**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to provide care and services consistent with professional standards of practice to appropriately identify pressure ulcers/pressure injuries (PU/PIs), to prevent pressure ulcers/injuries, and promote healing of existing PU/PIs, and failed to prevent the development of additional PU/PIs for 6 of 10 (Residents #27, #78, #151, #171, #478, and #479) sampled residents for pressure ulcers/injury. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #27 who was at risk of developing PU/PIs, had contractures to upper and lower extremities, and was dependent on staff for preventative interventions, repositioning and turning, developed an open pressure ulcer/injury to the palm of left hand from having long fingernails embedded into the skin and developed a stage 3 PU/PI to the right buttock that was identified as a stage 3, when Resident #78 with a Left Lateral Ankle Stage 4 PU/PI wound that was not consistent with the characteristics of staging, when Resident #151, who was dependent on staff for repositioning and turning and who was at risk for developing PU/PIs, developed pressure wounds to the right foot due to pressure from the foot board, when Resident #171, a resident at risk for developing pressure ulcers, developed a Stage 3 PU/PI to the coccyx that was identified as a stage 3, and when the facility failed to administer prescribed PU/PI treatments for Residents #478 and #479, and when Resident #478's wound was inconsistent with staging. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-686 on 9/5/2024 at 11:52 AM, and on 9/5/2024 at 12:24 PM of the amended IJ, in the Chapel. The facility was cited Immediate Jeopardy at F-686 at a scope and severity of J which is Substandard Quality of Care. The IJ was effective from 10/19/2023 and is ongoing. The findings include: 1. Review of the National Pressure Injury Advisory Panel 2019 Guidelines, revealed .Skin and soft tissue assessment is the basis of pressure injury prevention and treatment. Skin and tissue assessment is an essential component of any pressure injury risk assessment and should be conducted as soon as possible after admission, as a component of a full risk assessment .Each time the individual's clinical condition changes, a comprehensive skin and tissue assessment should be conducted to identify any alterations to skin characteristics or integrity, and to identify any new pressure injury risk factors . In addition to comprehensive skin assessment, a brief skin assessment of the pressure points should be undertaken during repositioning .Presence of persistent erythema can indicate a need to increase frequency of repositioning. Check pressure points onto which the individual will be repositioned to ensure that the skin and tissue has fully recovered from previous loading .Ongoing skin assessment is necessary to detect early signs of pressure injury . 2. Review of the facility's policy titled, Pressure Injury and Management, revised 8/30/2022, revealed .The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Definitions: 'Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. 'Avoidable' means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . Policy Explanation and Compliance Guidelines .2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .3. Assessment of Pressure Injury Risk .Licensed nurses will conduct a pressure injury risk assessment .upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly . 4. Interventions for Prevention and to Promote Healing .After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management .Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics) .Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to .Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) .Minimize exposure to moisture and keep skin clean .Provide appropriate, pressure-redistributing mattresses for all residents .Maintain or improve nutrition and hydration status .Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present .Pressure injuries will be differentiated from non-pressure injuries .Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics .Interventions will be documented in the care plan and communicated to all relevant staff .Compliance with interventions will be documented in the weekly summary charting .5. Monitoring .The nurse will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of the findings in the medical record .The attending physician (or designee) will be notified of .The presence of a new pressure injury upon identification .The progression towards healing, or lack of healing, of any pressure injuries weekly .Any complications (such as infection, development of a sinus tract, etc.) as needed .A Focused Incident review will be performed on each pressure injury that develops in the facility. Findings will be reported in the monthly QAA [Quality Assessment and Assurance] Committee Meeting .The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the QAA Committee Schedule, and as needed when actual or potential problems are identified .6. Modification of Interventions .Interventions on a resident's plan of care will be modified as needed .Changes in resident's degree of risk for developing a pressure injury .New onset or recurrent pressure injury development .Lack of progression towards healing .Resident non-compliance .Changes in the resident's goals . Review of the facility's policy titled Skin Assessment, dated 5/2023, revealed .It is our policy to perform a full body assessment as part of or systematic approach to pressure injury prevention and management .Policy Explanation and Compliance Guidelines .1. A skin assessment will be conducted by a licensed or registered nurse upon admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Procedure .Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points [can include sacrum, heels, greater trochanter (upper hip area) ischial area (lower hip area), back of the head, ears, shoulders, elbows, inner knees and malleoli (ankle bones)], bony prominences, and underneath medical devices .Remove any special garments or devices .Remove any dressings, using clean technique .and note findings . Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, ad lesions .3. Consider the general status of the resident's skin .Color .Temperature .Moisture status .Skin texture/turgor .Perfusion. 4. Considerations for a resident with darkly pigmented skin .Localized heat .Edema .Bogginess .Induration .Temperature differences of surrounding skin .Skin discoloration. 5. Considerations for a bariatric resident .Perform assessment with at least one other staff member to assist with mobility ad positioning of body parts .Thoroughly inspect each surface skin fold .6. Differentiating the extent of redness .Blanchable erythema (redness) loses its redness when a finger is pressed on the erythema for 3 seconds and released. Blanching is assessed following the removal of the finger .Non-blanchable erythema (redness) persists when touched. Review of the facility's policy titled, Skin Integrity- Foot Care, reviewed/revised on 4/1/2024, revealed .Policy: It is the policy of this facility to ensure residents receive proper treatment and care .to maintain mobility and good foot health .Policy Explanation and Compliance Guidelines: 1. This facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical conditions .The facility will utilize a systematic approach for the prevention and management of foot ulcers, including efforts to identify risk; stabilize, reduce, or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate .2. Assessment of risk .Licensed nurses will conduct pressure injury risk assessments and skin assessments in accordance with facility policy for those assessments .The comprehensive assessment process will be utilized for identifying additional risk factors or conditions that increase risk for impaired skin integrity of the foot. Examples include, but are not limited to .diabetes, peripheral vascular disease, peripheral arterial disease, venous insufficiency, peripheral neuropathy, and lack of sensation in the feet .Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after task. 3. Interventions for preventions and to Promote healing .Interventions will based on specific factors identified in the risk assessment, skin assessment, and assessment of any foot ulcers .Appropriate offloading or orthopedic devise, diabetic shoes, or pressure-relieving devices will be utilized .referrals to podiatrists, vascular or orthopedic surgeons, or wound care physicians will be made when appropriate. The facility will arrange for transportation to and from any appointments .Medical conditions will be managed and interventions will be implemented in accordance with professional standards of practice to prevent complications from medical conditions .Evidence-based treatments will be provided for all residents who have a foot ulcer .Pressure injuries will be differentiated from non-pressure ulcers . 4. Monitoring .The attending physician will assume responsibility for overall care and treatment of the resident's medical conditions .RNs [Registered Nurses] and LPNs [Licensed Practical Nurses] will participate in the management of medical conditions by following physician orders, assessment of residents, and reporting changes in condition .Interventions will be modified in a resident's plan of care as needed. Considerations for needed modifications include .Changes in medical condition or degree of risk for developing foot ulcers .New onset or recurrent foot ulcer .lack of progression towards healing .Resident non-compliance .Changes in the resident's goals and preferences. 6 .The facility will follow proper infection prevention practices for foot care equipment/devices, including but not limited to nail clippers .reusable medical devices .must be cleaned and reprocessed . 3. The facility's Pressure Injury Staging and Care Plan Consideration and Pressure Injury Management Guidelines documents (from The Named Company dated 2019) were provided to the survey team on 9/4/2024, when the facility was asked for the source used by the facility to identify and stage pressure ulcers/injuries. The documents are as follows: a. Review of the facility's Pressure Injury Staging and Care Plan Consideration document revealed, .Stage 1 Pressure Injury: Non-blanchable erythema of intact skin .Intact skin with a localized area of non-blanchable erythema [a skin discoloration that doesn't run white when pressed], which may appear differently in darkly pigmented skin Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis [middle layer of skin] .The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue [healing process for deep pressure ulcers], slough [dead tissue], and eschar [dead dark tissue] are not present. These injuries commonly result from adverse microclimate [temperature, humidity airflow near the skin] and shear in the skin over the pelvis and shear [pressure and friction exerted] in the heel . Stage 3 Pressure Injury . Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible .Undermining and tunneling [tunneling and separation in a wound that occurs under the skin] may occur .If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury .Stage 4 Pressure Injury .Full-thickness skin and tissue loss with exposed or directly palpable fascia [tissue, tendons, etc. that are exposed and can be felt in a stage 4 pressure ulcer/injury], muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible, Epibole (rolled edges), undermining and/or tunneling often occur .If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury . Unstageable Pressure Injury: Obscured Full-thickness skin and tissue loss .in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar .Deep Tissue Pressure Injury [DTPI]: .Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface .Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions . b. Review of the facility's Pressure Injury Management Guidelines document revealed, .Stage 1 .Off Load .Manage Moisture Cover/Protect .Strategies to Protect: Choose Moisture Barrier to match type and level of incontinence. Assess repositioning interval. Assess support surfaces. Assess wheel chair positioning .Stage 2 Partial Thickness .Off Load .Manage Exudate Cover/Protect .Cleanse with normal saline or Wound Cleanser. Light Exudate: Apply Hydrogel, Hydrogel Ag [silver], Honey Hydrogel, Xeroform or Petrolatum Gauze. Change Daily. Minimal/Moderate Exudate: Apply Hydrocolloid Dressing. Change Q3D [every 3 days] .Stage 3 Full Thickness . Off Load .Manage Exudate Fill cavity Cover/Protect .Cleanse with normal saline or Wound Cleanser. Light Exudate: Apply Hydrogel, Hydrogel Ag, Honey Hydrogel or Collagen. Moderate Exudate: Apply Collagen, Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Heavy Exudate: Apply Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Change QD [every day] or QOD [every other day] .Stage 4 Full Thickness .Off Load .Manage Exudate . Debride if needed .Fill cavity Cover/Protect .Cleanse with normal saline or Wound Cleanser. Light Exudate: Apply Hydrogel, Hydrogel Ag, Honey Hydrogel or Collagen. Moderate Exudate: Apply Collagen, Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Heavy Exudate: Apply Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Change QD or QOD .Unstageable 100 % [percent] Eschar Full Thickness .Off Load . Manage Exudate . Debride . Fill Cavity .Cover/Protect . Cleanse with normal saline or Wound Cleanser. Chose a debridement: Autolytic, enzymatic or sharp debridement. Light Exudate: Apply Hydrogel, Hydrogel Ag, Honey Hydrogel dressing. Moderate Exudate: Apply Collagen, Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Heavy Exudate: Apply Calcium Alginate, Honey Alginate or Super Absorbent, Change Dressing QD or QOD . Unstageable .Off Load .Keep Dry .Cover/Protect .Assess Support Surfaces .Decrease Friction/Shear .Stable Eschar: Keep area dry. Keep area intact. Assess wheelchair positioning and seating. Stable Eschar on heels: (dry, no erythema, no exudate, fluctuance [Sign of pus that has accumulated beneath the surface of the skin])- area does not need to be debrided. Paint with skin prep or betadine. Off load heels. No shoes . Deep Tissue Injury [DTI] .Off Load .Keep Dry .Cover/Protect .Assess Support Surfaces .Decrease Friction/Shear . Strategies to protect: DTI on heels: Suspend heels with pillows, specialty cushions, boots. DTI sacral/gluteal: Use moisture barrier to match type and amount of incontinence. Assess repositioning interval. Assess support surfaces. Assess wheelchair positioning and seating .Medical Device Related Pressure Injuries .Pressure injuries that result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant ulcer generally conforms to the pattern or shape of the device. Should be staged to the most severe tissue damaged depth .Off Load .Manage Exudate .Debride if needed .Fill cavity . Cover/Protect .Removal, padding or repositioning of device causing injury is of utmost importance to allow and/or prevention. Residents with any type of medical device in place should be assessed at least twice a day for possible skin injury. 4. Review of medical record revealed Resident #27 was admitted on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Diabetes, Contracture, Dysphagia, Dementia and Aphasia. Review of the Braden Scale assessment completed on 12/30/2022 revealed Resident #27 was at high risk of developing a pressure ulcer. The facility failed to provide Resident #27's Braden Scale Assessment since the admission assessment on 12/30/2022 after requesting. Review of Resident #27's care plan revealed .Approach Start Date 4/20/2023 CONTRACTURES: The resident has contractures of the LUE [left upper extremity], bilateral hands). Provide skin care to keep clean and prevent skin breakdown . Review of Resident #27's care plan revealed .Approach date 11/22/2023 . Resident is at risk for skin breakdown R/T [related to] immobility . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #27 was rarely/never understood with cognitive skills for daily decision making severely impaired. The resident did not have a Brief Interview for Mental Status (BIMS) score. Further review revealed Resident #27 had impaired Range of motion (ROM) to upper left side extremity and a ROM impairment to both lower extremities. Resident #27 was dependent on staff for all activities of daily living (ADL's). Review of Resident #27's Medication Administration Record (MAR) dated 8/1/2024 through 8/31/2024 revealed: Cleanse area to palm of left hand with wound cleanser, pat dry, apply calcium alginate with a dry 4 x (by) 4, on Monday, Wednesday, and Friday. Cleanse stage 3 (III) to right buttock with wound cleanser pat dry, apply silver alginate and cover with border foam 3 times weekly and as needed. Review of Resident #27's care plan revealed .Approach Start Date: 8/6/2024 Rolled wash cloth inside left hand . Review of Resident #27's Wound Event Note dated 8/7/2024, revealed laceration to palm of left hand, caused by fingernails embedded into left hand, with measurements, in centimeters (cm) by (x) length x width x depth (L x W x D), of 2.2 cm x 2.0 cm x 0.2 cm. The facility failed to provide signed physician orders for the pressure ulcer/injury treatment to Resident #27's left hand palm. Review of Resident #27's care plan revealed .Approach Start Date: 8/7/2024 Resident has skin tears or cuts palm of left hand .Record location, size (length, width, depth), color, surrounding skin, presence/absence of drainage/pain/signs of healing every week .Treat area per MD [Medical Doctor] orders . Review of Resident #27's progress note dated 8/13/2024, revealed .laceration measures 0.2 cm x 0.2 cm x 0.1 cm left palm . Review of the INTEGRATED WOUND CARE Follow-up Progress Note dated 8/16/2024, revealed a stage 3 pressure injury/ulcer was identified on Resident #27's right buttock as a pressure injury with moderate serosanguinous exudate and tissue type documented with 100% granulation. The wound measured 1.1 cm x 0.9 cm x 0.3 cm. Review of the medical record revealed Resident #27's stage 3 to right buttock pressure injury was identified on 8/16/2024 with measurements of 1.1 cm x 0.9 cm x 0.3 cm. Review of Resident #27's MARS dated 8/1/2024 -8/31/2024, revealed no wound treatment documentation for right buttock stage 3 pressure injury on 8/16/2024. The facility failed to provide signed physician orders for treatment of Resident #27's stage 3 pressure injury. Review of Resident #27's care plan revealed .Approach Start [NO DATE] Resident with stage 3 to right buttock .provide treatments as ordered .assess wounds and skin weekly for changes .keep clean and dry as possible .Minimize skin exposure to moisture .keep linen clean and dry and wrinkle free . The care plan was not revised/updated to reflect the date the Stage 3 was identified. Observation on 8/19/2024 at 9:30 AM and 2:45 PM, and on 8/20/2024 at 8:09 AM and 2:23 PM, revealed Resident #27's fingernails appeared trimmed with jagged edges, bilateral hands without hand rolls, and with a foul odor. The resident's legs were observed to be contracted. The facility failed to follow the care plan for bilateral hand rolls for Resident #27. During an interview on 8/20/2024 at 2:30 PM, CNA O was asked how many staff are supposed to turn and reposition Resident #27. CNA O stated, We try to use 2 staff to turn and repo [reposition]. CNA O was asked if she smelled an odor from Resident #27's hands. CNA O stated, They are sweaty and needs cleaning I will get someone to help me wash them. CNA O was asked when Resident #27's hands are washed. CNA O states, She is bathed daily, but we ask the nurse to help open her hands at times . CNA O was asked what she would do if she observed an injury or a wound on a resident. CNA O stated, I would need to tell my nurse. CNA O was asked if Resident #27 was supposed to have anything in her hands. CNA O stated, I think so, I will get some washcloths . CNA O was asked why she didn't have hand rolls in her hands. CNA O stated, .guess we forgot .we should have had them there in her hands when we came on shift this morning . CNA O was asked how often Resident #27's nails are trimmed. CNA O stated, I don't know the nurse takes care of that . CNA O was asked if Resident #27 can open her hands on her own. CNA O stated, .no she cannot do anything she had a stroke .we do all her care, she's totally dependent on staff . During an interview on 8/20/2024 at 3:15 PM, LPN N was asked who trims Resident #27's nails. LPN N stated, The CNA trims her nails weekly . LPN was asked who cleans her hands. LPN N stated, .the CNA cleans her hands daily . LPN N was asked if Resident #27 had a wound inside her left hand. LPN N stated, I think she does but the wound nurse takes care of the wounds . LPN N was asked would Resident #27 have interventions in place for her hand contractures. LPN N stated, She needs hand rolls for that . Observation on 8/20/2024 at 3:45 PM, revealed Resident #27 did not have hand rolls in her hands in accordance with the resident's care plan. The resident's legs were observed to be contracted. Observation and interview in Resident's room on 8/21/2024 at 10:30 AM, with LPN A revealed Resident #27's bilateral hands did not have hand rolls. LPN A was asked when Resident #27 should have hand rolls. LPN A stated, She should have hand rolls each shift, I will do that now. LPN A opened Resident #27's left contracted hand, removed the dressing from her left palmed hand. Observation of Resident #27's palm of left-hand revealed a round open wound. The round edge of the wound appeared white with a moist edge surrounding the wound. The wound bed was red. The dressing had light brown drainage, with a slight odor. The wound measured (L length x [by] width x Depth) 2.0 cm x 2.0 cm x 0.2 cm. LPN A was asked what caused the wound and