM F was unable to locate any quality control logs on the second and third floors of the facility. Review of the glucometer quality control binders at each of the nurse's station on the first floor revealed one binder did not have any documented quality controls and the other binder had two documented quality controls on 12/16/2017 and 1/1/2018. There were no further documented quality controls. On 3/6/23 at 4:31 PM, Registered Nurse (RN) J performed a blood glucose check on a resident. The glucometer strips had an opened date of 2/20/23. When asked about quality controls, RN J reported night shift performed the quality controls and that they were never performed at any other time. RN J reported if the glucose levels seem to be off, she would get a new glucometer. On 3/7/23 at 7:58 AM, RN K reported the facility performed quality controls on glucometers every 30 days, however RN K was not able to verbalize the procedure. On 3/7/23 at 2:06 PM, RN K reported she educated herself on the process. RN K reported quality controls should be performed each time a new bottle of strips was opened, the glucometer was dropped, or the glucometer seemed to not work properly. Two unopened boxes of quality control drops were observed in the medication room. RN K reported there were no quality control logs. In an interview on 3/7/23 at 1:54 PM, Licensed Practical Nurse (LPN) C reported she believed night shift performed the glucometer quality controls. LPN C was unable to find any further documented quality controls. In an interview on 3/7/23 at 2:17 PM, LPN L reported she did not know how to perform quality controls on the glucometers. In an interview on 3/7/22 at 3:02 PM, Director of Nursing (DON) B reported glucometer quality controls should be performed daily on night shift. When asked where the quality controls were documented, DON B reported she would have to check with the Unit Manager. In a telephone interview on 3/7/23 at 4:19 PM, LPN M reported dayshift had never performed quality controls on glucometers and believed it was a nightshift task. LPM M reported she recalled a resident with a continuous glucose monitor that would report the levels to a phone. LPN M reported she documented those numbers in the medical record instead of using the facility's glucometer. LPN M reported on 11/7/22, R494's sugar level was reading high on the Freestyle Libre and R494 had to be transferred to the hospital. LPN M reported when she checked R494's sugar with the facility's glucometer, the level was in the 300s. LPN M reported R494 was not her normal self around 8:00 AM on 11/7/22 and stated, something was wrong. In a telephone interview on 3/8/23 at 9:13 AM, RN N reported she was not aware of the facility's process of quality controls on glucometers. RN N reported she knew there were testing strips and solution but was not aware of how to perform or when to perform quality controls. When asked about late blood sugar checks and insulin administrations for R494, RN N reported there were always concerns with the heaviness [of the workload] of certain sections which caused issues with blood sugars and insulin administration. RN N reported she had to administer insulin late because the workload was too heavy. RN N reported there were also times when lunch trays were not served until 1-1:30 PM and then dinner was served at 5:00 PM. RN N reported R494's insulin was obviously late if it's documented on the MAR like that. In a telephone interview on 3/8/23 at 10:36 AM, LPN P reported it was a struggle to get meds [medications] and assessments done on time. LPN P reported on weekends there were always scheduling issues to deal with in the middle of medication pass which resulted in late medication administrations. LPN P reported they were not familiar with the Freestyle Libre, yet they had cared for R494. Review of the facility's glucometer (Assure) Quality Assurance/Quality Control (QA/QC) Reference Manual revealed You should check your meter and test strips using Assure Prism Control Solutions (Control 1 and 2). Assure Prism Control Solutions contain known amounts of glucose and are used to check that the meter and the test strips are working properly .Before using a new meter or a new vial/box of test strips, you should conduct a control solution test following the procedure with two different levels of solutions (Control 1 and 2) .You should do a control solution test: -To practice the test procedure using the control solution instead of blood. -When using the meter for the first time. -Whenever a new vial of test strips or box of individually wrapped test strips is opened. -If the meter or test strips do not function properly. -If the patient's symptoms are inconsistent with the blood glucose test result and you feel that the meter or test strips are not working properly. -If the meter is dropped or damaged. In an interview on 3/8/23 at 1:01 PM, DON B reported when R494 was admitted to the facility, it was the first time she or any of the nurses had a resident with a Freestyle Libre continuous glucose monitor. DON B stated, We didn't have a policy and procedure for that. DON B reported she decided the facility would use their own glucometers instead of using R494's Freestyle Libre so that staff would not have to access R494's smartphone. When asked if the Freestyle Libre sensor/monitor was changed after 14 days, DON B stated, couldn't tell you. DON B reported staff had an hour leeway for medication administration and was not sure why R494's glucose was checked, and insulin was given late, after meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00129402. Based on interview and record review, the facility failed to ensure residents were free from significant medications errors in one of 5 reviewed for medication regimen review (Resident #93), resulting in medication order changes, laboratory blood draws, intravenous fluids, and weight loss. Findings include: Resident #93 (R93) In review of R93's Minimum Data Set (MDS) assessment dated [DATE], he was [AGE] years old, was admitted to the facility on [DATE], had severely impaired cognition, his pain was assessed based on non-verbal sounds (crying, gasping, moaning). R4 had a diagnosis of stroke, seizure disorder, communication deficit, and high blood pressure. R93's MDS dated [DATE] revealed his death occurred in the facility. Physician Order for R93 dated 2/28/22 revealed Oxycodone Hydrochloride (HCl) (opioid) solution 5 milligrams (MG)/5 milliliters (ML), give 5 mg by mouth every 4 hours for pain; order to hold medication from 03/07/22 at 5:52 PM to 03/08/22 5:51 PM. In review of a Medication Error incident report dated 3/07/22 at 4:58 PM, R98 received a greater dose than ordered on 4 occasions by 2 different nurses. The same report indicated the nurse had received a code from the pharmacist to remove oxycodone medication from the back-up supply; R93's oxycodone order was a different concentration than what was available in the back-up pharmacy supply. Nurses progress note dated 3/07/22 at 5:41 PM revealed after looking closer at the oxycodone bottle and R93's order, she had noticed R93 had received a larger dose than ordered for 4 doses. The same noted indicated the pharmacist and physician were notified; orders received to hold oxycodone and monitor respiratory status. The same noted indicated R93's respiration rate was 16 (normal 12 to 20 breaths per minute). Controlled Substance Proof-of-Use Record dated 3/07/22 revealed a handwritten order under R93's name: oxycodone HCL oral solution 100 mg/5 ml, 20 mg/5 ml; Give 1 teaspoonful (5 mg) by mouth every 4 hours. The same form indicated on 3/ 07/22, R93 received 5 ml of oxycodone HCL at 1:55 AM, 5:45 PM, 8:00 AM, and 1:00 PM. R93 received 400 mg of oxycodone HCL over an 11-hour period (R93 should have received 20 mg of oxycodone). The same form indicated R93 received 100 mg of oxycodone HCL at 5:45 AM, and received another dose at 8:00 AM, less than 4 hours between doses. The 3/07/22 dose at 8:00 AM was given 2 hours and 15 minutes between doses. Medication Error incident report dated 3/07/22 at 4:58 PM did not indicate the medication was also administered at the wrong time. Nurses Progress Note dated 3/08/22 at 5:00 AM indicated the physician was notified, one time Reglan (speeds up muscle movements in gut to relieve stomach related symptoms) was ordered and administered. A chest x-ray was ordered. R93's respirations were irregular, 10 to 11 breaths per minute. Lung sounds were abnormal. Interdisciplinary team note dated 3/08/22 at 7:49 AM indicated a medication dose error noted, R93 was at baseline with minimal verbal communication, minimal signs and symptoms of pain or discomfort. Root cause of medication error was a discrepancy in dosage from order and back up from pharmacy. Interventions/follow up included increased monitoring, and STAT labs ordered. Interdisciplinary Note dated 3/09/22 at 10:59 AM indicated R93 had weight loss at 3.6 percent (%) over 7 days, loss due to poor oral intake (average less than 25 % of meals) and discontinuing his tube feeding. The same note indicated R93 current body weight was 124.8 pounds. Physician Progress Note dated 3/10/22 revealed R93 had inadvertent overdose of oxycodone over the weekend due to a change in formulation from 5 mg/5 ml to100 mg/ 5 ml. Opiate was held initially and was resumed only as needed. The same note indicated R93 was less alert on 3/10/22, and it was suspected that it was related to decreased nutrition, fluids, and medications. R93's potassium level was low on this same day and potassium medication was increased on 3/10/22. The same note indicated the physician spoke with the dietician about carefully resuming tube feeds at a slow rate and ramp up carefully over the weekend and next week, watching for aspiration. Plan was to follow daily labs and monitor for electrolyte abnormalities/re-feeding syndrome. The 3/07/22 Medication Error report indicated as a result of the oxycodone overdose, R93 had orders for a laboratory blood draws, chest x-ray for aspiration concern, abdominal x-ray for nausea and absence of urine/bowel movement, intravenous fluids were administered, and continued resident monitoring. Registered Nurse (RN) J was interviewed on 3/08/23 at 11:02 AM and recalled the night shift nurse received an order from an on-call physician and removed the medication from the pharmacy back up. The night nurse wrote information on the control sheet of how much to give. The oxycodone dose was different than what the facility normally used. Director of Nursing (DON) B was interviewed on 3/08/23 at 1:31 PM and stated there had been no educational in-services on medication error prevention since she was DON (hired 8/01/22). DON B indicated performance reviews and competencies were to be completed annually but had not completed any yet since date of hire. Any recent medication pass observations/education was requested from DON B at this same time. DON B provided a medication pass quiz for RN J that was not dated. In review of RN J employee file, the last medication pass observation was completed on 1/21/21.