**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 53 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, anxiety disorder, adult failure to thrive and diabetic foot ulcer. Resident 53's medical record was reviewed 6/2/24 through 6/6/24. A Other payment assessment MDS dated [DATE] revealed resident 53 had diabetes mellitus. A care plan dated 12/18/23 and updated on 1/2/24 revealed [Resident 53] has Diabetes Mellitus type II. The goal was [Resident 53] will have no complications related to diabetes through the review date. The interventions were Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness; Monitor PRN [as needed] any s/sx [signs and symptoms] of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd [abdominal] pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma; Monitor PRN any s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Physician's orders revealed the following: a. Start date of 2/27/24, Insulin Lispro Injection Solution 100 UNIT/ML [milliliter] (Insulin Lispro) Inject as per sliding scale: if 60 - 80 = 0; 81 - 150 = 2 units (u); 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 14 units, subcutaneously with meals for DM2 Notify Md if pt BS [blood sugar] >60 or <400. b. A start date of 2/27/24 revealed, Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 61 - 200 = 0 u; 201 - 250 = 2 u; 251 - 300 = 4 u; 301 - 350 = 5 u; 351 - 400 = 7 u, subcutaneously at bedtime for blood sugars. c. A start date of 12/13/23 and an discontinue date of 3/29/24 revealed, AC [before meals]/HS[at bed time] Blood Sugars before meals and at bedtime for DM Notify MD if pt's BS <60 or >400. d. On 4/24/24 at 7:00 AM, **DO NOT CHANGE THE TIMES** Blood sugar checks prior to meals before meals and at bedtime for DM2 monitoring. The March 2024, April 2024 and May 2024 MARs revealed the following blood sugars: a. On 3/9/24 at 8:00 AM, BS was 404. b. On 3/22/24 at 9:00 PM, BS was 400. c. On 3/28/24 at 9:00 PM, BS was 407. d. On 4/2/24 at 9:00 PM, BS was 400. e. On 4/5/24 at 9:00 PM, BS was 546. f. On 4/7/24 at 5:00 PM, BS was 414. g. On 4/11/24 at 9:00 PM, BS was 400 h. On 4/12/24 at 5:00 PM, BS was 517. i. On 4/12/24 at 9:00 PM, BS was 500. j. On 4/16/24 at 9:00 PM, BS was 464. k. On 4/18/24 at 8:00 AM, BS was 1211. l. On 4/26/24 at 8:00 AM, BS was 437. m. On 5/2/24 at 9:00 PM, BS was 404. n. On 5/3/24 at 8:00 AM and 5:00 PM, BS was 404. o. On 5/4/24 at 9:00 PM, BS was 461. p. On 5/6/24 at 9:00 PM, BS was 466. q. On 5/11/24 at 9:00 PM, BS was 404. r. On 5/15/24 at 5:00 PM, BS was 12. s. On 6/3/24 at 7:00 AM, BS was 430. There was no documentation located in resident 53's medical record that the physician was notified of the blood sugars less than 60 and over 400. On 6/6/24 at 7:54 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated when a resident needed a blood sugar obtained a notification came up to alert the nurses in the electronic medical record. LPN 3 stated after obtaining the sample she looked at the physicians order to determine how much insulin needed to be administered. LPN 3 stated if a BS was below 60 or over 400 she would contact the physician to see what the physician wanted her to do. LPN 3 stated high and low blood sugars could cause harm to the resident, so that was why the physician needed to be notified. On 6/6/24 at 8:00 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated if a resident was ordered to have sliding scale insulin, then she would administer the insulin according to the residents blood sugar. ADON 1 stated there was a standing physician's order to contact the physician if the BS is below 60 or above 400. ADON 1 stated she would think the nurse documented the physician notification in the residents progress notes. ADON 1 stated sometimes if the resident refused the insulin, then a progress note popped up in the electronic medical record for the staff to document. ADON 1 stated if a resident's BS was high, the resident could go to Ketoacidosis, and it could be life threatening. ADON 1 stated she was unable to find the physician was notified in resident 53's medical record. On 6/6/24 at 9:16 AM, an interview was conducted with the RNC. The RNC stated residents with sliding scale insulin should have BS parameters and when to notify the physician. The RNC stated generally BS under 60 and BS over 400, the physician should be notified. The facility's policy for Change in a Resident's Condition or Status was reviewed. The policy indicated the following: Our facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . g. need to transfer the resident to a hospital/treatment center; . i. specific instruction to notify the physician of changes in the resident's condition. 2. A 'significant change' of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident ' s health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . Based on interview and record review, it was determined the facility did not immediately consult with the 2 of 53 sample residents' physicians after there was a need to alter treatment significantly. Specifically, one resident had symptoms of a change in condition and the facility physician instructed the facility nurses to contact the surgeon, but no evidence could be located that this occurred. This resulted in the finding of a harm for this resident. In addition, a resident experienced elevated blood glucose levels without timely notification of the physician. Resident identifiers: 53 and 365. Findings included: Resident 365 was admitted to the facility on [DATE] with diagnoses that included spontaneous right patellar tendon rupture, encounter for other orthopedic aftercare, history of falling, and hypertension. Resident 365's entry Minimum Data Set (MDS) assessment indicated that facility staff assessed resident 365 as having a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively in tact. Resident 365's medical record was reviewed from 6/2/24 through 6/6/24 and revealed the following: a. On 9/24/22 a nurses note documented: Pt [patient] arrived to facility via wheelchair from [name of local hospital]. Pt had a right knee repair surgery 9/23. Pt is alert and oriented x4, moves upper extremities equally, is non weightbearing on RLE [right lower extremity], able to move LLE [left lower extremity], sensation intact. Bowel sounds audible all lobes, abdomen soft and nontender, Pt reports that LBM [last bowel movement] was 9/23 in the morning. Pt is incontinent of bowel and bladder, Pt has briefs, wipes, and cream in room for bowel care. Pt is alert, able to verbalize needs . b. On 9/26/22 a nurses note documented: Pt was c/o [complaining of] excruciating bladder spasms. The pt was not seen by his primary, [name of physician], this shift to express his concerns or symptoms. Pt asked RN [Registered Nurse] to ask house MD to do something to give him relief. RN messaged [name of physician] and received orders for a one time dose of 200mg of pyridium. RN administered medication and assessed pt 45 min after and he stated that he feels better and the spasms stopped. pt is alert and able to verbalize needs to staff, tolerated medications whole without complications . : c. An MD [Medical Doctor] Communication form dated 9/26/22, two days after resident 365 was admitted , revealed the following: . Concern: pt admitted Sat [Saturday] - is concerned he is developing infection, wants to see MD and discuss concerns. NEW ORDER 1 - Notify his ortho [orthopedic] Dr [doctor] who operated on him ASAP [as soon as possible] ! 2 - I will see him after clinic today. [Note: No documentation could be located to indicate that the physician saw resident 365 that day, or that facility staff had contacted the orthopedic surgeon during resident 365's stay. ] d. On 9/28/22 at 12:26 AM a nurses note documented: . pt had an episode of forgetfulness and confusion this shift. Pt was found sitting on the side of his bed. Staff asked what he was doing, pt stated that he was going to the bathroom. Staff reminded him that he is NWB [non weight bearing] on his R [right] knee and could not walk to the bathroom. Staff got him into bed safely, his R knee is bleeding through the bandage . e. On 9/28/22 at 9:41 AM a nurses note documented: . Pt is alert, able to verbalize needs, takes medications whole, . Night nurse reported that Pt had an episode of confusion last night, Nurse went in this AM [morning] to assess Pt. Pt has diminished lung sounds in the bases, SOBLF (?) and SOBOE [shortness of breath on exertion]. Pt's neuro [neurological] assessment showed minimal left sided facial weakness, moves all extremities equally, denies any numbness or tingling, no changes in sensation, or H/A [headache]. MD has been notified of situation. f. On 9/28/22 at 10:46 AM a nurses note documented: . As ordered by MD, nurse tried to contact surgeon about duration of Bactrim. Unable to reach them, Nurse left a message for the surgeon's office . [Note: This is two days after the physician wrote a note to contact the orthopedic physician for resident 365 as soon as possible regarding the resident's possible infection.] g. On 9/29/22, a nurses note documented: . Resident is alert and verbally responsive, able to make needs known. Resident c/o bladder spasms and not being able to void. Bladder scanned and 85 cc [cubic centimeters] residual noted. MD notified. h. On 9/29/22, the facility physician documented the following in a physician's note: . [Resident 365] .reported pain to his abdomen that started during physical therapy, pain us located to RLQ [right lower quadrant], upon examination no hernia or any other abnormalities were noted. Claims that is able to control bladder and bowels. However, he is experiencing bladder spasms with little urine output post spasms. Denies prior or similar problems prior to this surgery. Reported last PSA [Prostate Specific Antigen] levels were done back in January with normal results. Physician will place patent [sic] on Flomax . i. On 9/29/22 resident 365's blood pressure was 144/81. j. On 9/30/22 at 4:51 PM, resident 365's blood pressure was 143/76. k. On 9/30/22 at 4:52 PM, resident 365's blood pressure was 177/85. l. On 10/1/22 at 12:05 AM, a nurses progress note documented: Resident found on floor next to recliner and walker . When asked resident what happened he said he was not sure.No c/o pain. Resident already has baseline hx [history] of confusion and falls upon admission. Resident has no s/s [signs and symptoms] of injury at this time. No complaints of pain or distress. Resident educated on importance of call light and demonstrated its use. RLE [knee] dressing changed and inspection of surgical site completed. surgical scar well approximated, all staples intact and in place and trace drops of drainage. No swelling, redness, and surgical site is cool to the touch. Clean dressing re applied, wrapped, and ble knee brace secured . Will notify, PCP [primary care physician], family and on call administrator of incident and continue to monitor closely. m. On 10/1/22 at 8:30 PM a nurses progress note documented: resident POA [power of attorney] contacted staff and communicated concern regarding residents increased confusion . Family very concerned and request to send to ER [emergency room]. PCP contacted . transfer was completed. Will continue to monitor closely. n. On 10/2/22 at 10:16 AM a nurses progress note documented that the resident had been admitted to the hospital, and was in the intensive care unit. On 6/6/24 at 8:43 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that with regard to the physician note written about resident 365 on 9/26/22, STAT would have been a better word to use than asap. The RNC also stated that the facility nurses should have reached out after the doctor said to get in contact with the orthopedic surgeon. The RNC stated that best practice is to reach out and get a UA with the bladder spasms and excruciating pain. The RNC stated that the facility could still get a culture and sensitivity on a urinalysis even if the resident was on an antibiotic already. The RNC stated that the doctor should have ordered a UA and culture and sensitivity. The RNC did not have any other information regarding the facility's lack of response to the change of condition in resident 365.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 5 out of 53 sampled residents, that the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a staff member recorded a video in the shower room while a resident was in the bathtub naked, a cognitively impaired resident kissed two different cognitively impaired residents on two different occasions and another resident who was cognitively impaired was involved in a sexual relationship. Resident Identifiers: 5, 12, 17, 36, 42, and 374. Findings Included: 1. Resident 42 was admitted to the facility on [DATE] with the following diagnoses of delirium, unspecified dementia with psychotic disturbance, anxiety disorders, cognitive communication deficit, and major depressive disorder. Resident 42's medical records were reviewed on 6/5/24 through 6/6/24. A facility admission agreement signed and dated 9/2/20, section G subsection f documented the following authorization to pictures, Authorization to Photograph. Resident authorizes Facility and its affiliates to photograph client and/or portions of client's body for documentation of physical conditions, and/or to follow medical progress. Photos will be protected and the Client's right to privacy will be observed. On 3/1/24, a Quarterly and Annual Review documented resident 42 was confused at baseline line, struggled to answer questions and was a poor historian. It also documented resident 42 had not reported any history of trauma. On 5/23/24, a Montreal Cognitive Assessment (MoCA) assessment documented resident 42 had scored a 3 out of 30 which indicated severe cognitive impairment. On 5/31/24, a Quarterly Brief Interview for Mental Status (BIMS) assessment was done and documented resident 42 had severe cognitive impairment. On 5/31/24, a Quarterly and Annual Review documented resident 42 was confused at baseline and had not reported any history of trauma. On 2/2/24 at 4:07 PM, a facility incident report documented that an incident had occurred with resident 42 in the shower room. The incident description stated, it had been discovered due to a video clip that had been sent and resident 42 was unaware of what had occurred. It stated that resident 42 was in the bath tub being bathed by staff who took a recording of themselves with the resident 42 clearly visible in the background. The incident report documented the video had been sent via social media application to unknown sources and once the video had been discovered by the Certified Nursing Assistant (CNA) coordinator, it was reported to the abuse coordinator. No other information was located in the incident report. A form titled exhibit 358 was submitted to the State Survey Agency (SSA) on 2/3/24 at 11:15 AM. The form revealed that an allegation of mental/verbal abuse had occurred. The incident documented that a CNA had posted a video on a social media application of themselves dancing while showering a resident. Resident 42 was seen in the background of the video without their consent. This had been anonymously reported to human resources. It documented the incident had occurred on 2/2/24 at 11:30 PM and staff had become aware the following day at 10:00 AM. The form documented there had been no change to resident 42's mental status and no physical injury had occurred to them. The measure taken to protect residents' safety by the facility stated, the CNA no longer worked at the facility. Adult Protective Services and the Ombudsman had been notified of the incident. The form documented the incident had not been reported to a law enforcement agency. A form titled exhibit 359 was submitted to the SSA on 2/9/24 at 12:40 PM. The form 359 documented resident 42 had severe dementia and did not have any recollection