**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 (R4) Review of an admission Record revealed Resident #4 (R4) admitted to the facility on [DATE] with pertinent diagnoses which included osteomyelitis, multiple sclerosis, hypertension, anxiety, and major depressive disorder. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/2/22, reflected R4 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R4 required extensive assistance of two or more people person to toilet, transfer, dress and for bed mobility. R4 no longer resided in the facility. Review of R4's Wound assessment dated [DATE] revealed R4 admitted to the facility with a Stage 4 Sacral Pressure Ulcer that measured 32.57 centimeters (cm) x 7.62 cm x 5.91 cm with the depth of the wound measuring 2.2 cm. Treatment for the Pressure Ulcer included continuous wound vacuum therapy. Review of a Nurse's note dated 1/3/23 at 2:18 PM revealed Resident [R4] VS [vital signs] out of normal range today. NP [Nurse Practitioner] Nurse Practitioner (NP) D asked for VS [vital signs] to be monitored frequently. Resident wife arrived asking for resident to be sent out. Resident diaphoretic, Tachypneic, hypotensive and tachycardic. NP [nurse practitioner] notified of wife's request to send resident out to ER [emergency department] at 1350 [1:50 PM]. DON [Director of Nursing] notified at 1352 [1:52 PM] of same. [Local transportation service] notified of need for transfer at 1354 [1:54 PM]. Stated they had no units and would turn call over to [Local Emergency Medical Service] arrived at 1410 [2:10 PM] and departed at 1420 [2:20 PM] enroute to [Local Emergency Department] for eval [evaluation] and treatment . Review of a Physician Note dated 1/3/23 revealed a [AGE] year-old male with chronic medical conditions including MS [multiple sclerosis], sacral decubitus ulcer, overall decline since his most recent hospitalization. Staff notes patient had a temperature yesterday evening T-max 102.1. T-max today 101.1. Staff notes COVID negative. Staff reports patient is otherwise stable and patient continues to tolerate room air. Staff reports patient is tolerating Foley catheter. Patient is a questionable historian, however, he is able to respond to direct question. He reports he does not feel well. He notes he has a cough. He denies chills/fever. Staff notes poor oral intake .COVID negative. I will order stat labs CBC, CMP as well as stat radiology to do chest x-ray. UA pending .We will continue to monitor closely, q.[every] hour vital signs. Increase fluid if able. Patient is high risk for decompensation. Review of the Electronic Medical Record revealed the following vital signs: 1/2/23 7:21 PM 102.1 degrees Fahrenheit temperature; 146 / 100 Blood pressure 1/3/23 5:02 AM 101.1 degrees Fahrenheit temperature; 118/76 blood pressure 1/3/23 9:29 AM 98.0 degrees Fahrenheit temperature; 116/71 blood pressure The last set of vital signs was obtained at 9:29 AM which indicated no evidence of frequent monitoring of R4's vital signs as requested by Nurse Practitioner D. In an interview on 4/11/23 at 2:10 PM, Family Member (FM) E reported R4 went to the wound clinic about once a month for management of his sacral pressure ulcer. Family Member E reported that she visited R4 almost every day and at times she would come in and discover that R4's wound vacuum was not operating because the staff could not get the wound vacuum to seal so they wouldn't put it back on or she would observe the wound vacuum unplugged. FM E reported that the wound vacuum unit that R4 had could not hold a charge so in order to be functional, R4's wound vacuum had to be plugged in at all times. FM E reported that the day of 1/3/23 she had called the facility multiple times in an attempt to speak to R4 but did not get an answer from the facility, so FM E got around and went up to the facility to visit R4. Upon arrival to R4's room, FM E stated she recognized immediately that something was wrong with R4 because he was not able to answer FM E or recognize her, which was abnormal from his baseline. FM E inquired with the nurse in charge and was told that the nurse in charge was in contact with the doctor and the doctor reported to just monitor [R4] every half hour. I said absolutely not . send him to the hospital . FM E stated that the wound vacuum was not running when she arrived at the facility on 1/3/23 and that it had been off for a few days. FM E also stated that the reservoir on the wound vacuum had dark, dried blood in it and the wound smelled terrible, it made [R4'S] entire room smell terrible. Review of the Patient Care Record dated 1/3/23 at 2:09 PM obtained from the local Emergency Medical Service that assessed and transported R4 to the local Emergency Department revealed Upon arrival [staff] reports the patient is being sent to the ER (Emergency Department) because [R4'S] vital signs have been changing often which is abnormal for the patient. Staff reports the males wife (FM 'E') has requested he is sent out of the facility. Staff states the male has been diaphoretic today and is concerned this may