**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care. On [DATE] RN A failed to monitor Resident #1 but documented doing vitals during a timeframe which she had become deceased . On [DATE] RN A insisted to Police Officer C Resident #1 was alive when he checked on her at 6:30 AM. RN A documented the vitals for Resident #1 at 7:04 AM. CMA (Certified Medication Aide) B found Resident #1 unresponsive at 7:00 AM during a routine morning medication pass. Police Officer C stated Resident #1 showed obvious signs that were incompatible with life at 7:44 AM and indicated she had most likely already been deceased prior to when RN A checked on her at 6:30 AM. In an interview with RN A, he later stated he did not check on Resident #1 before CMA B found her unresponsive at 7:00 AM and the vitals he uploaded were a mistake. This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of serious injury or death. The findings included: Review of Resident #1's Face Sheet documented Resident #1 was a [AGE] year old female admitted on [DATE]. Resident #1 had a pacemaker. Resident #1 had diagnoses including atrial fibrillation (irregular heart rhythm that begins in the heart's upper chambers), hypertension (high blood pressure, motion sickness (motion caused nausea, vomiting, cold sweat, headache, dizziness, tiredness, loss of appetite, and increased salivation), acute pharyngitis (sore throat inflammation), dementia (decline in cognitive function), depressive disorder (persistent feelings of sadness or loss of interest), abdominal distension (swelling or enlargement of the abdomen), constipation (difficulty passing stools or infrequent bowel movements), muscle weakness (lack of muscle strength), asthma (inflammation of airways), gastro-esophageal reflux diseases (stomach acid flows back into the esophagus), anxiety (feeling of tension or worried thoughts), insomnia (sleep disorder that causes a difficulty in falling asleep or sleeping), dysphagia (difficulty swallowing), and gout (pain and inflammation of the joints). Review of Resident #1's Care Plan dated [DATE] documented Resident #1 had a pacemaker. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was assessed for a Brief Interview for Mental Status (BIMS) and received a score of 14 which indicated that her cognition was intact. Review of Resident #1's vital signs documented by RN A, dated [DATE] at 7:04 AM revealed Resident #1 BP: 130/69, SPO2: 96%, HR: 68, Resp: 18, and Temp: 97. Review of Resident #1's vital signs documented by RN H, dated [DATE] at 1:35 AM revealed Resident #1 BP: 112/68, SPO2: 98%, HR: 68, Resp: 18, and Temp: 97. Review of Resident #1's progress notes written by RN A, dated [DATE] at 10:30 AM documented Around 7 am The floor Med tech informed this nurse the patient is unresponsive .This nurse and the other nurses rush to the patient room and patient observed lying on the bed unresponsive and code blue initiated. pulse was not detective CPR started and then pulse detected by the machine reading varies from 62-122 .The emergency personnel arrived and took over .MD,Family, notified change of condition .The emergency personnel informed this nurse they could not get rhythm and told this nurse to inform the family that she expired . and was pronounced dead by paramedics at 9:33am and they going to call the medical examiner .this nurse notified the family and the MD and the ADON. Review of the Medical Examiner Report notes dated [DATE] documented the synopsis was a facility hospice death. There was no trauma. Resident #1 had diagnoses of A-FIB, pacemaker, obesity, GI, pressure ulcers, bladder issues, asthma, hypertension, heart disease, intestinal obstruction, and failure to thrive. Police Officer C stated a caretaker reported he took vitals on the decedent at 0630 hours. A MedTech found the decedent unresponsive at 0700 hours. CPR was started and FD was contacted. The FD reported the decedent was in full rigor (postmortem stiffening of the muscles that occurs after death, typically starting 2 to 6 hours after death and peaking around 12 hours postmortem) at 0740 hours. Police Officer C confirmed rigor was present in the jaw, neck, and arms. The PD was satisfied there was no foul play or trauma. Case was released to Police Officer C. Record review of a facility statement from RN A documented he was alerted to Resident #1's by CMA B who stated the patient was unresponsive. When RN A arrived, LPN F was already there. He checked the patient's pulse; they did not get a pulse. He stated he started CPR on Resident #1. RN A documented the incident in his progress notes. When Administrator G questioned RN A about the vitals, he stated he did not do vitals on the resident prior and only when he went into the room for CPR. Record review of a facility statement from LVN Q documented she was at the nurse's station when she saw LPN F running down the 300 Hall with the crash cart. She immediately followed to assist. Upon entering Resident #1's room, she checked the patient's pulse but was unable to detect one. She noted the patient appeared stiff and was cool to the touch. CPR was initiated by RN A. EMS arrived shortly after. In an interview on [DATE] at 11:20 AM, CMA B stated she started work at 6:00 AM. She was going room to room passing medicine until she got to Resident #1's room. She stated when she entered, she said Good Morning but there was no response. She stated normally she responds. She stated the door was already open, but the lights were still off. She stated she said Good Morning three times total. She turned on the lights and saw Resident #1 lying on her side on the bed. She stated she knew something was wrong immediately and began to shiver. She rushed to get LPN F. She stated they ran back to the room together and began listening to Resident #1's heart. They put her hand on her head to feel her temperature, supplied oxygen, and started CPR. CNA O was working the hall and was told to go inform RN A of the situation. The paramedics arrived after 6 or 7 minutes of notifying them. RN A arrived at the room and started checking the pulse for Resident #1 and taking her vitals. CMA B stated she never observed RN A checking on Resident #1. She stated she was able to tell something was wrong immediately and if RN A had checked on Resident #1, he should have also been able to tell something was wrong when he entered her room. She stated she did not remember for sure what Resident #1's skin temperature felt like to the touch. She stated the facility performed in-services on the same day. The in-service was about making sure the staff checked on the residents and documented correctly. She stated ADON D was the one who performed the in-service. In an interview on [DATE] at 11:41 AM, LVN P stated they immediately responded when CMA B found Resident #1 unresponsive. They stated RN A, CMA B, and LPN F were all assisting. They stated they heard CMA B and immediately brought the crash cart (emergency medical cart) to the room. LVN P was responsible for checking to see if Resident #1 had an advanced directive or not. Resident #1 was full code (patient wished to receive all available medical interventions). Resident #1 was laying on her right side facing towards the door. RN A delegated LVN P to call 911. It took EMS 5-10 minutes to arrive. Resident #1 was unresponsive. She was not responding to anything. LVN P stated they could not detect a pulse and Resident #1 was not responding to anything verbal. They stated Resident #1 was a little cold to the touch. Resident #1 was stiff. It took 3 people to roll her over. LVN P, RN A, and LPN F began CPR. Once the paramedics arrived, they took over. The facility performed in-services on the same day. The risk of not checking on a resident would be not being able to give a thorough assessment of the resident at that time that you are supposed to be checking on them. In an interview on [DATE] at 12:00 PM, CNA O stated they were working the hall that morning. The situation with Resident #1 happened at the beginning of her shift. She stated she noticed CMA B going into Resident #1's room and heard her immediately call for help. She stated she ran over towards her and that's when they found Resident #1 unresponsive. She stated she assisted LPN F with repositioning Resident #1 while CMA B went to get help. As soon as the crash cart arrived with LVN P they began giving CPR to Resident #1. RN A had also arrived to assist with checking vitals. CNA O stated they did not remember seeing RN A going into Resident #1's room before the start of the incident. She stated she did not remember seeing him go into anyone else's room either. She stated she did see one call light that was on at 6:30 AM for a different resident so she