**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure safe transfers with a full body mechanical lift. This resulted in an immediate jeopardy (IJ) for 1 of 4 residents (R1) who sustained a left femur fracture due to a fall from a lift. The immediate jeopardy (IJ) began on 8/29/25, when R1 fell out of a full mechanical lift sling that was not attached to the lift according to manufacturer instructions resulting in a fall with fracture for R1. The administrator and director of nursing (DON) were notified of the IJ on 9/10/25 at 1:49 p.m. The IJ was removed on 9/2/25, prior to the start of the survey, when the facility implemented immediate corrective action to prevent recurrence, therefore, the IJ was issued at past non-compliance.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition with diagnoses which included colon cancer, fracture of left humerus and hemiplegia.R1's care plan dated 6/10/25, indicated R1 required assistance of total/Hoyer mechanical lift (purple/medium sling or large green sling can be used).An orthopedic trauma provider consultation note from the hospital dated 8/30/25, indicated the history of the present illness included a fall from a Hoyer lift. R1 was found to have an acute left femur fracture that required surgical intervention.A hospitalist progress note dated 8/31/25, included under hospital summary: patient (R1) was at a facility and they were using the Hoyer lift to move [R1] when the lift failed and [R1] fell about 3 feet to the ground. Following the fall, [R1] had significant left hip pain and was brought to the emergency department (ED). In the ED, workup revealed a left subtrochanteric (femur) fracture.A nursing note dated 8/30/25 at 12:03 a.m., indicated at 9:45 p.m., 2 staff members were transferring R1 from his bed to a shower chair with a Hoyer lift. During the transfer, one loop of the sling handle came off the Hoyer hook, R1's right leg slid out of the sling and R1 landed on the floor in a sitting position and ended up on his back. A nursing note dated 8/30/25 at 3:57 p.m., indicated R1 had surgery following a left femur fracture.During an interview on 9/9/2025 at 2:47 p.m., family member (FM) stated she watched the video of when R1 fell out of the sling. She stated it was a horrible thing to watch. The strap on the lower left side did not appear to be attached correctly to the lift and came off during the transfer. FM confirmed R1 had a left femur fracture which required surgery with rod placement.During an interview on 9/9/25 at 4:12 p.m., nursing assistant (NA)-A stated she knew the correct way to hook the sling to the lift and identified the strap needed to be placed into the hook. NA-A stated she was assisting on 8/29/25, to transfer R1 from his bed to a shower chair using a full mechanical lift. She did not notice anything wrong with the straps when she attached them to the lift. During the transfer, one of the straps on the sling somehow came off the hook and R1 fell to the floor. NA-A stated she knew the correct way to hook the sling to the lift. The strap needed to be placed into the hook.During an interview on 9/9/25 at 4:34 p.m., licensed practical nurse (LPN)-B stated she was notified by NA-A about R1 falling from the sling onto the floor. When LPN-A entered the room, R1 was on the floor and saying Ow Ow and don't touch me. LPN-A called 911 to transfer R1 to the hospital for evaluation.During an interview on 9/10/25 at 9:09 a.m., a customer service representative from the manufacturer of the full mechanical lift stated a sling could detach from a lift hook if the person in the sling was over the weight limit, the sling was worn out or if the sling was improperly attached. The weight limit for all slings is 600 pounds. A sling used less than one year should still be in good condition if used and cleaned according to manufactures instructions. During an interview on 9/10/25, following incident video review, the DON confirmed the lower right strap had not been connected to the lift correctly and as a result it came off the hook and R1 fell to the floor. DON stated NA-A and NA-B were not following manufacturer's instructions for proper sling attachment during the transfer. DON confirmed the lower right sling loop was placed at the top of the hook instead of the lower part of the hook. Two attempts were made to contact NA-B with no return phone call.The manufacturer full body sling instruction manual undated, identified the sling was correctly attached to the lift when the loops of the sling were placed at the bottom of the hooks. The manual warnings include: if the sling is not properly applied, personal injury and damage to the sling could occur.The facility mechanical lift competency instructs: Attach the sling to the lift assuring that the loops are secured to the hooks.Review of facility policy titled The facility safe resident handling program policy undated, instructed when residents received care require assistance from facility to move, assistance was provided in a manner that was safe to both the resident and employee. The facility implemented the following actions prior to the survey which were verified through interview and document review and therefore the IJ was issued at past non-compliance:Staff involved in the incident were immediately suspended pending investigation.The lift and sling were put out of use.Education included how to identify what size a sling was, where to find a resident's sling size, how to attach the sling to the lift, and what to do if a resident's care plan did not identify sling size or if the proper sling size was not available. All nursing staff were competency tested on use of the full mechanical lift.Any staff that had not completed the education or competency test would be required to complete both at the start of their next scheduled shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide necessary care, treatment, and services to prevent pressure ulcer development for 1 of 3 residents (R1). This resulted in an immediate jeopardy (IJ) who presented to the emergency room (ER) on 4/3/25 with multiple pressure ulcers and wound infections. R1 remained hospitalized . The IJ began on 4/3/25, when the facility failed to assess, report to the provider, and treat pressure ulcers. R1 was found unresponsive and presented to the hospital emergency room on 4/3/25, and it was discovered she had multiple pressure ulcers and wound infections. R1 remained hospitalized . The facility administrator and director of nursing (DON) were notified of the IJ at 4:00 p.m. on 4/15/25. The facility implemented corrective action by 4/9/25, prior to the start of the survey and was issued as past non-compliance. Findings Include: R1's Braden Scale (a tool designed to assess a patient's risk for developing pressure ulcers) dated 2/24/25 at 10:45 a.m. identified sensory perception as slightly limited and responded to verbal commands. Skin was often moist, and linens had to be changed at least once a shift. She was chair fast, unable to bear own weight. Mobility was very limited and made occasional slight changes in body or extremity position. Nutrition was probably inadequate and would take occasional dietary supplements. Required moderate to maximum assistance in moving, frequently slid down in bed/chair, required frequent repositioning with maximum assistance. Spasticity, contractures, or agitation led to almost constant friction. R1's Braden score was 12 and indicated high risk (at risk 15-18, moderate risk 13-14, high risk 10-12, and very high risk 9 or below) for development of a pressure ulcer. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. She required substantial/moderate assistance for roll left/right, sit to lying, and lying to sitting, dependent upon staff for all transfers, toileting and personal hygiene, bathing, and lower body dressing, and used a manual wheelchair for mobility. She was frequently incontinent of bladder and always incontinent of bowel. She had a feeding tube. Active diagnoses included: stroke, aphasia (a language disorder that affects the ability to speak, read, write, and understand what others are saying caused by a stroke, brain injury, or progressive neurological disorders), hemiplegia/hemiparesis (weakness on one side), malnutrition, diabetes mellitus (DM), hypertension (HTN), and respiratory failure. At risk for pressure ulcers and no unhealed pressure ulcers or other ulcers, wounds, or skin problems identified. Skin and ulcer treatments included pressure reducing devices for chair and bed. She was administered insulin 7 out 7 days. R1's hospital physician notes dated 2/28/25 at 8:28 a.m. identified skin/wounds: WOCN (wound, ostomy, and continence nurse) not followed currently. Per chart, large head laceration repaired by trauma team. Per nursing notes: BUE (bilateral upper extremity extremities) bruising, head laceration, preventive Mepilex (a foam dressing used to reduce the risk of skin breakdown) on sacrum, LLE (lower leg extremity) edema leg wrap (wrap not removed due to pain/fracture), two plus pulses present bilaterally. R1's care plan dated 3/1/25, identified she had diabetes mellitus, and staff were directed to monitor/document/report to medical doctor (MD) for signs/symptoms (s/sx) of infection to any open areas: redness, pain, heat, swelling, or pus formation. She had an alternation in mobility related to stroke. Staff were directed to provide a pressure redistribution mattress to bed and cushion to wheelchair. She was at risk for alteration in skin integrity related to limited mobility secondary to stroke. Staff were directed to monitor skin integrity daily during cares. Weekly skin inspections by nurse. Turn and reposition every two to three hours. Document on skin condition and keep MD or physician assistant (PA) informed of changes. R1's goal outcome evaluation for plan of care dated 3/2/25 at 7:49 a.m. completed by hospital registered nurse prior to discharge back to facility. Skin: no new deficits noted. Repositioned carefully as movement caused a lot of discomfort. R1's Discharge summary