be due to his changing vital signs. Upon making contact with the patient [R4], patients family reports that the patients [R4] wound vac (vacuum) has not been turned on as it is supposed to and feels that the patients wound now has an odor to it .Patient (R4) appears to be unbathed and appears to have dried vomit on his face. Patients (R4's) sheets are also saturated. Family reports the patient is in the facility for osteomyelitis of his vertebrae which is why the patient has a wound vac (vacuum). Family states the patient is usually alert and oriented x4 and has found today that he is not oriented and not acting like himself .Patient alert and not oriented. Patient displays stupor and is found to be diaphoretic, pale and with skin hot the the [sic] touch. Patient displays labored breathing .patients wound vac (vacuum) is found with a small amount of dried blood that is almost black in color inside of the vac (vacuum) reservoir . R4 was transported Priority 2. Review of the same Patient Care Record revealed R4 had the following vital signs: 2:25 PM- 151/128 Blood Pressure, 110 Pulse, 24 Respiratory Rate, 82 percent oxygen saturation on room air, 101.5 degrees Fahrenheit temperature 2:25 PM- 151/128 Blood Pressure, 110 Pulse, 24 Respiratory Rate, 101.5 degrees Fahrenheit temperature Review of the Medical Records from R4's 1/3/23 hospitalization revealed Upon arrival (to the Emergency Department) [R4] was hypertensive with the blood pressure of 170/120, a heart rate of 120 . and an oxygen saturation of 82 percent on room air . Patient has had a cough .also has a wound to his coccyx and is supposed to have a wound vac (vacuum) but has not been turned on for the last two days according to the [family member E] who was at the nursing home. She requested transfer to the hospital due to his altered mental status. The physical exam revealed mucous membranes dry, core temperature was obtained . and was 39.8 (103.6 degrees Fahrenheit) rectally after evaluation I (emergency room Physician) am most concerned about sepsis .his white (blood) cell count was over 26,000 .his chest x ray shows bilateral pneumonia . patient has acute kidney injury with a significantly elevated creatine (indicating that the kidneys were not working as well as they should) .also has this infected wound . R4 was admitted to the local hospital in critical condition with diagnoses that included Septic Shock, Urinary Tract Infection, Pneumonia, Acute Kidney Injury secondary to dehydration, acute encephalopathy (permanent or temporary brain damage, disorder, or disease), acute hypoxic respiratory failure (not enough oxygen in your body or too much carbon dioxide), and lactic acidosis. Review of the Wound Consultation Notes from the same Medical Records revealed R4 had new necrotic tissue in the wound bed that was not present in the photographs from the prior wound clinic visit that occurred on 12-29-22 and a foul odor coming from the wound. Upon arrival to the Emergency Department, it was noted that the wound was assessed and discovered fecal matter in the wound. R4 underwent a wound debridement of his sacral pressure ulcer during his hospitalization. Review of the same medical records revealed R4 became hemodynamically unstable shortly after arrival to the local Emergency department. R4 required vasopressor medications (medication to elevate blood pressure) and a central venous catheter (a long, flexible tube your provider inserts into a vein in your neck, chest, arm or groin. It leads to your vena cava, a large vein that empties into your heart) in an attempt to ensure R4 stabilized medically. In an interview on 4/12/23 at 11:15 AM, Registered Nurse F reported that R4's wound vacuum would often give staff members trouble with both battery issues and issues with getting the vacuum to seal over the sacrum wound. RN F reported that the wound vacuum would not hold a charge and required to be always plugged in to remain powered on. RN F reported that a couple of times R4 would return from his Wound Clinic appointments and staff would not notice it so the Wound Vacuum would not get plugged back in and powered on. This would go unnoticed for a few hours. RN F also reported that she observed fecal matter in R4's sacrum wound a couple of times. In an interview on 4/13/23 at approximately 11:30 AM, LPN G reported that R4's wound vacuum was difficult to keep in place .we had some newer nurses and some of them didn't know how to do them (wound vacuum). (R4) was bowel incontinent and the stool would go right up underneath the plastic which would loosen the seal . at times it lost suction and the staff would have to redo the dressing change. LPN F also reported that it would take up to 40 minutes to complete R4's dressing change. When asked if staff had any additional education regarding the wound vacuum, LPN F stated that she had gone through several classes specific to wound vacuums but none at the facility. No classes on wound vacuums or additional education were offered at the current facility. LPN F also reported that if she has a resident that