what stage was the wound. LPN A stated, I originally found the wound on 8/7 [2024] during her weekly skin assessment. My wound event note was documented as a laceration .the injury was caused by her fingernails embedded into her left palm of her hand. LPN A was asked if the wound was caused by pressure to the left palm from her nails embedded into her hand. LPN A stated, Yes, it was . LPN A was asked if the laceration she documented was actually a pressure injury. LPN A stated, I can't say . LPN A was asked if she can stage a wound. LPN A stated .Yes I am certified, but the Wound Nurse Practitioner stages the wounds . LPN A was asked if the wound should be staged as a pressure injury. LPN A stated, .the nails were pressed into her skin by her contracted hand, and pressure was applied, I would say it could be a pressure injury . LPN A was asked who trims her fingernails and how often are they trimmed. LPN A stated, The charge nurse usually trims them .I can't say when the last time they were trimmed . LPN A was asked how long her fingernails were on the day the wound was found. LPN A stated, Her nails were very long .that's why they cut into her hand and why I documented a laceration . LPN A was asked how often Resident #27's hands are cleaned. LPN A stated, Staff should clean her hands everyday but the nurses may have to assist with opening her hands. LPN A was asked if Resident #27 can open her hands or position herself in bed. LPN A stated, No she's total dependence [on staff] with her care. LPN A was asked what interventions are in place for Resident #27's hand contractures. LPN A stated, She is supposed to have a hand roll or rolled wash cloths in her hands. LPN A was asked if Resident #27's hand had a foul odor and why she doesn't have hand rolls in place. LPN A stated, Yes, her hands have an odor and need to be cleaned .she needs hand rolls in her hands as well . LPN A was asked how often the dressing is changed. LPN A stated, 3 times a week. LPN A was asked why the laceration was changed to a skin tear on 8/23/2024. LPN A stated .I probably would not have changed the wound to a skin tear, but the wound NP documented that . LPN A was asked if the wound could have been prevented. LPN A stated, I believe so. LPN A was asked if the resident's left palm wound was larger than the last measurement. LPN A stated .I believe so, it's almost the same size as the day it was initially found . The resident's legs were observed to be contracted. The 8/21/2024 measurements were not documented in the medical record, and the 8/21/2024 measurements had increased in size from the 8/13/2024 measurements. Observation on 8/22/2024 at 7:30 AM, revealed Resident #27 did not have hand rolls in her hands in accordance with the care plan. Observation and interview in the resident's room on 8/22/2024 at 10:30 AM, revealed LPN C described Resident #27's right buttock as a stage 3 pressure injury. LPN C stated, .the wound appears as a full thickness tissue loss with the wound bed red with granulation tissue measuring 0.5 cm x 0.5 cm x 0.3 cm. LPN C was asked when the wound was found and at what stage was the wound when it was first documented. LPN C stated, The right buttock [pressure ulcer/injury] was found on 8/16/2024 at a Stage 3. LPN C was asked how Resident #27 developed a wound at a stage 3. LPN stated, .her comorbidities . LPN C was asked if a wound should initially start at a stage 3. LPN C stated, No, it should not start as a stage 3 pressure injury. Review of Resident #27's progress note dated 8/23/2024, revealed .skin tear to left hand measures 0.4 cm x 0.4 cmx 0.1 cm . Resident #27's left palm pressure injury healed on 8/24/2024. Review of the INTEGRATED WOUND CARE Follow-up Progress Note dated 8/23/2024, revealed Resident #27's .pressure ulcer stage 3 to right buttock was .documented as a pressure injury with moderate serosanguinous exudate and tissue type with 50% granulation and 50% dermis. The wound measured 0.5 cm x 0.5 cm x 0.3 cm . Review of Resident #27's shower/bath sheets dated 8/2/2024, 8/6/2024, 8/9/2024, 8/13/2024 revealed no documentation the resident had any skin integrity issues or open area to the right buttock. Review of the INTEGRATED WOUND CARE Follow-up Progress Note dated 8/26/2024, revealed Resident #27's pressure ulcer stage 3 to the right buttock was documented as a pressure injury with no exudate, with tissue type 100% epithelial, and measured 0.5 cm x 0.5 cm x 0.3 cm. The facility was asked for signed MD orders on 8/27/2024. The facility did not provide requested signed MD on 8/27/2024. The facility was asked for signed MD orders on 8/28/2024. The facility did not provide requested signed MD orders on 8/28/2024. The facility provided signed MD orders on 8/29/2024, but the orders did not include Resident #27's treatments to pressure injury to palm of left hand or stage 3 right buttock. During an interview on 8/29/2024 at 2:30 PM, the DON was asked if the Medical Regimen Review Report dated 8/1/2024 through 8/28/2024 included the complete signed physician orders August 2024 for Resident #27. The DON stated Yes. The DON was asked if she can see treatment orders on the report. The DON stated No, but I will check on that . The DON was asked if the treatment orders should be signed by the physician. The DON stated Yes. The DON was asked if a treatment isn't signed on the MAR or Treatment Administration Record (TAR), was the wound treatment completed. The DON stated, .if it's not documented it's not completed. Review of the INTEGRATED WOUND CARE Follow-up Progress Note dated 9/2/2024, revealed .Pressure ulcer Buttock right .Resolved 9/2/2024 .PLAN .MASD [moisture- associated skin damage] right Buttock .Cleanse with wound cleanser, pat dry. Apply collagen, border gauze. QD [every day]/ [and] prn [as needed] . The facility failed to reassess and implement interventions for the [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to complete skin assessments and administer wound treatments for residents determined to be at risk of skin breakdown for 4 of 7 sampled residents (Resident #1, #4, #5, and #8,) reviewed for pressure ulcer wounds. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 did not receive treatments for a pressure ulcer wound identified upon admission with measurable depth and the wound worsened to unstageable and required debridement, Resident #4 did not receive treatments for a Stage 2 pressure ulcer wound and the wound developed to a Stage 3, Resident #5 was admitted with pressure ulcer wounds, the resident did not receive treatments as ordered and developed additional pressure ulcer wounds, and Resident #8 did not receive treatments for a pressure ulcer wound identified upon admission and developed infection to the wound. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Regional Director of Operations, the Area Director of Clinical Services, the Regional Director of Clinical Services, the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-686 on 1/17/2023 at 6:12 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-686. The facility was cited Immediate Jeopardy F-686 at a scope and severity of J which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 1/19/2023, and the Removal Plan was validated onsite by the surveyors on 1/24/2023 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on 12/16/2022 through 1/24/2023. The findings include: 1. Review of the facility's policy titled, Wound Treatment Management dated 3/24/2022, revealed .To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .Wound treatments will be provided in accordance with physicians orders, including the cleansing method, type of dressing, and frequency of dressing changes .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse .The facility will follow specific physician orders for providing wound care .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound . Review of the facility's policy titled, Wound Care-Pressure Injuries Overview dated 3/24/2022, revealed .The purpose of this procedure is to provide information regarding clinical identification of pressure injuries and associated risk factors, which is derived from the definitions in 483.25(b)(1) Pressure Injuries (F686) .Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device .Eschar/Slough .is dead or devitalized tissue that is hard or soft in texture, usually black, brown, or tan in color, and may appear scab-like .Slough is non-viable yellow, tan, gray, green or brown tissue .Slough may be adherent to the base of the wound or present throughout the wound bed .Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis .presenting as a shallow open ulcer .The wound bed is viable, pink or red, moist, and may also appear as an intact or open/ruptured blister .Granulation tissue, slough and eschar are not present .Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss .the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar . Review of the facility's undated policy titled, Skin Assessment, revealed .It is our policy to perform a full body assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . Review of the facility's policy titled Nursing Services and Sufficient Staff dated, 8/30/2022, revealed .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Intestinal Obstruction, Muscle Weakness, Cognitive Communication Deficit, Dysphagia, and Hypertension. Review of the Braden Scale assessment completed on admission revealed Resident #1 was a high risk of developing a pressure ulcer. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 scored an 11 on the Brief Interview of Mental Status (BIMS) which indicated moderately impaired cognition. The resident required extensive assistance for bed mobility and was dependent for transfers. Review of a Treatment Nurse Communication Form dated 12/16/2022, revealed Resident #1 had pressure ulcer wounds as follows: Sacral region with measurements of length by (x) width x depth (LxWxD) of 0.4 centimeters (cm) x 3.5 cm x 0.4 cm. Left heel with measurements of 4.0 cm x 3.2 cm x 0.2 cm. Right heel with measurements of 0.2 cm x 3.0 cm x 0.1 cm. Review of the admission nursing assessment dated [DATE] documented .Right heel Bruising .Left heel Bruising .Sacrum Pressure sore . Review of a Nurse's Progress Note dated 12/16/2022 documented .Resident has pressure sore to sacrum and flaky skin, as well as bruising to heels . Review of the Care Plan initiated on 12/19/2022 documented, .The resident has pressure ulcer with potential for further pressure ulcer development .Assess/record/monitor wound healing as ordered and per protocol. Measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . There was no documentation of treatment orders to the sacrum, right heel and left heel pressure ulcer wounds from the admission date of 12/16/2022 until 12/21/2022. Review of a 12/21/2022 Physician's orders with a start date of 12/22/2022 documented the following treatment for sacral, right heel and left heel: .Cleanse Unstageable wound to Sacrum with sound cleanser. Pat dry. Apply Santyl and Calcium alginate to site. Cover with dry foam dressing/ Change dressing daily on Monday, Wednesday, and Friday and Prn (as needed) until resolved . .Cleanse Unstageable wound to R [right] heel with wound cleanser. Pat dry. Apply medi-honey and cover with Calcium alginate with silver. Cover site with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . .Cleanse Unstageable wound to L [left] heel with wound cleanser. Pat dry. Apply medi-honey and cover with Calcium alginate with silver. Cover site with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . Review of the 12/21/2022 wound care Physician's Initial Progress Note revealed: Unstageable Pressure Ulcer to the Sacrum which measured 5cm x 7cm with 50% dermis and 50% eschar. Right heel was documented as unstageable and measured 7cm x 5 cm with 50% dermis and 50% eschar. Left heel was documented as unstageable and measured 9cm x 7cm with 50% eschar and 50% serum filled blister. Review of the Treatment Administration Record (TAR) for December 2022, revealed there was no treatment administered as ordered for the unstageable wound to the sacrum, unstageable wound to the right heel, and unstageable wound to the left heel on 12/28/2022 and 12/30/2022. Review of the 1/4/2023 wound care Physician's Initial Progress Note revealed an Unstageable Pressure Ulcer to the Sacrum and measured 8.3 cm x 7.2 cm x 0.2 cm with 75% slough and 25% granulation. Review of the wound care Physician's Initial Progress Note dated 1/11/2023, revealed an Unstageable Pressure Ulcer to the Sacrum and measured 6.0 cm x 6.5 cm x 0.2 cm with 75% slough and 25 % granulation. The pressure ulcer wound was debrided on 1/11/2023. Review of the TAR for January 2023, revealed there was no treatment administered as ordered for the unstageable wound to the sacrum, unstageable wound to the right heel, and unstageable wound to the left heel on 1/6/2023. Observations in the resident's room on 12/27/2022 at 3:40 PM, revealed Resident #1 lying supine in bed. The resident was alert and oriented. When asked if she had any wounds to her skin she stated, I have a sore on my bottom .The nurse puts a cover [dressing] on it now. I guess it got worse. During an interview on 12/27/2022 at 1:02 PM, Resident #1's family member stated, .She has been here about a week or 10 days I guess and has a bad sore. That tells me they are not turning her as they should .That bed sore has gotten much worse in the 10 days she has been here . During an interview on 12/29/2022 at 9:59 AM, the Licensed Practical Nurse (LPN)/Wound Nurse reviewed the Physician orders and the TAR and stated, This is not okay. She [Resident #1] came in on the 16th [12/16/2022] and the order is not until the 21 [12/21/2022]. That's not okay . During a telephone interview on 12/29/2022 at 10:21 AM, when asked what the meaning was of unstageable related to a pressure ulcer wounds, LPN #1 stated, You can't measure the depth. When asked if she could measure the depth of the sacral wound and the wound to the right heel and left heel of Resident #1 upon admission, LPN #1 stated, Yes ma'am. I guess I should have called it a Stage 2 . When asked if treatments and wound care was provided for Resident #1, LPN #1 stated, Documented on the place where we document treatments if I did them . During an interview on 12/29/2022 at 11:08 AM, the DON confirmed there was no documentation of wound assessments or care provided for the pressure ulcer wounds from 12/16/2022 until 12/23/2022. The DON stated, If not documented, it wasn't done. What I see is an order on 12/21 [2022]. I see nothing before that. There were no treatments provided to the resident's sacrum, right heel and left heel from 12/16/2022 until 12/22/2022. During an interview on 1/4/2023 at 4:02 PM, when asked when the first treatment was administered to the pressure ulcer wounds, the LPN/Wound Nurse stated, .From the 16th till the 21st when [Named physician] saw her there is no documentation of a treatment. That's awful. When asked if there was documentation of wound assessments that described the wounds appearance, LPN/Treatment Nurse stated, I didn't document any assessments in the computer. I threw the papers away. I don't have any of my papers prior to the 7th [1/7/2023]. That's when I was inserviced what to document in the computer. When I came here, I wasn't told about pressure and non-pressure assessments. I did not receive the proper training for this system to document. I threw my papers away . During an interview on 1/4/2023 at 10:38 AM, the Regional Director of Clinical Services (RDCS) stated, We did a facility wide skin sweep over the weekend. We found some new wounds and we are taking care of that. When asked what she meant by a skin sweep the RDCS stated, A skin assessment of every resident to see if there were any wounds that had been missed. During an interview on 1/5/2023 at 9:58 AM, when asked if Resident #1 had Pressure Ulcer wounds, LPN #2/Unit Manager stated, I don't remember what her wounds are. I looked at her paperwork from the hospital .If there are wounds it's passed on to the treatment nurse. I wouldn't know about the wound location. 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Covid-19, and Epilepsy. Review of the quarterly MDS dated [DATE] revealed Resident #4 scored an 13 on the BIMS which indicated no cognitive impairment. The resident required extensive assistance for bed mobility and activities of daily living. Review of the Braden Scale assessment completed on 9/21/2022 and 1/3/2023 revealed Resident #1 was at risk of developing a pressure ulcer. Review of the Weekly Skin Reviews dated 11/30/2022, 12/7/2022, 12/14/2022, 12/21/2022, 12/28/2022, and 1/4/2023 revealed Resident #4 had redness to the sacrum. Review of the Nursing Daily Skilled Services assessments dated 12/29/2022, 1/1/2023, 1/2/2023, 1/3/2023, 1/9/2023, 1/10/2023, and 1/11/2023 documented there was no change in the resident's skin integrity. Review of the Shower Day Skin Inspection sheet dated 1/1/2022 [2023], revealed Resident #4 had a Stage 2 open area to the sacral region. There were no documented descriptions or measurements of the wound. Review of a Physician's order dated 1/1/2023, documented, .Cleanse stage 2 pressure ulcer to R buttock with wound cleanser. Pat dry. Apply hydrocolloid dressing to site and cover with bordered foam dressing MWF and PRN . Review of a Physician's order dated 1/4/2023, documented .Cleanse stage 2 pressure ulcer to sacrum with wound cleanser. Pat dry. Apply medi-honey followed by collagen. Cover with bordered foam dressing MWF and PRN . Review of the wound care Physician's Initial Progress Note dated 1/4/2023, revealed a Stage 3 Pressure Ulcer to the sacrum which measured 4.2cm x 3.7 cm x 0.1 cm with 25% slough, 50% epithelial, and 25% serum blister. Review of the wound care Physician's Progress Note dated 1/11/2023, revealed a Stage 3 Pressure Ulcer to Resident #4's lower back which measured 2.3 cm x 0.5 cm x 0.1 cm with 50% slough and 50% dermis. The facility failed to document accurate skin assessments and failed to identify that the resident's sacral pressure ulcer wound had progressed to a Stage 3. During an interview on 1/5/2023 at 12:44 PM, when asked when the Stage 2 to the sacrum was first identified, the DON stated, We did a facility wide skin sweep on the 1st [1/1/2023] and that is when it was found . The DON confirmed there was no documentation describing the wound or measurements of the wound until 1/4/2023. During a telephone interview on 1/6/2023 at 2:45 PM, when asked if she was notified of the Stage 2 Pressure Ulcer on 1/1/2023, the wound care Physician stated, Not that I recall. I saw the wound during my visit on the 4th [1/4/2023]. It was a Stage 3. Nurse was probably not aware of the slough . During an interview on 1/19/2023 at 2:55 PM, when asked when the Stage 3 to the lower back was first identified the LPN/Wound Nurse stated, Identified by [Named Wound Care Physician] during her visit on the 11th [1/11/2023]. 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Paraplegia, Chronic Osteomyelitis, Open Wound of Buttock, History of Failed Surgical Flap, Peripheral Vascular Disease, Anemia, and Protein-Calorie Malnutrition. Review of the annual MDS dated [DATE], revealed Resident #5 scored a 15 on the BIMS which indicated no cognitive impairment. The resident required supervision for activities of daily living. The MDS Section M Skin Conditions documented no pressure ulcer wounds and one surgical wound. Review of the Physician's orders dated 11/2/2022, documented .Cleanse Surgical Site to L buttock with wound cleaner. Dry with 4x4, Pack wound with dry collagen. Cover with dry bordered foam dressing Mon [Monday] Wed [Wednesday] Fri [Friday], and PRN . Review of the TAR for November 2022 and December 2022 revealed treatments were not provided as ordered for the surgical site to the left buttock on 11/7/2022, 11/14/2022, 11/21/2022, 11/25/2022, and 12/28/2022. Review of the Braden Scale assessment completed on 1/3/2023 revealed Resident #5 was at risk of developing a pressure ulcer. Review of the Physician's orders dated 1/4/2023, documented .Cleanse pressure ulcer to Right medial buttock with wound cleanser. Pat dry. Apply honey followed by collagen. Cover with bordered foam MWF and PRN . Review of the 1/6/2023 Weekly Summary revealed the did not have any Pressure Ulcer wounds. The weekly skin summary failed to identify the resident's right medial buttock pressure ulcer wound. Review of the wound care Physician's progress note dated 1/4/2023, revealed Resident #5 had a new Stage 3 Pressure Ulcer wound to the right medial buttock which measured 2.8 cm x 2.3 cm x 0.2 cm with 50% slough and 50% dermis. Observations in the resident's room on 1/5/2023 at 10:41 AM, revealed he was propelling himself in a wheelchair in his room and able to transfer himself to the bed. He was alert and oriented. Resident #5 stated, I had a bad place on my butt. I had surgery on that. Now they say I've got a new wound. I need a new cushion, but it hadn't come in yet. During an interview on 1/9/2023 at 12:57 PM, when asked when the Stage 3 to the right medial buttock was first identified, the DON stated, It was identified on the 4th [1/4/2023] on the other side of the buttock. The DON confirmed the new pressure ulcer was identified during the facility wide skin sweep on 1/1/2023. The facility failed to identify the right medial buttock pressure ulcer wound until progression to a Stage 3. 