dated [DATE] at 2:21 p.m. hospital stay from 2/27/25 through 3/2/25 due to an accident when she fell out of her wheelchair trying to grab an object. Known skin injury: forehead laceration repaired with sutures. Physical exam identified periorbital (around eyes) ecchymosis (bruising) and skin warm and dry. R1's orders/treatment administration record (TAR) identified: -On 11/26/25 at 3:00 p.m. air mattress-monitor working order and replace as needed every shift. Staff signed off all shift from 3/1/25 through 4/2/25, except 4 shifts. -On 12/4/25 at 7:00 a.m. Prosource TF20 ENfit compatible enteral liquid (20 grams of high-quality protein to a feeding tube). Give 1 packet by mouth every day shift for supplement. Staff signed off every morning from 3/3/25 through 4/2/25. -On 3/3/25 at 3:00 p.m. monitor for skin breakdown around the nose and behind the ears caused by oxygen tubing every shift. Staff signed off all three shifts from 3/3/25 through 4/2/25, except for 4 shifts. -On 3/13/25 at 3:00 p.m. enteral feeding: monitor skin around tube feeding site and change dressing if applicable every shift (7 a.m. to 3 p.m., 3 p.m. to 11 p.m., 11 p.m. to 7 a.m.) for monitoring. Staff signed off all three shifts from 3/13/25 through 4/2/25, except for 3 shifts. -On 1/30/25 at 5:30 a.m. weekly skin inspection by licensed nurse. Complete weekly skin inspection in point click care (PCC) in the morning every Thursday. Staff signed every Thursday 3/6/25, 3/13/25, 3/20/25, and 3/27/25. -On 3/28/25 at 11:00 p.m. barrier cream to peri area with brief changes every shift for skin care. Staff signed off all shifts 3/28/25 through 4/2/25, except for 1 time. R1's weekly skin inspection completed from 3/13/25 through 3/27/25, by licensed practical nurse (LPN)-B identified: -On 3/13/25 at 12:30 p.m. instructions: it was the nurse's responsibility to evaluate the resident's skin at minimum once a week to ensure skin integrity. Implement interventions as applicable. Bath type: bed bath. Summary of current skin condition: bruises to the face and both hand [sic] due to a previous fall. On 3/20/25 at 11:32 a.m. identified bath type: shower. Summary of current skin condition: no new skin issues noted. On 3/27/25 at 1:55 p.m. identified bath type: bed bath. Summary of current skin condition: resident had no new skin conditions, skin intact. A and D (an ointment rich in vitamins A and D used for a for skin protection, moisturizes, seals, and speeds up the recovery of damaged skin) applied to redness on bottom. R1's progress notes from 3/2/25 through 4/3/25, identified: -On 3/3/25 at 10:16 a.m. readmission visit by nurse practitioner (NP)-B following a hospitalization after a fall with head strike. R1 was found to have a right frontal subarachnoid hemorrhage (SAH) (bleeding in the space below one of the thin layers that cover and protect your brain), forehead laceration, and humeral (upper arm) neck fracture. Ordered forehead sutures to be removed on 3/6/25 . -On 3/5/25 at 2:07 p.m. had purple bruising on her face and sutures over her right eye . -On 3/5/25 at 8:45 p.m. R1 needs to be encouraged to be up two times daily, once on a.m.'s once on p.m.'s no exceptions every day and evening shift for monitoring since fall. She is weak and has been bed bound. -On 3/6/25 at 11:07 a.m. acute visit for pain made by NP-B . was recently taken off TF due to good oral (PO) intact but not continues to demonstrate problems with dysphagia (trouble with swallowing) . well developed in no acute distress . -On 3/12/25 at 7:49 a.m. follow up visit to assess bolus TF tolerance . tolerating bolus feedings and uninterested in food . -On 3/24/25 at 9:26 a.m. primary provider medical doctor (MD) came to see her and was told she had gone to a doctor's appointment. He did not see her today . past surgery history: percutaneous endoscopic gastrostomy (PEG) tube (a tube placed into the stomach through the abdominal wall most commonly to provide a means of feeding when oral intake is not adequate) was placed on 6/20/23 . -On 3/27/25 at 5:46 p.m. assisted with lunch today. Continued to pocket all food. Very slow to take liquids thru straw. Mighty shake given as she was not swallowing any food. Nurse practitioner (NP) made aware, and dietician notified. - On 3/28/25 at 2:52 p.m. The writer noticed the resident could not seat comfortably and hold her head in the chair. Writer asked the aid to put he back to bed for safety. -On 4/2/25 at 1:09 p.m. Interdisciplinary team (IDT) reported R1 was not eating or drinking anything orally. Nursing informed husband was ok with tube feeding (TF) to provide all nutrition needs. Currently received bolus feed two times a day (bid) but will increase to meet all her needs. -On 4/3/25 at 7:54 a.m. follow up visit made by NP-B for anorexia and resumption of full TF diet . upon visit, R1 was slumped over in her wheelchair not responding, she was slumped so far over she was about to fall headfirst onto the floor. Breathing shallow, blood pressure (BP) 90/50, heart rate (HR) 121, unable to obtain pulse oximeter (ox). Instructed staff to call emergency medical services (EMS) for altered mental status (AMS). Concern for stroke or infection. -On 4/3/25 at 8:42 R1 sent to the emergency room (ER). R1's progress notes lacked documentation of skin assessments. R1's hospital medical records from 4/3/25 through 4/8/25 identified: -On 4/3/25 hospital admission history and physical identified sacral pressure wound. Nursing notified primary team of large necrotic pressure wound to her sacrum with various other lesions to the perineum and surrounding erythema. Area has been cleansed and Mepilex added. Pictures in media lab. WOC consult placed. Clinical impressions: SIRS (systemic inflammatory response syndrome) (an exaggerated defense response of the body to a noxious stressor such as infection, trauma, survey, acute inflammation, ischemia or reperfusion, or malignancy, can be life threatening and affects the entire body) and CVA. Physical exam identified scattered bruising on left arm and small abrasion to nose. -On 4/3/25 at 9:39 a.m. emergency department (ED) provider notes identified admitting diagnoses: systemic inflammatory response syndrome (SIRS) rules out urosepsis, closed fracture of neck of the left humerus from a previous fall, and cerebrovascular accident (CVA) (stroke). -On 4/3/25 at 6:54 p.m. documented by a registered nurse (RN) identified during incontinence care for stool upon transfer, grapefruit-sized blackened pressure wound noted on sacrum alongside redness and areas of open skin on and around perineum. Picture obtained and placed in chart. Gently cleaned area and applied sacral Mepilex for protection. Provider also notified, WOC consult placed to follow-up. -On 4/5/25 at 11:42 p.m. comprehensive stroke evaluation impression: 1. subacute stroke in the setting known as intracranial atherosclerosis and hypotension due to infection. 2. Encephalopathy (brain dysfunction caused by an underlying condition) secondary to burden of prior stroke, acute stroke, and active infection. -On 4/6/25 at 1:39 p.m. GI: PEG Fell out, 16 French (Fr) foley in place per patient care order. Skin: bruising to face, bilateral upper extremities, and abdomen. Scabs to chest nose, thigh, and buttocks. Pressure wound to sacrum and left heel Peeling/scaling to bilateral feet. Redness/purulent drainage at PEG insertion site, culture sent. Right ear lobe swollen. Left groin open area. Left ear abrasion. -On 4/7/25 seen by medical doctor (MD)-C presented from nursing home with altered medical status (AMS) for one week, hypotensive, and hypoxia. admitted for encephalopathy workup, found to have sepsis 2/2 proteus (a gram-negative common pathogen responsible for complicated urinary tract infections) bacteremia and sub-acute cardiovascular accident (CVA). Stable but elevated leukocytosis and worsening . urinalysis was consistent with E. Coli (bacteria) urinary tract infection, urine culture with no growth, blood cultures initially showing Proteus. there is some concern that sepsis may be of abdominal origin especially with some erythema (redness) and purulent discharge around the patient's g-tube, which incidentally fell out. G-tube swabbed for culture. nursing notified primary team of large necrotic pressure would to patient's sacrum with various other lesions to the perineum and surround erythema. Area has been cleansed and Meplix added. Picture in media lab. 4/7/25 wound/ostomy/colostomy (WOC) reached out and recommended surgery consult for debridement . Physical exam skin: erythema around g-tube, no purulent drainage. Sacral wound necrotic and softening edges per WOC registered nurse (RN). Left heel pressure wound without skin break. -On 4/7/25 at 8:57 a.m. hospital wound registered nurse (RN)-A consult . left upper quadrant (LUQ) g-tube site: tube replaced on 4/7/25, peritubular (area surround the g-tube) assessment: erosion of epidermis, dermis and superficial scab that extends 0.3 centimeters (cm) from insertion site with serosanguinous (clear liquid mixed with blood) drainage . -On 4/8/25 a computed tomography (CT) (imaging test used to obtain detained internal images of the body) was completed to evaluate the sacral wound and underlying abscess and possible osteomyelitis. Impression: wound overlying the sacrum with extensive subcutaneous fat stranding fluid, and emphysema extending laterally within the subcutaneous fat superficial to the right gluteal maximus musculature, suspicious for tracking abscess. Particularly given the areas of rim enhancement. Additional pressure wounds are visualized overlying the ischium tuberosities (the bone in the lower pelvis that absorbs weight when you sit). Nonconvincing CT evidence of osteomyelitis. -On 4/8/25 at 12:18 p.m. Antimicrobial Stewardship Team note identified she presented to emergency department (ED) on 4/3/25 and initial testing revealed elevated white blood cells (WBC) and absolute neutrophils (AMC) (white blood cells that fight infection), as well as a positive urinalysis (UA) for nitrites and leukocyte esterase (white