of the incident. A summary of the interviews with witnesses confirmed resident 42 was exposed in a social media application video without their consent. The perpetrator no longer worked at the facility during the time of the investigation, and it documented the NA (Nursing Assistant] shortly sent in their resignation after the incident via text message. It documented the picture disappeared on the social media application. The investigation verified that the allegation had occurred and documented that several witnesses had confirmed that resident 42's back was seen while in the bathtub. The form documented that resident 42 was unable to understand the situation or recall the incident. It concluded that abuse had occurred because the NA had sent the video to a social media application where resident 42 was exposed and without their consent. Corrective actions taken by the facility included in-service education to staff regarding the facility's digital images policy and the relation to abuse. On 6/5/24 at 9:54 AM, an interview was conducted with CNA 6. CNA 6 stated resident 42 was a one person assist with showers and needed to have staff in the shower room with them. CNA 6 stated resident 42 was able to follow showering instructions and was able to help bathe themselves. CNA 6 stated staff were not allowed to have personal cellphones in resident areas because they need to respect residents personal home. On 6/5/24 at 3:51 PM, an interview was conducted with CNA 13. CNA 13 stated they had a shower schedule which notified the CNA's what rooms they were assigned to shower for the shift. CNA 13 stated resident 42 had showers scheduled for the evening shift. CNA 13 stated resident 42 was able to help with their showers if they were talked through it. CNA 13 stated there was a video taken of the shower room with resident 42 in it. CNA 13 stated resident 42 was tilted forward in the bathtub and their stomach and whole chest were visible in the video. CNA 13 stated they were not supposed to have their own person phones near resident care areas. CNA 13 stated resident 42 was unaware of the video taken of them. On 6/5/24 at 4:11 PM, a telephone interview was conducted with CNA 14. CNA 14 stated them and a few other CNA's were together outside of work hours when they viewed a video that showed a resident in the background. CNA 14 stated CNA 16 had filed a report stating they were injured and had been put on light duty. CNA 14 stated for safety purposes CNA 16 should not have been allowed to shower resident 42. CNA 14 stated CNA 16 had been taking pictures of themselves and resident 42 and then CNA 16 posted a video about being on light duty. CNA 14 stated resident 42 was in the background of the video. CNA 14 stated resident 42 was naked in the bathtub and they were seen playing with the water. CNA 14 stated resident 42's exposed chest made it visible they did not have breasts. CNA 14 stated resident 42's privacy was violated. CNA 14 stated staff were not allowed to have phones while they provided resident care and they were not allowed to take picture or videos of residents due to privacy violations. On 6/5/24 at 4:44 PM, an interview was conducted with the Administrator (ADMIN). The Admin stated the CNA coordinator had been notified by another CNA of a social media video where a resident was visible in the background. The Admin stated the CNA coordinator had informed them the video was taken around midnight the night before or around when the shower was done. The Admin stated the platform the video was taken on was temporary and the video disappeared a short time later. The Admin stated CNA 16 had taken a short video in the shower room where resident 42 appeared to be in the bathtub. The Admin stated they viewed the video and resident 42's bare back, shoulders and face were seen in the video. The Admin stated the video consisted of CNA 16 doing a dance and stating they loved light duty and then phone was turn and resident 42 was seen in the video. The Admin stated they notified Adult Protective Services (APS) and APS had not referred them to law enforcement. The Admin stated they had not notified the police. The Admin stated the police should have been notified so they could make the determination if the incident was considered a crime. The Admin stated CNA 16 resigned shortly after the incident and they had been unable to interview resident 42 since they were unable to recall what happened. The Admin stated they notified resident 42's son about the video and the son became upset. The Admin stated the investigation included asking anyone that viewed the video to delete it. The Admin stated they were unsure if they had individually asked all the CNAs about deleting the video. The Admin stated they wanted it deleted so it would not be viewed anymore. The Admin stated the staff should already know the digital media policy which was staff did not take pictures or video of a resident without their consent and they were not allowed to be distributed. On 6/5/24 at 5:05 PM, an interview was conducted with CNA 15. CNA 15 stated resident 42's CNA was supposed to be on light duty. CNA 15 stated CNA 16 posted a video to their private story on a social media application which showed CNA saying they were on light duty and could not wait to get off. CNA 15 stated CNA 16 was seen dancing and resident 42 was seen in the background of the video naked in the bathtub. CNA 15 stated resident 42 was observed to be naked from their head down to the their stomach due to the camera's angle. On 6/5/24 at 5:15 PM, an interview was conducted with the Resident Advocate (RA). The RA stated they were made aware of resident 42's incident after the Admin had submitted the 358 and notified APS. The RA stated the CNA coordinator had shown the Admin the social media video. The RA stated they were notified what had occurred in the video by the Admin. The RA stated it had been described that resident 42 was in a bathtub naked and they could be seen from the belly up while a CNA had been doing a dance. The RA stated they were the main contact for APS. The RA stated the APS investigator had asked for the CNA's contact information to let them know the incident had been reported. The RA stated the APS investigator had spoken to resident 42. The RA stated the APS investigator stated resident 42 did not remember what had happened and they had been talking gibberish during the interview. The RA stated the APS investigator notified them the case was going to be referred to the Attorney General's Office. The RA stated the APS investigator later told them, the attorney general was going to talk to resident 42. The RA stated they were unsure if the attorney general had come in and talked to resident 42. On 6/5/24 at 12:30 PM, an attempt was made to contact CNA 16 by phone. On 6/7/24 at 6:06 PM, CNA 16 responded by text message and stated the following, if you have any further questions can contact my attorney [name removed] at [phone number removed]. please do not contact me any further thank you. 2. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. Resident 5's medical record was reviewed on 6/3/24 through 6/6/24. On 4/4/24, a Quarterly Minimum Data Set (MDS) documented resident 5 had a BIMS score of 1 which indicated severe cognitive impairment. A care plan focus area initiated on 3/7/23 documented resident 5 had a potential communication problem related to difficulty understanding secondary to Dementia. Documented interventions included to ensure/provide a safe environment. On 3/29/24 at 10:24 AM, a facility incident report documented a resident-to-resident interaction had occurred in the activity room. The nursing description documented, Victim was in activity room with perpetrator. Victim lifted up her chin when she saw and then he kissed her on or near the lips. Victims did not appear disturbed, though has cognitive impairment. Resident 5 was unable to give a description of the incident. Immediate actions taken included the immediate separation of both resident. It documented the perpetrator was monitored and the victim was under the supervision of staff since they had been assisted to the day room. The incident report documented resident 5 to be wheelchair bound. The mental status section documented both the perpetrator and the victim had severe dementia. The incident report revealed the APS, the Ombudsman, the responsible party and the state had been notified of the incident. On 4/4/24 at 10:37 AM, a nurse note documented, Staff witnessed incident and immediately separated residents and began directly monitoring and supervising. Victim was then placed in day room. Staff immediately administrator [sic] who began process of investigation with staff and RA. Proper authorities and responsible parties were notified and safety of residents ensured by verifying supervision, monitoring, and placement of victim in separate location. Care plan updated. Victim assessed for any signs and symptoms of distress. None identified to this point. Care plan and medications reviewed for both residents. Psychotropics medication to be reviewed with physician and pharmacy. A physician order with a start date of 4/12/24 documented as followed: [Resident 5] to be monitored in the dayroom as able and as she tolerates for safety. every shift A form titled exhibit 358 was submitted to the State Survey Agency (SSA) on 3/29/24 at 3:30 PM. The form noted that the incident was an allegation of sexual abuse. The victim identified was resident 5 and the alleged perpetrator was resident 374 who was noted as a resident with dementia. Staff had become aware of the incident on 3/29/24 at 2:45 PM. A detailed account of the incident stated, Victim was in the activity room with perpetrator. Victim was kissed, on or close to the lips by the perpetrator. It is unknown if this was welcome because the victim was dementia. The immediate steps taken to ensure the resident's safety included the separation of the resident 5 from the perpetrator and kept safe from resident 374. The resident's family had been notified of the incident. The Agencies notified included the Ombudsman and APS. The exhibit 358 documented that the incident had not been reported to a law enforcement agency. A form titled 359 was submitted to the SSA on 4/5/24. The facility's investigation included 3 staff interviews and 5 resident interviews. The perpetrator statement documented resident 374 had dementia and was unable to be interviewed but he stated that resident 5 was his women. A staff interview documented resident 374 was observed to kiss resident 5 during an activity. Resident 5 put her hand out and he held it and went in and kissed her. No additional outcomes were documented to had occurred to either resident post incident. A summary of the witnesses interview documented, Residents were in the activity room, [resident 374] walked over to [resident 5]. She looked up at him and he leaned down and kissed her. Staff redirected [resident 374]. [Resident 5] did not react or respond in a manner to suggest that it was unwelcome; however, she doesn't have the cognitive capacity to consent. An interview summary with resident 374 documented he had dementia and stated resident 5 was his lady. An interview summary with other resident revealed other resident noted resident 374 was very friendly and had seen resident 374 attempt to kiss other women before. The relevant summary information provided documented, Perpetrator is a pleasant [AGE] year old male with vascular dementia. He is independently mobile, and takes a medication that has a potential side affect of increased libido (asking Dr. to review) His BIMS score is a 4. Victims is a [AGE] year old female with Alzheimer's dementia and multiple comorbitites. Her BIMS score is 1. The investigation verified the allegation type had occurred and stated, Multiple witnesses saw [resident 374] kiss [resident 5] near the mouth. Although it did not appear unwelcome, the victim does not have decision making capacity. The corrective actions taken from the investigation of the allegation included separating both residents and resident 374 was put on frequent checks. The systemic action documented was, Perpetrator's medication that has a side effect of increased libido was discontinued by his physician. No counseling needs or other interventions were documented to assist resident 5 with the sexual abuse that had been verified. The form documented, Victim has a BIMS score of 1 and cannot recall the incident. On 6/5/24 at 9:41 AM, an interview was conducted with CNA 5. CNA 5 stated resident 5 was not mentally with it. CNA 5 stated resident 5 was not able to consent kissing other residents. CNA 5 stated they were not aware of any incident that involved resident 5 being kissed. On 6/6/24 at 7:49 AM, an interview was conducted with CNA 12. CNA 12 stated resident 5 was confused. CNA 12 stated depending on how resident 5 was feeling during the day, they needed to have a second staff member with them during resident cares. CNA 12 stated they usually rounded on resident's every two hours. CNA 12 stated resident 5 was unable to consent to anything due to them being confused and being unable to recall events. CNA 12 stated resident 374 had a history of behaviors such as wandering and exit seeking. CNA 12 stated resident 374 attempted to link up with other residents and one time they had grabbed on to resident 374. CNA 12 stated resident 5 was unable to give consent for a kiss. On 6/6/24 at 8:12 AM, an interview was conducted with CNA 18. CNA 18 stated resident 5 required two-person physical assistance with a Hoyer lift with transfers. CNA 18 stated resident 5's dementia was so severe they were unable to recall the date. CNA 18 stated resident 5 was unable to express their needs. CNA 18 stated they were unaware of any interactions between resident 374 and resident 5. CNA 18 stated resident 374 believed they were a ladies man and they liked to show affection in the form of kisses. On 6/6/24 at 8:32 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated resident 5 was confused and when resident 5 was in the day room they needed to monitor them. LPN 3 stated they were aware a resident had kissed another resident and stated maybe resident 374 had kissed resident 5. LPN 3 stated resident 5 was not able to consent to being kissed. On 6/6/24 at 10:31 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated resident 5 was kind of able to make their needs known. ADON 1 stated resident 5 did not like being left on their own and liked human interaction. ADON 1 stated they did not believe resident 5 was able to consent to being kissed by another resident. ADON 1 stated there had been a resident that had been making advances towards other residents. ADON 1 stated they were unsure who those residents had been. On 6/6/24 at 10:50 AM, an interview was conducted with the Admin. The Admin stated they tried to interview both residents involved. The Admin stated they had been notified by the nurse, that two CNA's who stated they saw resident 374 kiss resident 5. The Admin stated they interviewed the CNAs and they stated resident 374 brought their face close to resident 5 and resident 5 was kissed when they looked and saw resident 374. The Admin stated they had been informed by staff that an activity at the time this happened. The Admin stated resident 374 had a prior history but they were unsure of what had occurred the first time. The Admin stated the doctor changed some of resident 374's medications due to the incident. The Admin stated resident 5 had a diagnosis of dementia with a BIMS score of 1 and it was unlikely that resident 5 remembered the incident. 4. A. Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of encounter for palliative care, rheumatoid arthritis, type II diabetes mellitus, vascular dementia, polyneuropathy, pulmonary hypertension, hypertension, hyperlipidemia, aphasia, cerebral infarction, thrombophilia, hemiplegia and hemiparesis, anxiety disorder, and major depressive disorder. On 6/2/24, resident 12's medical records were reviewed. On 9/8/23, resident 12's MDS assessment documented a BIMS score of 4/15, which would indicate that the resident was severely cognitively impaired. Resident 12's progress notes revealed the following: a. On 11/8/23 at 4:51 PM, the nurse note documented, Pt has been increaslingly (sic) tearful this shift. She is unable to verbalize why she is upset. POA [Power of Attorney] was called and visited. POA is concerned the behaviors may be caused by a UTI [urinary tract infection] or that the pt may need an increase in her antidepressant medication. PCC [sic] notified. b. On 11/9/23 at 10:34 PM, the nurse note documented, Pt had resident [374] who was in her room. She felt uncomfortable and asked me to get him out of her room. Pt's roommate claimed he had been in there earlier that day as well. c. On 1/18/24 at 4:45 PM, the nurse note documented, Resident has an episode of sadness and crying and requested for her daughter to call her up. Had Tylenol for headache and requested to put her to bed. She is on antibiotic for UTI without adverse reaction noted. Resident has runny nose and cough and informed [provider name removed]. Will continue to monitor resident. On 4/28/21, a care plan for impaired cognitive function/dementia or impaired thought process was initiated. Interventions included: use the resident preferred name; identify yourself at each interaction; face the resident when speaking and make eye contact; reduce any distractions; provide necessary cues; reorient and supervise as needed; and monitor for any changes in cognitive function. Resident 12's Kardex documented, DO NOT ALLOW PT TO BE IN PRESENCE OF [RESIDENT 374] UNATTENDED. PT IS NOT TO BE LEFT ALONE WITH [RESIDENT 374] D/T [due to] INAPPROPRIATE BEHAVIOR. The facility abuse investigation, form 358, documented that on 11/13/23 at 3:30 PM, resident 12's Power of Attorney (POA) informed the ADM that resident 374 took resident 12 back to her room and the roommate [resident 36] heard kissing noises. The form documented that the date of the alleged incident was 7/13/23. The report documented that the residents were separated. On 11/13/23, the ADM interview with resident 374 documented Resident has BIMS of 4-5. Could not describe situation but denies kissing. On 11/13/23, the interview with resident 12 documented, Asked if she's been kissing perpetrator, she says 'yes'. Asked why she's kissing him, replied 'because it feels good'. Resident has BIMS of 4-5. Roommate says 'She wants to but she doesn't want to.' The facility final investigation, form 359, documented the steps to investigate the allegation was, Asked the victim if [resident 374] has been kissing her; replied 'Yes'. Asked why, she responded, 'because it feels good' and 'it tasted good'. The summary of interviews documented, Resident's roommate says that perpetrator has been coming back into the room with her after dinner. Then they go on the other side of the room and she hears kissing sounds. Says victim wants to do it, but also doesn't want to do it. The report documented that the perpetrator was mobile which made it difficult to monitor his location and staff observed resident 374 wheeling resident 12 around. The conclusion of the facility investigation documented, Evidence does not verify that abuse occurred. Victim says they've been kissing because it feels good. Both residents have dementia. The corrective action taken documented that the residents were separated and staff were notified to intervene if resident 374 tried to wheel resident 12 around or enter her room. The investigation included a form for Tips on Assessing Consent to Sexual Intimacy in Older Adults and documented questions to ask residents with impaired cognition to determine capacity to consent to physical/sexual intimacy. The form documented that the IDT should meet and review the residents most recent BIMS scores, any documentation of behaviors, change in condition, responsible party input when applicable, responses to questions and any input from a therapist regarding decision making abilities. The form stated that a summary note of findings that included a determination of whether residents could knowingly consent to physical/sexual intimacy should be documented and care planned. The form documented that after the assessment was completed and determined that one or both residents were unable to consent that the staff should ensure that residents were protected from sexual abuse or exploitation. It should be noted that no documentation could be found to demonstrate that the facility evaluated resident 12 or resident 374 for the capacity to consent to sexual activity. On 6/3/24 at 2:26 PM, an interview was conducted with resident 36 who was resident 12's roommate. Resident 36 stated that there was a male resident that kissed resident 12 and would not let go. Resident 36 stated that she could hear the kissing, but did not see it because resident 12 and resident 374 were behind the privacy curtain. Resident 36 stated that she could hear resident 12 whining like a whimper during this time. Resident 36 stated that resident 12 did not say anything during the kissing noises. Resident 36 stated that she only witnessed the one incident and she informed resident 12's POA about it. Resident 36 stated that the male resident [resident 374] tried to enter resident 12's room afterwards but the facility put a sign up that kept him out. Resident 36 stated that after the incident resident 12 was more quiet than usual. On 6/3/24 at 2:38 PM, an interview was conducted with resident 12. Resident 12 replied yes when asked if she had a relationship with a male resident at the facility in the past. Resident 12 was unable to say who the individual was, to recall their name, or to describe what the relationship was like. On 6/3/24 at 3:21 PM, an interview was conducted with CNA 10. CNA 10 stated that resident 12 was a two-person assist for transfers utilizing the sit to stand lift. CNA 10 stated that resident 12 could propel herself in a manual wheelchair. CNA 10 stated that resident 12 had occasional confusion and sometimes could not answer questions properly. CNA 10 stated that sometimes resident 12 could not identify the people in the pictures in her room. CNA 10 stated that a few months ago resident 374 wanted to talk to resident 12 and be close to her. CNA 10 stated resident 12's family member did not like the interaction between resident 374 and resident 12 and told everyone to keep them separated and monitor them. CNA 10 stated that she was informed to keep the residents separated both verbally in report and in writing in the resident chart. On 6/4/24 at 9:42 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 12 had memory problems, was disoriented, could partially answer questions, and could not make decisions on her own. CNA 5 stated that resident 12 could not recall staff names. CNA 5 stated that they were not aware of any relationship between resident 12 and another male resident. CNA 5 stated that they were not aware of any male residents that were to be separated from resident 12. On 6/4/24 at 9:46 AM, an interview was conducted with CNA 11. CNA 11 stated that resident 374 was confused and had dementia. CNA 11 stated he would hear resident 374 ramble and say stuff that would not make sense. CNA 11 stated that resident 374 had sudden outbursts of aggressiveness with staff. CNA 11 stated he was not aware of any relationships between resident 374 and other female residents. CNA 11 stated that if a relationship were to happen between resident 374 and another resident he would know about it and be informed through report. On 6/4/24 at 10:07 AM, an interview was conducted with CNA 12. CNA 12 stated that resident 374 was alert and confused with short term and long term memory deficits. CNA 12 stated that resident 374 would link arms with other residents and walk arm in arm with them. CNA 12 stated that they were not aware of any inappropriate behaviors between resident 374 and other female residents. CNA 12 stated that they were not aware of resident 374 inappropriately touching or kissing other female residents. On 6/4/24 at 11:51 AM, a telephone interview was conducted with resident 12's POA. The POA stated that another male resident was kissing resident 12. The POA stated that the male resident was going into resident 12's room, and pushed her to dinner and lunch. The POA stated that as far as she knew everyone put a stop to it. The POA stated that her mother did not tell her about the incident but she was crying hysterically when she arrived. The POA stated that resident 12's roommate told her about the incident with another male resident. The POA stated that resident 12 had short term memory deficits. The POA stated that family would come to visit and by the next day resident 12 had no recollection of it. The POA stated that she did not want resident 12 to have the relationship with the other male resident. The POA stated that the facility placed a sign on resident 12's door that stated not to allow any other resident to enter the room. The POA stated that she made everyone aware to keep resident 12 and the other male resident separated. On 6/4/24 at 12:35 PM, an interview was conducted with the RA. The RA stated that on some occasions resident 374 had to be re-directed away from other residents, but she was not aware of who that was. The RA stated that resident 374 would assist people out of the dining room after meals and was always asking if he could help. The RA stated that it was reported that resident 374 kissed resident 12, but nobody saw it. The RA stated that resident 12's roommate, resident 36, said she heard kissing noises. The RA stated that she spoke to both residents about the incident. The RA stated that resident 12 was confused and she said something along the lines of she liked him. The RA stated that was what she recalled from memory. The RA stated that if a resident could consent to the sexual contact the physician would evaluate for that capacity to consent. The RA stated that she recalled that resident 12 said she liked resident 374, she was not traumatized and did not need a counselor. The RA stated that she did not speak with resident 12's roommate about the incident. The RA stated that resident 12 was confused, she could answer yes/no questions, and had memory deficits. The RA stated that she did not recall if she referred resident 12 to a social worker for an evaluation. The RA stated that normally she would discuss any incidents with the ADM and nurse management, and they would refer to the corporate team before submitting it to the SSA. The RA stated that she could not determine if resident 12 was capable to consent. The RA stated that she knew the incident was discussed in an IDT meeting but she did not recall what was determined. The RA stated that the incident was discussed with the corporate team but does not recall what was determined or what guidance was provided. The RA stated that they were to make sure that the residents had no sexual contact. It should be noted that no documentation could be found to demonstrate that an IDT meeting was conducted to evaluate the incident between resident 12 and resident 374. On 6/4/24 at 1:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that sexual abuse was inappropriate touching, acts, or words without consent. The DON stated that the resident needed to be of sound mind to consent to the sexual acts. The DON stated that the phy[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paroxysmal atrial fibrillation, fibromyalgia, type 2 diabetes mellitus, obesity and major depressive disorder. On 6/3/24 at 9:56 AM, an interview was conducted with resident 7. Resident 7 stated she had her teeth were extracted. Resident 7 stated she was wondering when she was getting dentures. Resident 7 stated she had not been to a follow-up appointment after having her teeth extracted. Resident 7's medical record was reviewed on 6/2/24 through 6/6/24. A nursing progress note dated 3/26/24 at 3:50 PM, Spoke with [name removed] surgical regarding PT [patient] surgery in the morning. PT to be NPO [nothing by mouth] after 0045 [12:45 PM]; may take BP [blood pressure] medication in morning if necessary. Faxed over health history. The next progress note was 4/1/24 at 2:02 PM from the Nutrition/Dietary note. The note revealed .RDN [Registered Dietitian Nutritionist] spoke with resident about mouth pain. Resident had all teeth pulled and needs altered texure (sic). There were no notes regarding monitoring of resident 7 after having dental surgery. On 6/6/24 at 8:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated she was aware that resident 7 had a dental procedure. ADON 1 stated when a resident returned to the facility after a surgical procedure, the physicians sent guidance and orders to care for the resident. ADON 1 stated the nurse needed to complete a progress note regarding the surgical procedure, what the physician ordered, what to monitor and when there was a follow-up appointment. ADON 1 stated after a dental procedure, nursing staff should monitor for pain and bleeding. ADON 1 confirmed there was no monitoring of resident 7 after the dental procedure. ADON 1 was unable to find orders from the dentist or information regarding the dental procedure. On 6/6/24 at 8:58 AM, a follow-up interview was conducted with resident 7. Resident 7 stated she had not heard anything about getting dentures. Resident 7 stated she had asked staff about her follow-up appointment for dentures but staff did not know anything. On 6/5/24 at 9:13 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they were not aware that resident 7 had teeth extracted and needed dentures. LPN 1 stated there was a transport director that scheduled appointments. LPN 1 was observed to review nursing progress notes. LPN 1 stated there was a note from resident 7's physician on 6/4/24 that resident 7 needed to be fitted for dentures. On 6/5/24 at 3:48 PM, an interview was conducted with the Transport Driver. The Transport Driver stated she scheduled appointments. The Transportation Driver stated resident 7 did not have a follow up dental appointment scheduled. The Transport Driver stated she transported resident 7 to a dental appointment a couple of months ago. On 6/6/24 at 9:01 AM, an interview was conducted with the RNC. The RNC stated after a resident had teeth extracted, nurses should monitor for bleeding, fever, and sign and symptoms of infection. The RNC stated usually a resident received prophylactic antibiotics after having teeth extracted and there would be alert charting by nurses. The RNC stated resident 7 was provided a follow-up dental appointment on 5/6/24 but there was no information regarding dentures on the form. The RNC stated there was no follow-up or monitoring of resident 7 after having her teeth extracted. 3. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. Resident 5's medical record was reviewed on 6/3/24 through 6/6/24. On 4/4/24, a Quarterly Minimum Data Set [MDS] documented resident 5 had a Brief Interview for Mental Status [BIMS] score of 1 which indicated severe cognitive impairment. There was no information located under the mobility section for functional abilities. The skin section of the MDS documented resident 5 was at risk from developing pressure ulcers/injuries and it documented at the time of the assessment resident 5's only skin problem were skin tears. Resident 5 was not noted to have MASD (Moisture Associated Skin Damage). On 5/2/24, a stated optional MDS documented resident 5 was a two-person extensive assist with transfers, toileting and bed mobility. On 12/19/23, a weekly skin review/assessment documented, Blanchable redness to buttocks rest of skin is dry and intact. On 1/3/24, a professional wound specialist note documented resident 5 had dermatitis associated with moisture. The examination section documented the age of the coccyx wound to be 1 week and it noted the wound type to be MASD. The stage of the wound documented it was limited to breakdown of skin and the wound bed had erythema and was blanchable. It noted the coccyx wound was shallow and stated the wound was likely to heal well but may be slowed down due to resident 5's inability to reposition herself and lying in bed all the time. On 1/6/24 at 7:34 AM, a skin/wound note documented, MASD TO COCCYX Wound bed is 100% [percent] pink, red, healthy, erythema, blanchable. Wound edges are attached to base. Periwound tissues are macerated. No drainage, no odor. A physician order with a start date of 1/7/24 documented as followed: BUTTOCKS EXCORIATION: Cleanse with NS [normal saline] and apply chamosyn with brief changes. every shift for buttocks excoriation. On 1/10/24 at 12:11 PM, a nutrition/dietary note documented, Moisture Associated Skin Damage [MASD] to coccyx noted to be new .will continue to monitor. On 1/10/24, a professional wound specialist note documented resident 5's MASD to coccyx was progressing well and had nice improvement. On 1/12/24 at 1:10 AM, an orders administration note documented, .She has 2 stage II [two] sacral area which were cleansed, skin prepped, covered with a pink silicone bordered bandage. She tolerated the care well. She verbalized being in pain, hydrocodone was effective. On 1/13/24 at 6:29 AM, a skin/wound note documented, MASD to coccyx: PROXIMAL: . Wound bed is 100% pink, red, healthy, erythema, blanchable. Wound edges are attached to base. Periwound tissues are macerated. No drainage, no odor. On 1/17/24, a professional wound specialist note documented resident 5's MASD to coccyx had resolved within 4 weeks and it documented a treatment order of chamosyn to coccyx area every day for 14 days. On 1/17/24 at 5:46 PM, a skin/wound note documented, Wound care to coccyx: Remove old dressing, cleanse with NS. Apply skin prep to periwound. Apply Medihoney wound gel to wound bed. Secure with bordered absorbent dressing. To be completed three times a week. one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday]. wound resolved, no dressing required On 1/20/24 at 1:15 PM, a skin/wound note documented, MASD TO COCCYX: Resolved. On 2/13/24 at 5:22 PM, an orders administration note documented, Weekly skin checks every Tues [Tuesday] Day shift. Please complete the WEEKLY SKIN ASSESSMENT after you do skin check. These are to be completed by the end of your shift. one time a day every Tue On 3/3/24 and 3/11/24, a weekly skin review/assessment documented, .redness noted to coccyx. On 3/13/24, a nurse note documented, Resident with blanchable redness to sacrum. Silicone dressing placed. On 3/17/24, a weekly skin review/assessment documented, redness noted to coccyx. On 3/25/24 and 3/31/24, a weekly skin review/assessment documented, redness noted to coccyx. ointment applied. reposition every 2 hours or PRN [as needed]. no other skin issues noted. On 3/28/24 at 8:17 PM, a physician progress note documented, Nursing report no skin lesions to sacrum or coccyx. She is not ambulatory and is confined to wheeled recliner. On 4/14/24, a weekly skin review/assessment documented, excoriation on the buttocks. On 4/30/24, a hospice visit note documented the hospice nurse had assisted a facility certified nursing assistant (CNA) in providing a brief change for resident 5 and noted resident 5's skin to be intact at the time. On 5/1/24, a hospice visit note documented resident 5 had healing skin tears to bilateral arms and there was no other evidence of skin break down. On 5/12/24, a weekly skin review/assessment documented, Excoriation on the buttocks . On 5/13/24, a hospice visit note documented an integumentary assessment was conducted and assessed resident 5's skin was pale and had poor turgor. A Braden risk assessment scale was done and revealed resident 5's skin was occasionally moist and required an extra linen change once a day. The assessment documented resident 5 had a potential problem with friction and shear due to their skin probably sliding down sheets and chairs. On 5/23/24, a weekly skin review/assessment documented, Excoriation on the buttocks. Hospice nurse is bringing skin barrier for this. On 5/23/24 at 3:54 PM, an alert note documented, Skin Check: 1. Moisture Associated Skin Damage [MASD] Excoriation on the buttocks. Hospice nurses is bringing skin barrier for this. Bowel prep meds [medication] are changed from scheduled to prn [as needed]. On 5/23/24, a hospice visit note documented, Redness present to coccyx area, no open sores, Advised staff to apply barrier cream with all brief changes and reposition frequently. An integumentary assessment was conducted and documented a Braden risk assessment scale. It stated resident 5's skin is often but not always moist and linens needed to be changed as often as 3 times in 24 hours. It stated resident 5 was completely immobile and did not make even slight changes in body without assistance. It stated resident 5 had a problem with friction and shear due constant friction from sliding down in bed, sliding against the sheet with transfers, and frequent repositioning. On 5/28/24, a weekly skin review/assessment documented, Multiple small skin tears noted during brief change in sacral area. Red, no odor. It documented there was a new skin integrity problem on resident 5's sacrum and documented the new skin problem as a skin tear. On 5/29/24 at 9:47 AM, a nurse note documented, New pressure sores found on resident's R [right] buttocks and coccyx. Other areas on L [left] buttocks becoming red. Hospice notified; no new orders at this time. Silicone dressings and zinc cream placed where appropriate. Pillows placed for pressure relief. On 5/29/24, a weekly skin review/assessment documented, New pressure sores to R buttock and coccyx, other areas on L buttocks becoming red. Hospice notified. The skin review documented resident 5 had altered skin integrity to their right buttocks and coccyx and documented the skin problem as a pressure. On 6/2/24, a weekly skin review/assessment documented, Current pressure sores to R buttock and coccyx, other areas on L buttocks becoming red. Hospice notified. On 6/2/24 at 6:35 PM an alert note documented, New Skin Issue found on Weekly Skin Check. Skin treatment in progress. On 6/3/24 at 2:20 PM, a nutrition/dietary note documented, Continues hospice cares. Recent notes of pressure sores. Will await upcoming wound note to complete full assessment. Resident 5's Medication Administration Records (MAR) and Treatment Administration Records (TAR) were reviewed for the past 5 months for the buttocks excoriation treatment which was scheduled for twice a day. The following documentation revealed: a. January: Resident 5 had 10 missed treatments out of 49 total treatments. b. February: Resident 5 had 13 missed treatments out 58 total treatments. [Note: There were 3 days where resident 5 had not receive treatments twice a day.] c. March: Resident 5 had 12 missed treatments out of 62 total treatments. [Note: There was 1 day where resident 5 had not received treatments twice a day.] d. April: Resident 5 had 11 missed treatments out of 60 total treatments. [Note: There were 2 days where resident 5 had not received treatments twice a day.] e. May: Resident 5 had 10 missed treatments out of 62 total treatments. [Note: There was 1 day where resident 5 had not received treatments twice a day.] On 6/5/24 at 10:37 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated resident 5 needed assistance with rolling in bed and was incontinent of bowel and bladder. LPN 4 stated incontinence care was provided to resident 5 and they checked on them frequently to see if they needed to be clean and if they needed barrier cream. LPN 4 stated if a resident's brief was not changed often enough, then it caused skin break. LPN 4 stated a type of skin break down that was developed was excoriation which was redness and inflammation of the skin. LPN 4 stated the wound nurse was notified as soon as they noticed any kind of skin breakdown on a resident. LPN 4 stated resident 5 had some pressure ulcer on their coccyx and sacrum area. LPN 5 stated resident 5 was on an air mattress which helped prevent ulcers by distributing the pressure to different areas and helped with circulation. LPN 5 stated they just barely received new orders for repositioning resident 5 every two hours. On 6/6/24 at 10:01 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 2. ADON 2 they were the wound care nurse. ADON 2 stated if a resident had a new wound or skin injury, staff filled out a form and turned it in to them and they notified the house doctor if needed. ADON 2 stated they put the orders in for wounds which informed the nurses of the specific wound care instructions. ADON 2 stated they monitored the skin breakdown and treatments ordered for all the residents. ADON 2 stated a pressure sore was a cause of Moisture Associated Skin Damage (MASD). ADON 2 stated the skin irritation occurred when a resident was in a wet brief. ADON 2 stated MASD had many stages and it started with an abrasion. ADON 2 stated MASD created friction on the skin and caused the skin to break down. ADON 2 stated the skin breakdown led to an abrasion from the brief pulling on the skin. ADON 2 stated if MASD was not cared for or taken care of regularly, then it became a pressure sore. On 6/6/24 at 10:15 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 1. ADON 1 stated they had previously been the wound care nurse at the facility. ADON 1 stated any time they had been notified of a wound, they examined and determined if the wound needed to be seen by the wound care provider. ADON 1 stated if a resident had MASD, the facility doctor followed up with the resident and wound care did not see them. ADON 1 stated MASD was moisture associated skin dermatitis and it was found under the breast and groin. ADON 1 stated MASD was an avoidable rash. ADON 1 stated a resident could have had moisture associated skin problems if they were in a wet brief for prolonged periods of time. ADON 1 stated frequent rounding and brief changes were done to prevent skin problems. ADON 1 stated resident 5 had MASD to their bottoms in January. ADON 1 stated the moisture weakened the skin and if not taken care of, turned into a greater issue. ADON 1 stated they were notified that resident 5 had pressure sores by the hospice nurse. ADON 1 stated resident 5's bottom had been blanchable last week but now it had opened and was no longer blanchable. Based on interview and record review, the facility did not ensure that 3 of 53 sample residents received treatment and care in accordance with professional standards of practice. Specifically, one resident experienced a change in condition, and the facility did not act in a timely manner to treat the condition. This resulted in a finding of harm for this resident. In addition, one resident was not monitored for a change in condition after a dental procedure, and a resident who was incontinent developed Moisture Associated Skin Damage (MASD). Resident identifiers: 5, 7, and 365. Findings include: 1. Resident 365 was admitted to the facility on [DATE] with diagnoses that included spontaneous right patellar tendon rupture, encounter for other orthopedic aftercare, history of falling, and hypertension. Resident 365's entry Minimum Data Set (MDS) assessment indicated that facility staff assessed resident 365 as having a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Resident 365's medical record was reviewed from 6/2/24 through 6/6/24 and revealed the following: a. On 9/24/22 a nurses note documented: Pt (patient) arrived to facility via wheelchair from [name of local hospital]. Pt had a right knee repair surgery 9/23. Pt is alert and oriented x4, moves upper extremities equally, is non weightbearing [sic] on RLE (right lower extremity), able to move LLE (left lower extremity), sensation intact. Bowel sounds audible all lobes, abdomen soft and nontender, Pt reports that LBM (last bowel movement) was 9/23 in the morning. Pt is incontinent of bowel and bladder, Pt has briefs, wipes, and cream in room for bowel care. Pt is alert, able to verbalize needs . b. On 9/26/22 a nurses note documented: Pt was c/o (complaining of) excruciating bladder spasms. The pt was not seen by his primary, [name of physician], this shift to express his concerns or symptoms. Pt asked RN (Registered Nurse) to ask house MD [medical doctor] to do something to give him relief. RN messaged [name of physician] and received orders for a one time dose of 200mg [milligrams] of pyridium. RN administered medication and assessed pt 45 min after and he stated that he feels better and the spasms stopped. pt is alert and able to verbalize needs to staff, tolerated medications whole without complications . c. An MD Communication form dated 9/26/22, two days after resident 365 was admitted , revealed the following: . Concern: pt (patient) admitted Sat (Saturday) - is concerned he is developing infection, wants to see MD and discuss concerns. NEW ORDER 1 - Notify his ortho (orthopedic) Dr (doctor) who operated on him ASAP [As Soon As Possible]! 2 - I will see him after clinic today. [Note: No documentation could be located to indicate that the physician saw resident 365 that day, or that facility staff had contacted the orthopedic surgeon during resident 365's stay. ] d. On 9/28/22 at 12:26 AM a nurses note documented: . pt had an episode of forgetfulness and confusion this shift. Pt was found sitting on the side of his bed. Staff asked what he was doing, pt stated that he was going to the bathroom. Staff reminded him that he is NWB (non weight bearing) on his R (right) knee and could not walk to the bathroom. Staff got him into bed safely, his R knee is bleeding through the bandage . e. On 9/28/22 at 9:41 AM a nurses note documented: . Pt is alert, able to verbalize needs, takes medications whole, . Night nurse reported that Pt had an episode of confusion last night, Nurse went in this AM (morning) to assess Pt. Pt has diminished lung sounds in the bases, SOBLF (?) and SOBOE (shortness of breath on exertion). Pt's neuro (neurological) assessment showed minimal left sided facial weakness, moves all extremities equally, denies any numbness or tingling, no changes in sensation, or H/A (headache). MD has been notified of situation. f. On 9/28/22 at 10:46 AM a nurses note documented: . As ordered by MD, nurse tried to contact surgeon about duration of Bactrim. Unable to reach them, Nurse left a message for the surgeon's office . [Note: This is two days after the physician wrote a note to contact the orthopedic physician for resident 365 as soon as possible regarding the resident's possible infection.] g. On 9/29/22, a nurses note documented: . Resident is alert and verbally responsive, able to make needs known. Resident c/o bladder spasms and not being able to void. Bladder scanned and 85 cc (cubic centimeters) residual noted. MD notified. h. On 9/29/22, the facility physician documented the following in a physician's note: . [Resident 365] .reported pain to his abdomen that started during physical therapy, pain us located to RLQ (right lower quadrant), upon examination no hernia or any other abnormalities were noted. Claims that is able to control bladder and bowels. However, he is experiencing bladder spasms with little urine output post spasms. Denies prior or similar problems prior to this surgery. Reported last PSA (Prostate Specific Antigen) levels were done back in January with normal results. Physician will place patent (sic) on Flomax . i. On 9/29/22 resident 365's blood pressure was 144/81. j. On 9/30/22 at 4:51 PM, resident 365's blood pressure was 143/76. k. On 9/30/22 at 4:52 PM, resident 365's blood