looks like they are feeling ill, best practice is to send the resident out to the hospital. We can't diagnose them so send them out, I'm not going risk their lives because someone doesn't want to send them out . if the resident needs to be sent out emergent, I would not use (transportation ambulance service) them at all, I would call 911 . In an interview on 4/13/23 at 2:24 PM, Director of Nursing B was unsure if a head-to-toe assessment was performed on R4 the day he was requested to be sent out to the hospital or who may have performed the head-to-toe assessment. In an interview on 4/12/23 at 12:27 PM, Paramedic H reported that the local transportation service initially contacted when R4 was requested to be sent to the hospital on 1/3/23 is used just for transport, they can't do EMS (emergency medical services). [The local transport service] can be contacted for any kind of Priority 3 calls or scheduled transfers, but anything that requires urgent/emergent response, those types of calls would require EMS services. Review of the Tri-County Emergency Medical Control Authority Systems Protocol dated 3/1/13 revealed Priority One and Priority Two patients are for patients whose conditions could reasonable be expected to worsen without immediate intervention. Priority 3 would be reserved for non-life-threatening calls. Resident #5 Review of an admission Record revealed Resident #5 (R5) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included urinary tract infection, acute kidney failure, malignant neoplasm of bladder, personal malignant neoplasm of prostate, major depressive disorder, and restless leg syndrome. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/19/22, reflected R5 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R5 required extensive assistance of two or more people to toilet and transfer. R5 no longer resided in the facility. R5 was admitted to a local Hospice shortly after admission to the facility. Review of a Physician Note dated 9/16/2022 at 10:47 AM revealed Staff notes patient (R5) was found to have his suprapubic catheter (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) dislodged. Staff notes patient is otherwise stable and afebrile. Staff notes Hospice is aware. Staff reports patient's nephrostomy tubes (drains urine directly from your kidney into a bag outside your body into a bag) appear to be functioning . Review of the Progress Notes revealed no other mention of an incident report and/or assessments regarding the dislodgment of the suprapubic catheter. Review of a Nurse's Note dated 9/20/23 at 6:53 AM revealed R5 was observed on the floor next to bed. Resident was assisted back into bed. No injuries . Review of the Progress Notes revealed no mention of an assessment to ensure the patency of the suprapubic catheter and/or the nephrostomy tubes. Review of a Physician Note dated 10/3/2022 at 12:34 PM revealed Patient (R5) was transferred to the hospital after his nephrostomy tube was dislodged. Patient was found to have lactic acidosis and leukocytosis, he was started on empiric antibiotics, he was also given blood transfusion for anemia. Patient is currently under Hospice care . His nephrostomy tube was replaced. He was transitioned to oral antibiotics and discharged back to our facility . Review of the Care Plan revealed that R5 had no Care Plan implemented for the nephrostomy tubes. Review of the Physician Orders revealed R4 had an order in place since admission to change the drain sponges on both nephrostomy tubes daily as well as an order to clean and change the split 4 x 4 dressings on R4's suprapubic catheter daily and as needed. In an interview on 4/10/23 at 12:23 PM, Hospice Nurse Practitioner (NP) K reported that the lack of care for R4 was very concerning. We attempted to have several care conferences with the facility, but we never actually ever were able to meet in person with the Director of Nursing (DON), I only spoke with her on the phone about wanting to set up a care conference but it never happened. We had several meetings with staff at the facility regarding providing adequate care for R4, especially his nephrostomy tubes. [R4] had multiple ER [Emergency Department] trips for dislodges tubes. Often times, we [Hospice NP and RN] would arrive and [R4] would have no dressing on his nephrostomy or suprapubic tubes and he would be sitting in stool with his bed saturated in urine. The urine would be there for so long that at times, the urine would be dried on the sheets. [R4] should not have been in this condition. On one occasion one nephrostomy tube was leaking and been pulled out and the aide [Certified Nursing Assistant] said she had notified the nurse a couple days ago. We evaluated it and at that time there was an actual dressing on it [the nephrostomy tube] because I put it on during a previous visit and dated it . I know one time I had the DON at the meeting, it was actually someone that was sitting in for the DON at the time, I had him come down and provided education on how to appropriately dress these nephrostomy tubes which was a daily