went into that resident's room. If RN A had gone to check on residents on the hall while CNA O was in that resident's room, then she wouldn't know. She stated the facility performed in-services for abuse/neglect and documentation. In an interview on [DATE] at 12:15 PM, LVN Q stated that there is a risk of missing the required resident check timings if you are not checking on a resident when you are supposed to. If the timings are incorrect then there is a risk that a resident could be crashing. That would not be right for the resident because had they been checked on like they were supposed to be then maybe something could have been noticed to prevent the resident from injury, accident, or worse. In an interview on [DATE] at 2:41 PM, RN H stated she was the overnight nurse that worked the hall before RN A. She stated during her shift there were no condition changes. She stated she performed her resident check rounds in the beginning of her shift. She stated around 1 AM, Resident #1 was asking to have the AC cooled down. She performed vitals for Resident #1 at 1:30 AM and she was stable at that time. She stated at that time Resident #1 was okay. She stated she performed another round at 4 AM. Resident #1 was observed laying down in her bed. She stated she performed a quick round because Resident #1 did not have to take medications overnight. She stated she briefly looked inside the room and asked if Resident #1 was okay but there was no response. She didn't want to disturb Resident #1's sleep because she wasn't saying anything. She was laying on her side with her face towards the window. When asked if she checked to see if Resident #1 was breathing, she stated she only went into the room to perform a quick round because she didn't want to disturb Resident #1. In a telephone interview on [DATE] at 12:30 PM, Physician E stated he was informed of the change in condition and was also told by the facility, RN A had got lazy with his charting. He stated he was told RN A documented he had checked on Resident #1 instead of actually checking on Resident #1 and put vitals that were not accurate but once someone else checked on her they realized she was deceased . He stated the EMS said she most likely passed away prior to any of the checks that were documented. He stated this resident was a high risk for cardiac arrest because she had a pacemaker but it was still a surprise and out of the ordinary. He did not think whether RN A checked on Resident #1 or not would have changed the outcome for Resident #1. He stated the risk of injury was high to all residents if the facility was not checking on residents and falsely documenting. He stated if this occurred to a resident who had been in better health then it definitely could have changed the resident's outcome and been preventable. In a telephone interview on [DATE] at 12:51 PM, RN A stated he came to work around 6:05 AM. He stated when he came to work, he usually did rounds on his halls. He stated he did not remember if he checked on Resident #1 or not during that time. He stated he was alerted of Resident #1 not responding by CMA B and rushed to her room. He stated he checked Resident #1's pulse but could not detect it. He stated she was sleeping with her face towards the door. He stated the nurses called a code blue, and everyone began rushing into the room to assist. He stated it took 5-10 minutes for EMS services to arrive. He stated he went to check on Resident #1 after taking over from the night shift nurse (RN H) around 7:00 AM. He stated he was told the resident was unresponsive around 7 AM to 7:30 AM. He stated Resident #1 was not stiff but she was a little cold to the touch. He stated he attempted to take her pulse with her finger, and it gave a pulse. He stated his documentation and vital checks were wrong. He stated he thought the pulse was around 68/122 He stated he did detect a pulse and the resident did have oxygen at that time. He stated the documentation that he put in the vitals could have been for another resident, he wasn't sure. He stated he always checked on his residents every morning but in this scenario he didn't have time to check on her yet. He stated he didn't know what the risk would be of not checking on the resident. He stated she was independent and was someone that would let you know if she needed something. In an interview on [DATE] at 12:35 PM, Assistant Director of Nurses (ADON) D revealed it was the facilities policy to check on the residents at the beginning of their shift and every 2 hours. He stated there was a concern RN A didn't document correctly. He stated the response the facility had upon finding resident was done correctly but it coincided with RN A not checking or documenting correctly. If a nurse were to go into her room in the morning and see her sleeping, then you would assume she was sleeping. She doesn't normally wake up until around 8 AM. This resident was good at using her call light and letting you know if she needed anything. He stated he expected his employees to check on the residents before they take over the shift during shift change. He stated when a nurse takes report you should do your checks. He stated at nighttime this was not a disoriented patient and there was nothing saying you specifically have to take vitals at nighttime for a resident such as this if they were sleeping. He stated for people who didn't talk you should go take their vitals but in this instance she was verbal. He stated he still expected his staff to make sure a resident was breathing and maybe say hi to see if the resident would respond. Otherwise, just let them sleep but make sure they were breathing. This was not a resident we were expecting. This was unexpected. In an interview on [DATE] at 3:16 PM, Police Officer C stated he was responding to a call at the facility at 7:44 AM. He stated once he arrived Resident #1 was not conscious and not breathing. He stated Resident #1 was found to be deceased with obvious signs incompatible with life. He interviewed RN A and RN A insisted Resident #1 was alive when he checked on her and took her vitals at 6:30 AM. He stated RN A later uploaded those vitals into the charting software at 7:04 AM. CMA B was passing medications and found Resident #1 was unresponsive at 7:00 AM. He shared his concern with Administrator G that he believed Resident #1 was in rigor mortis when CMA B found Resident #1 and appeared to have been deceased prior to when RN A claims they checked on her and took her vitals. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on [DATE]. The facility took the following actions to correct the non-compliance on [DATE]: Interview on [DATE] at 11:00 AM with Administrator G revealed he believed RN A falsified the vitals for Resident #1, documenting he had checked on Resident #1 when he had not. Resident #1 was most likely already deceased before CMA B discovered her. Administrator G stated RN A was immediately suspended on the day of the accident [DATE]. He stated the facility has already completed a plan of correction, plan of removal, and were continuing to monitor. Staff have been in-serviced on Abuse and Neglect. Staff have been in-serviced on how to correctly document. Staff have been in-serviced on resident checks. Record review of facility In-services conducted by the ADON dated [DATE] and signed by all staff on the following: a. Nursing Policies and Procedures b. Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. Interview on [DATE] at 12:35 PM with Assistant Director of Nursing D stated in-services have been completed for all floor staff and would continue to be conducted until every PRN staff member that has not presented to work has received the in-service at the start of their shift. Record Review of the Audit of Random Vital Signs Form revealed the facility performed random monitoring by observation and supervision thereafter by the DON and the ADON to monitor proper documentation of the residents in the facility. The document revealed the staff needed to correctly document resident vitals and pass an audit of random resident vital signs that were supported by resident testimony. The DON and the ADON would be conducting audits three times a week until every staff member continued to demonstrate proficiency and thereafter. The document included a section for dates and two random resident audits for documentation. Review of the Suspension Form dated [DATE] documented RN A was suspended. Interview on [DATE] at 11:20 AM with CMA B revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 11:41 AM with LVN P revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 12:00 PM with CNA O revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 12:15 PM with LVN Q revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 2:40 PM with RN I revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 2:45 PM with CMA J revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 2:50 PM with CMA K revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 2:55 PM with CMA L revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 3:00 PM with CNA M revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 3:05 PM with CNA N revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that pain management was provided for 2 (Resident#4 and Resident #36) of 8 residents reviewed for pain. 1. The facility failed to provide effective pain management for Resident #36 after she experienced a fall on 05/09/2024 she was observed by staff resulting in signs of pain such as grimancing and screaming with movement. 