pressure was 177/85. l. On 10/1/22 at 12:05 AM, a nurses progress note documented: Resident found on floor next to recliner and walker . When asked resident what happened he said he was not sure.No c/o pain. Resident already has baseline hx (history) of confusion and falls upon admission. Resident has no s/s (signs and symptoms) of injury at this time. No complaints of pain or distress. Resident educated on importance of call light and demonstrated its use. RLE (knee) dressing changed and inspection of surgical site completed. surgical scar well approximated, all staples intact and in place and trace drops of drainage. No swelling, redness, and surgical site is cool to the touch. Clean dressing re applied, wrapped, and ble [bilateral lower extremity] knee brace secured . Will notify, PCP (primary care physician), family and on call administrator of incident and continue to monitor closely. m. On 10/1/22 at 8:30 PM a nurses progress note documented: resident POA (power of attorney) contacted staff and communicated concern regarding residents increased confusion. Family very concerned and request to send to ER (emergency room). PCP contacted . transfer was completed. Will continue to monitor closely. n. On 10/2/22 at 10:16 AM a nurses progress note documented that the resident had been admitted to the hospital, and was in the intensive care unit. On 6/6/24 at 8:43 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that with regard to the physician note written about resident 365 on 9/26/22, STAT would have been a better word to use than asap. The RNC also stated that the facility nurses should have reached out after the doctor said to get in contact with the orthopedic surgeon. The RNC stated that best practice was to reach out and get a urinalysis (UA) with the bladder spasms and excruciating pain. The RNC stated that the facility could still get a culture and sensitivity on a urinalysis even if the resident was on an antibiotic already. The RNC stated that the doctor should have ordered a UA and culture and sensitivity. The RNC did not have any other information regarding the facility's lack of response to the change of condition in resident 365. The facility's policy for Change in a Resident's Condition or Status was reviewed. The policy indicated the following: Our facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . g. need to transfer the resident to a hospital/treatment center; . i. specific instruction to notify the physician of changes in the resident's condition. 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that for 2 out 53 sampled residents, that the facility did not ensure that the resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to extent possible. Specifically, a resident developed a UTI after facility staff were not instructed and trained on the proper changing, frequency, and monitoring of the resident's PureWick urinary system device and a resident had a delay in starting antibiotic therapy for a UTI. Resident identifiers: 36, 54. Findings Included: 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder, primary osteoarthritis, type 2 diabetes with neuropathy, hypothyroidism, morbid obesity, weakness, muscle weakness, anxiety, obstructive sleep apnea, hypertension, and a history of falling. Resident 54's medical record was reviewed 6/2/24-6/6/24. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 54 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 would suggest intact cognition. A care plan Focus addressing toileting cares initiated on 2/8/24, documented [Resident 54] has a risk for bladder incontinence and requires assistance with toileting cares r/t [related to] activity intolerance. The interventions included: a. Clean peri-area after each incontinent episode b. [Resident 54] uses a PureWick system for her incontinence c. Monitor and document intake and output per facility policy d. Monitor/document for s/sx [signs and symptoms] UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp [temperature], urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns Review of Resident 54's physician orders revealed the following: a. Urinalysis (UA) for dysuria one time only. This order was initiated on 3/1/24. b. Macrobid Oral Capsule 100 milligrams (mg) (Nitrofurantoin Monohyd Macro), Give 1 capsule by mouth two times a day for UTI for 7 days. The order was initiated on 3/6/24 and discontinued on 3/14/24. The medication was documented as administered on 3/6/24 through 3/13/24. Review of resident 54's progress notes revealed the following: a. On 3/1/24 at 1:34 PM, the note documented, .ordered UA for dysuria. b. On 3/1/24 at 3:33 PM, the noted documented, obtained UA. c. On 3/2/24 at 3:35 PM, the note documented, Received UA results, no Bacteria noted. Sent copy to PCP [primary care physician]. d. On 3/6/24 at 10:49 AM, the note documented, UA sensitivity results received from lab. <100,000 CFU/ml E. Coli. [Escherichia coli] MD [medical doctor] notified. New orders from Macrobid 100mg BID [twice a day] x 7 days. Ordered from .Pharmacy, NP [nurse practitioner] gave ok to start first dose HS [hour of sleep]. On 6/2/24 at 2:38 PM, an interview was conducted with resident 54. Resident 54 stated she personally purchased the PureWicks that were used. Resident 54 stated she had a urinary tract infection a few months ago and was given an antibiotic. On 6/4/24 at 9:27 AM, a follow-up interview was conducted with resident 54. Resident 54 stated that CNAs changed the PureWick once daily. Resident 54 stated she trained the CNA's on how to change the PureWick. Resident 54 stated 32 PureWicks come in a box and she purchased them monthly as she used one box a month. Resident 54 stated she informed staff when to change the PureWick. On 6/4/24 at 9:33 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated resident 54's orders are to monitor PureWick while she is in bed. LPN 2 stated she did not know when the PureWick got changed or how often. On 6/4/24 at 9:44 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated there was not a directive order for the PureWick and he was unaware how often it got changed. On 6/4/24 at 9:56 AM, an interview was conducted with Certified Nurse Assistant (CNA) 4. CNA 4 stated there was not a place to chart that the PureWick was changed. CNA 4 stated she was not sure that changing the PureWick was a CNA task. On 6/4/24 at 1:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was unaware that any residents in the facility used a PureWick. On 6/4/24 at 1:35 PM, an interview was conducted with the DON and Minimum Data Set (MDS) Coordinator. The DON stated that CNAs did not document in the medical record with regards to the PureWick. The MDS Coordinator stated that CNAs were to change the PureWick at 4:00 AM and 4:00 PM. On 6/6/24 at 9:20 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that facility staff had not received training on the PureWick urinary device. 2. Resident 36 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of the ovary, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, peripheral neuropathy, presence of left and right artificial knee joint, insomnia, and restless leg syndrome. On 6/02/24 at 2:18 PM, an interview was conducted with resident 36. Resident 36 stated she had frequent urinary tract infections (UTI) and may have a one now. Resident 36 stated that she had pain in her pelvis/abdomen area and burning with urination. Resident 36 stated that she gave a urine sample but she does not know the results of the urinalysis. On 6/05/24, resident 36's medical records were reviewed. On 3/1/24, resident 36's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status score of 14/15, which indicated the resident was cognitively intact. The assessment documented that resident 36 required a one-person physical assistance with supervision for bed mobility, transfers, and toilet use. On 1/9/24, the provider progress note documented that the resident had a history of UTI. UTI: Patient still feels that she has a bladder infection. She is generally not feeling well and has dysuria. She stopped her antibiotics about 4 days ago. The physician's assessment and plan documented, Patient with a UTI, will continue to monitor for now and follow up. We will check a UA and follow up with results. On 1/9/24, resident 36's provider ordered a UA with a culture and sensitivity (C & S). On 1/12/24, resident 36's urinalysis results documented the appearance of the specimen as slightly cloudy, with 1+ bacteria and 1+ mucus in the sample. On 1/12/24, resident 36's urine culture revealed Klebsiella pneumoniae as the infectious organism and it was susceptible to Nitrofurantoin or Macrobid. On 1/15/24 at 8:00 PM, a physician order for Macrobid Oral Capsule 100 milligrams (mg) two times a day for UTI for 5 days was entered for resident 36. Resident 36's Medication Administration Record (MAR) documented the Macrobid 100 mg by mouth two times a day was administered on 1/16/24 through 1/21/24 for a total of 9 doses administered. It should be noted that the medication order was for a total of 10 doses to be administered. On 1/15/24, the evening dose documented to see the progress note. On 1/16/24 at 11:19 PM, the MAR documented that Ceftriaxone Reconstituted 1 gram intramuscular injection, one time only for UTI was administered. Resident 36's progress notes revealed the following: a. On 1/1/24 at 8:06 PM, the note documented, Resident finished last dose of Macrobid for UTI, no ADR [adverse drug reaction] observed or reported. b. On 1/9/24 at 2:24 PM, the note documented, Received orders from [name of provider omitted] to do a repeat UA on this pt. [patient] received UA via straight cath per pt request. c. On 1/15/24 at 5:09 PM, the note documented, received orders from [name of provider omitted] to start this pt on macrbid (sic) 100 mg tab [tablet] BID [two times a day] for 5 days. d. On 1/15/24 at 7:43 PM, the progress note documented that the Macrobid had not arrived from the pharmacy. e. On 1/17/24 at 4:43 PM, the note documented, Pt on abx [antibiotic] for UTI. No adverse reactions noted. Pt is more unsteady on feet than at baseline. [NAME] in reach. Pt encouraged to wait for assistance before toileting or ambulating. f. On 1/21/24 at 3:08 PM, the note documented, Resident finished course of Macrobid for UTI. No ADR observed or reported. Fluids encouraged. On 6/04/24 at 2:39 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. The LPN stated they could get lab results back within a day or two, depending on if it was ordered immediately. The LPN stated that they documented a progress note to show that the lab order was completed, and it could be passed on in report for the next shift to follow up with the results. The LPN stated that the results were faxed to them. The LPN stated that once they reviewed the results they placed the results in the medical records basket to be scanned into the resident chart and notified the provider by the communication app or by telephone. The LPN stated that they would then document that the provider was notified in a progress note. On 6/04/24 at 2:46 PM, an interview was conducted with LPN 1. LPN 1 stated that it usually took 1-2 days to get lab results back. LPN 1 stated that they obtained the lab specimens and entered a progress note that it was completed. LPN 1 stated that it was passed off in report to the next shift. LPN 1 stated that if there were questions about labs they had documentation of when it was sent in the progress notes. LPN 1 stated that they could also call the lab and follow-up on the results. On 6/05/24 at 8:02 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the nurses should manage all of their patient's lab orders. The RNC stated that when the nurse sent a specimen they should follow-up with the lab for results by the end of the day and if it was ordered stat they should follow-up within a couple of hours. The RNC stated that the nurse should notify the provider immediately if the results were critical, otherwise the result was placed in the provider binder for review. The RNC stated that resident 36 had a lot of UTIs that were escherichia-coli associated. The RNC stated that they provided education with the aides on proper wiping from front to back. The RNC stated that resident 36's UA with C & S was ordered on 1/9/24 and results were obtained on 1/12/24. The RNC stated that the culture showed the organism as Klebsiella. The RNC stated that resident 36 was treated with Macrobid on 1/15/24 and Ceftriaxone on 1/16/24, and that the culture showed it was susceptible to both antibiotics. The RNC stated that it was not an appropriate timeframe for the treatment of the UTI. The RNC stated that treatment was dependent on the results of the culture and sensitivity report. The RNC stated that they had a difficult time getting this provider to respond. The RNC stated that if the nurses were not able to reach resident 36's provider they should call the facility medical director within 24 hours and then notify the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 53 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences. Specifically, the resident's pain medication was not administered per the physician orders and the resident had complaints of uncontrolled pain. Resident identifier: 50. Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses which included palliative care, chronic obstructive pulmonary disease, anxiety disorder, viral hepatitis, epilepsy, low back pain, hypertensive heart disease, neuromuscular dysfunction of the bladder, hemiplegia, insomnia, chronic pulmonary embolism, and osteoarthritis. On 6/02/24 at 2:41 PM, an interview was conducted with resident 50. Resident 50 stated that he had pain in his back and he had to wait for his pain medication. Resident 50 stated that when it was given on time the pain was managed and controlled. Resident 50 stated that he had an order for Oxycodone 10 milligrams (mg) that was scheduled every 4 hours and as needed. Resident 50 stated that sometimes the 4:00 AM dose was delayed to 6:00 AM or 7:00 AM. On 6/3/24, resident 50's medical records were reviewed. On 11/1/22, resident 50 had Oxycodone 10 mg every 4 hours for chronic pain ordered. Resident 50's administration time for the Oxycodone 10 mg in May 2024 revealed the following: a. On 5/1/24, the medication was documented as administered at 4:19 AM and 7:26 PM. b. On 5/2/24, the medication was documented as administered at 1:45 AM, 5:06 AM, and 8:01 PM. c. On 5/3/24, the medication was documented as administered at 12:06 AM, 5:07 AM, and 7:27 PM. d. On 5/4/24, the medication was documented as administered at 12:12 AM, 3:52 AM, and 7:39 PM. e. On 5/5/25, the medication was documented as administered at 3:01 AM, 5:04 AM, 8:04 AM, 11:21 AM, 4:01 PM, 7:49 PM, and 11:16 PM. f. On 5/6/24, the medication was documented as administered at 5:06 AM, 7:06 AM, 11:42 AM, 3:23 PM, 7:51 PM and 11:16 PM. g. On 5/7/24, the medication was documented as administered at 4:16 AM, 7:15 AM, 2:25 PM, 4:53 PM, and 7:18 PM. h. On 5/8/24, the medication was documented as administered at 12:08 AM, 4:50 AM, 7:37 AM, 11:37 AM, 4:58 PM and 7:43 PM. i. On 5/9/24, the medication was documented as administered at 12:16 AM, 5:34 AM, 7:57 AM, 11:44 AM, 4:16 PM, and 7:23 PM. j. On 5/10/24, the medication was documented as administered at 1:50 AM, 6:04 AM, 8:26 AM, 12:27 PM, and 5:20 PM. Resident 50's May 2024 Medication Administration Record (MAR) documented that the Oxycodone 10 mg was scheduled to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Resident 50's pain scores on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible, were documented as follows: a. On 5/1/24, the pain score was a 6/10 at 10:01 AM, a 4/10 at 11:29 AM, a 5/10 at 7:25 PM, and a 0/10 at 11:44 PM. b. On 5/2/24, the pain score was a 4 at 5:06 AM, a 2/10 at 7:15 AM, and a 4/10 at 7:58 PM. c. On 5/3/24, the pain score was a 4/10 