blood cells that indicate infection and inflammation). A head CT in ED showed a new subacute appearing infarct in the medial left occipital lobe . culture of nares was collected on 4/5/25 and tested positive for methicillin-resistant staphylococcus aureus (MRSA) (a bacterial infection many antibiotics don't work on). g-tube wound was cultures on 4/6/25 and currently growing 1+ pneumoniae (bacteria) and 1+ staphylococcus aureus (S aureus) (gram-positive bacteria). -On 4/8/25 at 2:06 p.m. identified she was initially seen on 4/4/25 by hospital registered nurse/WOC (RN)-A and sacrum and perineum skin issues were identified. Pictures were taken on 4/4/25 of identified pressure injuries of the sacrum/right buttock, and left thigh. On 4/9/25 pictures and measurements were taken of those same areas. Sacrum measured 10 centimeters (cm) x 13 cm x 0.1 cm, right buttock 4 cm x 2 cm x 0.1 cm, left thigh 10 cm x 6 cm x 0.1 cm, no tunneling, peri wound skin (surrounding skin) erythema (redness) blanchable (blood flow noted to the area). Sacrum wound was identified as a pressure injury, unstageable and present upon admission. The wound base of the sacrum wound was 95% eschar (a hardened, dry black or brown dead tissue and usually indicates a more advanced wound) /purple epidermis (outer most layer of skin), 5% dermis (the layer of skin found deep to the epidermis that supports and adds strength and pliability to the skin) and slough (a biproduct of the inflammatory phase and a barrier and delay to wound healing). A photo and measurements were taken on 4/7/25 of the deep tissue pressure injury (DTPI) located on the left heel and present on admission per bedside RN on 4/5/25. Measures were taken on 4/7/25 of left heel DTPI and identified 5 cm x 6.5 cm x 0 cm with a wound base 100% maroon, purple and epidermis. Peri wound dry and scaly, no pain and no drainage. Additionally, on 4/7/25 a left upper gastrostomy tube site was identified with erosion of epidermis, dermis, and superficial scab extended 0.3 cm from insertion site with a small amount of serosanguinous (seen in wounds during the healing phase) drainage. During an interview on 4/10/25 at 11:03 a.m. hospital registered wound nurse (RN)-A stated R1 was admitted to the hospital on [DATE] with systemic inflammatory response syndrome (SIRS) and possible stroke. R1 had been hospitalized at the end of February 2025 and discharge on [DATE] without any wounds other than surgical at that time. She had seen R1 three times since she was admitted to the hospital on [DATE] and again today. The sacral wound was deteriorating with two open areas with tunneling. The sacral wound was unstageable and measured 3.5. centimeters (cm) x 2.5 cm x .1 cm, the right buttock was stage 2 and measured 3.5 cm x 2.5 cm x .1 cm, left posterior thigh was a deep tissue injury and measured 7.5 cm x 4.5 cm x 0, and the left heel was a deep tissue injury and measured 5 cm x 6.5 cm x 0. The sacral had tan serosanguinous drainage with a mild odor. R1's skin damage was already there prior to being admitted to the hospital and was one of the largest wounds she had ever seen as a wound nurse in 8 years. When a deep tissue injury occurred, it took up to 72 hours to show up and sometimes it looked like a discoloration and then opened. The sacrum wound is located midline and when left on her back too long seemed like it was consistent with that position to develop. This sacral wound most likely will not have a chance to heal without surgery to clean out the dead/eschar/necrotic tissue and will 100% affect her morbidity and mortality. Today R1 had tunneling in her sacral wound which meat it had stared to release from inside out and had lots of soupy drainage. During an interview on 4/10/25 at 3:29 p.m. hospital social worker (SW) stated R1 was admitted to the hospital on [DATE] and pictures were taken of her skin with numerous skin concerns right away. R1 had reddened areas on her bottom and thigh and a large wound located on the sacrum that measured approximately three inches by three inches with a black necrotic center. Hard to believe the nurse's that provided care for R1 and assessed her skin did not notice some type of skin condition changes especially the large one the sacrum. The sacrum wound required treatment and not something only barrier cream would have taken care of. It was very disturbing to see the extensive damage to her skin. During an interview on 4/11/25 at 9:13 a.m. facility NP-A stated standard nursing care provided by nursing staff were expected to have visibility observed the resident's skin every time during cares and weekly skin assessments for skin breakdown and reported it to the nurse or nurse manager. Right before R1 was admitted to the hospital on [DATE] she had received a handwritten note from the floor manager LPN-C indicating R1 had the start of a coccyx injury/pressure ulcer caused by prolong immobility and malnutrition. We have a wound team to assess skin concerns such as this. LPN-C indicated she had alerted the wound team. Standing orders should have been placed until staff nurse told me it was worse or required my assistance. She relied on staff nurses to inform and update her and made her aware of changes. She stated things were getting missed by staff and R1's sacral wound could have been prevented. NP-A verified there was a huge gap of communication among staff regarding R1's skin issues and lacked documentation in her electronic medical record progress notes. NP-A viewed the hospital pictures taken of R1's skin and stated the sacrum wound have developed over several weeks and did not happen overnight. R1's left heel had the start of necrosis, malnourished, and most likely could have developed in a couple of days to a week but not overnight, that was for sure. Her expectation would have been to be notified when there was a change in condition right away or at least within the shift depending on how severe it was. She identified R1's wounds and condition as severe, very disturbing to her, and made her worry about how staff were assessing the resident's skin. R1's wounds could have been prevented if caught earlier and thorough skin assessments had been completed. There was harm done here and she was very worried about R1. During an interview on 4/11/25 at 11:22 a.m. NA-C stated R1 was unable to reposition herself in bed and was incontinent of bowel and bladder. Staff were expected to check and change and reposition her every two hours. On 4/1/25, while providing cares to R1 he noticed a little hole (about the size of top of a pen) in her bottom located on the left side of her buttock. He told the floor manager LPN-C and was told to leave her in bed the wound provider was there, did not see anything on her heels. Unable to identify staff that placed a dressing on her sacral area, no drainage, no odor, no pain. R1 had air mattress on her bed but no pressure relieving cushion on her wheelchair. He usually placed a folded blanket in her wheelchair to take pressure off her bottom. During an interview on 4/11/25 at 11:45 a.m. NA-B stated R1 was not able to reposition herself and always incontinent of bowel and bladder. R1 was dependent upon staff to check and change and reposition her every two to three hours. We were expected to document that each time in the electronic medical record. During cares, she noticed a wound on R1's bottom three weeks prior to her going to the hospital on 4/3/25. The wound on her bottom was dark black and approximately 2 to 3 inches in diameter, opened on one side, surround skin was slightly red without drainage. There was an odor to it, unsure how to explain that. She reported the wound to the nurse on the evening shift. A day later she noticed a dressing over R1's wound on her bottom was falling off and the trained medication aide (TMA) told her to leave it on and she would let the nurse manager know. R1 had a thin cushion in her wheelchair. Husband visited often and pushed her around in the wheelchair. During an interview on 4/11/25 at 12:35 p.m. hospital medical doctor (MD) stated R1 was admitted to the hospital with stroke, septic from blood infection from sacral wound and possible urinary tract infection (UTI). A sacral wound as large as R1's wound has most likely resulted from a pressure injury due to lack of repositioning. He questioned if appropriate care had been given to the resident at the facility and was suspicious of her cares the way she presented when brought to hospital by EMS. R1's prognosis was very poor and most likely will be placed on end of life care and very likely may result in death. The main cause was the sacral wound. There were other concerns of her not really waking up, unsure if it was the infection they were treating. The neurology team was being consulted. After R1 was discharged from the hospital to the facility beginning of March 2025, there were no skin issues identified. During an interview on 4/11/25 at 1:16 p.m. LPN-B stated she completed R1's weekly skin assessments on 3/13/25, 3/20/25, and 3/27/25. She completed the skin assessment when R1 had a shower day and may have sat in a shower chair or while the nursing assistant changed her brief in bed, unsure of the last time she assessed her while she laid in bed. R1 sat in the wheelchair fully dressed and she visualized only the skin not covered by clothing. She was not always able to assess the skin and relied on the NA's and asked them if they saw any skin problems when they checked and changed, repositioned, or transferred her. She cleaned around the gastrostomy tube (G-tube) and placed Neosporin (antibiotic ointment used to reduce the risk of infections) and change the dressing. She was unsure as to what should have been included on the weekly assessments. When she removed the sponge dressing from around R1's G-tube she noted a minimal red bloody drainage dried onto the dressing, possibly for the past three weeks. R1's bottom was red, and ointment was applied but lately that area had opened. Last time she saw R1's bottom was the Tuesday 4/1/25, before she was sent into