2. The facility failed to provide effective pain management for Resident #4 when his pain medication was reduced without his knowledge resulting in him experiencing unnecessary pain and suffering and psychosocial harm. On 05/16/2024 at 4:51 PM an immediate jeopardy was identified. While the IJ was removed on 05/17/2024 at 11:21 AM the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and the effectiveness of their Plan of Removal. These failures placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: 1. Review of Resident #36's Quarterly MDS dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (loss of cognition), stroke, depression (low mood), muscles weakness, unspecified lack of coordination, abnormal position, neurocognitive disorder with Lewy bodies (abnormal deposits of protein in brain leading to loss of cognition, balance, alertness), and a BIMS score of 3 (severe cognitive impairment). Review of Resident #36's Care Plan reflected problem start date of 03/30/2022 that the resident had difficulty making self-understood and had unclear speech. Review of care plan reflected problem start date of 03/10/2022 that the resident was at risk of complaints of chronic pain and used narcotic pain medication due to disease process with approaches of: monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors . monitor and record any non-verbal signs of pain, complaints of pain, and evaluate effectiveness of pain management interventions. Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/06/2024, signed by PTA CC 05/06/2024 at 11:08 AM revealed the resident showed no signs of pain, was treated in the gym and showed no signs of pain. The summary of skilled services included gait training, bilateral lower extremity exercises focused on progressive resistive exercise and bike exercises to enhance muscle strength. Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/06/2024, signed by OT BB 05/06/2024 at 6:29 PM revealed Resident #36 showed no signs of pain. Review of Resident #36's resident progress notes dated 05/09/2024 by LVN N revealed the resident had a witnessed fall on 05/09/2024 around 5:45 AM when the resident was observed in the hallway wobbling and then fell sliding into the ground on her right knee. The resident was provided a head-to-toe assessment, neuro checks were started, and the resident could not say why she was out of bed. The only injury noted was to her right knee, it was slightly red and sore. LVN N noted that the resident was put to bed. The resident was noted to have dementia and did not know why she was up. Review of Resident #36's progress notes for 05/09/2024 by LVN N at 1:43 AM revealed the resident continued on neuro checks for fall, no delayed injury noted. Right slightly red no swelling noted and resident was reminded to use walker and with supervision. Review of Resident #36's progress notes for 05/09/2024 by LVN P at 11:19 AM revealed Resident #36 had no delayed injuries due to pain and denied any pain or discomfort. Review of Resident #36's progress notes for 05/09/2024 by RN H at 4:33 PM revealed Resident #36 had no post fall injuries and the resident denied pain. Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/09/2024, signed by OT BB 05/09/2024 at 6:15 PM, revealed resident showed signs of pain that included grimacing, protective behaviors to areas of pain, limited resident ability to sit up at the edge of the bed and transfers, pain was relieved by sitting still and exacerbated with prolonged activity, and resident had a fall on the morning of 05/09/2024 and complained of pain to her lower right extremity. Review of Resident #36's progress notes for 05/09/2024 by RN H at 9:39 PM revealed Resident#36 was noted moaning, holding her right leg any time she is given incontinent care. Resident assessed. Right hip to ankle painful to touch, no redness no swelling noted. Tramadol 50mg tab routine admin [sic]. NP notified no new order received. Review of Resident #36's progress notes for 05/10/2024 by LVN N at 5:54 AM revealed there was an incident with Resident #36 and her roommate, and the resident was assessed head to toe, was asleep, had no discoloration or any injuries, denied any pain, and was moved to a different room. Review of Resident #36's progress notes dated 05/10/2024 by MDS LVN between 11:33-11:45 AM revealed a cognitive assessment of Resident #36 was completed and revealed that the resident was able to repeat 2 words, was unable to recall the correct year, month, or day of the week, resident speech was unclear, and resident stated that occasional pain, rarely disturb for sleep, activity, therapy activity, pain scale 7. Will continue to monitor. Review of Resident #36's progress notes dated 05/10/2024 at 12:49 PM by LVN Q revealed resident had no delayed injury, no neuro deficits. Review of Resident #36's progress notes dated 05/10/2024 at 8:46 PM by RN H revealed Resident #36 had continued neuro checks for fall, no post fall injury noted or reported, resident denied pain, and care was given as needed by staff. Review of Resident #36's progress notes dated 05/11/2024 at 2:38 AM by LVN N revealed Resident #36 needed assistance with all activity of daily living, had neuro checks due to fall, and was adjusting to room change. Review of Resident #36's progress notes dated 05/12/2024 at 7:34 PM by LVN R revealed Resident #36 was post fall and noted grimacing in pain during ADL's. Notified NP [Nurse Practitioner DD]. No new orders. Review of Resident #36's progress notes dated 05/12/2024 at 8:40 AM by LVN S revealed the Nurse Practitioner DD for Physician K was notified and a new order was received for an x-ray because Resident #36 was observed in therapy with a nurse aide screaming by holding her right hip. The pain increase [sic] when patient moves her right leg, turn to left side, and during care. Tylenol 500 mg for pain given. Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/13/2024, signed by Physical Therapist GG 05/13/2024 at 3:40 PM revealed resident consistently stated increased pain on the right lower extremity at the start of therapy session and was unable to complete bed mobility exercises due to increased pain and nursing was notified. Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/13/2024, signed by OT BB 05/13/2024 at 6:24 PM revealed the resident showed signs of pain to her lower right extremity that included reflexive behaviors such as saying ouch, stop, protecting, moaning, holding area of pain, limited resident ability to sit up for meals, and pain was relieved by remaining still and exacerbated with sitting and prolonged activity. OT BB noted that resident complained of severe pain with movement to lower right extremity and that Director of Rehabilitation reported the resident had an x-ray of the knee with negative results and a hip x-ray was recommended to be done. Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/14/2024, signed by PTA CC 05/14/2024 at 11:35 AM revealed the resident had increased pain on both sides of her lower extremities and nurse was aware and arranging for an x-ray series for bilateral hip assessment. Review of Resident #36's orders revealed there was a prescription for pain medication Tramadol 50 mg, one tablet, by mouth, twice a day for unspecified pain with a start date of 11/17/2022 through 05/15/2024 and an order for 500 mg of Tylenol, PRN (as needed) with a start date of 11/17/2022 through 05/15/2024 . Review of Resident #36's Medication Administration Report (MAR) for 05/01/2024 through 05/19/2024 revealed the resident had a PRN (as needed) order for Tylenol 500mg and was not given any PRN doses after her fall on 05/09/2024 until 05/14/2024 at 8:38 AM by LVN S for pain. Review of Resident #36's Medication Administration Report (MAR) for 05/01/2024 through 05/19/2024 revealed the resident had a PRN (as needed) order for Ibuprofen 200mg with a start date of 11/17/2022 and was not given any PRN doses after her fall on 05/09/2024. Review of Resident #36's MAR for 05/01/2024 through 05/19/2024 revealed resident was given Tramadol 50 mg, one tablet, by mouth twice a day for unspecified pain at 9:00 AM and 8:00 PM from 05/01/2024 through 05/15/2024. Review of MAR revealed Resident #36 order was changed to Tramadol 50 mg, one tablet, by mouth, 3 times a day starting on 05/15/2024. Review of X-Ray report with date of service of 05/15/2024 for Resident #36 reflected there is a possible nondisplaced intertrochanteric fracture of the right femur of indeterminate age. Review of X-Ray report with date of service of 05/14/2024 for Resident #36 reflected resident had an x-ray of her left and right hip due to unspecified pain with the findings of a nondisplaced right intertrochanteric fracture of indeterminate age with clinical follow up recommended. Observation on 05/14/2024 at 2:16 PM revealed Resident #36 was lying in bed, hair appeared clean, and was wearing a hospital gown and had a blanket. Resident #36 asked to be cleaned and did not appear to know how to use the call button that was within reach. RN H was informed that the resident was in need of assistance and stated she would help the resident immediately. Observation and interview on 05/15/2024 at 3:05 PM revealed X-ray Technician waiting outside of Resident #36's room with a portable x-ray. He stated he was waiting for RN H to assist him because the last time the resident was screaming. Observation on 05/15/2024 at 3:13 PM the resident was heard from outside the room with the door closed saying ow. Interview on 05/15/2024 at 3:30 PM with RN H revealed that Resident #36 recently had a witnessed fall on 05/09/2024 and that she assessed resident the day of the fall and observed some redness to her knee and lower extremity was painful to touch, resident was put in bed and the Nurse Practitioner was notified with no new orders and family was notified. RN H stated that resident did not appear to be in pain when in bed. RN H stated on 05/10/2024, Resident #36 did not appear to be in pain when she was in bed or when asked but there were some signs of pain during activities of daily living care and the Nurse Practitioner was notified with no new orders. RN H stated the x-ray was ordered on 05/15/2024 because the resident was observed screaming and yelling out and grimacing during activity of daily living care. RN H stated it was appropriate to contact the Nurse Practitioner instead of Physician. Interview on 05/16/2024 at 2:04 PM with DON revealed Resident #36 had a fall on 05/09/2024 and staff had told her that resident had some redness to her knee but was not complaining of pain and had good range of motion and thought she was fine, she was walking in the hall. DON stated that it was not uncommon for Resident #36 to complain of generalized pain and was not aware that staff and therapy were documenting that Resident #39 was showing symptoms of right hip pain after 05/09/2024 and that it would have been a change in condition for the resident. DON stated she had not read therapy's notes that noted resident was immobile and she did not have access to those notes. DON stated the Nurse Practitioner was notified of Resident #36's fall on 05/09/2024, were provided no new orders. DON stated that she was aware on 05/15/2024 that resident had hip pain so Dr. K was notified and ordered an x-ray. DON stated that the result of the x-ray was that resident had a hairline fracture and the plan was to not do surgery and to try to keep resident immobile as much as possible and manage pain. DON stated that staff are supposed to notify the physician but physicians direct staff to contact Nurse Practitioner if he was not available. DON stated that she had seen Resident #36 out of bed since her fall on 05/09/2024 and was not told of the symptoms of hip pain by staff. DON stated that Resident #36 was provided Tylenol for breakthrough pain. DON stated that nursing staff were responsible for monitoring, and notifying physician of resident pain if uncontrolled, and to document and provide pain medication given to residents and their pain levels. DON stated that not providing pain management for residents would impact their quality of life if their pain was not managed. DON stated that they always contacted NP EE for changes in condition. Interview on 05/16/2024 at 2:50 PM with Power of Attorney (POA) for Resident #36 revealed she was notified on 05/09/2024 that resident had fallen and did not have any pain. POA stated she was not notified about any symptoms or signs of pain for Resident #36 until 05/15/2024 when she was contacted by facility stating Resident #36 displayed signs of pain and an x-ray had been ordered. Interview on 05/16/2024 at 3:46 PM with Physician K revealed he was an attending physician at the facility and was notified that Resident #36 had a fall and was told she did not have pain. Physician K stated that he was at the facility on 05/14/2024 and a nurse practitioner informed him that the resident had pain, an x-ray was ordered, and resident had a nondisplaced fracture or a hairline fracture of her hip. Physician K stated he ordered a second x-ray to confirm the original findings because it would impact the treatment plan. Physician K stated that he expected if a resident had significant pain they would be sent to the Emergency Room. Physician K stated it was important for any new or different pain symptoms to be reported to the physician so he was aware of the resident's condition and able to make necessary orders. Physician K stated that staff not reporting resident with pain symptoms could result in a resident experiencing pain for extended periods of time or not receiving proper treatment. Interview on 05/17/2024 at 2:50 PM with Physician L revealed he was a pain management physician at facility and if a resident had a pain management concern physician facility staff might call them if resident was having pain but he was not aware that Resident #36 was experiencing pain after 05/09/2024 until 05/14/2024. Physician L stated that if he knew resident was experiencing pain after her fall on 05/09/2024 he would have ordered an x-ray sooner. Physician L stated he would expect staff to check for resident pain post fall by flexion and adduction and look for visual or verbal indications of pain such as grimacing or crying out. Physician L stated the risk to a resident by not notifying the physician about a change of condition of resident could result in a resident to not be provided care they needed or remain in pain. Observation on 05/19/2024 at 11:30 AM of Resident #36 revealed she was lying in bed sleeping, wearing hospital gown, covered with a blanket with call light within reach and water cup at bedside table. Interview on 05/20/2024 at 1:00 PM with Nurse Practitioner (NP) EE revealed if a resident was already on pain management and they were experiencing pain, the staff would reach out to her. NP EE stated she was not aware that resident was having pain until 05/15/2024 when the nurses told her that the resident was in a lot of pain when she moved. NP EE stated that she doesn't like to give stronger medications than Tylenol 3 or Tramadol and was able to write prescriptions for those medications without asking the Physician AA. NP EE stated Resident #36 was on already on Tramadol 50 mg two times a day for generalized pain and increased frequency to 3 times a day and added Tylenol 650 mg three times a day starting 05/15/2024. NP EE stated she did not know who ordered the x-ray and did not remember asking Physician AA about Resident #36. NP EE stated that the risk to a resident when they do not receive proper pain management was that they could have decreased movement, increase of pain, and decrease in quality of life. 2. Review of Resident #4's Comprehensive MDS dated [DATE] revealed resident was an [AGE] year-old male, admitted on [DATE], with diagnoses of postlaminectomy syndrome (a condition that causes pain or other sensations in the body after spinal surgery), muscle weakness, unspecified abnormalities of gait and mobility, chronic pain syndrome (pain that can be continuous or may come and go and persists for weeks or years), anemia (low iron), hyponatremia (low salt levels), hyperlipidemia (elevated levels of fat in blood), arthritis (inflammation of the joints causing pain and stiffness), stroke (loss of blood flow to the brain), dementia (loss of cognition), depression (persistent low moods), asthma, macular degeneration (eye disease causing vision loss), and a BIMS score of 15 (intact cognition). Review of Comprehensive MDS revealed the care area of pain was triggered for pain. Review of Resident #4's Care