at 5:07 AM, a 1/10 at 4:38 PM, and a 4/10 at 7:26 PM. d. On 5/4/24, the pain score was a 6/10 at 12:11 AM, a 1/10 at 1:45 AM, a 4/10 at 5:49 AM, a 7/10 at 5:45 PM, and a 4/10 at 7:42 PM. e. On 5/5/24, the pain score was a 5/10 at 5:04 AM, a 3/10 at 11:02 AM, and a 3/10 at 7:49 PM. f. On 5/6/24, the pain score was a 8/10 at 9:31 AM, a 4/10 at 11:45 AM, a 3/10 at 7:51 PM, and a 1/10 at 11:54 PM. g. On 5/7/24, the pain score was a 7/10 at 1:53 PM and a 4/10 at 7:19 PM. h. On 5/8/24, the pain score was a 6/10 at 12:11 AM, a 1/10 at 12:51 AM, a 2/10 at 11:20 AM, a 5/10 at 7:41 PM, and a 0/10 at 11:09 PM. i. On 5/9/24, the pain score was a 4/10 at 5:34 AM, a 8/10 at 11:45 AM, a 0/10 at 12:39 PM, a 7/10 at 1:49 PM, a 0/10 at 2:16 PM, and a 4/10 at 7:25 PM. j. On 5/10/24, the pain score was a 4/10 at 6:04 AM, a 3/10 at 7:05 AM, and a 5/10 at 11:38 PM. Resident 50 had a care plan for at risk for pain related to chronic immobility secondary to hemiplegia, back pain, osteoarthritis, and end of life initiated on 11/8/22. The care plan documented an intervention of Anticipate the resident's need for pain relief and respond immediately to any complaints of pain. This intervention was last revised on 11/15/23. Review of the facility policy on Administering Pain Medications defined pain management as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The policy documented Administer pain medications as ordered. If there are signs or symptoms of serious adverse consequences related to narcotic (opioid) analgesics (including somnolence, delirium, respiratory depression), notify the practitioner prior to administering. The policy was last revised in March 2024. On 6/06/24 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 50 had Oxycodone scheduled for administration every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. LPN 3 stated that the resident should receive 6 doses of Oxycodone a day. LPN 3 stated that narcotic pain medication should not be administered early and a complication of early administration was overdose. LPN 3 stated that resident 50 also received morphine scheduled and as needed for pain. LPN 3 stated that they monitored the resident for orientation, pain, effectiveness and how alert they were. LPN 3 stated that if the pain medication was scheduled they should be waking the resident to administer it if he was sleeping unless he refused. LPN 3 stated that if the resident refused they would document it in the Medication Administration Record and in a progress notes. On 6/06/24 at 8:29 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that licensed nurses should monitor adverse side effects, and non-pharmacological interventions to pain relief for any as needed (PRN) pain medications. The RNC stated that the licensed nurse should monitor pain scores and side effects of any scheduled pain medications. The RNC stated that for medications that were ordered to be administered every 4 hours the resident should be receiving 6 doses a day. The RNC stated that for narcotic pain medication a potential complication of administering doses too close together was overdose. The RNC stated that PRN narcotics should be administered at least 2 hours apart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure, for 3 of 53 sampled residents, were free of significant medication errors. Specifically, a resident was given linezolid for more days than what was ordered by the hospital, narcotics were given outside of physician ordered parameters, and lorazepam was given more often than what was ordered. Resident identifiers: 41, 50, and 372. Findings Included: 1. Resident 41 was admitted to the facility on [DATE] and again on 4/9/24 with diagnoses which include chronic respiratory failure with hypoxia, functional quadriplegia, obstructive pulmonary disease, neuromuscular dysfunction of bladder, protein-calorie malnutrition, protein-calorie malnutrition, contracture of muscle, rheumatoid arthritis, bed confinement status, urinary tract infection, pyelonephritis, resistance to multiple antibiotics, dependence of supplemental oxygen, acute respiratory failure, anemia in chronic kidney disease, heart failure, major depressive disorder, obstructive sleep apnea, anxiety disorder, insomnia, muscle weakness, and presence of automatic cardiac defibrillator. On 6/2/24 at 3:45 PM, an interview with resident 41 was conducted. Resident 41 stated that she had to go to the hospital on 4/1/24 because she had acute blood loss. Resident 41 stated that prior to her hospitalization while taking Linezolid, she had felt fatigued, confused, and had dark stools. Resident 41 stated that her hair had fallen out due to the acute blood loss. Resident 41's electronic medical record was reviewed. Hospital records dated 3/1/24 documented that resident 41 was admitted to the hospital on [DATE] with a primary diagnosis of sepsis secondary to a urinary tract infection (UTI). The hospital records revealed that resident 41 was discharged from the hospital on 3/9/24. Hospital discharge orders from 3/9/24 were reviewed. Linezolid 600 milligrams (mg) oral tablet was ordered with instructions that stated, 1 tabs (600 mg) Oral BID [twice a day] for 14 days. A review of resident 41's Medication Administration Records (MAR) revealed that resident 41 was given Linezolid Oral Tablet 600 MG twice a day from 3/9/24 to 4/1/24. It should be noted that the hospital orders for linezolid had instructions that stated, Oral BID for 14 days and the resident 41 received the medication for 23 days. Resident 41 received 17 extra doses of linezolid that were not ordered from the hospital discharge orders. A Nurses Note from 4/1/24 at 8:40 PM documented, resident co [complains of] feeling dehydrated. bp [blood pressure] 95/57 hr [heart rate] 97 o2 [oxygen] sat [saturation] 94%. Temp [temperature] wnl [within normal limits]. Primary care physician notified 500ml [milliliter] bolus of normal saline given over one hour as per md [medical director] order instructions. resident tolerated well. will continue to monitor closely. A Nurses Note from 4/1/24 at 10:35 PM documented, resident continues to c/o upset stomach and generalized malaise. bp no 85/45 hr 117 md notified and resident request to go to ER [emergency room]. MD notified. EMT [emergency medical technician] transferred resident to ER at this time. will continue to monitor closely for updates on condition. family is on phone and aware of transfer. Hospital records from 4/2/24 documented, .In the emergency room: [NAME] blood cell count was 2.9 with ANC [absolute neutrophil count] at 1200. Platelet count was 18. Hemoglobin was 4.7 . In the emergency room, 2 units of packed red blood cells were ordered and 1 unit of platelets .She was admitted to the hospitalist service for medical management .She presents with 2 days of dark stool in conjunction with low hemoglobin, platelets, and neutrophils. She recently completed a 2-week course of treatment with linezolid. I suspect she has myelosuppression from linezolid leading to thrombocytopenia/anemia and subsequent gastrointestinal bleeding .She will be admitted to the intermediate care unit for careful evaluation . On 6/5/24 at 12:11 PM, an interview with the Regional Nurse Consultant (RNC) was conducted. The RNC stated that it looked like whoever entered the order for the medication did not put an end date, and the medication was given until 4/1/23.3. Resident 50 was admitted to the facility on [DATE] with diagnoses which included palliative care, chronic obstructive pulmonary disease, anxiety disorder, viral hepatitis, epilepsy, low back pain, hypertensive heart disease, neuromuscular dysfunction of the bladder, hemiplegia, insomnia, chronic pulmonary embolism, and osteoarthritis. On 6/02/24 at 2:41 PM, an interview was conducted with resident 50. Resident 50 stated that he had pain in his back and he had to wait for his pain medication. Resident 50 stated that when it was given on time the pain was managed and controlled. Resident 50 stated that he had an order for Oxycodone 10 milligrams (mg) that was scheduled every 4 hours and as needed. Resident 50 stated that sometimes the 4:00 AM dose was delayed to 6:00 AM or 7:00 AM. On 6/3/24, resident 50's medical records were reviewed. On 11/1/22, resident 50 had Oxycodone 10 mg every 4 hours for chronic pain ordered. Resident 50's administration time for the Oxycodone 10 mg in May 2024 revealed the following: a. On 5/5/25, the medication was documented as administered at 3:01 AM, 5:04 AM, 8:04 AM, and 11:21 AM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. b. On 5/6/24, the medication was documented as administered at 5:06 AM and 7:06 AM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. c. On 5/7/24, the medication was documented as administered at 4:16 AM, 7:15 AM, 2:25 PM, 4:53 PM, and 7:18 PM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. d. On 5/8/24, the medication was documented as administered at 4:50 AM, 7:37 AM, 4:58 PM and 7:43 PM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. e. On 5/9/24, the medication was documented as administered at 5:34 AM, 7:57 AM, 11:44 AM, 4:16 PM, and 7:23 PM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. d. On 5/10/24, the medication was documented as administered at 6:04 AM and 8:26 AM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. Resident 50's May 2024 Medication Administration Record (MAR) documented that the Oxycodone 10 mg was scheduled to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Review of the facility policy on Administering Pain Medications defined pain management as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The policy documented Administer pain medications as ordered. If there are signs or symptoms of serious adverse consequences related to narcotic (opioid) analgesics (including somnolence, delirium, respiratory depression), notify the practitioner prior to administering. The policy was last revised in March 2024. On 6/06/24 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 50 had Oxycodone scheduled for administration every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. LPN 3 stated that the resident should receive 6 doses of Oxycodone a day. LPN 3 stated that narcotic pain medication should not be administered early and a complication of early administration was overdose. LPN 3 stated that resident 50 also received morphine scheduled and as needed for pain. LPN 3 stated that they monitored the resident for orientation, pain, effectiveness and how alert they were. On 6/06/24 at 8:29 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that for medications that were ordered to be administered every 4 hours the resident should be receiving 6 doses a day. The RNC stated that for narcotic pain medication a potential complication of administering doses too close together was overdose. The RNC stated that PRN narcotics should be administered at least 2 hours apart. [Cross-refer F697] 2. Resident 372 was admitted to the facility on [DATE] and readmitted on [DATE] and discharged on 10/10/23 with diagnoses which included palliative care, chronic respiratory failure, diastolic heart failure, obesity, and respiratory failure. Resident 372's medical record was reviewed 6/2/24 through 6/6/24. A Physician's Visit for follow up after a hospitalization dated 5/5/23 revealed no orders for Lorazepam. A hospice History and Physical dated 6/7/23 revealed no orders for Lorazepam. A hospice physician's order dated 6/12/23 revealed emergency kit as directed Lorazepam 2 mg/milliliters (ml) 0.5 ml by mouth (PO)/sublingual (SL) every 4 hours for anxiety as needed (PRN). A nursing progress note dated 9/20/23 at 9:09 AM revealed, Pt [patient] is requesting Lorazepam be scheduled. Called an (sic) notified hospice about patient's request. They stated to go ahead and have it scheduled. Scheduled for 6 times a day 4hrs [hours] apart and PRN q [every] 4 if needed during hours of sleep. Pt has been notified of change and state that she was happy cause she doesn't have to remember to ask the nurse to bring it in. A physician's order dated 9/21/23 and discontinued on 9/26/23 revealed Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours for anxiety, nausea, hold for sedition Do not wake up to give medication. A nursing progress note dated 9/26/23 at 12:31 PM revealed, Hospice nurse [name removed] came in to see patient today, gave verbal orders to update medication. Lorazepam TID [three times a day] and Bisacodyl 5mg BID [twice daily]. A Hospice physician's order dated 9/20/23 and signed by a facility nurse on 9/26/23 revealed Lorazepam 2 MG/ml give 0.5ml TID for anxiety. Hold for excessive sedation. A physician's order dated 9/26/23 and discontinued on 10/4/23 revealed, Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth three times a day for anxiety, nausea, hold for sedition Do not wake up to give medication. A hospice order dated 10/4/23 revealed resident was to have Lorazepam scheduled TID discontinued and schedule Lorazepam 2MG/ml concentrate take 0.5 ml by mouth at bedtime. A physician's order dated 10/4/23 and discontinued 10/17/23 revealed Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed for anxiety, nausea, hold for sedation. On 6/5/24 at 9:21 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated staff coordinated with a hospice nurse and team by contacting the hospice agency or nurse directly. LPN 1 stated the hospice nurse evaluated residents weekly and brought signed orders by the hospice physician. LPN 1 stated hospice provided all the supplies, medications, and refills if needed. LPN 1 stated if there was a narcotic, the order was sent to the pharmacy directly. LPN 1 stated the hospice nurse provided a paper copy of the physician's order to the nurse or was faxed to the facility. On 6/5/24 at 9:40 AM, an interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC). The RNC stated the hospice nurse faxed physician's orders or provided a verbal physician's orders to nurses. The RNC stated the physician orders were faxed to the pharmacy to get the medication filled. The RNC stated Lorazepam medication would require a written physician order. On 6/6/24 at 9:11 AM, a follow-up interview was conducted with the RNC. The RNC stated the orders were entered into the electronic medical record wrong. The RNC stated physician's orders should have been for three times a day from 9/20/23 through 9/26/23. The RNC stated the Lorazepam order should not have been scheduled for every 4 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 53 sampled residents, that the facility must assist a resident in making appointments and arranging for transpiration to and from the dental services location. Specifically, a resident had teeth extracted and there was no follow-up appointment for dentures scheduled. Resident identifier: 53. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paroxysmal atrial fibrillation, fibromyalgia, type 2 diabetes mellitus, obesity and major depressive disorder. On 6/3/24 at 9:56 AM, an interview was conducted with resident 7. Resident 7 stated she had her teeth extracted. Resident 7 stated she was wondering when she was getting dentures. Resident 7 stated she had not been to a follow-up appointment after having her teeth extracted. Resident 7's medical record was reviewed on 6/2/24 through 6/6/24. A nursing progress note dated 3/26/24 at 3:50 PM, Spoke with [name removed] surgical regarding PT [patient] surgery in the morning. PT to be NPO [nothing by mouth] after 0045 [12:45 PM]; may take BP [blood pressure] medication in morning if necessary. Faxed over health history. The next progress note was 4/1/24 at 2:02 PM from the Nutrition/Dietary note. The note revealed .RDN [Registered Dietitian Nutritionist] spoke with resident about mouth pain. Resident had all teeth pulled and needs altered texture. There were no notes regarding monitoring of resident 7 after having dental surgery. On 6/4/24 at 1:16 PM, an interview was conducted with the Resident Advocate (RA). The RA stated there was a dental service that came to the facility and saw residents. The RA stated she put together a list of residents to be seen. The RA stated if the resident was not able to see the dental service company that came to the facility, then the transportation driver scheduled the appointments. The RA stated resident 7 had dental work done outside the facility. The RA stated she did not know about dental appointments outside of the facility and the Transportation Driver knew about it. On 6/6/24 at 8:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated she was aware that resident 7 had a dental procedure. ADON 1 stated when a resident returned to the facility after a surgical procedure, the physicians sent guidance and orders to care for the resident. ADON 1 stated the nurse needed to complete a progress note regarding the surgical procedure, what the physician ordered, what to monitor and when there was a follow-up appointment. ADON 1 stated after a dental procedure, nursing staff should monitor for pain and bleeding. ADON 1 confirmed there was no monitoring of resident 7 after the dental procedure. ADON 1 was unable to find orders from the dentist or information regarding the dental procedure. The ADON stated she did not know about dentures or an appointment for resident 7. On 6/6/24 at 8:58 AM, a follow-up interview was conducted with resident 7. Resident 7 stated she had not heard anything about getting dentures. Resident 7 stated she had asked staff about her follow-up appointment for dentures but staff did not know anything. On 6/5/24 at 9:13 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they were not aware that resident 7 had teeth extracted and needed dentures. LPN 1 stated there was a transport director that scheduled appointments. LPN 1 was observed to review nursing progress notes. LPN 1 stated there was a note from resident 7's physician on 6/4/24 that resident 7 needed to be fitted for dentures. On 6/5/24 at 3:48 PM, an interview was conducted with the Transport Driver. The Transport Driver stated she scheduled appointments. The Transportation Driver stated resident 7 did not have a follow-up dental appointment scheduled. The Transport Driver stated she transported resident 7 to a dental appointment a couple of months ago. On 6/6/24 at 9:01 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated after a resident had teeth extracted, nurses should monitor for bleeding, fever, and sign and symptoms of infection. The RNC stated usually a resident received prophylactic antibiotics after having teeth extracted and there would be alert charting by nurses. The RNC stated resident 7 was provided a follow-up dental appointment on 5/6/24 but there was no information regarding dentures on the form. The RNC stated there was no follow-up or monitoring of resident 7 after having her teeth extracted. The RNC stated she did not know about dentures for resident 7. Additional information provided by the facility on 6/10/24 revealed an email from an outside dental service dated 6/6/24 at 12:26 PM. The email revealed [Name of company] referred [resident 7] to [name removed] Oral surgery for 28 teeth to be extracted on March 27th. This was a near full mouth extraction which can cause lots of swelling. We try to allow 6-8 weeks for the mouth to heal before we do an impression. We have [name of doctor removed] scheduled at another facility Saturday and asked if he could swing by [name of facility] after to get impressions for dentures. If [resident 7] isn't seen Saturday 6/8, she will be seen the following week. I will contact you with the date if needed. It should be noted that it was 10 weeks since resident 7's extractions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 367 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, dependence on renal dialysis, type 2 diabetes, hypertensive chronic kidney disease stage 5, chronic atrial fibrillation, and cognitive communication deficit. Resident 367's medical record was reviewed on 6/2/24-6/6/24. On 9/18/23, resident 367's Brief Interview for Mental Status (BIMS) Assessment documented that resident 367 had a score of 11, which would suggest moderate cognitive impairment. Resident 367's progress notes and incident reports revealed the following: a. On 9/19/23 at 5:09 PM, the incident report documented, Adon [assistant director of nursing] received phone at 1600 [4:00 PM]. Transport stated she strapped resident in, but while driving she hit her breaks [sic] and resident fell backwards in wheelchair. Transport stated she had told the resident that she was taking him to the ER [emergency room]. The resident said no he wants to go back to the facility, but transport insisted he should get evaluated. Resident was then taken back to the ER. evaluation indicated stable cervical and thoracic fractures. C-collar was placed and pt [patient] was cleared to return to the facility and resume therapy/care Reported abuse to abuse coordinator. b. On 9/19/23 at 8:00 PM, the hospital neurosurgery consult note documented .who presented to the emergency department today after falling backwards while in a wheelchair. He states that he landed on his back and neck. He presented to the ER and CT [computed tomography] scan of his cervical spine was obtained showing a C7 and T1 TP fracture. c. On 9/19/23 at 8:22 PM, a Nurses Note documented, ER nurse [name redacted] phoned and reported pt is wearing an Aspen Cervical Collar for broken neck an [sic] vertebra. Pt is being sent home with a take home pack of pain medications and was given an IM [intramuscular] injection of dilaudid while in the ER. [Local transport company] called for transport. d. On 9/20/23 at 1:10 AM, a Nurses Note documented, Patients discharge instructions from the ER state for minor fractures a neck brace will be required for 6-8 weeks. Notified provider. e. On 9/20/23 at 11:04 AM, the facility exhibit 358 entity report documented on 9/19/23 at 8:00 PM, it was reported the resident was transported to the hospital ER (emergency room) and when returning to the facility he had tipped his wheelchair back and fell. This fall resulted in the resident hitting his head. Per the Administrator, the resident told the transporter he felt fine. However, the transporter returned the resident to the ER where the resident was found to have a non-displaced cervical fracture. Per the Administrator, the course of treatment is a soft collar for about four weeks. As for the manner in which the resident was secured in the vehicle and what, if any, precautions were taken relative to his potential neck injury. APS and Ombudsman were notified. f. On 9/24/23 at 2:09 PM, a Nurses note documented, Resident was in bed awake, alert and with no cervical collar on. When reminded this should be on per Md [medical doctor] order patient states he doesn't want it on but will put it on if he gets out of bed. On 6/3/24 at 2:41 PM, an interview was conducted with the facility transport driver. The transport driver stated that she had been the driver since November of 2023. The transport driver stated that she received training. The transport driver stated the training she received consisted of videos and being shown how to strap the resident into the van while they were in a wheelchair. The transport driver stated the straps hooked to the bottom frame of the wheelchair and not on the wheels. On 6/3/24 at 5:26 PM, a phone interview was conducted with the former facility transport driver. The former driver stated she had not received any formal training. The former driver stated that she was shown how to strap a resident into the van. The former driver stated that she criss-crossed the straps and anchored them to the frame of the wheelchair. The former driver stated that she believed all four straps were locked but could not be sure. The former driver stated that she was headed back to the facility from the ER with resident 367 when they were stopped on a street with a small incline. The former driver stated that she accelerated the van and the wheelchair tipped and resident 367 fell over backwards while in the wheelchair. The former driver stated she pulled the van over in a parking lot and left resident 367 in the wheelchair tipped back onto the floor of the van. The former driver stated she was not comfortable moving 367 who had begun to complain of shoulder pain. The former driver stated that she called 911 and the fire department came and picked the resident up and placed resident 367 back in the upright position. The former driver stated that resident 367 wanted to go back to the facility, but she took him back to the ER instead where he was found to have a cervical and thoracic fracture. The former driver stated that after the accident with resident 367 staff were required to learn how to fasten and strap residents into the van to prevent accidents. On 6/4/24 at 9:48 AM, an interview was conducted with the Director of Maintenance (DM). The DM stated he inspected the van to ensure that the straps and latches were functioning properly. The DM stated he found no indication of anything broken or not functioning correctly. On 6/5/24 at 8:45 AM, an interview was conducted with the Administrator (ADM). The ADM stated that transport drivers were trained by demonstrating the procedure of strapping in residents by the previous driver and then driving with the previous driver for about a week. The ADM stated there were no issues found with the straps or seatbelt in regards to resident 367's fall. The ADM stated the maintenance manager checked the van and he found no issues with the equipment. Based on interview and record review it was determined, for 4 of 53 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident sustained multiple falls with one resulting in a fracture, a resident transported in the facility vehicle was not properly secured and sustained a fall with injury. These findings were cited at a harm. In addition, a resident with wandering behaviors, eloped from the facility and a resident was not secured in their wheelchair and sustained a fall. Resident identifiers: 5, 18, 367, and 374. Findings Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. Resident 5's medical record was reviewed on 6/3/24 thru 6/6/24. On 5/2/24, a State Optional Minimum Data Set (MDS) documented resident 5 was a two-person extensive assist with transfers, toileting and bed mobility. On 4/4/24, a Quarterly MDS documented resident 5 had a Brief Interview for Mental Status [BIMS] score of 1 which indicated severe cognitive impairment. There was no information located under the mobility section for functional abilities. A care plan focus area initiated on 8/11/23 documented resident 5 was at risk for falls related to impaired mobility and confusion secondary to Dementia/Alzheimer's. The listed interventions included: 1. Fall mattress in place. This was initiated on 8/25/23. 2. Bed in the lowest position and locked in place whenever resident 5 was in bed. This was initiated on 12/27/23. A care plan focus area initiated on 8/28/23 and resolved on 10/19/23 documented resident 5 had an unwitnessed fall on 8/25/23 resulting in bruising/swelling to right lower leg. Resolved interventions included: 1. Educated CNA's (certified nursing assistant) about safety protocols related to falls. 2. Fall mattress in place. On 10/15/23, a post fall Morse Fall Scale documented resident 5 had scored 75 which indicated they were a high fall risk. The document stated resident 5 had an impaired gait and overestimated/forgot limitations. Resident 5's progress notes and facility incident reports were reviewed and documented the following falls: a. On 8/25/23 at 12:25 PM, a late entry fall note documented, Per floor nurse: Resident found by CNA [certified nursing assistant] on floor. Bruising noted to right lower leg, under her shin. Resident unable to explain what happened. Fall assessment completed. Hospice notified regarding fall, waiting for further orders. b. On 8/25/23 at 3:50 PM, a facility incident report documented resident 5 had an unwitnessed fall in their room. The nursing description of the incident report documented, Pt [patient] was found by the CNA's on the floor next to the bed with her right leg tucked under her left leg. She was not crying out in pain. Pt reported no injury. CNA placed pt back in bed with assessment completed after movement to bed: she has a large bruise to the right lower leg under her shin. The Immediate actions taken included education on fall safety protocol and hospice had been notified of the fall. It documented the facility was waiting for an update from hospice on how to proceed post fall. A Pain Assessment in Advance Dementia (PAINAD) was done and documented resident 5's pain post fall was a 2 which indicated mild pain. The predisposing physiological factors listed included impaired memory, opioid therapy, antianxiety therapy and hospice patient. Confusion. The Predisposing situation factors listed included inadequate communication and side rails up. Resident 5's mental status was documented as oriented to person. c. On 12/26/23 at 8:53 AM, a nurse note documented, Pt [patient] was found on the floor next to her bed sitting on her bottom. Pt was in bed being combative hitting out at staff 15 minutes prior to this incident when staff was trying to change pt brief. EMT [emergency medical technician] was contacted and pt was transported to the ER [emergency room] where it wasdetermined [sic] pt has a fractured femur and tibia. Hospital is going to monitor pt overnight to determine surgery needs. Dr [doctor] notified at 12pm. Voice mail left for POA [power of attorney]. POA was determined to be deployed in saudi [NAME] and wife [name removed] POA at the moment. [name removed] spoke with hospital and the Dr will be in touch with her tomorrow. d. On 12/26/23 at 11:35 AM, a facility incident report documented resident 5 had an un-witnessed fall in their room. The incident report description stated resident 5 had been unable to give a description of their fall. The nursing description documented resident 5 had been found on the floor next to their bed on their bottom. It documented resident 5 had been combative with staff during a brief change, 15 minutes before the fall. Resident 5 was taken to the hospital and was required to stay overnight due to having a fractured femur and tibia and needing possible surgery. Resident 5's power of attorney was notified of the fall. The incident report documented no injuries had been observed post incident. The predisposing physiological factors listed included confusion and impaired memory. The predisposing situational factors listed included physical aggression and refusing 1 on 1 help. Resident 5 was documented to be a total assist with transfer. A Pain Assessment in Advance Dementia (PAINAD) was done and documented resident 5's pain post fall was a 10 which indicated severe pain. e. On 12/28/24 at 5:33 PM, a nurse note documented, Resident is admitted from [local hospital] around 1424pm [2:24 PM] via [name removed] ambulance on gurney. She is alert but weak and pale looking .Has R [right] lateral thigh surgical site with steri strips and covered with clear dressing. She has 2 little site with dressing. No bleeding noted. She is going to be on [name removed] hospice care and confirmed by daughter in law on the phone . On 12/26/23 at 11:35 AM, a facility incident report documented resident 5 had an un-witnessed fall in their room. The incident report description stated resident 5 had been unable to give a description of their fall. The nursing description documented resident 5 had been found on the floor next to their bed on their bottom. It documented resident 5 had been combative with staff during a brief change, 15 minutes before the fall. Resident 5 was taken to the hospital and was required