ER. She thought R1 had been seen by the wound team and the floor nurse manager was aware of it. She had not received any education on skin assessments. During an observation on 4/11/25 at 3:20 p.m. LPN-A walked down to R1's room with surveyor and verified her wheelchair did not have a pressure relieving cushion on it and there was a thin pillow approximately ¼ inches thick with a cover placed on it located in the seat of her wheelchair. She stated R1 should have had a pressure relieving cushion in her wheelchair to prevent pressure ulcers. She verified R1 wore gripper socks while in her wheelchair and shoes when she went out of facility with her husband. During an interview on 4/14/25 at 2:54 p.m. licensed practical nurse (LPN)-C clinical coordinator stated nursing staff would be expected to have completed a weekly skin assessment on each resident. The weekly skin assessment was usually scheduled on the same day as their bath day while in the shower without clothing on or if in the morning while the resident laid in bed so that the entire body and especially their bottom could be assessed. Nursing staff would be expected to have written up a risk management report, documented in the progress notes including measurements, called the provider and request an order to treat those area that were concerning. During the following morning meeting new skin concerns would have been reviewed, then reviewed by risk management and arranged for resident to be seen weekly by the wound care provider to have followed up. The family should have been notified along with the provider so that interventions could have been identified to help prevent the identified area(s) from getting worse and/or prevention of any new areas. R1 had not had skin issues until the week before she went into the hospital on (since last skin check 3/27/25) so floating her heels while in bed was not required, could have been an intervention but what they were doing was working. Although apparently it was not working after what happened to her skin. She had a wheelchair cushion . we give everyone one when they come in should have been a pressure redistribution cushion looks like a foam cushion or air filled with the little finger things that stick up on it. She had a foam one, not sure. The last weekly skin assessment competed on R1 identified she had redness to her bottom, started treating it with A and D ointment (house barrier cream) with brief changes on 3/28/25. There were no specific details placed in the weekly skin assessment such as size of reddened area or progress notes written. If a resident's bottom had been identified with a new skin problem such as a red area that would have been considered a change in condition and the provider should have been notified. On 3/31/25, she was informed by NA-C R1 had a red area on her bottom. During an observation on 4/14/25 at 3:30 p.m. LPN-C and surveyor entered R1's room together. LPN-C confirmed R1 had a pressure relieving mattress on her bed. Located on the manual wheelchair was a lawn chair cushion approximately ¼ inch thick with a cover over it. She stated thought R1 had a thicker cushion on her chair unable to identify when she had used it. She looked in R1's closets and stated it would have been a nursing intervention, like a standing order. Usually, a pressure relieving cushion was placed in the resident chair and does not leave the room but may have been sent down to the laundry, not sure. During an interview on 4/15/25 at 4:30 a.m. NA-D stated she had cared for R1 on 3/15/25, 3/21/25, 3/24/25, 4/1/25, and 4/3/25. She completed morning cares, washed her up and NA-C assisted her. There was a wound on R1's bottom with a dressing on it all five days she worked. NA-C informed her he had reported the wound to the floor manager LPN-C. Surrounding skin around dressing (approximately 2 inches by 2 inches) was pink, dry, and intact. On 4/3/35, she had arrived at work and R1 laid in bed with her heels positioned on a pillow. On 4/1/25 or 4/3/25 she was not asked by LPN-A to put R1 back to bed and was most likely feeding residents. During an interview on 4/15/25 at 5:00 a.m. NA-E stated he provided cares to R1 and when he positioned her in bed her heels rested on a pillow. She was at risk for pressure ulcers. During cares he noticed for the first time about one month ago a sore on R1's bottom located on the left side of her buttock unsure of the size, unable to really explain it well, was a dark area on her body located on the left side of her buttocks. He had told the nurse (LPN-D), and she informed him the next time we checked and changed here she wanted to see the sore, treat it, and placed a bandage dressing on it. He stated she was checked and changed at least three times during the night shift and sometimes more often. During an interview on 4/15/25 at 8:46 a.m. facility wound provider/ nurse practitioner (NP)-A stated staff were expected to remove the residents clothing prior to completing a weekly skin assessment so that the entire body could have been viewed. She expected staff to make her aware of any resident skin concerns so that they could have been taken care of appropriately, prevented from getting worse and/or getting them in other areas. NP-A viewed R1's pictures of her wounds and stated those pictures are worrisome and if those areas are left untreated especially when she was a diabetic could have led to a bad outcome such as death. The sacral and heel wounds were from pressure and could have been from a lack of repositioning. R1 also had issues with malnutrition, would have made a wound get worse in a matter of hours or in a short period of time. Would have made it even more important to have reported the wounds to the nurse manager and her to assess it right away. During an interview on 4/15/25 at 11:05 a.m. LPN-D stated staff nurses were expected to complete the weekly skin audits and visualize all resident's skin when completed. The assessment should have included any new and current skin issues/wounds/g-tube sites. The weekly skin assessment was important to avoid pressure sores and infection. She had filled in one night and worked as an NA the end of March 2025. She assisted with check and changes and repositioning R1 every two to three hours. She identified a wound on R1's bottom to the left side sacral area, was the size of a baseball, edges looked ruff/ridged, was open in the middle and along the inside of the outer edge approximately ¼ inch all the way around was black, and dry without drainage. The left heals had an area the size of a quarter, looked new, slightly discolored, felt soft/boggy, and intact skin. She informed the floor manager LPN-C the next day when she came back to work the evening shift. LPN-C was leaving for the day, and she stopped her, informed her R1 had a wound that needed attention LPN-C stated ok and left the building. The following day she reminded LPN-C again and went to R1's room with her, had NA's transfer her to the bed, removed her clothing so we could assess all her skin. LPN-C stated Oh my God no one had told her about R1's sacral wound, left the room and walked to the treatment cart. LPN-D showed LPN-C R1's left heel and she sounded shocked and disappointed. LPN-D left R1's room, completed the medications passes, and unsure if LPN-D returned. The provider should have been notified for orders to treat her sacral wound. During a follow-up interview on 4/15/25 at 11:56 a.m. hospital wound RN-A stated the surgeon at the hospital deemed that R1 would not be able to tolerate surgery[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to implement a process to supervise and monitor R3, who is known to smoke with oxygen on, to ensure he left the oxygen in the facility while he was smoking in the designated smoking patio resulting in risk of injury, burns, or fire which had the potential to cause serious harm, injury, impairment, or death to 1 out of 16 residents (R3) reviewed who smoked. The immediate jeopardy began on 4/4/25 when the failure to monitor and supervise R3's smoking, and was identified on 4/4/25. The administrator, director of nursing, and regional nurse consultant were notified of the immediate jeopardy at 4:10 p.m. on 4/4/25. The immediate jeopardy was removed on 4/4/25, but noncompliance remained at the lower scope and severity level of D - isolated, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 had diagnoses of acute respiratory failure with hypoxia (low blood oxygen), heart failure, asthma, and tobacco use. R3's MDS indicated he was cognitively intact. R3's care plan, dated 1/31/25, indicated R3 smoked at the facility unsafely with his oxygen tank on his scooter. Interventions identified: risk versus benefits completed with the resident, spoke about concerns of safety, and resident signed smoking plan. R3's Resident Safe Smoking Oxygen contract, dated 1/31/25, indicated R3 would remove oxygen tank, leaving it at the nursing station or entrance to smoking patio. Contract indicated nursing staff would assist or R3 had demonstrated independence with removal of the oxygen tank. Further, the contract indicated failure to abide by the contract would result in a smoking privilege review by the interdisciplinary team. R3's chart lacked follow up smoking assessments after the 1/31/25 incident. A progress note, dated 3/29/25, indicated R3 was observed multiple times smoking at unassigned times. On 4/4/25 at 10:00 a.m., family member (FM)-A stated she had observed a resident on a royal blue scooter on several occasions smoking with oxygen on the smoking patio. FM-A shared a photo with the surveyor, taken on 3/26/25, of R3 smoking with his oxygen tank in the front basket of his scooter. FM-A stated they had reported this to the facility social worker. On 4/4/25, at 10:12 a.m., R3 was observed to be smoking on the designated smoking patio with his oxygen on per nasal cannula (NC) at 3 liters (L). R3 stated it was his own oxygen tank, so it did not matter. On 4/4/25, at 10:28 a.m., Fire Marshall-A stated smoking while wearing oxygen posed a risk, as