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region, Sepsis Unspecified Organism, Urinary Tract Infection, Cerebral Infarction, Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis of Deep Vein or Right Upper Extremity, and Osteomyelitis. Review of the Shower Day Skin Inspection sheet dated 12/22/2022, revealed Resident #8 had a wound to the sacral region which measured 6.8 cm x 11.3 cm x 0.0 cm. Review of the Physician's orders dated 12/23/2022, documented .Cleanse Unstageable pressure ulcer to Sacrum with wound cleaner. Pat dry. Apply Dakin's wet to dry dressing to site. Cover with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . Review of the admission nursing assessment dated [DATE], revealed Resident #8 had a pressure related skin condition. Review of the Braden Scale assessment completed on 12/23/2022 revealed Resident #8 was a very high risk of developing a pressure ulcer wound. Review of the quarterly MDS dated [DATE], revealed Resident #8 scored a 7 on the BIMS which indicated severe cognitive impairment. The resident required extensive assist for activities of daily living. The MDS Section M Skin Conditions documented one unstageable pressure ulcer wound. Review of the TAR for December 2022, revealed there was no treatment administered for the unstageable Pressure Ulcer wound to the sacrum from 12/22/2022 - 12/31/2022. Review of the Physician's orders dated 1/4/2023, documented .Cleanse DTI [Deep Tissue Injury] to lateral L foot with wound cleanser. Pat dry. Apply skin prep MWF and PRN . Santyl Ointment 250 UNIT/GM [gram] (Collagenase) Apply to sacrum topically every day shift every Mon, Wed, Fri for stage 4 pressure ulcer to sacrum. Cleanse stage 4 ulcer to sacrum with Dakin's solution. Pat dry. Apply santyl and medihoney followed by calcium alginate. Cover with bordered foam MWF and PRN . Review of the wound care Physician's Progress Note dated 1/4/2023, documented .Debrided sacrum of necrotic tendon, bone, and fascia. Recommend Ciprofloxacin 750 mg BID [twice daily] PO [by mouth] for osteomyelitis .Sacrum Pressure Ulcer Stage 4 7.8 [cm] x 11.3 [cm] .Left lateral foot Deep Tissue Injury .8.5 [cm] x 3.7 [cm] x 0[cm] . There was no documentation the facility identified the left lateral foot wound until 1/4/2023. Review of the Physician's orders dated 1/5/2023, documented .Ciprofloxacin HCL Tablet 750 MG [milligrams] by mouth two times a day related to OSTEOMYELITIS OF VERTEBRA, SACRAL AND SACROCOCCYGEAL REGION for 4 weeks . Review of the TAR for January 2023, revealed there was no treatment administered as ordered for the unstageable Pressure Ulcer wound to the sacrum on 1/2/2023. Observations in the resident's room on 1/4/2023 at 9:30 AM, revealed Resident #8 lying supine in bed. She was alert with confusion. During an interview on 1/4/2023 at 10:47 AM, when if the facility wide skin assessments completed on all residents had revealed new wounds, the Regional Director of Clinical Services RDCS stated, I have a list. There were several new wounds. We are on it now though. Started an inservice already. When asked what monitoring was being done to ensure skin assessments were completed, the RDCS stated, We are meeting about that today. During an interview on 1/4/2023 at 2:36 PM, when asked when the Pressure Ulcer wound to Resident #8's left foot was first identified, the LPN/Wound Care Nurse stated .It was actually noted today during Physician rounds as a left lateral deep tissue injury. I would assume no one saw it or looked at the foot . During an interview on 1/6/2023 at 2:45 PM, when asked when the was the 1st notification Resident #8 had a Pressure Ulcer wound to the sacrum, the wound care physician stated, I saw her on Wednesday [1/4/2023] for the first time. That was the first time my attention was brought to the wound . During an interview on 1/9/2023 at 11:18 AM, when asked where in the medical record would the nurse completing a weekly summary describe a new wound that had been identified, the DON stated, I would have to go look. I'm not sure. During an interview on 1/10/2023 at 9:50 AM, when asked from the admission measurements on 12/22/2022 until the physician was notified on 1/2/2022 was the Pressure Ulcer to the sacrum assessed and monitored, the LPN/Wound Care Nurse stated, Those assessments were not completed. When asked if the TAR had documentation of the treatments administered, the LPN/Wound Treatment Nurse stated, They [TAR dates] are all blank. She [LPN #1] didn't sign off that she did the treatments .That's awful . During an interview on 1/10/2023 at 2:10 PM, the DON confirmed no assessments were completed and no treatments were administered for the Pressure Ulcer wounds from admission on [DATE] - 1/2/2023 for Residnet #8. The surveyors verified the Removal Plan by: 1. The DON/SDC (Staff Development Coordinator)/and three Nursing Supervisors will conduct skin assessments on all current residents on 1/18/2023. Any additional concerns will be addressed immediately. The surveyors confirmed this by record review and interview. 2. A medical record review was completed on all residents admitted to the facility after 12/27/2022 by DON/ADCS(Area Director Clinical Services)/RDCS (Regional Director Clinical Services) to ensure initial skin assessments were completed on 1/17/2023. The surveyors confirmed this by record review and interview. 3. A care plan audit was conducted by the Care Plan Coordinator(s) to ensure that treatment recommendations/orders were on the care plan that the care plan was being followed. Audit was complete on 1/18/2023. The surveyors confirmed this by record review and interview. 4. All facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed by the Administrator, DON and QAPI (Quality Assurance Performance Improvement) team on 1/18/2023 without the need for amendment. The surveyors confirmed this by record review and interview. 5. DON/SDC provided education to all licensed nurses on facility policies and procedures related to skin/wound care, assessing residents upon admission, and assuring completion of treatments as ordered. Education began on 1/17/2023 and was completed on 1/18/2023. New nurses and agency nurses will not be able to work until they have been educated. The surveyors confirmed this by review of sign in sheets and interviews. 6. DON/SDC educated all nurse aides on preventative skin care beginning 1/17/2023 with 100% of CNAs (Certified Nursing Assistant) being educated by 1/18/2023. No additional concerns have been noted related to preventative care. The surveyors confirmed this by review of sign in sheets and interviews. 7. Beginning 1/18/2023 the DON/SDC/Unit Managers will conduct daily treatment record and nursing documentation audits to ensure accurate and complete documentation of skin related treatments and preventative measures. Audits will be conducted Monday thru Friday in the Clinical meeting. Weekend audits will be conducted by the DON or house supervisor assuring that audits are complete 7 days a week. Audits will include all current treatment orders as well as assuring that all new admission have a head-to-toe skin assessment documented within 24 hours of admission. Audits will be on-going. The surveyors confirmed this by record review and interviews. 8. A QAPI PIP (Performance Improvement Project) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA (Quality Assessment and Assurance) meeting. Monitoring/auditing and reporting will continue for a minimum of three months. The surveyors confirmed this by record review and interviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to ensure the implementation of Residents' Right to be free of abuse neglect as evidenced by the failure to complete assessments, provide the necessary care, services and treatments for residents determined to be at risk of skin breakdown for 4 of 7 sampled residents (Resident #1, #4, #5, and #8,) reviewed for pressure ulcer wounds; failed to complete assessments and provide treatments as ordered for 2 of 2 sampled residents (Resident #3 and #6) reviewed with other wounds; and the facility failed to provide sufficient licensed nursing staff to administer significant medications as ordered by the physician for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, #72) reviewed with significant medications ordered. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 did not receive treatments for a pressure ulcer wound identified upon admission and the wound worsened and required debridement. Resident #4 did not receive treatments for a Stage 2 pressure ulcer wound and the wound developed to a Stage 3. Resident #5 had a Stage 3 pressure ulcer wound that the facility failed to identify. Resident #8 did not receive treatments for a pressure ulcer wound identified upon admission and developed an infection in the wound. The facility failed to identify and provide wound treatments for for Resident #3 and #6 and the wounds developed into gangrene; and the facility failed to provide a licensed nurse to assess, monitor, and administer medications as ordered by the physician. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Regional Director of Operations, the Area Director of Clinical Services, the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-684 and F-686 on 1/17/2023 at 6:12 PM, in the Chapel. The Regional Director of Operations, the Area Director of Clinical Services, the Regional Special Projects Nurse, and the Administrator were notified of the Immediate Jeopardy (IJ) for F600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F686 at a scope and severity of J which is Substandard Quality of Care. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. Non-compliance of F600, F684, F725, F760, F835, and F867 continues at a scope and severity of K. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F684 and F686, was received on 1/19/2023, and the Removal Plan was validated onsite by the surveyors on 1/24/2023 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on 12/16/2022 through 1/24/2023 for F684 and F686. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, Abuse, Neglect and Exploitation revised 3/3/2022 revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect .'Neglect' means failure of a facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Define how care provision will be changed and/or improved to protect residents .Training of staff on changes made and demonstration of staff competency .Identification of staff responsible for implementation or corrective actions .Identification of staff responsible for monitoring the implementation of the plan . Review of the facility's policy titled Wound Treatment Management dated 3/24/2022 revealed, .To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .Wound treatments will be provided in accordance with physicians orders, including the cleansing method, type of dressing, and frequency of dressing changes .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound . Review of the facility's undated policy titled Skin Assessment revealed, .It is our policy to perform a full body assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . Review of the facility's policy titled Nursing Services and Sufficient Staff revised 8/30/2022 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans .a. Except when waived, licensed nurses; and b. Other nursing personnel, including but not limited to nurse aides .The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to residents' needs . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Intestinal Obstruction, Muscle Weakness, Cognitive Communication Deficit, Dysphagia, and Hypertension. Review of the Braden Scale assessment completed on admission revealed Resident #1 was a high risk of developing a pressure ulcer. Review of a Treatment Nurse Communication Form dated 12/16/2022 revealed Resident #1 had a wound to the sacral region with measurements of length by (x) width x depth (LxWxD) of 0.4 centimeters (cm) x 3.5 cm x 0.4 cm, a wound to the left heel with measurements of 4.0 cm x 3.2 cm x 0.2 cm, and a wound to the right heel with measurements of 0.2 cm x 3.0 cm x 0.1 cm. Review of the admission nursing assessment dated [DATE] documented, .Right heel Bruising to heel .Left heel Bruising to heel .Sacrum Pressure sore on sacrum . Review of a Nurse's Progress Note dated 12/16/2022 documented, .Resident has pressure sore to sacrum and flaky skin, as well as bruising to heels . Review of the Care Plan initiated on 12/19/2022 documented, .The resident has pressure ulcer with potential for further pressure ulcer development .Assess/record/monitor wound healing as ordered and per protocol. Measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . Review of a Physician's order dated 12/21/2022 with a start date of 12/22/2022 documented, .Cleanse Unstageable wound to Sacrum with sound cleanser. Pat dry. Apply Santyl and Calcium alginate to site. Cover with dry foam dressing. Change dressing daily on Monday, Wednesday, and Friday and Prn (as needed) until resolved . There was no documentation of treatment orders for the sacral pressure ulcer wound from the admission date of 12/16/2022 until 12/21/2022. Review of a Physician's order dated 12/21/2022 with a start date of 12/22/2022 documented, .Cleanse Unstageable wound to R [right] heel with wound cleanser. Pat dry. Apply medi-honey and cover with Calcium alginate with silver. Cover site with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . There was no documentation of treatment orders to the right heel pressure ulcer wound from the admission date of 12/16/2022 until 12/21/2022. Review of a Physician's order dated 12/21/2022 with a start date of 12/22/2022 documented, .Cleanse Unstageable wound to L [left] heel with wound cleanser. Pat dry. Apply medi-honey and cover with Calcium alginate with silver. Cover site with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . There was no documentation of treatment orders to the left heel pressure ulcer wound from the admission date of 12/16/2022 until 12/22/2022. Review of the wound care Physician's Initial Progress Note dated 12/21/2022 revealed an Unstageable Pressure Ulcer to the Sacrum which measured 5 cm x 7cm with 50 percent (%) dermis and 50% eschar. The right heel was documented as unstageable and measured 7 cm x 5 cm with 50% dermis and 50% eschar. The left heel was documented as unstageable and measured 9 cm x 7 cm with 50% eschar and 50% serum filled blister. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored an 11 on the Brief Interview of Mental Status (BIMS) which indicated moderately impaired cognition. The resident required extensive assistance for bed mobility and was dependent for transfers. Review of the wound care Physician's Initial Progress Note dated 1/4/2023 revealed an Unstageable Pressure Ulcer to the Sacrum and measured 8.3 cm x 7.2 cm x 0.2 cm with 75% slough and 25% granulation. Review of the wound care Physician's Initial Progress Note dated 1/11/2023 revealed an Unstageable Pressure Ulcer to the Sacrum and measured 6.0 cm x 6.5 cm x 0.2 cm with 75% slough and 25 % granulation. The pressure ulcer wound was debrided on 1/11/2023. Review of the Treatment Administration Record (TAR) for December 2022 revealed there was no treatment administered as ordered for the unstageable wound to the sacrum, unstageable wound to the right heel, and unstageable wound to the left heel on 12/28/2022 and 12/30/2022. Review of the TAR for January 2023 revealed there was no treatment administered as ordered for the unstageable wound to the sacrum, unstageable wound to the right heel, and unstageable wound to the left heel on 1/6/2023. Observations in the resident's room on 12/27/2022 at 3:40 PM revealed Resident #1 lying supine in bed. The resident was alert and oriented. When asked if she had any wounds to her skin she stated, I have a sore on my bottom .The nurse puts a cover [dressing] on it now. I guess it got worse. During an interview on 12/27/2022 at 1:02 PM, Resident #1's family member stated, .She has been here about a week or 10 days I guess and has a bad sore. That tells me they are not turning her as they should .That bed sore has gotten much worse in the 10 days she has been here . During an interview on 12/29/2022 at 9:59 AM, the Licensed Practical Nurse (LPN) #5 reviewed the Physician orders and the TAR and stated, This is not okay. She [Resident #1] came in on the 16th [12/16/2022] and the order is not until the 21st [12/22/2022]. That's not okay . During a telephone interview on 12/29/2022 at 10:21 AM, when asked what the meaning was of unstageable related to a pressure ulcer wounds, LPN #1 stated, You can't measure the depth. When asked if she could measure the depth of the sacral wound and the wound to the right heel and left heel of Resident #1 upon admission, LPN #1 stated, Yes ma'am. I guess I should have called it a Stage 2 . When asked if treatments and wound care was provided for Resident #1, LPN #1 stated, Documented on the place where we document treatments if I did them . During an interview on 12/29/2022 at 11:08 AM, the DON confirmed there was no documentation of wound assessments or care provided for the pressure ulcer wounds from 12/16/2022 until 12/23/2022. The DON stated, If not documented, it wasn't done. What I see is an order on 12/21 [2022]. I see nothing before that. During an interview on 1/4/2023 at 4:02 PM, when asked when the first treatment was administered to the pressure ulcer wounds the LPN #5 stated, .From the 16th till the 21st when [Named physician] saw her there is no documentation of a treatment. That's awful. When asked if there was documentation of wound assessments that described the wounds appearance, LPN #5 stated, I didn't document any assessments in the computer. I threw the papers away. I don't have any of my papers prior to the 7th [1/7/2023]. That's when I was inserviced what to document in the computer. When I came here, I wasn't told about pressure and non-pressure assessments. I did not receive the proper training for this system to document. I threw my papers away that had the assessments . During an interview on 1/4/2023 at 10:38 AM, the Regional Director of Clinical Services (RDCS) stated, We did a facility wide skin sweep over the weekend. We found some new wounds and we are taking care of that. When asked what she meant by a skin sweep the RDCS stated, A skin assessment of every resident to see if there were any wounds that had been missed . During an interview on 1/5/2023 at 9:58 AM, when asked if Resident #1 had Pressure Ulcer wounds, LPN #2/Unit Manager stated, I don't remember what her wounds are. I looked at her paperwork from the hospital .If there are wounds it's passed on to the treatment nurse. I wouldn't know about the wound location . 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Covid-19, and Epilepsy. (a) Review of the Braden Scale assessment completed on 9/21/2022 and 1/3/2023 revealed Resident #4 was at risk of developing a pressure ulcer. Review of the quarterly MDS dated [DATE] revealed Resident #4 scored a 13 on the BIMS which indicated no cognitive impairment. The resident required extensive assistance for bed mobility and activities of daily living. Review of the Weekly Skin Reviews dated 11/30/2022, 12/7/2022, 12/14/2022, 12/21/2022, 12/28/2022, and 1/4/2023 revealed Resident #4 had redness to the sacrum. Review of the Nursing Daily Skilled Services assessments dated 12/29/2022, 1/1/2023, 1/2/2023, 1/3/2023, 1/9/2023, 1/10/2023, and 1/11/2023 documented there was no change in the resident's skin integrity. Review of the current Shower Day Skin Inspection sheet dated 1/1/2022 (2023) revealed Resident #4 had a Stage 2 open area to the sacral region. There were no documented descriptions or measurements of the wound. Review of a Physician's order dated 1/1/2023 revealed, .Cleanse stage 2 pressure ulcer to R [right] buttock with wound cleanser. Pat dry. Apply hydrocolloid dressing to site and cover with bordered foam dressing MWF [Monday-Wednesday, Friday] and PRN [as needed] . Review of a Physician's order dated 1/4/2023 revealed, .Cleanse stage 2 pressure ulcer to sacrum with wound cleanser. Pat dry. Apply medi-honey followed by collagen. Cover with bordered foam dressing MWF and PRN . Review of the wound care Physician's Initial Progress Note dated 1/4/2023 revealed a Stage 3 Pressure Ulcer to the sacrum which measured 4.2 cm x 3.7 cm x 0.1 cm with 25% slough, 50% epithelial, and 25% serum blister. Review of the wound care Physician's Progress Note dated 1/11/2023 revealed a Stage 3 Pressure Ulcer to Resident #4's lower back which measured 2.3 cm x 0.5 cm x 0.1 cm with 50% slough and 50% dermis. During an interview on 1/5/2023 at 12:44 PM, when asked when the Stage 2 to the sacrum was first identified, the DON stated, We did a facility wide skin sweep on the 1st [1/1/2023] and that is when it was found . The DON confirmed there was no documentation describing the wound or measurements of the wound until 1/4/2023. During an interview on 1/9/2023 at 1:47 AM, The DON stated, She has no TARs for months other than January. During a telephone interview on 1/6/2023 at 2:45 PM, when asked if she was notified of the Stage 2 Pressure Ulcer on 1/1/2023, the wound care Physician stated, Not that I recall. I saw the wound during my visit on the 4th [1/4/2023]. It was a Stage 3. Nurse was probably not aware of the slough . During an interview on 1/19/2023 at 2:55 PM, when asked when the Stage 3 to the lower back was first identified the LPN/Wound Nurse stated, Identified by [Named Wound Care Physician] during her visit on the 11th [1/11/2023]. (b) Review of the Physician's medication order dated 9/1/2022 for Resident #4 revealed, .Alogliptin Benzoate 12.5 MG (milligrams) Tablet Give one tablet by mouth one time a day related to TYPE 2 DIABETES MELLITUS .AmLODIPine Besylate Tablet 10 MG Give one tablet one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Review of the Medication Administration Record (MAR) dated December 2022 revealed no documentation of Alogliptin administered at 9:00 AM on 12/4/2022 and 12/25/2022 as ordered by the physician. There was no documentation the Amlodipine was administered at 9:00 AM or 9:00 PM on 12/4/2022 and 12/25/2022. There was no documentation to reveal the resident's blood pressure was assessed. 