clean and change, several days later that date was still on the dressing. It was saturated, the [nephrostomy] tube was pulled out and not in position. We had to send [R4] to the ER. I saw [R4] way more often than I typically do just because of everything that was going on. Before care conferences we [hospice staff] would have to come in and spend a good 20 to 30 minutes getting [R4] cleaned up to get him ready up for his wife. The bed linens were constantly soaked and [R4] would be sitting in soiled briefs. I spoke to the DON about doing check and changes, the additional visits that myself and the nurses made because the facility wasn't doing care and tried to educate the facility so we could collaborate to give him the best care. I've been in several facilities, and this is the worst I've ever seen. Review of the Hospice Notes for R4 dated 9/28/22 revealed had just left facility care conference with social worker, LPN (Licensed Practical Nurse) filling in for Nursing Manager, Activities Director, Hospice Social Worker, Hospice Nurse Practitioner, and patients wife along with two advocates .our concerns were addressed with patient not being given the care that he needs, especially with dressing changes for the suprapubic and the nephrostomy tubes. Multiple disciplines have all been in from hospice, all stating that patient was not clean, and dressings were not on the drain sites. After the care conference Nurse Practitioner .went to patients room. Patient looked drastically different than 10 days ago when [hospice] saw him last. Patient looks thinner, pale, a beard starting to grow. Hospice nurse assessed and found he was alert and oriented to self only, 10 days earlier he was alert and oriented x 3 .patients sheets, mattress, blankets, and clothing saturated with urine. Upon further assessment discovered that right nephrostomy tube was almost an inch out from sutures and coiled . there was a scant amount of urine in right nephrostomy tube drain bag but floor RN (Registered Nurse) .was unable to confirm the last time it was drained .[hospice staff] gave patient a full bed bath, cleaned the bowel from his bottom, and did complete clothing, dressing, and bed sheet change . Review of the same Hospice Note dated 9/28/23 revealed Care conference at facility .meeting was brief as facility stated they needed to get to another meeting. Concerns were expressed about the need for daily dressing changes on the nephrostomy tubes as hospice staff have found dressings almost a week old or no dressing at all .after care conference saw PT [patient] laying in bed with no shirt on hands dirty, hair disshelved, sitting in stool and bed linens with large amount of dried urine. Assessment of right nephrostomy tube revieled [sic] a saturated dressing, removed dressing and noted nephrostomy tube was out by atleast 1in. small amount of urine in bag of right nephrostomy tube. Per aide (certified nursing assistant) she noted bed was soaked yesterday too .explained to patient and [family member] that patient needed to go to the hospital to have the right nephrostomy tube replaced . PT [patient] is AAOX1 [only recognizable to self] today, was AAOX3 [alert and responsive to their environment, and knows who they are, where they are, and the approximate time] on admission. Has not received any PRN (as needed) doses of the Morphine or Ativan. Review of a Nurse Note dated 9/28/22 at 6:02 PM revealed R5 was transferred to the hospital. Review of the Hospital Record dated 9/28/22 revealed R5 had a dislodged right sided nephrostomy tube and endorsed being in a significant amount of pain. R5 could not recall how the nephrostomy tube was dislodged. R5 had an elevated white blood cell count (indicative of infection) and blood loss anemia. R5's computed tomography imaging scans confirmed that the right nephrostomy tube was nearly completed withdrawn from the skin and the left side of R5's abdomen had fluid collection under the skin consistent with urinoma (a collection of urine under the skin). Additionally, the left side of R5's abdomen was moderately distended with concern for left sided kidney hemorrhage (bleed). R5 was also diagnoses with an acute kidney injury secondary to obstruction with the right sided nephrostomy tube being dislodged. R5 received 4 grams of Zosyn (antibiotic) for the possible peritoneal fluid infection. R5 was given three units of packed red blood cells to correct the anemia. The same Hospital Note revealed R5 was not being cared for well at the facility and the Physician noted she would work with the hospital Case Manager to find different placement. In an interview on 4/12/23 at 1:54 PM, Family Member Q stated he [R5] wasn't getting good care .they let him lay in his poop . I would come in and see and smell that he wasn't cleaned up . In an interview on 4/11/23 at 2:10 PM, Registered Nurse (RN) F reported that staffing was an issue related to R5's dressing change. When asked if staffing shortages was the issue for ensuring dressing changes were completed as ordered, RN F reported absolutely I did not have enough