oxygen rich atmosphere can cause an intense fire quickly. On 4/4/25, at 11:06 a.m., RN-A stated there is not a plan to monitor the designated smoking area. On 4/4/25, at 11:44 a.m., R3 stated he has been told of the dangers of smoking with oxygen before but did not believe his personal oxygen tanks would blow up or cause a fire. Therefore, he was not leaving the oxygen in the building. On 4/4/25, R2 stated he had observed a few other residents smoking on a regular basis while wearing oxygen on the smoking patio. On 4/4/25, at 12:29 p.m., the administrator stated R3 had been observed smoking with oxygen on 1/31/25. The administrator stated this was addressed by providing R3 with education on the potential danger and risks of slow leak of oxygen. R3 agreed to leave oxygen in facility while going out to smoke. The administrator stated the designated smoking patio does not have direct supervision by staff but does have video surveillance available to view in the administrator's office. The administrator stated no other staff had access to view the video surveillance. The administrator stated the facility has not attempted to withhold smoking material or exchange smoking material for the oxygen tank. The administrator stated smoking with oxygen posed a potential risk of the oxygen tank exploding or propelling, burns or fires. The administrator stated she would observe the video surveillance when she was in her office, but did not offer a specific frequency. On 4/4/25, at 2:49 p.m., the nurse practitioner stated oxygen always poses a safety risk while smoking. She stated R3 was endangering other people by smoking while wearing oxygen. A facility document Resident Smoking Policy, dated 10/24, directed the facility was committed to providing the highest level of customer care and service while assuring residents' needs were being met in a safe manner. Any resident who did not comply with the policy may lose smoking privilege. The policy lacked direction regarding smoking with the use of oxygen. The immediate jeopardy began on 4/4/25, was removed on 4/4/25, when the facility conducted a smoking assessment for R3, revoked R3's smoking privileges at the facility, revised R3's care plan to indicate his smoking privileges had been revoked, reviewed the smoking policy with R3, notified R3's NP, received an order for nicotine lozenges and placed R3 on every 15 minute safety checks. The deficient practice was corrected on 4/4/25, after the facility provided education to all staff regarding designated smoking areas of the facility, no oxygen allowed on the smoking patio, the nurse assigned to the unit closest to the smoking patio's responsibility to monitor the smoking patio every two hours and document, any resident who used oxygen would be required to exchange their oxygen for their smoking materials with the nurse. The facility also held a quality assessment performance quality improvement (QAPI) meeting on 4/4/25 to review and determine a process to monitor for safe smoking practices. Further, the education instructed the staff to provide education to residents, notify the nurse if residents were non-compliant, document instances of non-compliance, and notify the administrator or nurse on-call. The facility also posted the smoking policy on the door to the smoking patio and a sign indicating no oxygen allowed in that area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a system was in place to prevent the diversion of medications for 30 of 79 residents (R1, R5, R12, R15, R16, R27, R35, R41, R49, R50, R54, R58, R63, R73, R75, R76, R77, R141, R146, R149, R345, R25, R143, R144, R145, R147, R148, R150, and R151) reviewed for drug diversion and were free from misappropriation of their property when their medications to treat moderate to severe pain and other conditions were taken by a staff member. This resulted in diversion of 111 tablets of oxycodone 5 milligram (mg), 21 tablets of oxycodone 2.5 mg, 28 tablets of oxycodone 10 mg, 1 tablet Aderall, 6 tablets Percocet, and 4 tablets Ambien which resulted in the likelihood of serious harm or adverse event to residents prescribed controlled substances. The IJ began on 1/28/25, when registered nurse (RN)-A identified narcotics were given by trained medication assistant (TMA)-A via a G-Tube (flexible tube inserted in the abdomen and into the stomach) for R12 on a daily medication report. RN-A notified RN-B of the concern that TMA-A had given narcotic medication via the G-tube for a R12. The facility administrator and director of nursing (DON) were notified of the IJ on 2/11/25 at 3:45 p.m., which was identified at the scope and severity of K, pattern. The facility had implemented immediate corrective action on 1/30/25 to prevent recurrence, therefore the IJ was issued at past non-compliance. Findings include: Review of the facility narcotic record indicated TMA-A had signed out medications as removed from narcotic book and the medication cart, however TMA-A did not consistently document in the medication administration record (MAR) as administered. R1's annual Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact, and diagnoses included right-side paralysis following unspecified cerebrovascular disease and seizure disorder. R1's Order Summary Report, printed 2/11/25, indicated a physician order dated 12/17/24 for oxycodone (an opioid medication) 5 milligrams (mg) by mouth (po) every 24 hours as needed (PRN) for moderate to severe pain. R1's record indicated R1's oxycodone dosage was increased on 1/15/25 from 5 mg po every 24 hours PRN to 5 mg every 6 hours PRN with a maximum of 2 doses per day. R1's individual narcotic record indicated 25 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R1's Medication Administration Record (MAR), dated 1/1/25 to 1/31/25, indicated 19 doses of oxycodone were administered. Discrepancy of 6 doses. R5's quarterly MDS, dated [DATE], indicated R5 was cognitively intact, and diagnoses included atrial fibrillation (irregular heartbeat) and heart failure. R5's Order Summary Report, printed 2/11/25, indicated a physician order dated 10/2/24 for oxycodone 5 mg po two times a day (BID) PRN for moderate pain. R5's individual narcotic record indicated 40 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R5's MAR dated 1/1/25 to 1/31/25, indicated 29 doses of oxycodone were administered. Discrepancy of 11 doses. R12's admission MDS, dated [DATE], indicated R12 was cognitively intact, and diagnoses included epilepsy, severe protein-calorie malnutrition, and muscle wasting and atrophy. R12's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/7/25 for oxycodone 5 mg via G-Tube (flexible tube inserted surgically through the abdominal wall into the stomach for delivering nutrition, fluids, and medications when a person is unable to eat/drink orally) every 4 hours PRN for pain. R12's individual narcotic record indicated 34 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25, with 7 doses signed out by TMA-A. However, R12's MAR dated 1/1/25 to 1/31/25, indicated 18 doses of oxycodone were administered, and 6 of the doses were administered by TMA-A. Additionally, R12's medications were ordered via G-tube, which required a nurse to administer R12's medications. TMA performing tasks not within their scope of practice. Discrepancy of 16 doses. R15's admission MDS, dated [DATE], indicated R15 was cognitively intact, and diagnoses included paraplegia (paralysis of all or part of the trunk, legs, and pelvic organs) and cerebral palsy. R15's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/10/25 for oxycodone 5 mg po every 6 hours PRN for pain; amphetamine-dextroamphetamine (Adderall) 5 mg po every morning related to attention and concentration deficit; and Adderall 5 mg po at noon PRN for attention and concentration deficit. R15's individual narcotic record indicated 3 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R15's MAR dated 1/1/25 to 1/31/25, indicated 2 doses of oxycodone were administered. Discrepancy of 1 dose. R15's individual narcotic record indicated 22 doses of Adderall were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R15's MAR dated 1/1/25 to 1/31/25, indicated 21 doses of Adderall were administered. Discrepancy of 1 dose. R16's quarterly MDS, dated [DATE], indicated R16 was cognitively intact, and diagnoses included acute osteomyelitis left femur (thigh bone infection) and intervertebral disc degeneration. R16's Order Summary Report, printed 2/11/25, indicated a physician order dated 9/30/24 for oxycodone 5 mg po every 6 hours PRN for pain. R16's individual narcotic record indicated 46 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R16's MAR dated 1/1/25 to 1/31/25, indicated 33 doses of oxycodone were administered. Discrepancy of 13 doses. R27's admission MDS, dated [DATE], indicated R27 was cognitively intact, and diagnoses included cellulitis (skin infection) of left lower limb, and osteomyelitis of the tibia and fibula (long bones in the lower leg). R27's MAR dated 1/1/25 to 1/31/25, indicated a physician order dated 1/21/25 for oxycodone 2.5 mg po every 6 hours PRN for moderate to severe pain; a physician order dated 1/6/25 for Percocet - 1-tab po every 4 hours PRN for moderate pain; a physician order dated 1/7/25 for Ambien 10 mg po every 24 hours PRN for sleep; and a physician order dated 1/14/25 for Oxycontin 10 mg po BID for pain. R27's individual narcotic record indicated 9 doses of oxycodone were signed out of the narcotic log from 1/22/25 through 1/27/25. However, R27's MAR dated 1/1/25 to 1/31/25, indicated 6 doses of oxycodone were administered. Additionally, R27's individual narcotic record indicated 9 doses were sent with patient on 1/28/25. However, the document lacked a nurse's signature. Discrepancy of 12 doses. R27's individual narcotic record indicated 16 doses of Percocet were signed out of the narcotic log from 1/7/25 through 1/17/25. However, R27's MAR dated 1/1/25 to 1/31/25, indicated 10 doses of Percocet were administered. Discrepancy of 6 doses. R27's individual narcotic record indicated 7 