Plan with problem start date of 03/25/2024 revealed Resident is at risk complaints of chronic pain, use routine pain meds and Narcotic PRN [as needed] R/T [due to] chronic pain syndrome, disease process. Review of Resident #4's face sheet dated 05/14/2024 revealed Resident #4 had a Resident Representative, and he was his own representative. Observation and interview on 05/14/2024 at 1:46 PM with Resident #4 revealed he was lying in bed with a slightly curled position and with a blanket wrapped over his neck and appeared stiff. He stated he does not get his oxycodone every 4 hours even though the Physician prescribed it. He stated the staff taunt him by saying he has 1 minute until he can have his next dose or 6 minutes and it made him feel really bad and he felt that he was having more breakthrough pain due to the delays. Resident #4 stated he had chronic pain due to previous surgeries, cervical (neck) fusion and lumbar (back) fusion. He stated some of the hardware caused him pain and that he took the same dosage for years with his orthopedic Physician and his pain was usually controlled enough at a level 2 or 4 when he took his medication regularly. Resident #4 stated that he was involved in his care planning and stated that the facility was aware that he had chronic pain syndrome and needed oxycodone every 4 hours. The facility said they can accommodate his need, but the order would have to be PRN. This means when needed, so you would need to ask for it every 4 hours if you needed the pain medication. Resident #4 stated that he understood that to mean he needs to ask every 4 hours, so he did. He stated it seemed like they did not understand his pain, that his pain will flare up if he misses the dose of oxycodone every 4 hours. Review Resident #4 orders revealed following orders: -Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours with a start date of 04/29/2024 and end date of 05/01/2024. -Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/01/2024 and end date of 05/02/2024. -Oxycodone, Schedule II, 10 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/02/2024 and end date of 05/02/2024. -Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/18/2024. -Buprenorphine Schedule III patch, 10mcg/hour one transdermal film every 7 days for chronic pain with a start date of 04/30/2024 and end date of 05/03/2024 and another start date of 05/03/2024 with end date of 05/17/2024. Review of Resident orders with a start date of 05/18/2024 for Resident #4 for psychology evaluation for possible drug seeking behavior and decreased perception of pain. Review of Resident #4 orders Medication Administration History for 05/01/2024 through 05/18/2024 revealed resident received Oxycodone, 10 mg for pain on: 05/01/2024: none 05/02/2024 at: -6:18 PM by LVN M 05/03/2024 at: -6:41 PM by LVN M 05/04/2024 at : -12:17 PM by LVN T -4:15 PM by LVN M 05/05/2024 at: -6:52 AM by LVN P -11:23 AM by LVN P -4:07 PM by LVN P -8:17 PM by LVN P 05/06/2024: -7:23 AM by LVN G -11:37 AM by LVN G -3:41 PM by RN I -7:40 PM by RN I 05/07/2024: -5:59 AM by LVN O -10:05 AM LVN G -7:32 PM by RN I 05/08/2024: -5:06 AM by LVN T -9:10 AM by LVN G -4:16 PM by RN I -8:18 by RN I 05/09/2024: -9:13 AM by LVN G -3:15 PM by RN I -7:15 PM by RN I 05/10/2024: -8:47 AM by LVN G -5:02 PM by LVN V 05/11/2024: -1:56 PM by LVN V 05/12/2024: -7:00 AM by LVN P -11:54 AM by LVN V -3:55 PM by LVN P -8:04 PM by LVN P 05/13/2024: -4:30 AM by LVN X -8:37 AM by LVN G -4:38 PM by RN I -9:05 PM by RN I 05/14/2024: -5:05 AM by LVN T -5:06 PM by RN I -9:09 PM by RN I 05/15/2024: -5:02 AM by LVN T -11:55 AM by LVN G -4:20 PM by RN I -8:21 PM by RN I 05/16/2024: -2:50 AM by LVN O -8:04 by LVN G -3:41 PM by RN I -7:50 PM by RN I 05/17/2024: -8:40 AM by LVN G -12:34 PM by LVN G -5:43 PM by LVN V -9:35 PM by LVN V 05/18/2024: -4:39 AM by LVN O -8:46 AM by LVN P Review of Resident #4 orders Medication Administration History for 05/01/2024 through 05/18/2024 revealed resident received Oxycodone, 15 mg for pain on: 05/18/2024 at 9:09 PM by LVN P 05/19/2024 at 10:11 AM by LVN P Review of Resident #4's nurse's progress notes revealed note dated 04/27/204 by LVN N at 11:56 PM .resident continue on excessive amount of pain med gets it every 4 hours around clock prn [as needed] will contact pain doctor to reevaluate him. Review of Resident #4's nurse's progress notes revealed note dated 04/28/204 by LVN N at 5:50 AM Resident continues on skill charting appears obsessed [sic] with pain med demanding it every 4hr around the clock does not seem to be in pain when checking [sic] on resident always sleeping. Review of Resident #4's nurse's progress notes revealed note dated 04/29/204 at 1:26 AM by LVN N .Appears to be taking to [sic] many pain pills will have day shift get in touch with dr. Review of Resident #4's progress notes revealed note dated 04/29/2024 at 12:20 PM by LVN M As per DON, Oxycodone 15mg changed to schedule Q4hr as Pt continues to request for Pain medication every 4 hrs. Review of Resident #4's progress notes revealed note dated 05/02/2024 at 1:01 AM by LVN N Residents oxycodone 15 changed to 10mg q 4hr prn but was put on pain patch 10mg. Review of Resident #4's progress notes revealed note dated 05/03/2024 at 8:29 AM by LVN M Resident continues on pain mgt with oxycodone 10mg PRN Q4hrs, no discomfort reported at this time, plan of care on-going. Review of Resident #4's progress notes revealed note dated 05/07/2024 at 8:35 AM by LVN G Resident refused to take morning medication when he was offered. Resident wants CMA to wait until later. Medication will be offered in a later time. Review of Resident #4's progress notes revealed note dated 05/08/2024 at 2:16 PM by LVN G Resident refused patches to be placed. Review of Resident #4's progress notes revealed note dated 05/10/2024 at 1:32 PM by LVN G: Resident continues to refuse pain patches. Resident also using Icy Hot cream topically for pain. No order in place. Notified pain NP to obtain order, no order needed for the icy hot, per NP. NP wants resident to be encouraged to use pain patches. NP will be in the facility and will see resident. Review of Resident #4's progress notes revealed note dated 05/15/2024 at 10:43 AM by LVN G: Resident refused pain patches and buprenorphine patch. Resident states I don't want them. I have to talk to my Dr. That is too much chemicals for my heart. This nurse explained to the resident that buprenorphine patch is for pain and he gets it once a week but resident refused stating that he gets oxycodone and does not need that patch. Pain management NP notified. WCTM. Review of Resident #4's progress notes revealed note dated 05/15/2024 at 1:14 PM by LVN G NP called back about resident's refusal of pain patches. Will talk to resident when in facility. Interview on 05/15/2024 at 2:06 PM with Resident #4 revealed he was told by a nurse that he had been prescribed a patch for pain and was concerned about the interactions between that patch and his current pain medication since he had heart problems in the past and bad experiences with patches. Resident #4 stated that he said he told the nurse that he wanted to talk to his Physician about the concern. He stated his previous Physician, he was with for 10 years, and felt that he had figured out a pain management schedule that already had been working for him. Resident #4 stated that the staff told him that this was how it was, you talk with the nurse practitioner, he told them he was not going to use the patch, and he did not want any of his pain medications changed.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury for one (Resident #1) of four residents reviewed for wounds. 1. The facility failed to perform weekly skin assessments for Resident #1. The facility failed to identify early signs of skin breakdown and implement interventions to prevent the re-opening of a Stage 3 Sacral pressure ulcer (PU) {Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present}. The wound deteriorated into a Stage 4 PU {Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer}. 2. Resident #1 did not receive scheduled daily wound care on 04/07/23, 04/10/23, 04/23/23, 04/29/23, 05/07/23, 05/11/23, 05/13/23, & 05/14/23. 3. The facility failed to offer relevant alternatives when Resident #1 declined the specific intervention to remain in bed throughout the day to offload pressure from Stage 3 Sacral PU. Staff did not assist with repositioning to relieve pressure when Resident #1 sat up in wheelchair for more than 4 hours at a time during the day. 4. The facility failed to provide appropriate pressure-relieving device(s), LAL mattress, identified in Resident #1's care plan on 10/13/22 until 04/17/23. 