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Paraplegia, Chronic Osteomyelitis, Open Wound of Buttock, History of Failed Surgical Flap, Peripheral Vascular Disease, Anemia, and Protein-Calorie Malnutrition. Review of the annual MDS dated [DATE] revealed Resident #5 scored a 15 on the BIMS which indicated no cognitive impairment. The resident required supervision for activities of daily living. The MDS Section M Skin Conditions documented no pressure ulcer wounds and one surgical wound. (a) Review of the Physician's orders dated 11/2/2022, documented .Cleanse Surgical Site to L [left] buttock with wound cleaner. Dry with 4x4, Pack wound with dry collagen. Cover with dry bordered foam dressing Mon [Monday] Wed [Wednesday] Fri [Friday], and PRN . Review of the TAR for November 2022 and December 2022 revealed treatments were not provided as ordered for the surgical site to the left buttock on 11/7/2022, 11/14/2022, 11/21/2022, 11/25/2022, and 12/28/2022. Review of the Braden Scale assessment completed on 1/3/2023 revealed Resident #5 was at risk of developing a pressure ulcer. Review of the Physician's orders dated 1/4/2023 documented, .Cleanse pressure ulcer to Right medial buttock with wound cleanser. Pat dry. Apply honey followed by collagen. Cover with bordered foam MWF and PRN . Review of the wound care Physician's progress note dated 1/4/2023 revealed Resident #5 had a new Stage 3 Pressure Ulcer wound to the right medial buttock which measured 2.8 cm x 2.3 cm x 0.2 cm with 50% slough and 50% dermis. Review of the Weekly Summary dated 1/6/2023 documented no Pressure Ulcer wounds. Observations in the resident's room on 1/5/2023 at 10:41 AM revealed the Resident was propelling himself in a wheelchair in his room and able to transfer himself to the bed. He was alert and oriented. Resident #5 stated, I had a bad place on my butt. I had surgery on that. Now they say I've got a new wound. I need a new cushion, but it hadn't come in yet. During an interview on 1/9/2023 at 12:57 PM, when asked when the Stage 3 to the right medial buttock was first identified, the DON stated, It was identified on the 4th [1/4/2023] on the other side of the buttock. The DON confirmed the new pressure ulcer was identified during the facility wide skin sweep on 1/1/2023. (b) Review of the Physician's medication orders for Resident #5 revealed, .Start Date 10/21/2022 Lantus SoloStar 100 UNIT/ML (milliliter) Solution pen-injector Inject 10 unit subcutaneously at bedtime for DM [Diabetes Mellitus] .Start Date 8/2/2019 Minocycline HCL capsule 100 MG Give 100 mg by mouth two times a day for infection .Start Date 2/1/2022 rifAMpin Capsule 300 MG Give 300 mg by mouth two times a day for chronic osteomyelitis . Review of the MAR dated December 2022 revealed no documentation Lantus Solostar, Minocycline HCL, and Rifampin was administered at 9:00 PM on 12/22/2022 and 12/31/2022 as ordered by the physician. During an interview on 1/11/2023 at 1:10 PM when asked if Resident #5 received the medications as ordered on 12/22/2022 and 12/31/2022 LPN #2 stated, No, I don't see that. Could have been when there was only one nurse on the hall and she may have missed it . 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region, Sepsis Unspecified Organism, Urinary Tract Infection, Cerebral Infarction, Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis of Deep Vein or Right Upper Extremity, and Osteomyelitis. Review of the quarterly MDS dated [DATE] revealed Resident #8 scored a 7 on the BIMS which indicated severe cognitive impairment. The resident required extensive assist for activities of daily living. The MDS Section M Skin Conditions documented one unstageable pressure ulcer wound. (a) Review of the Shower Day Skin Inspection sheet dated 12/22/2022 revealed Resident #8 had a wound to the sacral region which measured 6.8 cm x 11.3 cm x 0.0 cm. Review of the Braden Scale assessment completed on 12/23/2022 revealed Resident #8 was a very high risk of developing a pressure ulcer wound. Review of the admission nursing assessment dated [DATE] revealed Resident #8 had a pressure related skin condition. There was no assessment with descriptions of the wound. Review of the Physician's orders dated 12/23/2022 documented, .Cleanse Unstageable pressure ulcer to Sacrum with wound cleaner. Pat dry. Apply Dakin's wet to dry dressing to site. Cover with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . Review of the TAR for December 2022 revealed there was no treatment administered as ordered for the unstageable Pressure Ulcer wound to the sacrum, identified upon admission from 12/22/2022 - 12/31/2022. Review of the Physician's orders dated 1/4/2023 documented, .Cleanse DTI [Deep Tissue Injury] to lateral L foot with wound cleanser. Pat dry. Apply skin prep MWF and PRN .Santyl Ointment 250 UNIT/GM [gram] (Collagenase) Apply to sacrum topically every day shift every Mon, Wed, Fri for stage 4 pressure ulcer to sacrum. Cleanse stage 4 ulcer to sacrum with Dakin's solution. Pat dry. Apply santyl and medihoney followed by calcium alginate. Cover with bordered foam MWF and PRN . Review of the wound care Physician's Progress Note dated 1/4/2023 documented, .Debrided sacrum of necrotic tendon, bone, and fascia. Recommend Ciprofloxacin 750 mg BID [twice daily] PO [by mouth] for osteomyelitis .Sacrum Pressure Ulcer Stage 4, 7.8 [cm] x 11.3 [cm] .Left lateral foot Deep Tissue Injury .8.5 [cm] x 3.7 [cm] x 0 [cm] . Review of the Physician's orders dated 1/5/2023 documented, .Ciprofloxacin HCL Tablet 750 MG [milligrams] by mouth two times a day related to OSTEOMYELITIS OF VERTEBRA, SACRAL AND SACROCOCCYGEAL REGION for 4 weeks . Review of the TAR for January 2023 revealed there was no treatment administered as ordered for the unstageable Pressure Ulcer wound to the sacrum on 1/2/2023. Observations in the resident's room on 1/4/2023 at 9:30 AM revealed Resident #8 lying supine in bed. She was alert with confusion. During an interview on 1/4/2023 at 2:36 PM when asked when the Pressure Ulcer was wound to Resident #8's left foot was first identified the LPN/Wound Care Nurse stated, .It was actually noted today during Physician rounds as a left lateral deep tissue injury. I would assume no one saw it or looked at the foot . During an interview on 1/6/2023 at 2:45 PM when asked when was the first notification Resident #8 had a Pressure Ulcer wound to the sacrum the wound care physician stated, I saw her on Wednesday [1/4/2023] for the first time. That was the first time my attention was brought to the wound . During an interview on 1/10/2023 at 9:50 AM when asked from the admission measurements on 12/22/2022 until the physician was notified on 1/2/2022 was the Pressure Ulcer to the sacrum assessed and monitored, and the LPN/Wound Care Nurse stated, Those assessments were not completed. When asked if the TAR had documentation of the treatments administered the LPN/Wound Treatment Nurse stated, They [TAR dates] are all blank. She [LPN #1] didn't sign off that she did the treatments .That's awful . During an interview on 1/10/2023 at 2:10 PM the DON confirmed no assessments were completed and no treatments were administered for the Pressure Ulcer wounds from admission on [DATE]- 1/2/2023. (b) Review of the Physician's orders revealed, .Start Date 12/25/2022 Doxycycline Monohydrate Capsule 100 MG Give 100 mg by mouth two times a day for sepsis .Start Date 12/23/2022 Eliquis Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day .Start Date 12/29/2022 Metronidazole Tablet 500 MG Give 500 mg by mouth three times a day for sepsis .Start Date 12/29/2022 NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 60-149 = 0 units: 150-199 = 4 units; 200-249 = 6 units; 250-299 = 8 units; 300-349 = 10 units; 350-400 = 12 units .subcutaneously two times a day related to DIABETES MELLITUS . Review of the MAR dated December 2022 revealed no documentation Doxycycline Monohydrate, Eliquis, Metronidazole was administered at 9:00 PM on 12/31/2022, the Novolog insulin per sliding scale was not administered on 12/29/2022-12/31/2022, and the blood glucose levels were tested as ordered by the physician. 6. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region Stage 4, History of Venous Thrombosis and Embolism, Human Immunodeficiency Disease, Protein-Calorie Malnutrition, and Hypertension. Review of the admission MDS dated [DATE] revealed Resident #3 scored a 12 on the BIMS which indicated moderately impaired cognition. The resident required extensive assistance for bed mobility and was dependent for transfers. Resident #3 had 1 Stage 2 pressure ulcer and 1 Stage 4 pressure ulcer documented in Section M Skin Conditions. (a) Review of the admission nursing assessment dated [DATE] documented, .Right toe(s) open area . There was no documentation of skin assessments describing the open area to the right toe(s) that was observed upon admission. Review of a Weekly Skin Review dated 12/28/2022 and 1/4/2023 revealed no new skin issues identified. Review of a Telemedicine note by the wound care Physician dated 12/30/2022 documented, .Pt [patient - Resident #3] is being seen today for evaluation and treatment of .gangrene to left toes 1-5 and right toes 1-5 . left Toes 1-5 Gangrene 4 cm x 8.2 cm x 0 cm .right Toes 1-5 Gangrene 3.8 cm x 8.5 cm x 0 cm . Review of a Physician's order with a start date of 12/31/2022 documented, .Cleanse thick, dry flaky skin to toes 1-5 to L [left] foot with wound cleanser. Pat dry. Apply skin repair cream to foot and leave open to air MWF [Monday, Wednesday, Friday] and PRN .Cleanse thick, dry flaky skin to toes 1-5 to R [right] foot with wound cleanser. Pat dry. Apply skin repair cream to foot and leave open to air MWF and PRN . Review of a Physician's order with a start date of 1/2/2023 documented, .Cleanse gangrene to toes 1-5 to L foot with wound cleanser. Pat dry. Apply calcium alginate with silver and wrap with kerlix MWF and PRN .Cleanse gangrene to toes 1-5 to R foot with wound cleanser. Pat dry. Apply calcium alginate with silver and wrap with kerlix MWF and PRN . Review of the Treatment Administration Record (TAR) for December 2022 revealed there was no treatment administered as ordered for the gangrene to the toes of the right and left foot on 12/31/2022. During an interview on 1/5/2023 at 9:53 AM when asked if she was aware Resident #3 had wounds to her toes Certified Nursing Assistant (CNA) #1 stated, .Yes Ma'am. I only saw the sores on her toes. I didn't see the heels. I told the nurse last weekend . During an interview on 1/9/2023 at 4:15 PM, the LPN/Wound Care Nurse confirmed the treatments for the gangrene to the toes of the right and left foot were not administered as ordered. (b) Review of the Physician's orders revealed, .Start Date 12/23/2022 Azithromycin Tablet 500 MG Give 1 tablet by mouth one time a day for HIV [Human Immunodeficiency Virus] .Start Date 12/22/2022 Bactrim DS Tablet 800-160 MG Give 1 tablet by mouth one time a day for bacterial infection .Biktarvy Tablet 50-200-25 MG Give 1 tablet by mouth one time a day for HIV .Start Date 12/23/2022 Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day .Eliquis Tablet 5 MG Give 5 mg by mouth two times a day . Review of the MAR dated December 2022 revealed no documentation Carvedilol was administered at 9:00 AM on 12/23/2022 and 9:00 AM and 9:00 PM on 12/25/2022 as ordered by the physician, Eliquis was not administered on 12/23/2022 and 12/24/2022 at 9:00 PM and 9:00 AM on 12/25/2022. There was no documentation Bactrim DS and Biktarvy were administered at 9:00 AM and 9:00 PM on 12/25/2022 and Azithromycin was not administered at 9:00 AM on 12/25/2022. 7. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence Upon Dialysis, Pressure Ulcer of Sacral Region Stage 4, Heart Failure, Type 2 Diabetes Mellitus, Nontraumatic Subarachnoid Hemorrhage, Encephalopathy, and Severe Protein-Calorie Malnutrition. Review of the Physician's order with a start date of 12/7/2022 documented, .Cleanse diabetic ulcer to L lateral heel with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon [Monday], Wed [Wednesday], Fri [Friday] and PRN .Cleanse diabetic ulcer to R calf with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon, Wed, Fri and PRN .Cleanse diabetic ulcer to R lateral heel with wound cleanser. Pat dry. Apply collagen and cover with bordered gauze Mon, Wed, Fri, and PRN . Review of a Physician's order with a start date of 12/9/2022 documented, .Cleanse diabetic ulcer to R medial heel with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon, Wed, Fri, and PRN . Review of the quarterly MDS dated [DATE] revealed Resident #6 scored 13 on the BIMS which indicated no cognitive impairment. The resident required extensive assistance for activities of daily living, except for eating. Review of a Physician's order with a start [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to identify wounds and provide treatments for 2 of 2 sampled residents (Resident #3 and #6) reviewed with wounds and failed to ensure medications were administered as ordered for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, and #72) reviewed with significant medications. The facility's failure resulted in Immediate Jeopardy (IJ) when the facility failed to identify and provide treatments for wounds for Resident #3 and #6 and the wounds developed into gangrene and the facility's failure to administer significant medications as ordered had the likelihood to cause serious adverse outcomes and unstable declines in the residents' medical conditions. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Regional Director of Operations (RDO), the Area Director of Clinical Services (ADCS), the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-684 on 1/17/2023 at 6:12 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-684. The facility was cited Immediate Jeopardy F-684 at a scope and severity of K which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 1/19/2023, and the Removal Plan was validated onsite by the surveyors on 1/24/2023 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on 12/16/2022 through 1/24/2023. Noncompliance continues at F684 at a scope and severity of E. The findings include: 1. Review of the facility's policy titled, Wound Treatment Management dated 3/24/2022, revealed .To promote healing of various types of wounds .Wound treatments will be provided in accordance with physicians orders .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound . Review of the facility's undated policy titled, Skin Assessment, revealed .A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included a Stage 4 Pressure Ulcer to the Sacral area. The 12/28/2022 admission Minimum Data Set (MDS) revealed Resident #3 had moderately impaired cognition, required extensive assistance for bed mobility and was dependent for transfers. a. Review of the 12/21/2022 admission nursing assessment revealed .Right toe(s) open area . There was no skin assessment describing the area to the right toe(s) upon admission. Review of a Telemedicine note by the wound care Physician dated 12/30/2022 documented, .Pt [patient - Resident #3] is being seen today for evaluation and treatment of .gangrene to left toes 1-5 and right toes 1-5 . left toes 1-5 Gangrene 4 cm x 8.2 cm x 0 cm. right toes 1-5 Gangrene 3.8 cm x 8.5 cm x 0 m Review of the 12/31/2022 Physician's order revealed an order to cleanse thick, dry flaky skin to toes 1-5 to left and right feet with, wound cleanser. Pat dry. Apply skin repair cream to foot and leave open to air Monday, Wednesday, and Friday, and as needed. Review of the Treatment Administration Record (TAR) for December 2022 revealed there was no treatment administered as ordered for the gangrene to the toes of the right and left feet on 12/31/2022. Review of a Weekly Skin Review dated 12/28/2022 and 1/4/2023 revealed no new skin issues identified. Review of the 1/2/2023 Physician's order revealed an order change to cleanse gangrene to toes 1-5 to left and right feet with, wound cleanser, pat dry, apply calcium alginate with silver and wrap with kerlix MWF [Monday-Wednesday-Friday] and PRN [as needed]. During an interview on 1/5/2023 at 9:53 AM, when asked if she was aware Resident #3 had wounds, Certified Nursing Assistant (CNA) #1 stated, .Yes Ma'am. I only saw the sores on her toes. I didn't see the heels. I told the nurse last weekend . During an interview on 1/9/2023 at 4:15 PM, the LPN/Wound Care Nurse confirmed the treatments for the gangrene to the toes of the right and left foot were not administered as ordered. b. Review of Resident #3's medication orders revealed on 12/22/2022 the Physician ordered Bactrim DS 800-160 milligrams (mgs) 1 tablet by mouth one time a day for bacterial infection, and Biktarvy Tablet 50-200-25 mg 1 tablet by mouth one time a day for Human Immunodeficiency Virus (HIV). The 12/23/2022 Physician's orders revealed Azithromycin Tablet 500 mg 1 tablet by mouth one time a day for HIV, Carvedilol Tablet 6.25 mg 1 tablet by mouth two times a day, and Eliquis 5 mg by mouth two times a day. Review of the December 2022 MAR revealed the following: Carvedilol was not administered on 12/23/2022 at 9:00 AM; and on 12/25/2022 at 9:00 AM and 9:00 PM as ordered. The Eliquis was not administered on 12/23/2022 and 12/24/2022 at 9:00 AM 9:00 PM. There Bactrim DS and Biktarvy was not administered on 12/25/2022 at 9:00 AM and 9:00 PM. The Azithromycin was not administered on 12/25/2022 at 9:00 AM. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Pressure Ulcer of Sacral Region Stage 4, Type 2 Diabetes Mellitus, and Severe Protein-Calorie Malnutrition. The quarterly MDS dated [DATE] revealed Resident #6 had no cognitive impairment and required extensive assistance for activities of daily living except for eating. Review of the Physician's order dated 12/7/2022 documented the following: .Cleanse diabetic ulcer to L [left] lateral heel with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon,Wed, Fri [Monday, Wednesday, Friday] and PRN .Cleanse diabetic ulcer to R [right] calf with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon, Wed, Fri and PRN . Cleanse diabetic ulcer to R lateral heel with wound cleanser. Pat dry. Apply collagen and cover with bordered gauze Mon, Wed, Fri, and PRN . Review of the 12/9/2022 Physician's order revealed, Cleanse diabetic ulcer to R medial heel with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon, Wed, Fri, and PRN . An additional 12/28/202 Physician's order revealed, .Cleanse diabetic ulcer to R lateral heel with wound cleanser. Pat dry. Apply collagen and cover with bordered gauze Mon, Wed, Fri, and PRN . Review of the December 2022 TAR revealed the following: There was no treatment administered as ordered for the right lateral heel wound on 12/19/2022, 12/26/2022, and 12/28/2022. There was no treatment administered as ordered for the right medial heel wound on 12/19/2022, 12/26/2022, and 12/28/2022. There was no treatment administered as ordered for the left lateral heel and the right calf wounds on 12/19/2022, 12/26/2022, and 12/28/2022. Review of a Shower Day Skin Inspection sheet dated 1/1/2022 (2023), used to record skin assessment observations for January 2023, revealed there was no documentation the skin condition of Resident #6's fingers was assessed. Review of a 1/4/2023 Physician's order revealed, .Cleanse gangrene to 4th digit of R hand with wound cleanser. Pat dry. Apply skin prep MWF and PRN . Observations in the resident's room on 1/4/2023 at 4:46 PM revealed Resident #6 was alert and oriented. The skin of the 4th finger on her left hand appeared dry and dark black from the first joint of the finger to the tip. She had very long, painted fingernails that needed cleaning. The resident stated, .The doctor saw my finger today and said she will get some medicine for it . During an interview on 1/5/2023 at 10:05 AM, when asked if Resident #6 had a wound to her finger, CNA #2 stated, I know her finger is black. I saw it last week when I cleaned her nails. I thought it was a blood blister. It was like a bruise, but with a red color. When asked if she reported the discoloration to anyone, CNA #2 stated, Yes, I told the nurse .I don't know her name. She was agency [contract staff]. During a telephone interview on 1/6/2023 at 2:45 PM, when asked what the signs and symptoms of gangrene are, the wound care Physician stated, .The beginning signs and symptoms would be a color change in the skin, pain, coldness, and after a day or so there may be a blood blister. She [Resident #6] has dry gangrene. I want to refer her to a vascular surgeon for evaluation for removal of the affected area of the finger . During an interview on 1/9/2023 at 3:20 PM, when asked if a skin assessment would include a resident's hands and fingers, the DON stated, Yes it would. When asked if the change in condition of Resident #6's finger was observed during the assessment on 1/1/2023 or during assisted bathing, the DON stated, She likes to do things for herself. She has long nails. I can't answer why it wasn't seen. I don't know if it was reported. During a telephone interview on 1/19/2023 at 1:34 PM with Resident #6's family member stated, When I came on the 1st [1/1/2023] I told them about her finger. I was upset. It looked like a blister .They were not aware until I told them. How could they not see that? . 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Covid-19, and Epilepsy. Review of the 9/1/2022 Physician's medication order revealed, Alogliptin Benzoate 12.5 milligrams (mg) 1 tablet by mouth one time a day related to Type 2 Diabetes Mellitus, and Amlodipine Besylate 10 mg 1 tablet daily related to Hypertension. Review of the December 2022 Medication Administration Record (MAR) revealed the Alogliptin was not administered at 9:00 AM on 12/4/2022 and 12/25/2022 as ordered. The Amlodipine was not administered at 9:00 AM or 9:00 PM on 12/4/2022 and 12/25/2022. There was no documentation the resident's blood pressure was assessed. 5. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Osteomyelitis and an open wound to the buttocks. The 10/26/2022 MDS revealed Resident #5 had no cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 8/2/2019 - Minocycline HCL 100 mg 2 times a day infection. 10/21/2022 Lantus SoloStar 100 units/milliliter - give 10 units subcutaneously at bedtime for Diabetes Mellitus. 2/1/2022 Rifampin Capsule 300 mg - 1 tablet two times a day for Osteomyelitis. Review of the the December 2022 MAR revealed on 12/22/2022 and 12/312022 the Lantus Solostar, Minocycline HCL, and Rifampin were not administered at 9:00 PM on 12/22/2022 and 12/31/2022 as ordered. During an interview on 1/11/2023 at 1:10 PM, LPN #5 was asked if the medications were administered on 12/22/2022 and 12/31/2022. LPN #2 stated, No, I don't see that. Could have been when there was only one nurse on the hall and she may have missed it . 6. Review of the medical record revealed Resident # 7 was admitted on [DATE] with diagnoses that included Diabetes and Hypertension (HTN). Review of the Physician Orders revealed the following dates and orders: 10/4/2022 - Amlodipine Besylate 5 mg 1 tablet two times a day for HTN. 11/22/2022 - Basaglar KwikPen 100 units/ml inject 32 unit subcutaneously at bedtime related to Type 2 Diabetes. Review of the January 2023 MAR revealed on 1/9/2023 the Amlodipine Besylate 5 mg and Basaglar KwikPen was not administered at 9:00 PM as ordered. 7. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region, Sepsis Unspecified Organism, Urinary Tract Infection, Cerebral Infarction, Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis of Deep Vein or Right Upper Extremity, and Osteomyelitis. The 12/29/2022 MDS revealed the resident had severe cognitive impairment. Review of the Physician's orders revealed the following dates and orders: 12/23/2022 - Eliquis (Apixaban) 5 mg by mouth two times a day. 12/25/2022 - Doxycycline Monohydrate Capsule 100 mg by mouth two times a day for sepsis. 12/29/2022 - Metronidazole Tablet 500 mg by mouth three times a day for sepsis, and NovoLOG FlexPen 100 units/ml sliding scale related to Diabetes Mellitus. Review of the December 2022 MAR dated revealed the Doxycycline Monohydrate, Eliquis, Metronidazole were not administered at 9:00 PM on 12/31/2022 and the Novolog insulin per sliding scale was not administered on 12/29/2022-12/31/2022 as ordered. 8. Review of the medical record revealed Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The 11/21/2022 MDS revealed the resident had no cognitive impairment. Review of the Physician's orders revealed the following dates and orders: 11/30/2022 - Clonidine HCL 0.3 mg 1 tablet by mouth three times a day for hypertension. HOLD for SBP [systolic blood pressure] < [less than]100, DBP [diastolic blood pressure] < 60, HR [heart rate] < than 60. Notify MD. 12/1/2022 - Minoxidil Tablet 2.5 mg 1 tablet by mouth two times a day related to Hypertension. 12/10/2022 - Methlmazole 5 mg 1 tablet by mouth one time a day related to Thyrotoicosis. Review of the January 2023 MAR revealed the Methlmazole was not administered at 9:00 AM on 1/1/2023. The Minoxidil was not administered on 1/4/2022 and 1/6/2022 at 9:00 AM; and on 1/4/2022 and 1/5/2022 at 9:00 PM as ordered. During an interview on 1/10/2023 at 3:37 PM Resident #14 stated, .Sometimes I don't get my early morning medicine for my thyroid problem. They tell me they don't want to wake me up. I just want my pill brought to me . 9. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and Hypertension. The 11/19/2022 MDS revealed the resident had no cognitive impairment. Review of the Physician's orders revealed the following dates and orders: 6/10/2021 - Midodrine HCL Tablet 10 mg 1 tablet by mouth every 8 hours for Postural Hypotension hold for SBP greater than (>) 110, and DBP > 70 and; Novolog FlexPen 100 units/ml Give as per sliding scale for elevated blood glucose levels before meals and at bedtime . 7/13/2022 - Metoprolol Tartrate 50 mg 1 tablet by mouth every 12 hours for hypertension Hold for SBP less than 110, DBP less than 60 or heart rate less than 60 beats per minute; and Sacubitril-Valsartan 24-26 mg 1 tablet by mouth every 12 hours. Review of the January 2023 MAR revealed no documentation Metoprolol Sacubitril-Valsartan was administered at 9:00 PM on 1/9/2023 as ordered. The Midodrine was not administered at 10:00 PM on 1/9/2023 and at 6:00 AM on 1/10/2023. The Novolog Insulin was not administered on 1/9/2023 at 8:00 PM as ordered and the resident's blood glucose level was not assessed at 8:00 PM. There was no documentation the resident's Blood pressure was checked. During an interview on 1/10/2023 at 7:10 PM Resident #23 was was asked about the medications that were not administered. Resident #23 stated, .I didn't get it. No nurse here. The CNA told me. I went to the desk downstairs and the receptionist said they trying to get someone to come. No one came . 10. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included History of Venous Thrombosis and Embolism. The 1/8/2023 MDS revealed the resident had no cognitive impairment. Review of the 9/25/2021 Physician's orders revealed Apixaban Tablet (Eliquis) 5 mg give by mouth two times a day. Review of the January 2023 MAR revealed the Apixaban was not administered on 1/9/2023 at 9:00 PM as ordered. During an interview on 1/10/2023 at 4:01 PM the resident was asked about the 1/9/2023 medication. Resident #24 stated, No, I didn't get all my medicine. There was no nurse. 11. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses including Supraventricular Tachycardia. The 1/4/2023 MDS revealed the resident had moderate cognitive impairment. Review of the 4/30/2020 Physician's orders revealed Metoprolol Tartrate Tablet 25 mg give by mouth two times a day for HTN Hold for heart rate less than 60 or SBP less than 110. Review of the January 2023 MAR revealed the Metoprolol Tartrate was not administered on 1/9/2023 at 9:00 PM as ordered or the resident's blood checked. 12. Review of the medical record revealed Resident #29 was admitted on [DATE] with the diagnosis of Heart Failure. The 12/8/2022 MDS revealed the resident had moderate cognitive impairment. Review of the 12/17/2020 Physician's orders revealed Carvedilol Tablet 25 mg give by mouth two times a day for Heart Failure. Hold if HR less than 60 bpm. Review of the January 2023 MAR revealed the Carvedilol was not administered on 1/9/2023 at 9:00 PM as ordered or the heart rate checked. 13. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis Left Nondominant Side, Osteoarthritis, and Benign Neoplasm of Skin. The 12/13/2022 MDS revealed the resident had no cognitive impairment. Review of the 11/06/2021 Physician's orders revealed Apixaban Tablet 5 mg 1 tablet two times a day for anticoagulant therapy, and Carvedilol Tablet 6.25 mg 1 tablet by mouth two times a day. Review of the January 2023 MAR revealed the Apixaban and Carvedilol were not administered on 1/9/2023 at 9:00 PM as ordered. 14. Review of the medical record revealed Resident #31 admitted on [DATE] with diagnoses that included Hypertension, History Transient Ischemic Attack, and Cerebral Infarction. The 12/24/2022 MDS revealed the resident had no cognitive impairment. Review of the 10/24/2022 Physician's orders revealed Diltiazem HCL 30 mg give 1 tablet by mouth three times a day for HTN, hold for SBP < 100, DBP < 60, or HR < 60. Review of the January 2023 MAR revealed the Diltiazem was not administered on 1/9/2023 at 9:00 PM as ordered. There was no documentation the resident's blood pressure and heart rate were assessed. 15. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus. The 10/15/2022 MDS revealed the resident had no cognitive impairment. Review of the 9/20/2022 Physician's orders revealed Lantus SoloStar 100 units/ml inject 26 units Intradermally at bedtime. Review of the January 2023 MAR revealed the Lantus insulin was not administered on 1/9/2023. 16. Review of the medical record revealed Resident #34 admitted on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. The 12/14/2022 MDS revealed the resident had no cognitive impairment. Review of the 12/08/2022 Physician's orders revealed Insulin Lispro (1 Unit Dial) 100 unit/ml pen-injector, inject 3 units subcutaneously before meals, and Insulin Glargine-yfgn 100 units/ml pen-injector inject 40 units subcutaneously at bedtime. Review of the December 2022 MAR revealed the Insulin Lispro was not administered on 12/15/2022 at 5:00 PM as ordered, and the Insulin Glargine-yfgn was not administered on 1/9/2023 at 9:00 PM as ordered. 17. Review of the medical record revealed Resident #35 was admitted on [DATE] with a diagnosis of Essential Hypertension. The 12/14/2022 MDS revealed the resident had no cognitive impairment. Review of the physician's orders revealed the following orders and dates: 3/13/2021- Eliquis Tablet 2.5 mg give 1 tablet by mouth two times a day. 10/24/2022 - Coreg Tablet 6.25MG (Carvedilol) give 1 tablet by mouth two times a day for HTN. Hold for SBP less than 100, DBP less than 60 or HR less than 60, Review of the January 2023 MAR revealed the Coreg and Eliquis were not administered on 1/9/2023 at 9:00 PM as ordered. There was no documentation the resident's blood pressure and heart rate were assessed. 18. Review of the medical record revealed Resident #36 was readmitted on [DATE] with diagnoses that included Hypertension and Hypothyroidism Disease. The 11/10/2022 MDS revealed the resident had no cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 12/17/2022 - Levothyroxine Sodium Tablet 150 MCG Give 150 micrograms (mcg) by mouth on time a day every Mon, Tue, Wed, Thu, Fri, and Sat. Review of the January 2023 MAR revealed the Levothyroxine and Hydralazine were not administered on 1/9/2023 at 9:00 PM as ordered. 19. Review of the medical record revealed Resident #37 was readmitted on [DATE] with diagnoses that included Epilepsy, Cerebral Infarction, and Schizoaffective Disorder, and Hallucinations. The 12/14/2022 MDS revealed the resident had a severe cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 10/6/2022 - Lacosamide Tablet 200 mg give 200 mg by mouth two times a day for seizure disorder. 12/13/2022 - Risperidone Tablet 0.5 mg give 1 tablet by mouth at bedtime related to schizoaffective disorder. Review of the January 2023 MAR the Risperidone and Lacosamide were not administered on 1/9/2023 at 9:00 PM as ordered. 20. Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and Unspecified Psychosis. The 1/2/2023 MDS revealed the resident had severe cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 6/10/2022 - Depakote Tablet Delayed Release 250 mg give 1 tablet by mouth three times a day. 8/4/2022 - Humalog KwikPen 100 units/ml pen-injector inject as per sliding scale subcutaneously before meals and at bedtime. Review of the January 2023 MAR revealed the Depakote was not administered on 1/9/2023 at 9:00 PM as ordered, and the Humalog insulin was not administered on 1/9/2023 at 8:00 PM as ordered by the physician. The MAR revealed the resident's blood glucose level was not checked for the sliding scale insulin on 1/9/2023 as ordered. 21. Review of the medical record, revealed Resident #39 readmitted on [DATE] with diagnoses that included Cerebral Infarction, Atrial Fibrillation, and Hypothyroidism. The 12/2/2022 MDS revealed the resident had severe cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 6/6/2022 - Eliquis Tablet 5 mg give 1 tablet by mouth two times a day, and Levetiracetam Tablet 500 mg give 1000 mg by mouth two times a day. 6/25/2022 - Levothyroxine Sodium Tablet 125 MCG give 1 tablet by mouth one time a day. Review of the January 2023 MAR the Levothyroxine was not administered on 1/10/2023 at 6:00 AM as ordered, and the Eliquis and Levetiracetam were not not administered on 1/9/2023 at 9:00 PM as ordered. 22. Review of the medical record revealed Resident #40 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Seizures, Asthma, and Hypothyroidism. The 11/2/2022 MDS revealed the resident had moderate cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 7/27/2022 - Levothyroxine Sodium Tablet 100 MCG give 1 tablet by mouth one time a day, Rosuvastatin Calcium Oral Tablet 5 MG give 5 mg by mouth at bedtime, and Levetira tablet 250 MG give 250 mg by mouth two times a day. 8/10/2022 - Basaglar KwikPen 100 units/ml pen-injector inject 10 units subcutaneously at bedtime. Review of the January 2023 MAR revealed the Basaglar insulin, Rosuvastatin Calcium, and Levetiracetam were not administered on 1/9/2023 at 9:00 PM as ordered. The Levothyroxine was not administered at 6:00 AM on 1/10/2023 as ordered. 23. Review of the medical record revealed Resident #41 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease on dialysis, Atrial Fibrillation, Congestive Heart Failure, Chronic Pulmonary Edema, and Atherosclerotic Heart Disease. The 12/24/2022 MDS revealed the resident had moderate cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 11/30/2021 - Hydralazine HCL 25 mg give 50 mg by mouth two times a day. 5/22/2021 - Clopidogrel Bisulfate 75 mg give 1 tablet by mouth one time a day, and Isosorbide Mononitrate ER (extended release) 30 mg give 1 tablet by mouth one time a day. 1/5/2023 - Carvedilol Oral 12.5 mg give 1 tablet by mouth two times a day. Review of the January 2023 MAR revealed the Clopidogrel, Isosorbide Mononitrate, and Hydralazine were not administered on 1/10/2023 at 6:00 AM as ordered. The Carvedilol was not administered on 1/9/2023 at 9:00 PM as ordered. 24. Review of the medical record revealed Resident #42 was admitted on [DATE] and had a diagnosis of Diabetes. The 12/28/2022 MDS revealed the resident 42 had no cognitive impairment. Review of the Physician Orders revealed the following orders and dates: 3/11/2022 - Janumet XR ER [PHONE NUMBER] mg give 1 tablet by mouth one time a day for Diabetes Mellitus. 8/2/2022 - Lantus SoloStar 100 units/ml pen-injector inject 30 units subcutaneously at bedtime related to TYPE 2 DIABETES. 11/22/2022 - Glimepiride 1 mg by mouth one time a day for Diabetes Mellitus. Review of the January 2023 MAR revealed the Glimepiride 1 mg and the Janumet ER [PHONE NUMBER] mg were not administered at 6:00 AM on 1/10/2023. The Lantus SoloStar 100 units/ml was not administered at 9:00 PM on 1/9/2023 as ordered. 25. Review of the medical record revealed Resident #45 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Atherosclerotic Heart Disease, and Hypertension. The 1/7/2023 MDS the resident had no cognitive impairment. Review of the Physician Orders revealed the following orders and dates: 3/10/2022 - hydralazine HCl 25 MG give 1 tablet by mouth two times a day related to Hypertension. 5/20/2022 - Entresto 49-51 mg give 1 tablet by mouth two times a day related to Other Heart Failure. Review of the January 2023 MAR revealed the Entresto 49-51 mg was not administered at 9:00 PM on 1/9/2023. The Hydralazine 25 mg was not administered at 8:00 PM on 1/9/2023 as ordered. 26. Review of the medical record revealed Resident #46 admitted on [DATE] had a diagnosis of Hypertension. The 12/3/2022 MDS revealed the resident had moderate cognitive impairment. Review of the 11/21/2022 Physician Orders revealed Metoprolol Tartrate 12.5 mg by mouth two times a day for hypertension. Review of the January 2023 MAR revealed the Metoprolol 12.5 mg was not administered at 9:00 PM on 1/9/2023 as ordered. 27. Review of the medical record revealed Resident #47 was admitted on [DATE] and had diagnoses that included Anxiety Disorder and Schizoaffective Disorder. The 11/4/2022 MDS revealed the resident had no cognitive impairment. Review of the 10/20/2022 Physician Orders revealed Quetipine Fumerate 100 mg give 1.5 tablet by mouth at HS for a total dose of 150 mg related to Schizoaffective Disorder. Review of the January 2023 MAR revealed the Quetipine Fumerate was not administered at 9:00 PM on 1/9/2023 as ordered. 28. Review of the medical record revealed Resident #48 was admitted on [DATE] and had a diagnosis Diabetes The 12/18/2022 MDS revealed the resident had a severe cognitive impairment. Review of the 7/21/2022 Physician Orders revealed Glargine-yfgn insulin 100 units/ml pen-injector inject 28 unit subcutaneously two times a day related to Diabetes. Review of the January 2023 MAR revealed the Glargine-yfgn 100 units/ml was not administered at 9:00 PM on 1/9/2023 as ordered. 29. Review of the medical record, revealed Resident #49 admitted on [DATE] with diagnoses that include Diabetes, and Hypertension. The 12/16/2022 MDS revealed the resident was severely impaired cognitive impairment. Review of the Physician Orders revealed the following orders and dates: 8/12/2021 - Metoprolol Tartrate 100 mg give 1 tablet by mouth two times a day for Hypertension. 1/19/2022 - Novolog FlexPen 100 units/ml pen-injector inject subcutaneously before meals and at bedtime related to Diabetes. 10/4/2022 - Verapamil HCl 40 MG give 40 mg by mouth three times a day for Hypertension. Review of the January 2023 MAR revealed the Metoprolol Tartrate Tablet 100 MG was not administered at 9:00 PM on 1/9/2023 as ordered. The Verapamil HCl Tablet 40 MG was not administered at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023 as ordered. The Novolog FlexPen 100 UNIT/ML was not administered at 6:30 AM on 1/3/2023, at 6:30 AM and 8:00 PM on 1/9/2023, and at 6:30 AM on 1/10/2023 as ordered. 30. Review of the medical record, revealed Resident #50 admitted on [DATE] with a diagnosis of Hypertension. The 11/08/2022 MDS revealed the resident had moderate cognitive impairment. Review of the Physician Orders dated 11/17/2022 revealed Hydralazine HCl 50 mg give 1 tablet by mouth four times a day for Hypertension. Review of the January 2023 MAR revealed the Hydralazine HCl 50 mg was not administered at 9:00 PM on 1/9/2023 as ordered. 31. Review of the medical record revealed Resident #51 was admitted on [DATE] with a diagnosis of Hypertension. The 11/25/2022 MDS revealed the resident had a severe cognitive impairment. Review of the 3/1/2022 Physician Orders revealed Eliquis 5 mg give 5 mg by mouth two times a day for blood thinner related to Hypertension. Review of the January 2023 MAR revealed the Eliquis 5 mg was not administered at 8:00 PM on 1/9/2023 as ordered. 32. Review of the medical record revealed Resident #52 was admitted on [DATE] with diagnoses of Cerebral Infarction, Seizures, and Hypertension. The 12/17/2022 MDS revealed the resident had a moderate cognitive impairment. Review of the 3/12/2022 Physician Orders dated 3/12/2020 revealed Levetiracetam 1000 mg give 1000 mg by mouth two times a day for Seizures. Review of the January 2023 MAR revealed the Levetiracetam 1000 mg was not administered at 9:00 PM on 1/9/2023 as ordered. 33. Review of the medical record revealed Resident #53 was admitted on [DATE] with a diagnosis of Hypertension. The 12/3/2022 MDS revealed the resident had moderate cognitive impairment. Review of the 10/4/2022 Physician Orders revealed Hydralazine HCl 25 mg give 1 tablet by mouth two times a day for Hypertension. Review of the January 2023 MAR revealed the Hydralazine HCl 25 MG was not administered at 9:00 PM on 1/9/2023 as ordered. 34. Review of the medical record revealed Resident #55 was admitted on [DATE] with diagnoses that included of Atrial Fibrillation, Diabetes and Hypertension. The 11/2/2022 MDS revealed the resident had severe cognitive impairment. Review of the Physician Orders, revealed the following orders and dates: 2/12/2020 Apixaban 2.5 mg give 2.5 mg by mouth two times a day for Anticoagulation, and Metoprolol Tartrate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, daily staffing records, medical record review, observation, and interview, the facility failed to ensure a sufficient number of licensed staff was available to provide care and services to all residents based on physician orders when there was no nurse to provide assessments and services for 1 of 2 sampled residents (Resident #22) admitted to the 3rd floor on 1/9/2023 and administer significant and other medications for 29 of 40 sampled residents (Resident #7, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, 52, #53, #55, #56, and #57) reviewed on the 3rd floor with orders for medications. The facility's failure to ensure staffing was sufficient to provide oversight of the residents and ensure timely assessments and medications were administered resulted in Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Regional Director of Operations, Area Director of Clinical Services, Special Projects Nurse, and the Administrator, were notified of the Immediate Jeopardy (IJ) for F600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F725 at a scope and severity of K which is Substandard Quality of Care. The Immediate Jeopardy for F725 began on 1/9/2023 and is ongoing. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Nursing Services and Sufficient Staff revised 8/30/2022 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. a. Except when waived, licensed nurses; and b. Other nursing personnel, including but not limited to nurse aides .The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to residents' needs . Review of the Director of Nursing job description dated 12/2011 revealed, .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment . Review of the facility's policy titled Medication Administration dated 1/21/2022 revealed, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. If other than PO [by mouth] route, administer in accordance with facility policy for the relevant route of administration [i.e., injection, eye, ear, rectal, etc.] .Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR .Report and document any adverse side effects or refusals .Example guidelines for Medication Administration [unless otherwise ordered by physician], this list is not all-inclusive .Medication requiring vital signs prior to administration: Digitalis, Lanoxin, Digoxin, Anti-Hypertensives .Medication timing [excludes insulin]: .AC [before meals] 30 minutes before meal service. PC [administered after meals]. BID [twice daily] 9 am, 9 pm. HS [at bedtime] 9 pm. QD [daily] 9 am. QID [four times daily] 9 am, 1 pm, 5 pm, 9 pm . Review of the facility's CMS Daily Staffing Record dated 1/9/2023 revealed on the 7:00 PM - 7:00 AM shift the facility had a total of 3 Licensed Practical Nurses (LPNs) with a total of 21 actual hours worked with a census of 146 residents. Review of the Census By Floors form dated 1/9/2023 revealed a total census of 145 residents. A total of 54 residents resided on the 3rd floor. Review of the printed electronic Medication Administration Record (MAR) revealed the MAR had pre-printed medication due times for each medication per physician orders. 2. Review of the medical record revealed Resident #22 was admitted to the facility 1/9/2023 with diagnoses of Seizures, Syncope and Collapse, Rhabdomyolysis, Metabolic Encephalopathy, Essential Hypertension, Muscle Weakness, and Dysphagia. Review of Resident #22's medical record revealed no assessments were completed upon admission and no documentation was in the medical record related to the resident's condition and needs. Review of the hospital transfer orders dated 1/9/2023 revealed, .Admit To Midtown Health and Rehab .Stg [Stage] III [3] B [bilateral] buttocks and sacrum .multiple erupted blister B heel blisters . The resident had no medications ordered. Review of a Nurse's Progress Note dated 1/10/2023 timed 12:59 PM revealed staff were unable to feed Resident #22 due to the Resident clinching her teeth together and being combative. Resident #22 was transferred to the hospital for evaluation. During an interview on 1/10/2023 at 2:05 PM, when asked if she was notified there was no nurse on the 3rd floor on 1/9/2023 for the 7:00 PM-7:00 AM shift, LPN #6 stated, I left here about 7 [7:00 PM] last night. I was on call for staff. [Named LPN] called me and said he was waiting on a nurse. I called the SDC [Staff Development Coordinator] and she put out a call to [Named agency]. I went to bed. I got here the next morning at 8:06 [AM]. There were 2 admissions came in. Not sure if anyone did the admissions . During an interview on 1/10/2023 at 3:41 PM, when asked if she was notified there was no nurse on the 3rd floor on 1/9/2023 for the 7:00 PM-7:00 AM shift, the SDC stated, The nurses called out. [Named LPN] called me and asked me to put out a post. I put a post out to agency. Nobody responded. I watched for awhile then I went to bed. I wasn't on call, so I didn't follow up . During an interview on 1/10/2023 at 1:30 PM, when asked if the residents on the 3rd floor received medications on 1/9/2023 as ordered by the physician, the Director of Nursing (DON) stated, No, they did not. There was no nurse. When asked if the 2 newly admitted residents were assessed and provided care and services the DON stated, I'll find out. I know one [Resident #22] had to be sent out to the hospital already. During an interview on 1/11/2023 at 1:28 PM the DON stated, .[Named LPN] made it to the floor at 8:28 [AM on 1/10/2023]. He put her medication orders in and went in and checked on her . When asked if Resident #22 was assessed on 1/9/2023, the DON stated, If it wasn't documented, it wasn't done. 3. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses of Diabetes, Unspecified Sequelae of Cerebral Infarction, Anxiety Disorder, and Hypertension. The Quarterly MDS assessment dated [DATE], revealed Resident # 7 with a BIMS of 14 which indicated no cognitive impairment. Review of the Physician Orders revealed, .start date 10/4/2022 AmLODIPine Besylate Tablet 5 MG Give 5 mg by mouth two times a day for HTN .start date 11/22/2022 Basaglar KwikPen 100 UNIT/ML Solution pen-injector Inject 32 unit subcutaneously at bedtime related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed the Amlodipine Besylate Tablet 5 MG was not administered at 9:00 PM on 1/9/2023, and the Basaglar KwikPen 100 UNIT/ML was not administered at 9:00 PM on 1/9/2023 as ordered. 4. Review of the medical record revealed Resident #23 admitted on [DATE] with diagnoses of Atrial Fibrillation, Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Angina Pectoris, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS dated [DATE] revealed the resident scored a 13 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following: Start Date 6/10/2021, Midodrine HCL Tablet 10 MG Give 1 tablet by mouth every 8 hours for Postural Hypotension. Hold for SBP [Systolic Blood pressure] > [greater than] 110, DBP [Diastolic Blood pressure] > 70. Novolog FlexPen 100 UNIT/ML pen-injector give as per sliding scale: If 150-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; 301-350 give 8 units; 351-400 give 10 units; 401 an greater give 12 units and notify MD before meals and at bedtime. Start Date 7/13/2022 Metoprolol Tartrate Tablet 50 MG give 1 tablet by mouth every 12 hours for Hypertension. Hold for SBP < 110, DBP < 60 or HR equal to or less than (=/<) 60 beats per minute (bpm). Sacubitril-Valsartan Tablet 24-26 mg give 1 tablet by mouth every 12 hours. Review of the MAR dated January 2023 revealed no documentation Metoprolol Sacubitril-Valsartan were administered at 9:00 PM on 1/9/2023 as ordered by the physician. The Midodrine was not administered at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023. The Novolog Insulin was not administered on 1/9/2023 at 8:00 PM as ordered by the physician. The resident's blood glucose level was not assessed at 8:00 PM. During an interview on 1/10/2023 at 7:10 PM when asked if he received medications timely on 1/9/2023, Resident #23 stated, .I didn't get it. No nurse here. The CNA told me. I went to the desk downstairs and the receptionist said they trying to get someone to come. No one came . 5. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses of Cerebral Palsy, Essential Hypertension, History of Venous Thrombosis and Embolism, and Rhabdomyolysis. Review of the quarterly MDS dated [DATE] revealed the resident scored a 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 9/25/2021 Apixaban Tablet 5 MG Give 5 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation Apixaban was administered on 1/9/2023 at 9:00 PM as ordered by the physician. During an interview on 1/10/2023 at 4:01 PM, when asked if she received her medications on 1/9/2023, Resident #24 stated, No, I didn't get all my medicine. There was no nurse. 6. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses of Supraventricular Tachycardia, Schizophrenia, Osteoarthritis, and Anemia. The MDS dated [DATE] revealed the resident scored 9 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 4/30/2020 Metoprolol Tartrate Tablet 25 MG Give 25mg by mouth two times a day for HTN Hold for HR <60 or SBP <110 . Review of the MAR dated January 2023 revealed no documentation Metoprolol Tartrate was administered on 1/9/2023 at 9:00 PM as ordered by the physician. 7. Review of the medical record revealed Resident #29 was admitted on [DATE] with diagnoses of Heart Failure, Glaucoma, Essential Hypertension, Tremor, Chest Pain, and Hypomagnesia. The quarterly MDS dated [DATE], revealed the resident scored 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/17/2020 Carvedilol Tablet 25 MG Give 25 mg by mouth two times a day for Heart Failure Hold if HR less than 60 . Review of the MAR dated January 2023 revealed no documentation Carvedilol was administered on 1/9/2023 at 9:00 PM as ordered by the physician. 8. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis Left Nondominant Side, Osteoarthritis, and Benign Neoplasm of Skin. The annual MDS dated [DATE] revealed the resident scored 12 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 11/06/2021 Apixaban Tablet 5 MG Give 1 tablet two times a day for anticoagulant therapy .Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation the Apixaban and Carvedilol were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 9. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Thyrotoxicosis, Essential Hypertension, History Transient Ischemic Attack, and Cerebral Infarction. The quarterly MDS dated [DATE], revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 10/24/2022 Diltiazem HCL Tablet 30 MG Give 1 tablet by mouth three times a day for HTN Hold for SBP < 100, DBP < 60, or HR < 60 . Review of the MAR dated January 2023 revealed no documentation the Diltiazem was administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the resident's blood pressure and heart rate were assessed. 10. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses of Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Anemia, and Chronic Obstructive Pulmonary Disease. The quarterly MDS dated [DATE] revealed the resident scored 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 9/20/2022 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 26 units Intradermally at bedtime . Review of the MAR dated January 2023 revealed no documentation Lantus insulin was administered on 1/9/2023 as ordered by the physician. 11. Review of the medical record revealed Resident #34 was admitted on [DATE] with diagnoses of Congestive Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, and History of Malignant Neoplasm of Prostate. The admission MDS dated [DATE], revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/08/2022 Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector Inject 3 units subcutaneously before meals .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 40 units subcutaneously at bedtime . Review of the MAR dated December 2022 revealed no documentation the Insulin Lispro was administered on 12/15/2022 at 5:00 PM as ordered by the physician and there was no documentation Insulin Glargine-yfgn was administered on 1/9/2023 at 9:00 PM as ordered by the physician. 12. Review of the medical record revealed Resident #35 was admitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes, Essential Hypertension, and Major Depressive Disorder. The admission MDS dated [DATE], revealed the resident scored 12 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 10/24/2022 Coreg Tablet 6.25 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN. Hold for SBP < 100, DBP < 60 or HR <60 .Start Date 3/13/2021 Eliquis Tablet 2.5 MG Give 1 tablet by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation Coreg and Eliquis were administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the resident's blood pressure and heart rate were assessed. 13. Review of the medical record revealed Resident #36 was readmitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Essential Hypertension, Hypothyroidism, and Human Immunodeficiency Virus Disease. The admission MDS dated [DATE] revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/17/2022 Levothyroxine Sodium Tablet 150 MCG [micrograms] Give 150 mcg by mouth on time a day every Mon, Tue, Wed, Thu, Fri, Sat .Start Date 12/16/2022 Hydralazine HCL Tablet 25 MG Give 1 tablet by mouth three times a day . Review of the MAR dated January 2023 revealed no documentation Levothyroxine and Hydralazine were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 14. Review of the medical record revealed Resident #37 was readmitted on [DATE] with diagnoses of Epilepsy, Cerebral Infarction, Type 2 Diabetes Mellitus, Schizoaffective Disorder, and Hallucinations. The quarterly MDS dated [DATE] revealed the resident scored 8 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/13/2022 Risperidone Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER .Start Date 10/6/2022 Lacosamide Tablet 200 MG Give 200 mg by mouth two times a day for SEIZURE DISORDER . Review of the MAR dated January 2023 revealed no documentation Risperidone and Lacosamide were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 15. Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Unspecified Psychosis, and Essential Hypertension. The quarterly MDS dated [DATE], revealed the resident scored 4 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed, .Start Date 6/10/2022 Depakote Tablet Delayed Release 250 MG Give 1 tablet by mouth three times a day .Start Date 8/4/2022 HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale . The sliding scale orders revealed If blood glucose levels were 0-149 give 0, if less than 70 call MD, if 150-180 give 1 unit, if 181-210 give 2 units, if 211-240 give 3 units, if 241-270 give 4 units, if 271-300 give 5 units, if greater than 300 notify MD, subcutaneously before meals and at bedtime. Review of the MAR dated January 2023 revealed no documentation the Depakote was administered on 1/9/2023 at 9:00 PM as ordered by the physician and Humalog insulin was not administered on 1/9/2023 at 8:00 PM as ordered, and the resident's blood glucose level was not checked for the sliding scale insulin on 1/9/2023 at 8:00 PM as ordered. 16. Review of the medical record revealed Resident #39 was readmitted on [DATE] with diagnoses of Epilepsy, Type 2 Diabetes Mellitus, Cerebral Infarction, Atrial Fibrillation, and Hypothyroidism. The quarterly MDS dated [DATE] revealed the resident scored 5 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed, .Start Date 6/25/2022 Levothyroxine Sodium Tablet 125 MCG Give 1 tablet by mouth one time a day .Start Date 6/6/2022 Eliquis Tablet 5 MG Give 1 tablet by mouth two times a day .levetiracetam Tablet 500 MG Give 1000 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation the Levothyroxine was administered on 1/10/2023 at 6:00 AM as ordered by the physician and the Eliquis and Levetiracetam were not administered on 1/9/2023 at 9:00 PM as ordered by the physician. 17. Review of the medical record revealed Resident #40 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Seizures, Asthma, and Hypothyroidism. The quarterly MDS dated [DATE] revealed the resident scored 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 8/10/2022 Basaglar KwikPen 100 UNIT/ML Solution pen-injector Inject 10 units subcutaneously at bedtime .Start Date 7/27/2022 Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth one time a day .Rosuvastatin Calcium Oral Tablet 5 MG Give 5 mg by mouth at bedtime .Start Date 7/27/2022 levETIRAcetam Tablet 250 MG Give 250 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation the Basaglar insulin, Rosuvastatin Calcium, and Levetiracetam were administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the Levothyroxine was administered at 6:00 AM on 1/10/2023 as ordered by the physician. 18. Review of the medical record revealed Resident #41 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease, Dependence on Renal Dialysis, Atrial Fibrillation, Congestive Heart Failure, Chronic Pulmonary Edema, and Atherosclerotic Heart Disease. The quarterly MDS dated [DATE] revealed the resident scored 10 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 5/22/2021 Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day .Isosorbide Mononitrate ER [extended release] Tablet 30 MG Give 1 tablet by mouth one time a day .Start Date 1/5/2023 Carvedilol Oral Tablet 12.5 MG Give 1 tablet by mouth tow times a day .Start Date 11/30/2021 HydrALAZINE HCL Tablet 25 MG Give 50 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation the Clopidogrel, Isosorbide Mononitrate, and Hydralazine were administered on 1/10/2023 at 6:00 AM as ordered by the physician. There was no documentation Carvedilol was administered as ordered on 1/9/2023 at 9:00 PM as ordered by the physician. 19. Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses of Atherosclerotic Heart Disease, Diabetes, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 42 had a BIMS score of 13 which indicated no cognitive impairment. Review of the Physician Orders revealed, .start date 11/22/2022 Glimepiride Tablet 1 MG Give 1 mg by mouth one time a day for Diabetes Mellitus .start date 3/11/2022 Janumet XR Tablet Extended Release 24 Hour [PHONE NUMBER] MG (SITagliptin-metFORMIN HCl ER) Give 1 tablet by mouth one time a day for Diabetes Mellitus .start date 8/2/2022 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 30 unit subcutaneously at bedtime related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed no documentation of the Glimepiride Tablet 1 MG administered at 6:00 AM on 1/10/2023, Janumet XR Tablet Extended Release 24 Hour [PHONE NUMBER] MG administered at 6:00 AM on 1/10/2023, Lantus SoloStar 100 UNIT/ML administered at 9:00 PM on 1/9/2023 as ordered by the physician. 20. Review of the medical record revealed Resident #45 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Atherosclerotic Heart Disease, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 45 had a BIMS score of 13 which indicated no cognitive impairment. Review of the Physician Orders revealed, .start date 5/20/2022 Entresto Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day related to OTHER HEART FAILURE .start date 3/10/2022 hydrALAZINE HCl Tablet 25 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Review of the MAR dated January 2023 revealed no documentation of the Entresto Tablet 49-51 MG administered at 9:00 PM on 1/9/2023, hydrALAZINE HCl Tablet 25 MG administered at 8:00 PM on 1/9/2023 as ordered by the physician. 21. Review of the medical record revealed Resident #46 was admitted on [DATE] with diagnoses of Gastro-Esophageal Reflux Disease, Blindness, One Eye, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 46 had a BIMS score of 12 which indicated moderate cognitive impairment. Review of the Physician Orders dated 11/21/2022 revealed, .Metoprolol Tartrate Tablet Give 12.5 milligram by mouth two times a day for hypertension . Review of the MAR dated January 2023 revealed no documentation of the Metoprolol Tartrate 12.5 mg administered at 9:00 PM on 1/9/2023 as ordered by the physician. 22. Review of the medical record revealed Resident #47 was admitted on [DATE] with diagnoses of Functional Quadriplegia, Anxiety Disorder, Schizoaffective Disorder, Insomnia, and Spinal Stenosis. The annual MDS assessment dated [DATE] revealed Resident # 47 had a BIMS score of 15 which indicated no cognitive impairment Review of the Physician Orders revealed, .start date 12/20/2022 QUEtipine Fumerate Tablet 100 MG Give 1.5 tablet by mouth at HS for a total dose of 150 mg related to SCHIZOAFFECTIVE DISORDER . Review of the MAR dated January 2023 revealed no documentation the Quetipine Fumerate was administered at 9:00 PM on 1/9/2023 as ordered by the physician. 23. Review of the medical record revealed Resident #48 was admitted on [DATE] with diagnoses of Diabetes, Dementia, and Hypertension. The quarterly MDS assessment dated [DATE] revealed Resident # 48 had a BIMS score of 5 which indicated severe cognitive impairment. Review of the Physician Orders dated 7/21/2022 revealed, .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 28 unit subcutaneously two times a day related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed no documentation the Insulin Glargine-yfgn 100 UNIT/ML was administered at 9:00 PM on 1/9/2023 as ordered by the physician. 24. Review of the medical record revealed Resident #49 was admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Diabetes, and Hypertension. The Quarterly MDS assessment dated [DATE] revealed Resident #49 with Severely impaired cognitive skills and no behaviors. Review of the Physician Orders revealed, .start date 8/12/2021 Metoprolol Tartrate Tablet 100 MG Give 1 tablet by mouth two times a day for HTN [hypertension] .start date 10/4/2022 Verapamil HCl Tablet 40 MG Give 40 mg by mouth three times a day for HtN . Start date 1/19/2022 .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject subcutaneously before meals and at bedtime related to TYPE 2 DIABETES .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 60 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = Call MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . Review of the MAR dated January 2023 revealed no documentation of Metoprolol Tartrate Tablet 100 MG administered at 9:00 PM on 1/9/2023, Verapamil HCl Tablet 40 MG administered at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023, the Sliding scale blood glucose/sugar checks and the NovoLOG FlexPen 100 UNIT/ML administered at 6:30 AM on 1/3/2023, and at 06:30 AM, and 8:00 PM on 1/9/2023, and at 6:30 AM on 1/10/2023 as ordered by the physician. 25. Review of the medical record revealed Resident # 50 was admitted on [DATE] with diagnoses of Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Cerebral Infarction, and Hypertension. The Annual MDS assessment dated [DATE], revealed Resident # 50 had a BIMS score of 10 which indicated moderate cognitive impairment. Review of the Physician Orders dated 11/17/2022 revealed, .hydrALAZINE HCl Tablet 50 MG Give 1 tablet by mouth four times a day for hypertension . Review of the MAR dated January 2023 revealed no documentation of hydrALAZINE HCl Tablet 50 MG administered at 9:00 PM on 1/9/2023 as ordered by the physician. 26. Review of the medical record revealed Resident # 51 was admitted on [DATE] with diagnoses of Dementia, Acute Kidney Failure, Alzheimer's Disease, and Hypertension. The Quarterly MDS assessment dated [DATE] revealed Resident # 51 had a BIMS score of 2 which indicated severe cognitive impairment. Review of the Physician Orders dated 3/1/2022 revealed, .Eliquis Tablet 5 MG .5 mg by mouth two times a day for blood thinner related to ESSENTIAL (PRIMARY) HYPERTENSION . Review of the MAR dated January 2023 revealed no documentation of the Eliquis Tablet 5 MG administered at 8:00 PM on 1/9/2023 as ordered by the physician. 