doses of Ambien were signed out of the narcotic log from 1/12/25 through 1/27/25. However, R27's MAR dated 1/1/25 to 1/31/25, indicated 6 doses of Ambien were administered. Additionally, R27's individual narcotic record indicated 3 doses were sent with patient. However, the document contained 4 scribble marks and lacked a date. Discrepancy of 4 doses. R27's individual narcotic record indicated 2 doses of Oxycontin 10 mg were marked as sent with ex, error, multiple scribble marks, and distroid [sic]. However, the facility was unable to provide a Record of Disposal for the Oxycontin. Discrepancy of 2 doses. R35's admission MDS, dated [DATE], indicated R35 was cognitively intact, and diagnoses included fracture of right lower leg, osteoporosis, and heart failure. R35's MAR dated 1/1/25 to 1/31/25, indicated a physician order start date 12/31/24 for oxycodone 2.5 mg po every 24 hours PRN for pain, and discontinued date 1/20/25. R35's individual narcotic record indicated 11 doses of oxycodone were signed out of the narcotic log from 1/2/25 through 1/23/25, with 2 doses signed out on 1/23/25 (2 days after medication was discontinued). However, R35's MAR dated 1/1/25 to 1/31/25, indicated 2 doses of oxycodone were administered. Discrepancy of 9 doses. R41's quarterly MDS, dated [DATE], indicated R41 was cognitively intact, and diagnoses included right leg below knee amputation and heart failure. R41's MAR dated 1/1/25 to 1/31/25, indicated a physician order dated 1/25/25 for oxycodone 5 mg to 10 mg po every 4 hours PRN for pain. R41's individual narcotic record indicated 7 doses of oxycodone 5 mg were signed out of the narcotic log on 1/28/25. However, R41's MAR dated 1/1/25 to 1/31/25, indicated 6 doses of oxycodone 5 mg were administered on 1/28/25. Additionally, 6 doses of oxycodone 5 mg were signed out of the narcotic log on 1/29/25. However, R41's MAR dated 1/1/25 to 1/31/25, indicated 4 doses were administered on 1/29/25. Discrepancy of 3 doses. R49's admission MDS, dated [DATE], indicated R49 was cognitively intact, and diagnoses included fracture of left fibula and tibia (both long bones in lower leg) and respiratory failure. R49's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/13/25 for oxycodone 5 mg po BID for pain. R49's individual narcotic record indicated 3 doses of oxycodone were signed out of the narcotic log from 1/14/25 through 1/18/25. However, R49's MAR dated 1/1/25 to 1/31/25, indicated 2 doses of oxycodone were administered. Discrepancy of 1 dose. R50's admission MDS, dated [DATE], indicated R50 was cognitively intact, and diagnoses included fracture of right femur (thigh bone) and asthma. R50's MAR dated 1/1/25 to 1/31/25, indicated a physician order dated 1/6/25 for oxycodone 5 mg po every 24 hours PRN for pain. R50's individual narcotic record indicated 20 doses of oxycodone were signed out of the narcotic log from 1/8/25 through 1/31/25. However, R50's MAR dated 1/1/25 to 1/31/25, indicated 14 doses of oxycodone were administered. Discrepancy of 6 doses. R54's admission MDS, dated [DATE], indicated R54 had mild cognitive impairment, and diagnoses included acute respiratory failure, osteoporosis, and R54 required tracheostomy care, suctioning, and a feeding tube. R54's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/8/25 for oxycodone 5 mg via PEG-tub every 6 hours PRN for moderate to severe pain. R54's individual narcotic record indicated 6 doses of oxycodone were signed out of the narcotic log from 1/24/25 through 1/25/25. However, R54's MAR dated 1/1/25 to 1/31/25, indicated 4 doses of oxycodone were administered. Discrepancy of 2 doses. R58's quarterly MDS, dated [DATE], indicated R58 was cognitively intact, and diagnoses included heart failure and right leg below knee amputation. R58's Order Summary Report, printed 2/11/25, indicated a physician order dated 7/22/24 for oxycodone 5 mg po PRN for pain. R58's individual narcotic record indicated 35 doses of oxycodone were signed out of the narcotic log from 1/7/25 through 1/23/25. However, R58's MAR dated 1/1/25 to 1/31/25, indicated 27 doses of oxycodone were administered. Discrepancy of 8 doses. R63's significant change MDS, dated [DATE], indicated R63 was cognitively intact, and diagnoses included left side hemiplegia and hemiparesis and rheumatoid arthritis. R63's MAR dated 1/1/25 to 1/31/25 indicated a physician order dated 1/3/25 for oxycodone 10 mg po every 4 hours PRN for moderate to severe pain. R63's individual narcotic record indicated 128 doses of oxycodone 10 mg were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R63's MAR dated 1/1/25 to 1/31/25, indicated 104 doses of oxycodone 10 mg were administered. Discrepancy of 24 doses. R73's quarterly MDS, dated [DATE], indicated R73 was cognitively intact, and diagnoses included multiple fractures of pelvis, lumbar vertebra fracture, and multiple rib fractures. R73's Order Summary Report, printed 2/11/25, indicated a physician order dated 11/6/24 for oxycodone 5 mg po every 8 hours PRN for pain. R73's individual narcotic record indicated 60 doses of oxycodone 5 mg were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R73's MAR dated 1/1/25 to 1/31/25, indicated 50 doses of oxycodone were administered. Discrepancy of 10 doses. R75's admission MDS, dated [DATE], indicated R75 had moderately impaired cognition, and diagnoses included pancreatic cancer and generalized abdominal pain. R75's Order Summary Report, printed 2/11/25, indicated a physician order dated 12/28/24 for oxycodone 5 mg po BID PRN for pain. R75's individual narcotic record indicated 5 doses of oxycodone 5 mg were signed out of the narcotic log from 1/17/25 through 1/20/25. However, R75's MAR dated 1/1/25 to 1/31/25, indicated 3 doses of oxycodone were administered. Discrepancy of 2 doses. R76's admission MDS, dated [DATE], indicated R76 was cognitively intact, and diagnoses included systemic lupus erythematosus (immune system attacks healthy tissues and organs), migraines, and cervicalgia (neck pain). R76's Order Summary Report, printed 2/11/25, indicated a physician order dated 12/24/24 for oxycodone 5 mg - 10 mg po every 6 hours PRN for pain. R76's individual narcotic record indicated 79 tabs of oxycodone 5 mg were signed out of the narcotic log from 1/2/25 through 1/31/25. However, R76's MAR dated 1/1/25 to 1/31/25, indicated 67 tabs oxycodone 5 mg were administered. Discrepancy of 12 doses. R77's quarterly MDS, dated [DATE], indicated R77 had severe cognitive impairment, and diagnoses included nontraumatic intracerebral hemorrhage (ruptured blood vessel causing bleeding in the brain), diabetes, and required a feeding tube. R77's Order Summary Report, printed 2/11/25, indicated a physician order dated 10/24/24 for oxycodone 5 mg via G-tube every 24 hours PRN for moderate pain. R77's individual narcotic record indicated 22 tabs of oxycodone 5 mg were signed out of the narcotic log from 1/1/25 through 1/29/25, with 12 tabs signed out by TMA-A. However, R77's MAR dated 1/1/25 to 1/31/25, indicated 12 tabs oxycodone 5 mg were administered, and 11 of the doses were administered by TMA-A. Additionally, R77's medications were ordered via G-tube, which required a nurse to administer R77's medications. TMA performing tasks not within her scope of practice. Discrepancy of 10 doses. In purple is this the surveyor adding this. R141's admission MDS, dated [DATE], indicated R141 had severe cognitive impairment, and diagnoses included cerebral infarction (stroke), left side hemiplegia, chronic pain, and R141 required a feeding tube. R141's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/22/25 for oxycodone 5 mg via G-tube every 6 hours as needed for severe pain. R141's individual narcotic record indicated 2 tabs of oxycodone 5 mg were signed out of the narcotic log from 1/23/25 through 1/24/25, with 1 tab signed out by TMA-A. However, R141's MAR dated 1/1/25 to 1/31/25, indicated 1 tab oxycodone 5 mg was administered, and the dose was administered by TMA-A. Additionally, R141's medications were ordered via G-tube, which required a nurse to administer R141's medications. TMA performing tasks not within her scope of practice. Discrepancy of 1 dose. R146's discharge MDS, dated [DATE], indicated R146 admitted to the facility on [DATE], and discharged from the facility on 12/13/24. R146's individual narcotic record #42, indicated 15 tabs of oxycodone 5 mg tabs were sent home with patient on 12/13/24, with TMA-A's signature and R146's signature noted. However, facility reported that investigation interview with R146 identified she received 7 tabs of oxycodone. Discrepancy of 8 doses. R146's individual narcotic record #17, indicated 8 tabs of oxycodone 10 mg tabs were destroyed on 11/22/24, with the initials SE and TMA-A's signature noted. Initials in question. However, during facility investigation interview RN-A stated the initials SE were forged because the nurse with the initials SE was out of the country on 11/22/24. discrepancy of 8 doses. R149's quarterly MDS, dated [DATE], indicated R149 was cognitively intact, and diagnoses included heart failure and chronic pain syndrome. R149's MAR dated 1/1/25 to 1/31/25, indicated a physician order dated 11/6/24 for oxycodone 5 mg po BID for pain, and an order dated 1/9/25 for oxycodone 5 mg po for acute one time only on 1/9/25. R149's individual narcotic record indicated 4 doses of oxycodone 5 mg were signed out of the narcotic log on 1/9/25. However, R149's MAR dated 1/1/25 to 1/31/25, indicated 3 doses of oxycodone were administered. Discrepancy of 1 dose. R345's admission MDS, dated [DATE], indicated R345 was cognitively intact, and diagnoses included fracture of sacrum, peritonitis (infection of membrane lining abdominal wall. R345's MAR, dated 1/1/25 to 1/31/25, indicated a physician order dated 1/17/25 for oxycodone 10 mg po every 8 hours PRN for pain. R345's individual narcotic record indicated 4 doses of oxycodone 10 mg were signed out of the narcotic log on 1/18/25, and 3 doses on 1/23/25. However, R63's MAR dated 1/1/25 to 1/31/25, indicated only 3 doses of