5. The facility failed to provide treatment and services to heal and to prevent infection to Resident #1's sacral PU. Resident #1's sacral wound developed an MRSA infection (a staph (group of bacteria) infection that is difficult to treat because of resistance to some antibiotics) that required IV antibiotic therapy. The resident was admitted to the hospital on [DATE] after RP request. On 05/19/23 at 5:17 PM an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the NFA. While the IJ was removed on 05/22/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: Record review of Resident #1's MDS quarterly review assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had medically complex conditions that included HF (when the heart cannot pump enough blood and oxygen to support other organs in your body); DM (chronic condition that affects the way the body processes blood sugar (glucose), the body either doesn't produce enough insulin, or it resists insulin); Non-Alzheimer's Dementia (a decline in mental ability severe enough to interfere with daily life - Alzheimer's is a specific disease); Depression; and stiffness of right hand. Resident #1's BIMS score was 11, which suggested moderately impaired cognition. Resident #1 had no behavioral symptoms or exhibited rejection of care behavior during the MDS review period. Resident #1's functional status reflected one-person limited assistance with eating and required one-person extensive assistance for dressing, toilet use and personal hygiene. Resident #1 was always incontinent of bladder and always continent of bowel. The MDS Quarterly review indicated Resident #1 was at risk of pressure ulcer/injury (PU/PI). Resident #1 did not have one or more unhealed PU/PI, venous or arterial ulcers. Skin and Ulcer/Injury treatments included Q2 turn and reposition. A record review of Resident #1's MDS Annual assessment dated [DATE] revealed the following: Section M Skin Conditions. Unhealed PU/PI: The MDS Annual assessment reflected one Stage 3 and one Stage 4 unhealed pressure ulcers/injuries. Skin and Ulcer/Injury treatments included in the MDS Annual assessment: Pressure reducing device for bed, turning/repositioning program, PU/PI care, and applications of ointments/medications. A review of Resident #1's comprehensive care plan, last care conference dated 05/10/23, indicated: Category: Indwelling Catheter [Start: 04/28/23] Problem: Resident requires an indwelling urinary catheter r/t wound Stage 3 and 4 [Edit: 05/04/23] Goal: Resident will have catheter care managed appropriately AEB not exhibiting signs of infection or urethral trauma through the next review date. [Target: 08/04/23; Edit: 05/04/23] Approach: [Start: 04/28/23] -Assess drainage. Record the amount, type, color, odor. Observe for leakage -Change catheter per MD order -Provide assistance for catheter care -Provide catheter care as scheduled and as needed -Report s/sx of UTI Category: Baseline Care Plan [Start: 04/28/23] Problem: Resident is prescribed Antibiotic therapy [Edit: 05/04/23] Goal: Resident will take antibiotic as ordered without serious complications through the next review date. [Target: 08/04/23; Edit: 05/04/23] Approach: [Start: 04/28/23] -Administer antibiotic as order. Evaluate/record effectiveness. Evaluate/report adverse side effects. -Monitor lab work: as order. Notify MD of results. Category: Baseline Care Plan [Start: 03/28/23] Problem: Resident non-compliant laying bed for release pressure to bottom, likes stay up in w/c all day [Edit: 05/04/23] Goal: Resident will be compliant to laying bed for release pressure to bottom through the next review date. [Target: 08/04/23; Edit: 05/04/23] Approach: [Start: 03/28/23] -Assist resident transfer bed after meals -Explain procedure, encourage resident laying bed after meals for release pressure to bottom -Maintain a calm environment and approach to the resident -Observe resident right Category: Continence Status (Bowel/Bladder) [Start: 10/03/21] Problem: [Resident #1] experiences bladder incontinence r/t impaired mobility, weakness. [Edit: 05/04/23] Goal: Will have a decrease in incontinence episodes through review date [Target: 08/04/23; Edit: 05/04/23] Approach: [Start: 10/03/21] -Adapt environment to maximize independence (e.g., path free of obstacles, grab bars, elevated toilet seat, bedside commode, etc.) -Ensure adequate bowel elimination -Keep call light in reach -Obtain therapy consult as needed -Provide incontinence care after each incontinent episode -Report s/sx of UTI Category: Pressure Ulcer/Injury [Start: 07/19/2022] Problem: Resident has a pressure ulcer stage 4 to sacrum AND Stage 3 left heel. [Edit: 05/04/23] Goal: Resident will respond to ulcer treatment AEB improved wound healing with less pain and drainage or positive lab results. [Target: 08/09/22; Created: 07/19/22] Approach: [Start: 07/19/22] -Reposition while in bed [Start: 05/04/23] -Sugar free liquid protein supplement for promoting wound healing [Start: 03/23/23] -LAL mattress as needed [Start 10/13/2022] -Assess condition of surrounding skin. Report emergence of skin excoriation (repetitive picking of skin that leads to skin lesions) -Keep resident and RP aware of wound healing progress and any MD order changes -Observe and report signs of localized infection -Record the amount, type, and odor of drainage from the wound -Record the color, consistency, and location of exudate (fluid that leaks out of blood vessels into nearby tissues) -Use aseptic (to maintain sterility and free of contamination) techniques when performing dressing changes Review of Resident #1's physician orders indicated: - Start Date 09/21/21: Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. 2 PM - 10 PM. - Start Date 08/08/22: Reposition Q2H. Every 2 hours. {Times entered from midnight, 2:00 AM, 4:00 AM, 6:00 AM . to 10:00 PM every two hours on TAR} [D/C Date: 01/19/23] - Start Date 01/17/23: Boots on at night. At bedtime. 7:00 PM [D/C Date 04/19/23] - Start Date 01/19/23: Reposition Q2 hours. Every Shift. First, Second, Third. - Start Date 03/28/23: Other Test: UA with C&S (Urinalysis with Culture and Sensitivity) - Start Date 03/31/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply calcium alginate and dry dressing. Once A Day. [D/C Date: 04/06/23] - Start Date 04/02/23: Daily Wound Treatment: Unstageable DTI of the left heel. Apply skin prep daily. Once a Day. [D/C Date 04/27/23] - Start Date 04/03/23: Other Test: Arterial doppler study LLE. Once between the 3rd - 5th of the Month. [D/C Date: 04/26/23] - Start Date 04/06/23: Indwelling FC 16 Fr/10 mL d/t sacral wound. Continuous Second, Third. - Start Date 04/06/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply silver alginate and dry dressing. Once A Day. [D/C Date 04/14/23] - Start Date 04/14/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate, Santyl and cover with dry dressing. Once A Day. [D/C Date 04/27/23] - Start Date 04/19/23: Boots on while in bed. At bedtime 7:00 PM - Start Date 04/19/23: Air Loss Mattress. Every Shift. First, Second, Third. - Start Date 04/26/23: Other Test: CBC with differential (measures the number of each type of these white blood cells), CMP (a test that measures chemical balance and metabolism in the blood), TSH (blood test that measures the thyroid stimulating hormone), A1C (a blood test that measures average blood sugar levels over the past 3 months), and prealbumin level (a protein that is made mainly by the liver). - Start Date 04/27/23: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing. Once A Day and PRN. - Start Date 04/27/23: Daily Wound Treatment: Stage 3 Pressure wound to the left heel. Cleanse wound, apply Xeroform and dry dressing. Once A Day. [D/C Date: 05/04/23] - Start Date 05/01/23: doxycycline Hyclate 100 mg capsule, 1 capsule, oral, twice a day [End Date: 05/06/23] - Start Date 05/11/23: Midline Catheter Intermittent Use: Flush 10 ML NS before and after medication administration. Every Shift. First, Second, Third. - Start Date 05/11/23: Zosyn in dextrose piggyback; 3.375 gram/50 mL Intravenous. Every 8 hours. [D/C Date: 05/11/23] - Start Date 05/12/23: doxycycline Hyclate 100 mg capsule, 1 capsule, oral, twice a day [End Date: 05/26/23] - Start Date 05/12/23: Ertapenem Solution, Reconstituted (Recon Soln), 1 gram, intravenous once a day [D/C Date 05/12/23] - Start Date 05/15/23: May send to hospital for evaluation of Stage 4 sacral wound per family request. Once A Day. 06:00 (6 AM) - 14:00 (2 PM) [End Date: 05/15/23] Review of Resident #1's April 2023 TAR reflected blank spaces in the columns that represented the day(s)/date(s) in April and treatment time, 6 AM - 2 PM. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s): - Friday 7th and Monday 10th: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply silver alginate and dry dressing. Special Instructions to identify drainage, general appearance, and surrounding skin - Sunday 23rd: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate, Santyl and cover with dry dressing - Friday 7th, Monday 10th, and Sunday 23rd: Daily Wound Treatment: Unstageable DTI of the left heel. Apply skin prep daily - Saturday 29th: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing - Saturday 29th: Daily Wound Treatment: Stage 3 Pressure wound to the left heel. Cleanse wound, apply Xeroform and dry dressing was blank, did not reflect the initials of a person providing treatment, under the column, that represented the day/date in April. Review of Resident #1's May 2023 TAR reflected blank spaces in the columns that represented the day(s)/date(s) in May and treatment time, 6 AM - 2 PM. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s): - Friday 7th, Thursday 11th, Saturday 13th, and Sunday 14th: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing Review of Resident #1's April 2023 TAR reflected initials in the columns that represented the day(s)/date(s) in April and scheduled time, 2 PM - 10 PM, Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. [Start 09/21/21 - Open Ended] was performed as ordered. The nurse must also complete a Focused Observation Weekly Skin Assessment to include HTT skin assessment, new or existing skin issues, interventions if applicable, if WCN, PCP, RP were notified, and document in the EMR (Electronic Medical Record). The April weekly skin assessments revealed: - 04/04/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. - 04/11/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. - 04/18/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. - 04/25/23: LVN A initialed the TAR. LVN A completed a Focused Observation Comprehensive Assessment. LVN A answered No to the question Alterations in skin? Review of Resident #1's May 2023 TAR reflected initials in the columns that represented the day(s)/date(s) in May and scheduled time, 2 PM - 10 PM, Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. [Start 09/21/21 - Open Ended] was performed as ordered. The nurse must also complete a Focused Observation Weekly Skin Assessment to include HTT skin assessment, new or existing skin issues, interventions if applicable, if WCN, PCP, RP were notified, and document in the EMR. The weekly skin assessments revealed: - 05/02/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. LVN A completed a Daily Skilled Focused Observation Comprehensive Assessment on 05/03/23. LVN A answered No to the question Alterations in skin? in the skin section - 05/09/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. Resident #1 transferred to the hospital on [DATE] per RP request. Review of ADL documentation/flow sheets, the POC (Point of Care) responses in PCC indicated Resident #1 had moisture associated skin damage: - On 03/12/23, charted by CNA C - On 3/14/23, charted by CNA C - On 3/15/23, charted by CNA C Review of a nurse progress note dated 03/16/23 entered by the WCN, stated Resident #1 was seen by the WMD for assessment and evaluation of a reopened stage 3 pressure wound to the sacrum. The nurse also documented Resident #1 was advised to stay up less sitting on the wheelchair, to allow wound to heal. A review of the WMD Wound Evaluation and Management Summary dated 03/16/23 reflected, At the request of the referring provider, [PCP], a thorough wound care assessment and evaluation was performed. [Resident #1] has a stage 3 pressure wound, sacrum, for at least 1 day duration. There is light serous exudate. The wound measured (L x W x D): 0.7 x 0.6 x 0.2 cm. Additional wound detail indicated reopened stage 3 pressure wound. Recommendations: Off-load wound; reposition per facility protocol. A review of the WMD Wound Evaluation and Management Summary dated 03/30/23 reflected, the stage 3 sacrum pressure wound measured (L x W x D): 1.2 x 0.7 x 0.2 cm. There was moderate serous exudate. The stage 3 pressure wound sacrum improved evidenced by decreased surface area. Additionally, the WMD documentation revealed an Unstageable DTI (Deep Tissue Injury) of the left heel, a blood-filled blister, >1 day. The wound measured (L x W x D) 6.5 x 7.5 x Not Measurable cm. There was no exudate. Recommendations: Off-load wound; Reposition per facility protocol; Float heels in bed; Pressure off-loading boot. The WMD recommended a lower extremity arterial doppler (an ultrasound exam of the arteries in the legs that can help evaluate whether there are blockages) on 03/30/23. A review of the WMD Wound Evaluation and Management Summary dated 04/06/23 reflected, the stage 3 sacrum pressure wound increased in size (L x W x D): 2.2 x 1.7 x 0.2 cm. There was moderate serous exudate. The stage 3 pressure wound sacrum deteriorated. The WMD documentation indicated no change in the Unstageable DTI (Deep Tissue Injury) of the left heel. A review of the April 24-hour reports for Resident #1, dated 04/06/23, 04/11/23, and 04/14/23 in the Day Shift (6A - 2P) column entered by LVN B revealed communication between the health care team and provided information about multiple requests for LAL mattress and heel boots for off-loading wound(s) to sacrum and left heel. A review of the WMD Wound Evaluation and Management Summary dated 04/13/23 reflected, the stage 3 sacrum pressure wound increased in size (L x W x D): 4 x 2.5 x 0.2 cm. There was moderate serous exudate, 20% slough, and 80% granulation. A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD indicated a generalized decline of Resident #1. The documentation indicated the Unstageable DTI of the left heel deteriorated. The wound measured (L x W x D): 10 x 9 x Not Measurable cm. Additional details reflected the WMD suggested [Resident #1] to see a vascular physician. A review of the WMD Wound Evaluation and Management Summary dated 04/27/23 reflected, the stage 3 sacrum pressure wound deteriorated into a stage 4 pressure wound. The wound measured (L x W x D): 5 x 4 x 2 cm. There was moderate serous exudate, undermining (when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) 2 cm at 9 o'clock, 50% necrotic tissue, and 20% granulation tissue. Other viable tissue: 30% (muscle, fascia). A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD documentation indicated the Unstageable DTI of the left heel deteriorated into a stage 3 pressure wound. The wound measured (L x W x D): 2 x 1 x 0.3 with improvement. The WMD recommended a WBC lab draw - the WBC collected on 04/27/23 resulted 30.7 CRITICAL HIGH [Range: 3.8 - 10.1]. The WMD Wound Evaluation and Management Summary dated 04/27/23 stated the WMD performed a wound culture on stage 4 pressure wound, sacrum. The WMD discussed the size increase and deterioration of the sacral wound and heel wound improvement with the RP via phone. The WMD put off consulting a vascular physician and recommended focus on the sacral wound. The WMD started oral antibiotic therapy. A review of the WMD Wound Evaluation and Management Summary dated 05/04/23 reflected, the stage 4 sacrum pressure wound measured (L x W x D): 5 x 5 x 2.5 cm. There was moderate serous exudate, undermining 6 cm at 9 o'clock, 20% necrotic tissue, and 50% granulation tissue. Other viable tissue: 30% (muscle, fascia). Additional wound detail indicated the sacral wound had less necrotic tissue and WBC trended down. (The WBC collected on 04/28/23 resulted 23.9 CRITICAL HIGH; and on 05/04/23 resulted 12.0 HIGH). A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD documentation indicated the stage 3 pressure wound of the left heel was resolved. A review of the WMD Wound Evaluation and Management Summary dated 05/11/23 indicated, the stage 4 sacrum pressure wound measured (L x W x D): 6 x 5 x 3 cm. There was moderate serous exudate, undermining 6 cm at 9 o'clock, 10% slough, and 60% granulation tissue. Other viable tissue: 30% (muscle, fascia). Wound progress indicated improvement. A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. Review of Resident #1's wound culture of the stage 4 pressure wound sacrum results presented E. coli (Escherichia coli) and Proteus microorganisms (resistant bacteria methicillin-resistant Staphylococcus aureus) on 05/11/23. Review of a nurse progress note dated 05/10/23 entered by LVN A, stated she was informed by NP of wound to [Resident #1] right 3rd/4th toe. LVN A documented that she cleaned wound with normal saline and patted dry. An interview and observation on 05/18/23 at 9:12 AM at the hospital revealed Resident #1 in an upright position, the HOB elevated between 60 - 90 degrees, bi-lateral offloading boots. Hips offloaded with wedges. Resident #1 appeared groomed and