27. Review of the medical record revealed Resident #52 was admitted on [DATE] with diagnoses of Cerebral Infarction, Seizures, and Hypertension. The Quarterly MDS assessment dated [DATE] revealed Resident # 52 had a BIMS score of 9 which indicated moderate cognitive impairment. Review of the Physician Orders dated 3/12/2020 revealed, .levETIRAcetam Tablet 1000 MG Give 1000 mg by mouth two times a day for Seizures . Review of the MAR dated January 2023 revealed no documentation of the levETIRAcetam Tablet 1000 MG administered at 9:00 PM on 1/9/2023 as ordered by the physician. 28. Review of the medical record revealed Resident #53 admitted on [DATE] with diagnoses of Diabetes, Chronic Obstructive Pulmonary Disease, Hypertension, and Cardiomegaly. The Quarterly MDS assessment dated [DATE], revealed Resident # 53 with a BIMS of 8 which indicated moderate cognitive impairment. Review of the Physician Orders dated 10/4/2022 revealed, .HydrALAZINE HCl Tablet 25 MG Give 1 tablet by mouth two times a day for HTN . Review of the MAR dated January 2023 revealed no documentation of HydrALAZINE HCl Tablet 25 MG administered at 9:00 PM on 1/9/2023 as ordered by the physician. 29. Review of the medical record revealed Resident #55 admitted on [DATE] with diagnoses of Heart Failure, Atrial Fibrillation, Diabetes, and Hypertension. The Annual MDS assessment dated [DATE] revealed Resident #55 had a BIMS score of 7 which indicated severe cognitive impairment. Review of the Physician Orders revealed, .start date 9/21/2021 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 5 unit subcutaneously at bedtime for DIABETES .start date 2/12/2020 Apixaban Tablet 2.5 MG Give 2.5 mg by mouth two times a day for ANTICOAGULATION .Metoprolol Tartrate Tablet Give 12.5 mg by mouth two times a day for HTN .start date 10/27/2022 HumaLOG KwikPen 100 UNIT/ML Solution pen-injector

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors when significant medications including anti-diabetics, antiarrhythmic's, antihypertensive, anticonvulsant, anti-platelets and cardiac medications were not administered as ordered by the physician. One or more unit doses scheduled to be administered were not administered for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, #72) reviewed with significant medications. The facility's failure resulted in Immediate Jeopardy when these residents failed to receive the necessary significant medications resulting in a likelihood of a serious adverse outcome such as cardiac complications, seizures, risk of bleeding, or death. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Director of Operations, Area Director of Clinical Services, Regional Director of Clinical Services, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-684 and F-686 on 1/17/2023 at 6:12 PM, in the Chapel. The Administrator, Regional Director of Operations, Area Director of Clinical Services, and Special Projects Nurse were notified of the Immediate Jeopardy (IJ) for F-600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F760 at a scope and severity of K which is Substandard Quality of Care. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. The Immediate Jeopardy for F760 began on 1/9/2023 and is ongoing. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Medication Administration dated 1/21/2022 revealed, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .Identify resident by photo in the MAR [medication administration record] .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Review MAR to identify medication to be administered .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. If other than PO [by mouth] route, administer in accordance with facility policy for the relevant route of administration [i.e., injection, eye, ear, rectal, etc.] .Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR .Report and document any adverse side effects or refusals. Correct any discrepancies and report to nurse manager .Example guidelines for Medication Administration [unless otherwise ordered by physician], this list is not all-inclusive .Medication requiring vital signs prior to administration: Digitalis, Lanoxin, Digoxin, Anti-Hypertensives .Medication timing [excludes insulin]: .AC 30 minutes before meal service. PC administered after meals. BID [twice daily] 9 am, 9 pm. HS [at bedtime] 9 pm. QD [daily] 9 am. QID [four times daily] 9 am, 1 pm, 5 pm, 9 pm . Review of the facility's policy titled Blood Glucose Monitoring dated 1/2/2020 revised 3/4/2022 revealed, .It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders. Policy Explanation and Compliance Guidelines: The facility will perform blood glucose monitoring as per physician's orders. The nurse will perform the blood glucose test utilizing the glucometer as per manufacturer's instructions .Report critical test results to physician timely . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region Stage 4, History of Venous Thrombosis and Embolism, Human Immunodeficiency Disease, Protein-Calorie Malnutrition, and Hypertension. The admission MDS dated [DATE] revealed Resident #3 had. Review of the Physician's orders revealed the following medications: .Start Date 12/22/2022 Bactrim DS Tablet 800-160 MG [milligrams] [Human Immunodeficiency Virus] Give 1 tablet by mouth one time a day for bacterial infection .Biktarvy Tablet 50-200-25 MG Give 1 tablet by mouth one time a day for HIV . .Start Date 12/23/2022 Azithromycin Tablet 500 MG Give 1 tablet by mouth one time a day for HIV [Human Immunodeficiency Virus] .Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day .Eliquis Tablet 5 MG Give 5 mg by mouth two times a day . Review of the Medication Administration Record [MAR] dated December 2022 revealed no documentation the following medications were administered as ordered on the listed dates and times: Carvedilol at 9:00 AM on 12/23/2022; and 9:00 AM and 9:00 PM on 12/25/2022. Eliquis on 12/23/2022 and 12/24/2022 at 9:00 PM, and 9:00 AM on 12/25/2022. Bactrim DS and Biktarvy at 9:00 AM and 9:00 PM on 12/25/2022. Azithromycin at 9:00 AM on 12/25/2022. 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Covid-19, and Epilepsy. The quarterly MDS dated [DATE] revealed Resident #4 had no cognitive impairment. Review of the Physician's order dated 9/1/2022 revealed the following medications: Alogliptin Benzoate 12.5 MG Tablet Give one tablet by mouth one time a day related to DIABETES MELLITUS. AmLODIPine Besylate Tablet 10 MG Give one tablet one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Review of the MAR dated December 2022 revealed no documentation the following medications and/or checks were administered as ordered on the listed dates and times: Alogliptin at 9:00 AM on 12/4/2022 and 12/25/2022. Amlodipine at 9:00 AM or 9:00 PM on 12/4/2022 and 12/25/2022; there was no documentation to reveal the resident's blood pressure was assessed. 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Paraplegia, Chronic Osteomyelitis, Open Wound of Buttock, History of Failed Surgical Flap, Peripheral Vascular Disease, Anemia, and Protein-Calorie Malnutrition. The annual MDS dated [DATE] revealed Resident #5 scored a 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 8/2/2019, . Minocycline HCL capsule 100 MG Give 100 mg by mouth two times a day for infection . Start Date 2/1/2022, .rifAMpin Capsule 300 MG Give 300 mg by mouth two times a day for chronic osteomyelitis . Start Date 10/21/2022, .Lantus SoloStar 100 UNIT/ML (milliliter) Solution pen-injector Inject 10 unit subcutaneously at bedtime for DM [Diabetes Mellitus] . Review of the MAR dated December 2022 revealed no documentation the Lantus Solostar, Minocycline HCL, and Rifampin were administered at 9:00 PM on 12/22/2022 and 12/31/2022 as ordered by the physician. During an interview on 1/11/2023 at 1:10 PM, when asked if Resident #5 received the medications as ordered on 12/22/2022 and 12/31/2022, LPN #2 stated, No, I don't see that. Could have been when there was only one nurse on the hall and she may have missed it . 5. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses of Diabetes, Unspecified Sequelae of Cerebral Infarction, Anxiety Disorder, and Hypertension. The Quarterly MDS assessment dated [DATE] revealed Resident # 7 with a BIMS of 14 which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start date 10/4/2022, .AmLODIPine Besylate Tablet 5 MG Give 5 mg by mouth two times a day for HTN . Start date 11/22/2022, .Basaglar KwikPen 100 UNIT/ML Solution pen-injector Inject 32 unit subcutaneously at bedtime related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: AmLODIPine Besylate Tablet 5 MG at 9:00 PM on 1/9/2023. Basaglar KwikPen 100 UNIT/ML at 9:00 PM on 1/9/2023 as ordered by the physician. 6. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region, Sepsis Unspecified Organism, Urinary Tract Infection, Cerebral Infarction, Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis of Deep Vein or Right Upper Extremity, and Osteomyelitis. The quarterly MDS dated [DATE] revealed Resident #8 scored a 7 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date, .12/25/2022 Doxycycline Monohydrate Capsule 100 MG Give 100 mg by mouth two times a day for sepsis Start Date, .12/23/2022 Eliquis Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day . Start Date 12/29/2022, .Metronidazole Tablet 500 MG Give 500 mg by mouth three times a day for sepsis . Start Date 12/29/2022, .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 60-149 = 0 units: 150-199 = 4 units; 200-249 = 6 units; 250-299 = 8 units; 300-349 = 10 units; 350-400 = 12 units .subcutaneously two times a day related to DIABETES MELLITUS . Review of the MAR dated December 2022 revealed no documentation the following medications were administered as ordered on the listed dates and times: Doxycycline Monohydrate, Eliquis, and Metronidazole at 9:00 PM on 12/31/2022. Novolog insulin and sliding scale blood glucose level check on 12/29/2022-12/31/2022. 7. Review of the medical record revealed Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Congestive Heart Failure, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, Insomnia, and Obstructive Sleep Apnea. The quarterly MDS dated [DATE] revealed the resident scored a 14 on the BIMS which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 12/10/2022, .methlMAzole tablet 5 MG Give 1 tablet by mouth one time a day related to THYROTOXICOSIS . Start Date 12/1/2022, .Minoxidil Tablet 2.5 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Start Date 11/30/2022, .CloNiDine HCL Tablet 0.3 MG Give 1 tablet by mouth three times a day for hypertension. HOLD for SBP < 100 DBP < 60 HR < than 60. Notify MD . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Methlmazole at 9:00 AM on 1/1/2023. Minoxidil on 1/4/2022 and 1/6/2022 at 9:00 AM, and 1/4/2022 and 1/5/2022 at 9:00 PM. During an interview on 1/10/2023 at 3:37 PM Resident #14 stated, .Sometimes I don't get my early morning medicine for my thyroid problem. They tell me they don't want to wake me up. I just want my pill brought to me . 8. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Angina Pectoris, and Chronic Obstructive Pulmonary Disease. The quarterly MDS dated [DATE] revealed the resident scored a 13 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 7/13/2022, .Metoprolol Tartrate Tablet 50 MG Give 1 tablet by mouth every 12 hours for hypertension Hold for SBP [Systolic Blood Pressure] < [less than] 110, DBP [diastolic blood pressure] < 60 OR HR = [equal to]/< 60 .Sacubitril-Valsartan Tablet 24-26 MG Give 1 tablet by mouth every 12 hours . Start Date 6/10/2021, .Midodrine HCL Tablet 10 MG Give 1 tablet by mouth every 8 hours for POSTURAL HYPOTENSION HOLD FOR SBP > 110, DBP > 70 .Novolog FlexPen 100 UNIT/ML Solution pen-injector Give as per sliding scale: If 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401 AND GREATER GIVE 12 UNITS AND NOTIFY MD by mouth before meals and at bedtime . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Metoprolol Sacubitril-Valsartan at 9:00 PM on 1/9/2023. Midodrine at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023. There was no documentation the Resident's blood pressure had been checked to determine if the medication should be held. Novolog Insulin on 1/9/2023 at 8:00 PM. The resident's blood glucose level was not assessed at 8:00 PM. During an interview on 1/10/2023 at 7:10 PM when asked if he received medications timely on 1/9/2023, Resident #23 stated, .I didn't get it. No nurse here. The CNA told me. I went to the desk downstairs and the receptionist said they trying to get someone to come. No one came . 9. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses of Cerebral Palsy, Essential Hypertension, History of Venous Thrombosis and Embolism, and Rhabdomyolysis. The quarterly MDS dated [DATE] revealed the resident scored a 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 9/25/2021 Apixaban Tablet 5 MG Give 5 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation Apixaban was administered on 1/9/2023 at 9:00 PM as ordered by the physician. During an interview on 1/10/2023 at 4:01 PM, when asked if she received her medications on 1/9/2023, Resident #24 stated, No, I didn't get all my medicine. There was no nurse. 10. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses of Supraventricular Tachycardia, Schizophrenia, Osteoarthritis, and Anemia. The quarterly MDS dated [DATE] revealed the resident scored 9 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 4/30/2020 Metoprolol Tartrate Tablet 25 MG Give 25mg by mouth two times a day for HTN [hypertension] Hold for HR < 60 or SBP < 110 . Review of the MAR dated January 2023 revealed no documentation Metoprolol Tartrate was administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the Resident's blood pressure had been checked to determine if the medication needed to be held. 11. Review of the medical record revealed Resident #29 admitted on [DATE] with diagnoses of Heart Failure, Glaucoma, Essential Hypertension, Tremor, Chest Pain, and Hypomagnesia. The quarterly MDS dated [DATE] revealed the resident scored 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/17/2020 Carvedilol Tablet 25 MG Give 25 mg by mouth two times a day for Heart Failure Hold if HR less than 60 . Review of the MAR dated January 2023 revealed no documentation Carvedilol was administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the Resident's HR had been checked to determine if the medication needed to be held. 12. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis Left Nondominant Side, Osteoarthritis, and Benign Neoplasm of Skin. The annual MDS dated [DATE] revealed the resident scored 12 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 11/06/2021 Apixaban Tablet 5 MG Give 1 tablet two times a day for anticoagulant therapy .Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation Apixaban and Carvedilol were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 13. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Thyrotoxicosis, Essential Hypertension, History Transient Ischemic Attack, and Cerebral Infarction. The quarterly MDS dated [DATE] revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 10/24/2022 Diltiazem HCL Tablet 30 MG Give 1 tablet by mouth three times a day for HTN Hold for SBP < 100, DBP < 60, or HR < 60 . Review of the MAR dated January 2023 revealed no documentation Diltiazem was administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the resident's blood pressure and heart rate were assessed. 14. Review of the medical record, revealed Resident #33 admitted on [DATE] with diagnoses of Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Anemia, and Chronic Obstructive Pulmonary Disease. The quarterly MDS dated [DATE] revealed the resident scored 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 9/20/2022 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 26 units Intradermally at bedtime . Review of the MAR dated January 2023 revealed no documentation Lantus insulin was administered on 1/9/2023 as ordered by the physician. 15. Review of the medical record, revealed Resident #34 admitted on [DATE] with diagnoses of Congestive Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, and History of Malignant Neoplasm of Prostate. The admission MDS dated [DATE] revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 12/08/2022, .Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector Inject 3 units subcutaneously before meals . Start Date 12/8/2022, .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 40 units subcutaneously at bedtime . Review of the MAR dated December 2022 and January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Insulin Lispro on 12/15/2022 at 5:00 PM. Insulin Glargine-yfgn on 1/9/2023 at 9:00 PM. 16. Review of the medical record revealed Resident #35 admitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes, Essential Hypertension, and Major Depressive Disorder. The admission MDS dated [DATE] revealed the resident scored 12 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 3/13/2021, .Eliquis Tablet 2.5 MG Give 1 tablet by mouth two times a day . Start Date 10/24/2022, .Coreg Tablet 6.25MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN. Hold for SBP < 100, DBP < 60 or HR <60 . Review of the MAR dated January 2023 revealed no documentation the Coreg and Eliquis on 1/9/2023 at 9:00 PM as ordered. There was no documentation the Resident's blood pressure had been checked to determine if the medication should be held. 17. Review of the medical record revealed Resident #36 was readmitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Essential Hypertension, Hypothyroidism, and Human Immunodeficiency Virus Disease. The admission MDS dated [DATE] revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 12/16/2022, .Hydralazine HCL Tablet 25 MG Give 1 tablet by mouth three times a day . Start Date 12/17/2022, .Levothyroxine Sodium Tablet 150 MCG Give 150 mcg by mouth on time a day every Mon, Tue, Wed, Thu, Fri, Sat . Review of the MAR dated January 2023 revealed no documentation the Levothyroxine and Hydralazine were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 18. Review of the medical record revealed Resident #37 was on 10/6/2022 with diagnoses of Epilepsy, Cerebral Infarction, Type 2 Diabetes Mellitus, Schizoaffective Disorder, and Hallucinations. The quarterly MDS dated [DATE] revealed the resident scored 8 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 10/6/2022, .Lacosamide Tablet 200 MG Give 200 mg by mouth two times a day for SEIZURE DISORDER . Start Date 12/13/2022, .Risperidone Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER . Review of the MAR dated January 2023 revealed no documentation Risperidone and Lacosamide were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 19. Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Unspecified Psychosis, and Essential Hypertension. The quarterly MDS dated [DATE] revealed the resident scored 4 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 6/10/2022, .Depakote Tablet Delayed Release 250 MG Give 1 tablet by mouth three times a day . Start Date 8/4/2022, .HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: If 0-149 = 0 less than 70 call MD; 150-180=1 unit; 181-210=2 units; 211-240=3 units; 241-270=4 units; 271-300=5 units greater than 300 notify MD, subcutaneously before meals and at bedtime . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Depakote on 1/9/2023 at 9:00 PM. Humalog insulin was not administered and there was no evidence a sliding scale blood glucose level check was performed on 1/9/2023 at 8:00 PM. 20. Review of the medical record revealed Resident #39 was readmitted on [DATE] with diagnoses of Epilepsy, Type 2 Diabetes Mellitus, Cerebral Infarction, Atrial Fibrillation, and Hypothyroidism. The quarterly MDS dated [DATE] revealed the resident scored 5 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 6/6/2022, .Eliquis Tablet 5 MG Give 1 tablet by mouth two times a day .levetiracetam Tablet 500 MG Give 1000 mg by mouth two times a day . Start Date 6/25/2022, .Levothyroxine Sodium Tablet 125 MCG Give 1 tablet by mouth one time a day . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Levothyroxine on 1/10/2023 at 6:00 AM. Eliquis and Levetiracetam on 1/9/2023 at 9:00 PM. 21. Review of the medical record revealed Resident #40 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Seizures, Asthma, and Hypothyroidism. The quarterly MDS dated [DATE], revealed the resident scored 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 7/27/2022, .Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth one time a day .Rosuvastatin Calcium Oral Tablet 5 MG Give 5 mg by mouth at bedtime . Start Date 7/27/2022 .levETIRAcetam Tablet 250 MG Give 250 mg by mouth two times a day . Start Date 8/10/2022, .Basaglar KwikPen 100 UNIT/ML Solution pen-injector Inject 10 units subcutaneously at bedtime . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Basaglar insulin, Rosuvastatin Calcium, and Levetiracetam on 1/9/2023 at 9:00 PM. Levothyroxine at 6:00 AM on 1/10/2023. 22. Review of the medical record revealed Resident #41 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease, Dependence on Renal Dialysis, Atrial Fibrillation, Congestive Heart Failure, Chronic Pulmonary Edema, and Atherosclerotic Heart Disease. The quarterly MDS dated [DATE], revealed the resident scored 10 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 5/22/2021, .Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day .Isosorbide Mononitrate ER [extended release] Tablet 30 MG Give 1 tablet by mouth one time a day . Start Date 11/30/2021, .HydrALAZINE HCL Tablet 25 MG Give 50 mg by mouth two times a day . Start Date 1/5/2023, .Carvedilol Oral Tablet 12.5 MG Give 1 tablet by mouth tow times a day . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Clopidogrel, Isosorbide Mononitrate, and Hydralazine on 1/10/2023 at 6:00 AM. Carvedilol on 1/9/2023 at 9:00 PM. 23. Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses of Atherosclerotic Heart Disease, Diabetes, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 42 had a BIMS score of 13 which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start date 3/11/2022, .Janumet XR Tablet Extended Release 24 Hour [PHONE NUMBER] MG (SITagliptin-metFORMIN HCl ER) Give 1 tablet by mouth one time a day for Diabetes Mellitus . Start date 8/2/2022, .Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 30 unit subcutaneously at bedtime related to TYPE 2 DIABETES . Start date 11/22/2022, .Glimepiride Tablet 1 MG Give 1 mg by mouth one time a day for Diabetes Mellitus . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Lantus SoloStar 100 UNIT/ML at 9:00 PM on 1/9/2023. Glimepiride Tablet 1 MG at 6:00 AM on 1/10/2023. Janumet XR Tablet Extended Release 24 Hour [PHONE NUMBER] MG at 6:00 AM on 1/10/2023. 24. Review of the medical record revealed Resident #45 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Atherosclerotic Heart Disease, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 45 had a BIMS score of 13 which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start date 3/10/2022, .hydrALAZINE HCl Tablet 25 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Start date 5/20/2022, .Entresto Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day related to OTHER HEART FAILURE . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: On 1/9/2023 HydrALAZINE HCl Tablet 25 MG at 8:00 PM and at 9:00 PM Entresto Tablet 49-51 MG. 25. Review of the medical record revealed Resident #46 was admitted on [DATE] with diagnoses of Gastro-Esophageal Reflux Disease, Blindness, One Eye, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 46 had a BIMS score of 12 which indicated moderate cognitive impairment. Review of the Physician Orders dated 11/21/2022, revealed .Metoprolol Tartrate Tablet Give 12.5 milligram by mouth two times a day for hypertension . Review of the MAR dated January 2023 revealed no documentation of Metoprolol Tartrate Tablet Give 12.5 milligram administered at 9:00 PM on 1/9/2023 as ordered by the physician. 26. Review of the medical record revealed Resident #47 was admitted on [DATE] with diagnoses of Functional Quadriplegia, Anxiety Disorder, Schizoaffective Disorder, Insomnia, and Spinal Stenosis. The annual MDS assessment dated [DATE] revealed Resident #47 had a BIMS score of 15 which indicated no cognitive impairment. Review of the Physician Orders revealed, .start date 12/20/2022 QUEtipine Fumerate Tablet 100 MG Give 1.5 tablet by mouth at HS for a total dose of 150 mg related to SCHIZOAFFECTIVE DISORDER . Review of the MAR dated January 2023 revealed no documentation Quetipine Fumerate was administered at 9:00 PM on 1/9/2023 as ordered by the physician. 27. Review of the medical record revealed Resident #48 was admitted on [DATE] with diagnoses of Diabetes, Dementia, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 48 had a BIMS score of 5 which indicated severe cognitive impairment. Review of the Physician Orders dated 7/21/2022 revealed, .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 28 unit subcutaneously two times a day related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed no documentation Insulin Glargine-yfgn 100 UNIT/ML administered at 9:00 PM on 1/9/2023 as ordered by the physician. 28. Review of the medical record revealed Resident #49 admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Diabetes, and Hypertension. The Quarterly MDS assessment dated [DATE], revealed Resident # 49 with Severely impaired cognitive skills and no behaviors. Review of the Physician's orders revealed the following medications: Start date 8/12/2021, .Metoprolol Tartrate Tablet 100 MG Give 1 tablet by mouth two times a day for HTN [hypertension] . Start date 10/4/2022, .Verapamil HCl Tablet 40 MG Give 40 mg by mouth three times a day for Htn [hypertension] . Start date 1/19/2022, .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject subcutaneously before meals and at bedtime related to TYPE 2 DIABETES .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 60 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = Call MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT CO[TRUNCATED]

Based on policy review, job description review, record review, medical record review, and interview, facility Administration failed to administer the facility in a manner to provide oversight, to monitor and provide a safe environment, ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the facility failed to provide sufficient licensed nursing staff, failed to administer medications as ordered by the physician, failed to identify wounds and provide necessary treatment and services for residents determined to be at risk for pressure ulcer injury and other wounds. The facility Administration failed to have in place a system to provide sufficient licensed nursing staff with knowledge and skills necessary to ensure residents were free from significant medication errors when medications were not administered as ordered by the physician for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, #72) reviewed that required medications and treatments. The medications not administered included anti-diabetics, anticoagulants, anticonvulsant's, antiarrhythmic's, Hypertensives, and cardiac medications were not administered as ordered by the physician, when insufficient staffing of licensed nurses to perform assessments, treatments, monitor and meet individualized resident needs were not provided. The facility Administration failed to ensure residents with wounds received appropriate assessments and received wound treatment for 6 of 9 sampled residents (Resident #1, #3, #4, #5, #6, and #8) reviewed for pressure ulcer wounds and other wounds. Resident #1 did not receive treatments for a pressure ulcer wound identified upon admission and the wound worsened, Resident #3 did not receive treatments for wounds identified upon admission, Resident #4 did not receive treatments when a Stage 2 pressure wound was identified and developed to a Stage 4, Resident #5 was admitted with pressure ulcer wounds, the resident did not receive treatments as ordered and developed additional pressure ulcer wounds, Resident #6 did not receive treatments as ordered and was not identified with gangrene to her finger, Resident #8 did not receive treatments for a pressure ulcer wound identified upon admission and developed infection to the wound. The facility's failure to administer medications as ordered and provide care and services for residents with wounds resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Director of Operations, Area Director of Clinical Services, Regional Director of Clinical Services, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F684 and F686 on 1/17/2023 at 6:12 PM, in the Chapel. The Administrator, Regional Director of Operations, Area Director of Clinical Services, and Special Projects Nurse were notified of the Immediate Jeopardy (IJ) for F600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F600, F684, F725, F835, and F725 at a scope and severity of K which is Substandard Quality of Care. The facility was cited F686 at a scope and severity of J which is Substandard Quality of Care. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. Non-compliance of F600, F725, F760, F835, and F867 continues at a scope and severity of K. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Nursing Services and Sufficient Staff revised 8/30/2022 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. a. Except when waived, licensed nurses; and b. Other nursing personnel, including but not limited to nurse aides .The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to residents' needs . Review of the Administrator job description, dated 12/2018 revealed, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Essential Duties & [Symbol for and] Responsibilities: .Identify and participate in process improvement, initiatives that improve the customer experience, enhance work flow, and/or improve the work environment .management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .Lead the facility management staff and consultants in developing and working from the business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . Review of the Director of Nursing job description, dated 12/2011 revealed, .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Identify and participate in process improvement initiatives that improve the customer experience, enhance work floor, and/or improve the work environment. Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .In the absence of the Administrator and Assistant Administrator (if applicable), assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Participate in Department Supervisor Meetings, Resident Care Plan Meetings, Budget Committee Meetings, Safety Committee Meetings, Quality Assessment and Assurance Committee Meetings, In-service Education, Family Council and any other meeting as directed by the Administrator. Meet monthly with staff on each unit .Participate in coordination of resident services through departmental and appropriate staff committee meetings. Meet monthly with nursing staff regarding Chart Audit and Physician's Orders. Review audit with Medical Records prior to submitting to Administration .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guideline .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Study Infection Control Reports, Medication Incident Reports and Resident Incident Reports for corrective action. Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures for a more efficient operation .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment .Confirm accurate completion of forms/reports .Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines. Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Review Quality Indicator reports and submit to [NAME] President of Clinical Services on monthly basis .Participate in monthly QA. Ensure staffing levels are maintained .Along with the Administrator engage the medical director in all department activity . 2. Review of facility policies, medical record review, observation, and interview during the survey revealed Residents #1, #3, #4, #5, #6, and #8 did not receive the necessary services and treatments for pressure ulcer wounds and other wounds. Refer to F684, and F686. 3. Review of facility policies, medical record review, observation, and interview revealed Residents #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #58, #59, #60, #68, #69, #71, #72 did not receive their anticonvulsant medications, antiarrhythmic medications, antihypertensive medications, antibiotics, anti-platelet medications, Antidiuretic medications, and antipsychotic medications in accordance physican orders. Refer to F600, F684, F725, and F760. 4. During an interview on 1/11/2023 at 12:15 PM, when asked who was responsible to ensure there was adequate staff on each shift to provide care to all residents, the Administrator stated, I'm not involved with the daily staffing. That would be the DON [Director of Nursing] and SDC [Staff Development Coordinator] . During an interview on 1/11/2023 at 12:47 PM, when asked if the facility had a Nurse supervisor or charge nurse on all shifts, the DON stated, .They are all charge nurses. They should have known what to do .It was an unexpected staff shortage [1/9/2023] .We rely on agency staff to pick up shifts and no one responded . During an interview on 1/11/2023 at 3:47 PM, when asked if she was aware there was no nurse to provide medications and services to the residents on the 3rd floor on 1/9/2023, the Regional Director of Operations stated, I was told there was no nurse and no one responded .We have plenty of available bodies by using agency [contract staff] .Nobody has said anything to me about workload .They should have called the DON .I don't know the specifics of the on-call person, each building is different . During an interview on 1/23/2023 at 10:15 AM, the Area Director of Clinical Services reviewed the Quality Assurance Performance Improvement (QAPI) minutes and stated, We see the problems you are finding .We know staffing is one of the problems . During an interview on 1/23/2023 at 10:46 AM, when asked if staffing had been addressed in the QAPI Committee meetings, the Regional Special Projects Nurse reviewed the QAPI minutes and stated, I don't see anything on staffing discussed in the forms I have in front of me . Refer to F600, F684, F686, F725, and F760.

Based on policy review, job description review, record review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the facility failed to provide sufficient licensed nursing staff, failed to administer medications as ordered by the physician, failed to identify wounds and provide necessary treatment and services for residents determined to be at risk for pressure ulcer injury and other wounds. The facility failed to ensure the QAPI committee reviewed and validated systemic problems and determined a system was in place to ensure sufficient licensed nursing staff with knowledge and skills necessary to assure safety and provide individualized care for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, #72) reviewed that required medications and treatments, and provide appropriate assessments and treatments for 6 of 9 (Resident #1, #3, #4, #5, #6, #8) sampled residents with wounds that worsened resulting in Immediate Jeopardy. Resident #1 did not receive treatments for a pressure ulcer wound identified upon admission and the wound worsened, Resident #3 did not receive treatments for wounds identified upon admission, Resident #4 did not receive treatments when a Stage 2 pressure wound was identified and developed to a Stage 4, Resident #5 was admitted with presuure ulcer wounds, the resident did not receive treatments as ordered and developed additional pressure ulcer wounds, Resident #6 did not receive treatments as ordered and was not identified with gangrene to her finger, Resident #8 did not receive treatments for a pressure ulcer wound identified upon admission and developed infection to the wound, when medications antidiabetics, anticoagulants, anticonvulsants, antiarrhythmics, hypertensives, and cardiac medications were not administered as ordered by the physician, when insufficient staffing of licensed nurses to perform assessments, treatments, monitor and meet individualized resident needs. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Director of Operations, Area Director of Clinical Services, Regional Director of Clinical Services, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F684 and F686 on 1/17/2023 at 6:12 PM, in the Chapel. The Administrator, Regional Director of Operations, Area Director of Clinical Services, and Special Projects Nurse were notified of the Immediate Jeopardy (IJ) for F600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F-600, F684, F725, F760, F835, and F867 at a scope and severity of K which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F686 at a scope and severity of J. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F684 and F686, was received on 1/19/2023, and the Removal Plan was validated onsite by the surveyors on 1/24/2023 through policy review, medical record review, observation, review of education records, and staff interviews. Non-compliance of F600, F725, F760, F835, and F867 continues at a scope and severity of K. The IJ began on 12/16/2022 and is ongoing for F867. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Quality Assurance and Performance Improvement [QAPI] dated 8/20/2022 revealed, .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides .The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan .Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements .The QAPI plan will address the following elements .Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: Tracking and measuring performance. Establishing goals and thresholds for performance improvements. Identifying and prioritizing quality deficiencies. Systematically analyzing underlying causes of systemic quality deficiencies. Developing and implementing corrective action or performance improvement activities. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed .The facility must also consider the incidence, prevalence, and severity of problems or potential problems identified .The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include but is not limited to: The written QAPI plan. Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events. Data collection and analysis at regular intervals. Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 2. Review of the Administrator job description dated 12/2018 revealed, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Essential Duties & [Symbol for and] Responsibilities: .Identify and participate in process improvement, initiatives that improve the customer experience, enhance work flow, and/or improve the work environment .management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .Lead the facility management staff and consultants in developing and working from the business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . Review of the Director of Nursing job description dated 12/2011 revealed, .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Identify and participate in process improvement initiatives that improve the customer experience, enhance work floor, and/or improve the work environment. Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .In the absence of the Administrator and Assistant Administrator (if applicable), assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Participate in Department Supervisor Meetings, Resident Care Plan Meetings, Budget Committee Meetings, Safety Committee Meetings, Quality Assessment and Assurance Committee Meetings, In-service Education, Family Council and any other meeting as directed by the Administrator. Meet monthly with staff on each unit .Participate in coordination of resident services through departmental and appropriate staff committee meetings. Meet monthly with nursing staff regarding Chart Audit and Physician's Orders. Review audit with Medical Records prior to submitting to Administration .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations. Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Study Infection Control Reports, Medication Incident Reports and Resident Incident Reports for corrective action. Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures for a more efficient operation .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment .Confirm accurate completion of forms/reports .Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines. Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Review Quality Indicator reports and submit to [NAME] President of Clinical Services on monthly basis .Participate in monthly QA. Ensure staffing levels are maintained .Along with the Administrator engage the medical director in all department activity . 3. Review of the QAPI documentation dated 9/7/2022 and 11/22/2022 revealed no documentation or evidence of data collection and analysis, documentation demonstrating the development, implementation and evaluation of corrective actions or performance improvement activities. During an interview on 1/19/2023 at 12:12 PM the Director of Nursing stated, .I don't see anything in September of data analysis .No we have no quantitative or qualitative anything. We have nothing like that .I don't see any documentation of a November meeting .I have no documentation of any PIPs [performance improvement plan] . During an interview on 1/23/2023 at 10:41 AM, the Area Director of Clinical Services confirmed September 2022 and November 2022 QAPI meeting contained no documentation of data collection and analysis at regular intervals and of reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events. She stated, .I expect to see data collection and analysis .I can't locate analysis or any of that [development, implementation and evaluation] .If you don't have analysis you can't have the other things .We have policies but failed to follow the policies . 4. The QAPI committee failed to ensure all residents' right to be free of abuse neglect by failure to follow policies to provide needed care and services for all residents. Refer to F600 5. The QAPI committee failure to complete assessments, provide the necessary care, services and treatments for residents with pressure ulcer wounds and other wounds. Refer to F684 and F686 6. The QAPI committee failed to establish, monitor, and implement policies and procedures to ensure adequate staffing. Refer to F725 7. The QAPI committee failed to ensure residents were free from significant medication errors when significant medications including antidiabetic, antiarrhythmics, antihypertensive, anticonvulsant, antiplatelets and cardiac medications were not administered as ordered by the physician. Refer to F760 8. The QAPI committee failed to ensure the facility Administration was administered in a manner to provide oversight, to monitor and provide a safe environment, ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the facility failed to provide sufficient licensed nursing staff, failed to administer medications as ordered by the physician, failed to identify wounds and provide necessary treatment and services for residents determined to be at risk for pressure ulcer injury and other wounds. Refer to F835