oxycodone 10 mg were administered on 1/18/25, and 2 doses on 1/23/25. Discrepancy of 2 doses An interview on 2/5/25 at 1:53 p.m. with administrator stated RN-A had identified what she thought might be an issue on 1/29/25. RN-A sent an email to the regional nurse consultant (RN-B) and an investigation was started. TMA-A was suspended 1/29/25. An interview on 2/5/25 at 2:23 p.m., RN-A stated RN-A stated each morning a report was ran for missed medications. She looked in the progress notes to read the documentation about why the medication was missed. RN-A stated the report showed TMA-A repeatedly had given oxycodone. RN-A stated she had first noticed around 1/28/25, when the G-tube medications caught her eye as they were signed out by TMA-A. RN-A discussed oxycodone with R35. However, R35 did not know what oxycodone was for nor did she have any pain. RN-A discussed daily oxycodone use with R77. R77 told RN-A that TMA-A told R77 that she had to have her oxyodone via her G-tube but R77 stated she was to have orally to see how she did with oral medications, as they wanted to remove her G-tube. RN-A stated R77 had gotten her medication via G-tube but was charted given orally by TMA-A. It was not uncommon for TMA-A to request keys to the medication cart and staff handed them over. RN-A stated it was out of the TMA's scope of practice to destroy medications or to administer G-tube medications. Therefore, RN-A emailed RN-B and an audit was completed for all resident receiving oxycodone on the transitional care unit (TCU). RN-A stated the TMA-A was suspended on 1/29/25 at the end of her shift. An interview on 2/10/25 at 12:43 p.m., TMA-A stated she was the staffing coordinator and would fill in as a TMA on the unit. TMA-A stated she had set up medications for the nurses. TMA-A denied giving any G-tube medication to resident. TMA-A stated she was not to sign out medications that she had not given. TMA-A denied she had given residents their discharged medications. TMA-A indicated she counted narcotics with the licensed staff and was not sure why the licensed staff had not signed out when they had counted the narcotics. TMA-A denied documenting other staff initials in the narcotic book or in the MAR. TMA-A stated she had given narcotics to residents without talking with the licensed staff. TMA-A indicated she had been suspended since 1/30/25, then was terminated on 2/10/25. An interview on 2/11/25 at 10:04 a.m. TMA-B stated she did not have anyone set up any medications for her to give to the residents. TMA-B stated TMA's do not give any G-tube medications and no liquid morphine. TMA-B indicated that only the nurses destroy medications when they are discontinued. TMA-B stated TMA's do not sign out any narcotics going home with discharge residents. An interview on 2/11/25 at 10:51 a.m. RN-E stated TMA's do not destroy medications, only licensed staff could do that. RN-E stated TMA's do not sign out narcotics and give to residents who were discharged . RN-E stated she did not have TMA's set up medications then RN-A administered them. RN-E stated TMA's cannot give heparin, insulin, or any G-tube medications. An interview on 2/11/25 at 11:11 a.m. care coordinator (CC)-C stated TMA's could not give insulin, injections, nor G-tube medications. CC-C stated TMA's have to talk to licensed staff before giving any as needed medication to a resident. The the licensed staff needed to evaluate the resident. The facility policy Medication Administration dated 4/2018, indicated The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident ' s medication administration record (MAR) are compared with the medication label. It indicated the person who prepares the dose for administration is the person who administers the dose. The individual who administers the medication dose records the administration on the resident ' s MAR/eMAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. A facility policy Preparation and General Guidelines of Controlled Substances dated 5/2022, indicated Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (Accountability Record). 3) Remaining quantity (Accountability Record). 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record). A facility policy Medication Storage in the Facility, Controlled Substance Storage dated 5/2022, indicated At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented. The emergency supply may be verified by assuring that the seal on the supply has not been broken. The facility initiated corrective action prior to the start of survey including; education on 1/30/25, the staff were educated not to give the medication cart keys to anyone until the end of the shift to on coming staff. The medication cart and narcotic lock box keys were change out. TMA's were given education on what the expectations of the TMA's can and cannot do. TMA's cannot give narcotics without discussion with licensed staff and the licensed staff have to document their assessment of the resident. Staff must verify in PCC if narcotic given. Audits completed to make sure they are accurate with documentation of the narcotic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1), who wished to have CPR in the event of cardiopulmonary arrest (absence of pulse and respirations). This deficient practice resulted in an immediate jeopardy (IJ) when R1 was found absent of pulse and respirations, no CPR was initiated, and R1 experienced certain death. The facility implemented corrective action, so the deficient practice was issued at past non-compliance. The IJ began on [DATE], when R1 was found unresponsive with an absence of pulse and respirations, CPR was not initiated, and R1 experienced certain death. The facility administrator and director of nursing (DON) were notified of the IJ on [DATE], at 5:00 p.m., which was identified at the scope and severity of an isolated IJ. The IJ was removed on [DATE] when the facility implemented immediate corrective action to prevent recurrence, therefore, the IJ was issued at past non-compliance. Findings include: A Facility Reported Incident (FRI) report was submitted to the State Agency (SA) on [DATE]. The report identified, on [DATE], at 5:50 a.m., R1 was found unresponsive in her room, cool to the touch, and absent of vital signs. R1 was full code (wished CPR); however, CPR was not performed. R1's significant change Minimum Data Set (MDS), dated [DATE], identified R1 was cognitively intact. R1's POLST, dated [DATE], identified R1 wished for attempted resuscitation/CPR [Full code], if she were found with no pulse and/or active breaths. The POLST was signed by R1 and a medical provider. An IDT (interdisciplinary team) Care Conference form, locked [DATE], identified R1 was a Full code and wished to remain as such. A provider visit note, dated [DATE], identified R1 was seen by physician assistant (PA)-A. The note identified R1's Code Status as Full Scope of Treatment. R1's Order Summary Report, active orders as of [DATE], identified an active CPR order. A progress note, entered on [DATE], at 7:23 a.m., identified the following timeline of events: -12:00 a.m., during rounds, R1 slept with no issues. -2:00 a.m., R1 was changed, repositioned, and she interacted with staff normally. -5:40 a.m., the nurse was updated by a nursing assistant after the nursing assistant discovered R1's condition. The nurse responded and found R1 unresponsive. The nurse grabbed the defibrator [sic] with the other nurse to start resuscitations, but it was too late, [R1] had ceased to breath, no pulse no respiration. The administrator, family, and the provider were updated. The note lacked identification R1 was provided CPR or that the AED was utilized. When interviewed on [DATE], at 2:44 p.m., licensed practical nurse (LPN)-A stated when a resident was found unresponsive, she was expected to assess for a pulse and respirations - if absent, she was to first verify their code status. If the code status indicated Full code, she was expected to immediately initiate CPR, send others to grab the crash cart and the defibrillator (AED), page a code blue overhead, and call 911. CPR was stopped only when the paramedics gave the okay. She explained that around 2:00 a.m., R1 slept without concerns. Around 5:40 a.m., a nursing assistant called her into R1's room. Right away, LPN-A approached R1 and found her on her back in the middle of the bed. LPN-A checked R1's pulse, shook her, and called her name; however, R1 lacked a response and was without a pulse or respirations. R1 was not cold but her feet were cooler than the rest of her body. Her body was clammy, her color was faded, and she lacked any stiffness when LPN-A shook her hand. LPN-A stated, It was too late. LPN-A added, I was very confused as this has never happened to me before. I was very shaken and confused. It was scary. LPN-A indicated she left R1's room and sought registered nurse (RN)-A for guidance. Once they returned to R1's room, RN-A assessed R1 and confirmed R1 lacked a pulse or respirations. LPN-A identified the AED was brought into R1's room and opened; however, after they verified R1 was a Full code, the AED was not used as it was too late. LPN-A stated after, she contacted the administrator and was told, It was okay; however, she explained, in hindsight, she learned the administrator thought LPN-A had performed CPR and there was miscommunication during that call as she was just providing the administrator with an update on R1's passing - not looking for guidance on what to do during this situation. LPN-A denied she contacted the DON, the on-call nurse, nor the provider for guidance. She stated she should have contacted the DON as the DON is clinical, whereas the administrator was not. LPN-A stated she failed to follow the facility's policy for timely code status verification and CPR initiation. LPN-A identified she was suspended right away and was since provided education that included paper education, conversations with management, and mock drill participation's in which she has to be the champion. On [DATE] and [DATE], interviews were attempted with