in a clean gown; single lumen midline catheter to right arm. FC draining yellow urine by gravity to drainage bag. NPWT unit (Wound vac) noted at bedside, continuous suction set at 125 mm/hg to sacrum pressure wound site, foam bridged to left hip. Scant dark red drainage noted in tubing and approximately 150 cc dark red solidified drainage in the wound vac canister. Resident #1 was awake, alert and oriented to self and surroundings. Flat affect congruent with mood. Resident #1 spoke in a soft, low-pitched tone and at a slow pace. During the interview, Resident #1 acknowledged understanding of the RN Investigator presence and purpose of visit. Resident #1 denied staff behavior/interaction, infection control, Abuse/Neglect, or quality of care or ADL concerns. Some responses indicated understanding of questions but was unable to describe specific instances about accommodation of needs and care provided at the SNF. A review of the ED to Hospital admission provider note dated 05/15/23 showed Resident #1 presented to the ED from SNF via EMS c/o wound check. Per EMS, [Resident #1] had a large sacral wound that recently cultured and grew MRSA. [Resident #1] was placed on doxycycline 100 mg BID on 05/12/23. Admit diagnosis: Decubitus ulcer of back. A review of in-patient admission hospital medical records dated 05/15/23 through 05/18/23 indicated Resident #1 had wound healing issues of a non-healing stage 4 sacral ulcer despite antibiotics and wound care. A CT (Computed Tomography - a diagnostic imaging test) of Pelvis with Contrast resulted a large sacral decubitus ulcer measured 10.6 x 5 x 3.8 cm extended directly next to the sacrum and coccyx. Assessment and plan revealed IV antibiotic therapy, resident is not a surgical candidate, no benefit from extended IV course, and recommended palliative care consult. A review of in-patient admission hospital medical records dated 05/15/23 revealed skin assessments and wound images: - Sacrum pressure wound, 6.5 x 3.5 x 1.4 cm, small serous drainage, no odor - Right lateral third toe abrasion, scant serous drainage, no odor. From what appeared to possibly be from 4th toenail - Left lateral fifth metatarsal head with appearance of maroon/purple intact skin consistent with DTPI - Left medial first metatarsal head with appearance of maroon/purple intact skin consistent with DTPI - Left medial knee intact blister - unclear cause - Heels with evidence of old healed wounds, no skin currently open and no appearance of wounds on heels During an interview on 05/17/23 at 10:57 AM, the WCN stated responsibilities were daily wound care, Monday - Friday (the nurses provided wound care on Saturday and Sunday), review shower sheets and followed up on any noted skin issues; followed up labs and notified the MD of lab results. The WCN said that the nurses completed weekly skin assessments, documented in the EMR and informed [WCN] of any new skin issues or changes. The WCN said that she audited new admission charts to ensure HTT skin assessment was done, weekly, and quarterly. The WCN said that she would complete a HTT assessment if notified by the admitting nurse of any identified skin issues to confirm the findings and documented in the EMR. The WCN stated recalled Resident #1 had a stage 3 PU to the sacrum that reopened. The WCN said that the CNAs look at the skin during baths/showers for skin issues. The WCN stated she stays informed of the treatment and care needs of residents with wounds because she must be notified by nurses of any new skin issues, and she rounds with the WMD every Thursday morning. The WCN said that she was informed one morning that Resident #1 had an open area to her lower back. The WCN stated the WMD was notified assessed, evaluated, and treated the pressure wound area. The WCN said that the WMD recommended Q2 turn and reposition, LAL mattress, and heel boots when a DTI on the left heel was discovered. The WCN stated blood labs were drawn that resulted a high WBC count, the WMD was notified, and Resident #1 was started on an oral antibiotic for 10 days. The WCN said that a culture was done of the sacral wound that resulted with MRSA. The WCN stated the RP inquired about IV antibiotic therapy, the WCN contacted the PCP and received a new order for a midline insertion and start IV Zosyn. The WCN said that the pharmacy informed Resident #1 had an allergy to active ingredients in Zosyn and would call back with an alternate antibiotic. The WCN stated a new order received from the NP the next day to start Ertapenem (Brand name: Invanz, an antibiotic that treats serious bacterial infections) IV (Intravenously) but the pharmacy notified [Resident #1] is also allergic to that medicine. During an interview on 05/17/23 at 2:39 PM, CNA C indicated he was familiar with Resident #1. CNA C stated Resident #1 liked to sit up in wheelchair for activities and for meals in the dining room. CNA C said that Resident #1 was a two-person assist with a mechanical lift. CNA C said that he would transfer Resident #1 to bed to provide incontinence care after meals and assist Resident #1 back to wheelchair. CNA C stated he first noticed redness, like a rash, and a small open area on Resident #1's lower back, the tailbone area when provided a shower. CNA C said he notified the nurse and documented in the POC. CNA C stated that he did not apply barrier cream because of the open area. CNA C said he provided care to Resident #1 in the past and recalled the open area had healed before. CNA C stated that the nurses provided wound care but did not know what treatment was done to the wound. CNA C said that Resident #1 did not like to lay in the bed, but the nurses said that [Resident #1] should stay in bed all day to keep pressure off the wound. CNA C said that he was unaware of interventions to reposition or offload pressure when a resident was up to the wheelchair. During an interview on 05/18/23 at 2:21 PM, the ADON stated her responsibility was to oversee staff and follow up on dietary recommendation, attend clinical meetings and review documentation for Medicare part A/managed care residents. The ADON said that she is responsible for Angel Rounds to ensure safety and address resident concerns not necessarily done daily but she performed observations throughout the day. The ADON stated that she attended morning meetings when the 24-hour reports are reviewed and residents' needs are discussed to determine interventions needed to be implemented. The ADON said that she was familiar with Resident #1 that she was able to make her wants and needs known. The ADON said that she spoke with the RP that [Resident #1] was hospice appropriate, the wound culture results, allergies to ordered IV medications, and that Resident #1 was getting older. The ADON said she explained to the RP that the disease process with aging was the reason Resident #1 is unable to metabolize food, wound takes longer to heal, but refused to stay in bed throughout the day to allow staff to turn and reposition every two hours. The ADON stated that Resident #1 did not want to stay in bed because it prevented her from playing BINGO, eat in the dining room and socialize. The ADON said that it was necessary for Resident #1 to stay in bed to relieve pressure on the sacrum wound and [Resident #1] had the right to choose when wanted to get in/out of bed and the staff are required to honor resident rights. The ADON replied when asked about pressure relieving devices and offloading when resident is up to wheelchair that the resident was too weak to reposition in the wheelchair. The ADON said that the staff that ordered central supplies was responsible for ordering the LAL mattresses for Resident #1 as indicated on care plan. The ADON stated that Resident #1 had a LAL mattress before, but it was returned when the wound healed. During an interview on 05/18/2023 at 4:08 PM, CNA D said he worked with Resident #1. CNA D stated Resident #1 required two-persons assist with ADLs, mechanical lift for transfers, and he provided bed baths T/Th/S on the 2P - 10P shift. CNA D said that he reviewed the POC to determine the resident's level of functioning and care needs. CNA D said Resident #1 was up to the wheelchair when he came on shift and would transfer to bed after dinner. CNA D said that he noticed a very small area on Resident #1's back side where a wound had healed reopened during a bed bath and now its really big. CNA D stated he documented the open area on the shower sheet and notified the nurse. During an interview on 05/18/2023 at 4:32 PM, LVN A stated that she was the primary nurse for Resident #1, Monday - Friday on the 2P - 10P shift. LVN A said that she did the HTT skin assessments on Tuesdays. LVN A stated that she answered no