time to do those [dressing change]. It was difficult enough trying to get medications done on top of everything else. I did not have enough time to do the dressing changes . I would always try to do dressing changes and they would be late or just not done and I had to pass the responsibility off to the next shift. When asked if the facility provided any additional education regarding the nephrostomy and suprapubic dressing changes, RN F stated no, In an interview on 4/13/23 at approximately 11:30 AM, LPN G reported that she was aware of the concerns with Hospice regarding care and dressing changes but did not receive additional education. In an interview on 4/13/23 at 4:00 PM, Former Director of Nursing (DON) R reported that she was aware of the care concerns that Hospice brought forward to the facility. DON R reported that staff was provided additional education and competencies regarding nephrostomy and suprapubic dressing changes. Personal files including education and competencies were requested and reviewed on 4/13/23 for Licensed Practical Nurses G, R, S, T, and U, nurses that commonly cared for R5. After review of the files, it was determined that none of the aforementioned employees received any additional education related to the care of R5, including dressing changes, suprapubic tube care, and nephrostomy tube care. Resident #17 Review of an admission Record revealed Resident #17 (R17) admitted to the facility on [DATE] and readmitted to the facility on [DATE] with pertinent diagnoses which included hypertension, type two diabetes, quadriplegic, neuromuscular dysfunction of bladder, depression, and muscle weakness. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/27/23, reflected R17 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R17 required extensive assistance of two or more people person to toilet, and dress and total dependence to transfer. Review of the Electronic Medical Record revealed that R17 admitted to the facility with an indwelling urinary catheter related to the diagnosis of neuromuscular dysfunction of the bladder. Review of R17's Care Plan revealed that there was no Care Plan implemented for R17's indwelling Urinary Catheter. Review of a Nurses' Note dated 10/18/22 at 12:58 PM revealed Resident complained on [sic] burning upon urination, frequency, and has blood in urine. Contacted NP (Nurse Practitioner) Review of a Nurses' Note dated 10/18/22 at 10:37 PM revealed Resident [R17] c/o (complaining off) pain with urination. CNA (Certified Nursing Assistant) was putting resident to bed and noticed residents' penis was very swollen and notified writer. Upon examination writer noticed that the foley cath [catheter] balloon had been dislodged into the shaft of the penis. Resident did tell writer that when getting up for the day it was accidentally pulled on . Review of a Nurses' Note dated 10/20/22 at 5:02 AM revealed Resident c/o (complaining off) pain in the urethra. Observed blood in foley bag and large cloths in tubing. Urine unable to pass, changed catheter. Large clot observed in catheter that was removed . Review of a Nurses' Note dated 10/20/22 at 7:18 AM revealed resident presents with red blood in catheter, c/o (complained of) suprapubic pain, nurse from night shift changed catheter, after having no output .no output since 4am . notified doctor, advised to flush catheter again .resident requested to be sent out to the hospital. Review of the Hospital Records dated 10/20/22 revealed R17 presented to the hospital on [DATE] for [complaint] of hematuria (blood in urine) and anasarca ( severe and generalized form of edema, with subcutaneous tissue swelling throughout the entire body) of unknown etiology. Patient has a chronic foley catheter since February 2022 .patient states that he feels pain during urination and states that he had never had this problem in the past . R17 was ultimately diagnosed with hemorrhagic cystitis (bleeding and inflammation of the bladder) and underwent a procedure to have a suprapubic catheter placed (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow). Review of a Nursing Evaluation Summary Note dated 11/8/22 at 2:17 AM revealed R17 returned to the facility. Review of R17's Care Plan revealed the Indwelling and Suprapubic Catheter Care Plan was initiated on 11/9/22. Interventions included having a catheter anchor in place and maintain patency of both catheter. Review of the Physician Order's revealed there was no order set pertaining to the surgical wound care and management for R17. Review of a NP/PA Progress Note dated 11/15/22 at 10:02 PM revealed .nurse reports patient [R17] has been becoming increasingly confused for the last few days. Nurse observed yellow and greed [sic] discharge around indwelling catheter. Oxygen sat [saturation] 81% (percent). Temp (temperature) 101.7 (degrees Fahrenheit) .send to ER (Emergency Department) to be further evaluated. Review of a Nurses' Note dated 11/15/22 at 11:16 PM revealed R17 had increased confusion and had some yellow/green drainage from R17's penis and suprapubic site. The