NA-D, the nursing assistant who updated LPN-A on R1's unresponsive status; however, these were unsuccessful. During a telephone interview on [DATE], at 9:38 a.m., physician assistant (PA)-A stated the facility updated her that R1 was found unresponsive, and the attempted CPR was unsuccessful. If a Full code resident was found unresponsive, with no pulse or respirations, she identified she expected staff to initiate chest compressions and AED use if the AED advised a shock. In addition, she expected 911 to be called. When she was updated that R1 was not provided with CPR, she wished to reserve any comments related to the lack of CPR, as she was unaware of the event details, especially considering not being initially provided all the facts. She indicated she was present at the facility and observed at least two mock CPR drills. On [DATE], between 10:22 a.m. and 11:35 a.m., the following staff were interviewed respectively: LPN-B at 10:22 a.m., nursing assistant (NA)-A at 10:30 a.m., NA-B at 10:39 a.m., RN-B at 10:49 a.m., NA-C at 10:56 a.m., LPN -C at 11:06 a.m., and LPN-E at 11:35 a.m. The nurses stated if a resident was found unresponsive, they were to assess for a pulse and respirations. If none found, they were to verify the code status and if full code, CPR was to be initiated right away. The nurses were able to identify where the code status identification was located. In addition, all the nurses indicated there were no reasons why CPR would not be initiated if a resident were Full code. All nurses acknowledged they were up to date on their CPR certifications. All the NAs identified if they found a resident unresponsive, they were to update a nurse immediately. All the NAs identified they were not allowed to perform CPR, only to assist in the accompanying code processes such as getting the crash cart and AED. All staff explained they were to use the overhead paging system for a code blue call, the crash cart and AED were to be obtained, and call 911 when a resident's code status warranted Full code action. All staff were able to direct where the crash cart and the AED were located. All staff explained the education they had received, and the mock CPR drills they had participated in. All acknowledged the education and drills were very helpful. When interviewed on [DATE], at 11:18 a.m., LPN-D, identified herself as the long-term care (LTC) coordinator. She explained if a resident were found unresponsive, assessed to be free of pulse or respirations, and identified to be a Full code, she expected staff to yell for help, call a code and initiate CPR. LPN-D identified nurses were responsible for CPR, and she confirmed all nurses were CPR certified. She indicated there were no reasons why CPR would not be initiated for a Full code resident, and the paramedics were the only ones who could stop CPR once initiated. LPN-D confirmed R1 was a Full code. She was aware of CPR not being initiated and she identified she was confused by the whole episode as performing CPR on a Full code resident was nursing 101. She explained, it was her understanding there was a communication breakdown as LPN-A contacted the administrator versus the DON or the on-call nurse, along with confusion as to when LPN-A contacted the administrator. In response to the failed systems, education was provided to all staff and mock CPR drills were initiated daily for each shift. These drills continued and would continue until all nurses participated and demonstrated competency. During an interview on [DATE], at 11:47 a.m., the DON stated if a resident was found unresponsive, and CPR was assessed to be indicated based on a verified Full code status, the licensed staff were to initiate CPR no matter what. The DON explained she was contacted by the administrator on the morning of [DATE]. The administrator informed her that after a phone call with LPN-A, and the administrator had additional time to process the call, the administrator was concerned staff did not perform CPR on R1, despite the administrator's knowledge R1 was Full code. Both she and the administrator presented to the facility on [DATE] and initiated a plan to educate all staff going forward. This included paper education with an associated quiz and mock CPR drills. This education would continue until all the staff were educated and all the nurses demonstrated participation. She stated additional follow ups included LPN-A's suspension, review of licensed staff CPR certification statuses and a whole house review of residents' code status with verification to ensure the POLST, orders, and care plan reflected each other. No concerns were identified with the review and verifications. When interviewed on [DATE], at 12:34 p.m., RN-A explained if a resident were found unresponsive, without a pulse and respirations, he was to check the code status. If the resident were a Full code, he was then to initiate CPR right away. He denied there were any reasons why CPR would be withheld if the resident were Full code. RN-A acknowledged he worked the morning of [DATE] and was approached by LPN-A around 5:40 a.m. He stated LPN-A informed him that R1 was unresponsive and asked him to come and see R1. He denied knowledge R1 had passed until he arrived at her room and assessed her. RN-A explained R1 was absent of a pulse and respirations. This prompted him to direct LPN-A to verify R1's code status and to grab the crash cart. In response, LPN-A informed him she contacted the administrator and the administrator told LPN-A not to do CPR. RN-A confirmed he, nor LPN-A, initiated CPR, or used the AED on R1. After he exited R1's room, he consulted another nurse related to his concerns that R1 was a full code and CPR was not initiated, especially as CPR should have been performed. RN-A and the nurse conferred and felt maybe there were a change in the policy, and they had just not yet been updated. RN-A identified education since this incident which included his participation in three mock CPR drills so far. During a telephone interview on [DATE], at 1:24 p.m., R1's family member (FM)-A identified he never personally reviewed R1's POLST; however, [R1] always said she wanted to be Full code. Based on this, he expected they would have attempted resuscitations when they found her on [DATE]. Further, he expected, after they initiated CPR, they would have transferred her to the hospital so hospital staff could have taken over. During an interview on [DATE], at 1:32 p.m., the administrator confirmed LPN-A contacted her on [DATE] at approximately 5:50 a.m., and told her It was too late, it was too late, related to R1: LPN-A stated this matter of fact and did not sound panicked. The administrator initially understood during this first call that CPR was attempted on R1 and it was unsuccessful; however, during the investigation, it was discovered there were communication failures that started with that first call and continued through a third call. After the administrator was able to process the initial phone call once she woke up more, as the phone call woke her up, she called back to the facility and spoke again to LPN-A. She questioned LPN-A if the AED instructed them not to perform a shock. LPN-A responded to her, Yes, [RN-A] took the AED. After the administrator contacted R1's family, she again called back to the facility and spoke a third time to LPN-A. She questioned LPN-A if they took the AED into R1's room: LPN-A confirmed this. As the administrator continued to feel something was off with the events that occurred, she contacted the DON and instructed the DON they needed to investigate further. She arrived at the facility between 8:00 a.m. and 8:30 a.m. During staff interviews, the administrator discovered LPN-A informed RN-A the administrator directed LPN-A to not perform CPR. After this, the DON took over the remainder of the investigation. The administrator acknowledged an action plan was put into place on [DATE] to mitigate repeat episodes once it was confirmed R1 was not provided with CPR. She expected if CPR was indicated, staff were to perform it. Steps in the correction plan included LPN-A's suspension, prepped, and provided staff education which included paper education and mock CPR drills, along with audits. The administrator confirmed there were no concerns identified with the audits and the drills continued. The IJ that began on [DATE] was removed the same day, when it was verified through staff interviews and document review, the facility performed the following corrective actions all on [DATE]: -The facility implemented a full-on investigation that included staff interviews along with family, provider, coroner, and medical director notifications. -LPN-A was suspended. -A FRI was submitted to the SA. -A full house CPR/POLST audit was conducted that verified POLSTs, orders, and care plans all reflected each other. -All licensed staff CPR certifications were verified and reflected all were current. -The CPR policy was reviewed, and no changes were needed. -All staff training on the Code Blue policy, which included a quiz, was initiated. - All staff participation in mock Code Blue drills were initiated. Drills have continued and will continue until each nurse has been deemed competent in the policy processes. -Audits related to CPR protocols would continue to be completed with five staff weekly for four weeks. A Cardiopulmonary Resuscitation policy, dated 2/2024, directed care would be provided according to the resident and/or the resident's representative identified preferences indicated by the physician orders and within the plan of care. CPR was to be initiated, by certified staff, for a resident who experienced a cardiac or respiratory arrest after code status was verified and an assessment revealed no signs of irreversible death were present. If irreversible signs of death were present, CPR was not to be initiated. The policy defined irreversible signs of death based on the American Heart Association which included rigor mortis (body limb stiffening) and dependent lividity (purplish red discoloration to the skin).