Nurses' note also revealed that there was some odor with the drainage. R17 was transferred to the Emergency Department. Review of a Physician Progress Note dated 11/16/22 at 7:27 PM revealed that R17 was evaluated at the Emergency Department and discharged back to the facility with an antibiotic. Review of the Treatment Administration Record revealed R17 had an order to cleanse suprapubic insertion site with wound cleanser; apply split gauze dressing every evening shift that was not initiated until 11/22/22, 14 days after returning to the facility with a newly surgically placed suprapubic catheter. In an interview on 4/13/23 2:24 PM, Director of Nursing B reported that she did not think that R17 had a catheter securement device and stated that he may have refused it. Documentation was requested of the refusal, but was not provided. Director of Nursing B could not speak further on the hospitalization and suprapubic catheter care of R17. This citation pertains to intake MI00133592, MI00134607, MI00132301, and MI00134412. Based on observation, interview, and record review, the facility failed to monitor, provide care and treatments according to professional standards of practice, the care plan, and resident choice in 6 of 6 residents reviewed for care and services (Resident #2, #4, #5, #12, #14, & #17), resulting in the medications, treatments or care not provided (Resident #2, #4, #5, #12, #14,#17), emergency room transfers (Resident #4, #5, #17), a delay in treatment (Resident #5), and treatment for infection (Resident #5). Findings include: Resident #2 (R2) R2's hospital history and physical dated 2/09/23, indicated she was alert and oriented to person, place and time; had fallen at home at an assisted living facility and had a humeral (large bone of upper arm) fracture. R2's history and physical revealed she had the diagnoses of chronic back pain, heart failure and diabetes mellitus. R2's entry Minimum Data Set (MDS) assessment indicated she admitted to the facility on a Friday, 2/10/23. R2's discharge MDS indicated she was discharged on 2/14/23. In review of R2's admission assessment, it was not completed until Monday, 2/13/23. R2's care plans were not initiated until 2/13/23. In review of R2's February 2023 Medication Administration Record (MAR), Aspart insulin, 7 units with meals not given on 2/10/23 at dinner and 2/11/23 at dinner. Aspart insulin was discontinued on 2/12/23 with no rapid acting insulin administered on 2/12/23, Aspart insulin was re-ordered on 2/13/23, but not administered on 2/13/23 and 2/14/23. R2 did not receive coumadin on 2/10/23. R2 did not receive Levemir insulin at night on 2/10/23. In review of R2's Inventory of Personal Effects dated 2/10/23, 2 insulin pens were given to the nurse. Director of Nursing (DON) B was interviewed on 4/13/23 at 2:40 PM and stated the facility had insulin in their back-up supply. Social Services director O was interviewed on 4/13/23 at 3:48 PM and stated R2 was transferred to a different facility. Resident #12 (R12) R12's MDS dated [DATE] revealed he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), cognitive screener, score of 5 (00-07 severe cognitive impairment). In review of Medication Reconciliation Summary dated 11/01/22, active medications included Cyancoabalmin1000 milligrams (mg)daily (Vitamin B12) and Cholecalciferol 10 micrograms (mg) (D3 400 units). In review of R12's November 2022 Medication Administration Record (MAR) Cyanocobalamin 1000 mg was not transcribed to the MAR and Cholecalciferol 10 mcg (D3 400 units) was transcribed as Cholecalciferol 1000 units. Licensed Practical Nurse unit manager (LPN) P was interviewed on 4/13/23 at 4:11 PM and stated R12's medication list had active and suspended medications listed and caused confusion with her and the facility physician. LPN P stated she did not call the facility that sent the medication list for clarification. Nurse Consultant Q was interviewed on 4/13/23 at 3:59 PM and stated she talked to R12's spouse at one point regarding medication concerns and the physician changed the medications. R12's blood pressures ranged 139 to 179/70-104 from 11/24/22 to 1/03/23. Lisinopril-hydrochlorothiazide was listed on the Medication Reconciliation Summary dated 11/01/22 as suspended. Nurses Notes dated 1/11/23 at 2:44 PM indicated R12's Lisinopril-hydrochlorothiazide Tablet 10-12.5 MG was updated to twice daily per wife stating that he had previously taken it twice a day. Unit manager called and clarified with Physician and got the order updated. R12 was discharged from the facility on 1/04/23. Resident #14 (R14) During an observation on 4/12/23 at 4:30 PM, Nurse Assistant L assisted R14 turn from his back to his right side; R14's catheter bag was hooked on the bed frame on the left side of the bed. R14 did not have a catheter securement device and pulling was observed. NA L assist R14 to his back, removed the catheter from the bed frame, and then turned him back onto his right side to observe his wound dressing on his coccyx. R14's coccyx pressure ulcer dressing was observed and [TRUNCATED]