to stay overnight due to having a fractured femur and tibia and needing possible surgery. Resident 5's power of attorney was notified of the fall. The incident report documented no injuries had been observed post incident. The predisposing physiological factors listed included confusion and impaired memory. The predisposing situational factors listed included physical aggression and refusing 1 on 1 help. Resident 5 was documented to be a total assist with transfer. A Pain Assessment in Advance Dementia (PAINAD) was done and documented resident 5's pain post fall was a 10 which indicated severe pain. An exhibit form 358 was submitted to the State Survey Agency (SSA) on 12/26/23 at 11:30 AM. The exhibit documented resident 5 had a fall with injury and staff had become aware of the incident on 12/26/23 at 11 AM. The exhibit documented resident 5 had fallen in their room and the suspected injury had either been a hip fracture or dislocation. Resident 5 was sent to the emergency for evaluation and treatment due to the injury obtained. On 12/26/23 at 1:51 PM, a hospital history and physical report documented resident 5 had arrived to the emergency room with right hip pain after being found down bedside their bed. It documented, Upon arrival, EMS [emergency medical services] reported an obvious deformity of her right hip/pelvis and possible deformity of her right knee. An exhibit form 359 was submitted to the SSA on 1/2/24 at 1:15 PM. The additional information section of the exhibit form documented a hip fracture had been confirmed. The X-ray report showed that resident 5 had sustained a closed fracture proximal end of femur. The witness interview summary documented the fall had not been witnessed. It documented the certified nursing assistant (CNA) had gone in to change resident 5's brief minutes earlier and resident 5 was being combative. The CNA stopped the brief change and went to find additional help. When the CNA returned with a nurse, resident 5 was found sitting on the floor. A staff interview documented resident 5 had been very confused and restless and must have either rolled off the bed or tried to stand up. Resident 5's CNA for the shift stated the bed was in the low position and the fall mat had been in place when they arrived on shift. It documented when the CNA returned to resident 5's room at 11 AM, the fall mat was not in place, but the bed was still in the low position. The CNA raised the bed to change resident 5's brief but resident 5 became combative. The interview documented the CNA had lowered resident 5's bed to close to the lowest position and stepped into the hall to get assistance. It documented the CNA heard resident 5 fall and entered the room to find resident 5 on the floor. The investigation documented there was no perpetrator identified for the incident. The investigation concluded the allegation of a fall with an injury had been verified and documented, resident 5's care plan stated that here should be a floor mat. Even through (sic) the CNA only left the room quickly to get assistance and did lower the bed, the floor mat was not in place. Corrective actions implemented after the investigation included a point of care task for CNAs to ensure the floor mat was in place and one on one CNA education/training regarding fall mats and other interventions. On 6/5/24 at 9:41 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated resident 5 was dependent on all cares. CNA 5 stated resident 5 was bedbound and was unable to walk. CNA 5 stated resident 5 was a fall risk but they were unsure if resident 5 had any falls. CNA 5 stated resident 5's bed was put in the lowest position and they had a fall mat next to their bed. On 6/5/24 at 11:09 PM, an interview was conducted with CNA 7. CNA 7 stated resident 5 was a total care resident. CNA 7 stated resident 5 was able to make their needs known occasionally. CNA 7 stated resident 5 had a fall mat because they climbed out of bed. CNA 7 stated resident 5 was a fall risk and they had interventions in place such as a fall mat, bed in the lowest position, frequent checks and having resident 5 in the day room with staff. CNA 7 stated they were sure resident 5 had been injured due to previous falls. On 6/6/24 at 7:57 AM, an interview was conducted with CNA 17. CNA 17 stated resident 5 was mentally out of it. CNA 17 stated resident 5 frequently rolled themselves out of bed. CNA 17 stated the resident was placed in the day room during the day so staff was able to observe them often. On 6/6/24 at 7:49 AM, an interview was conducted with CNA 12. CNA 12 stated resident 5 was confused. CNA 12 stated depending on how resident 5 was feeling during the day, they needed to have a second staff member with them during resident cares. CNA 12 stated they usually rounded on resident's every two hours. CNA 12 stated resident 5 was a fall risk and needed a hoyer lift for transfers. CNA 12 stated resident 5 was a fall risk and had interventions in place such as a fall mat, bed in the lowest position, and frequent checks. CNA 12 stated they were aware resident 5 had falls in the past but they were unsure of the severity of the falls. On 6/6/24 at 8:12 AM, an interview was conducted with CNA 18. CNA 18 stated resident 5 was a total assist and was a two-person hoyer lift with transfers. CNA 18 stated resident 5's dementia was so severe they were unable to recall the date. CNA 18 stated resident 5 was unable to express their needs. CNA 18 stated resident 5 was a fall risk because they forgot they were unable to bear weight and tried to stand. CNA 18 stated if resident 5 was in bed, staff made sure resident 5's bed was in the lowest position with the fall mat in place. CNA 18 stated resident 5 was put in high traffic areas near staff so staff always had eyes on resident 5. CNA 18 stated resident 5 had a fall about 5 months ago where they messed their leg up. CNA 18 stated they had heard details about the fall and stated whoever resident 5's aid was at the time, left the resident's room to find help. CNA 18 stated resident 5 fell and landed on her hip in the short time the aid had left to find help. On 6/6/24 at 8:32 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated they looked in the care plan to see what interventions were put in place to prevent a resident from falling. LPN 3 stated resident 5 had a fall where something was fractured. LPN 3 stated interventions for resident 5 were frequent two-hour checks, bed in the low position and the floor mat. LPN 3 stated resident 5 was confused and when resident 5 was in the day room they needed to monitor them. On 6/6/24 at 9:38 AM, an interview was conducted with the Resident Advocate (RA). The RA stated resident 5 required a bit of help from staff and was dependent for most of their cares. The RA stated resident 5 was wheelchair bound. The RA stated they believed resident 5 was a high fall risk. The RA stated fall interventions included the bed in the lowest position and fall mats if the residents crawled out of bed. The RA stated they were unsure if resident 5 had any falls with injury. On 6/6/24 at 10:31 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 1. The ADON 1 stated resident 5 was able to reposition themselves while in bed and they were able to roll out of bed. The ADON 1 stated resident 5 was unable to get out of bed safely. The ADON 1 stated resident 5 had fall interventions that included the bed in the lowest position and the fall mat on the floor when resident 5 was in bed. The ADON 1 stated resident 5 had rolled out of bed and broken their hip. The ADON 1 stated they were unsure of the specific details of the fall. The ADON 1 stated they assisted resident 5's nurse after the resident had fallen. The ADON 1 stated they remembered seeing resident 5 on the floor and the fall mat was stood up against the wall. The ADON 1 stated they were unsure if the emergency medical technicians had moved it out of the way to assist resident 5. 3. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinsonism, type 2 diabetes, morbid obesity, chronic kidney disease, acquired absence of left leg above knee, chronic obstructive pulmonary disease, and major depressive disorder. On 6/2/24 at 2:12 PM, an interview was conducted with resident 18 who stated she had fallen out of her motorized wheelchair. Resident 18 stated she had fallen asleep while sitting in her wheelchair, fell forward onto the floor and hit her head. Resident 18 stated staff who were across the hall heard a thud and went to her room to see what had happened. Resident 18 stated she was assessed and sent to the hospital for evaluation. Resident 18 stated she sustained a broken patella. Resident 18 was observed to have a seatbelt on her motorized wheelchair, but was not wearing it. Resident 18 stated she had been told by her physician to wear the seatbelt, and was observed to put it on in the presence of the surveyor. Resident 18's medical records were reviewed between 6/2/24 and 6/6/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident 18 had a BIMS (Brief Interview for Mental Status) of 13 indicating resident 18 was cognitively intact. An annual MDS dated [DATE] revealed resident 18 required one person physical assistance for transferring. The assessment also revealed that resident required on person physical assistance for toileting. A physician order dated 12/28/23 revealed, Ensure seat belt is on when pt [patient] is in wheelchair. [Resident's name removed] is able to remove her seatbelt with no assistance from staff. A care plan focus area initiated on 8/30/22 revealed, [Resident's name removed] is at risk for falls r/t [related to] L [left] AKA [above the knee amputation], Parkinsonism. The goal was, [resident's name removed] will be free of falls through the review date. Interventions included, Educated resident on transferring to her bed when she is ready to go to sleep; Educated resident on using safety belt while in power chair; Therapy to eval [evaluate] for another power chair that tilts back for repositioning; Educated resident to ask for staff assistance with toileting; Re-enforce education regarding asking for assistance with transferring; Sent to ER for eval [evaluation]. Seatbelt to be used while in wheelchair. [Resident's name removed] is able to take seat belt off with no assistance from staff; .Document the fall risk measures in the resident care plan and update as needed (quarterly and after each fall). Certified Nursing Assistant (CNA) KARDEX with special instructions for resident care included, Ensure seat belt is on when pt is in wheelchair. [Resident's name removed] is able to remove her seatbelt with no assistance. CNA Tasks, which included, Ensure seat belt is on when pt is in wheelchair. [Resident's name removed] is able to remove her seatbelt with no assistance revealed yes responses to the question Task Completed? for: a. 6/2/2024: 10:58 AM 10:49 PM b. 6/3/2024: 11:28 PM c. 6/4/2024: 10:46 PM d. 6/5/2024: 3:58 PM e. 6/6/2024: 12:35 AM 10:00 PM An incident report dated 12/18/23 revealed, Pt fell asleep in her chair and fell onto the floor right on her face. Pt had a small cut to her R [right] cheek bone and on her lip. Pt stated that her L [left] shoulder hurt. Pt stated that she fell asleep in her chair and fell on her face. Immediate action taken included that resident 18 was taken to the hospital. Injuries observed at the time of the incident included Face. Resident level of pain was recorded as 6/10. Level of consciousness was alert. Mobility was Extensive Assist with Transfers. The location was in the resident's room. Mental status was oriented to person, place, and situation. An incident report dated 5/25/23 revealed, Resident found laying on her stomach on the floor. Wheelchair next to her. Resident reports she fell asleep in wheelchair and fell forward and states she hit front of forehead. Immediate action taken included, Assisted resident into wheelchair, Neuros started. Skin check completed. Redness to knee noted. No markings noted where resident hit head. Resident c/o [complained of] headache. Injuries observed at the time of the incident stated, No injuries observed at time of incident. Level of pain was not completed. Mobility was not completed. Mental status was not completed. A hospital history and physical dated 12/19/23 revealed, Pt arrives via EMS [emergency medical services] with complaints of head pain and memory issues. Pt comes [name of facility removed]. Pt reportedly fell from her jazzy yesterday and hit her head. Today she feels like her memory is not intact. Pt complains of head pain .Pt is a long-term resident of [name of facility removed] regional. She presented to the emergency department yesterday 12/18/23 after ground-level fall out of her wheelchair landing on her face. After extensive workup patient was discharged back to [name of facility removed] regional in stable condition. Today she returns to the emergency department with reports from staff that patient is altered mentally, confused, and yelling out people's names that are not there. In the ED [emergency department] she was on room air, hemodynamically stable, and afebrile. Repeat CT [computer tomography] of her head was performed and was unremarkable .She was alert and oriented x2. She was able to tell me her full name, her children's names, that she lived at [name of facility removed] regional and that she was in the hospital, however, she did not know the city or state and thought it was February. ED provider has requested the hospitalist service admit the patient for observation. An emergency department report dated 5/25/23 revealed, [Resident's name removed] is a [AGE] year-old female with multiple medical problems .She is presenting today after syncope and fall. She was trying to get up from her wheelchair earlier when she felt short of breath and passed out and woke up on the ground. She believes she fell onto her forehead and now has pain in her head, neck, upper back, right shoulder, hips, right knee. She has not been able to get up after. She was given one of her pain pills as well as Tylenol and felt some improvement in her symptoms. EMS arrived and brought the patient here to the emergency department. They state she initially had some low blood pressure with staff, but these improved. On arrival here in the emergency department, the patient is lying in the stretcher in no acute distress. She has tenderness across her forehead, cervical spine, right shoulder, lower back, hips, right knee. Her exam is otherwise notable for left knee AKA .Her trauma work-up included CT scans of her head, neck, chest, abdomen, pelvis as well as an x-ray of her knee. Her CT scan showed no acute abnormalities. Her x-ray of her knee did show a patellar fracture . It should be noted that the patellar fracture noted in the ED report was pre-existing to resident 18's fall on 5/25/23 according to an orthopedic progress note dated 6/6/23. A nurses progress note dated 12/18/23 at 3:14 PM revealed, Pt was found laying on the ground in prone position. Pt stated that she fell asleep in her chair and fell forward. Pt had a wound to her R cheek and lip, also stated that her L shoulder was hurting. Initial vitals were elevated. Notified PCP [primary care provider] and decided that it was in this pts bed (sic) interest to be evaluated in the hospital, [family member] notified. A progress note labeled Fall Note dated 5/25/23 at 6:13 PM revealed, The nurse hears screaming coming from a resident's room. This nurse walks towards voice. Resident's door shut. This nurse opens door and finds resident on ground. Resident reports she fell asleep in her power chair and fell out. This nurse assures resident is alright then leaves room to quickly get help. This nurse and three other CNAs assist resident with sitting up. D/T (due to) positioning and how close resident was to dresser, staff was unable to use hoyer to transfer resident back to power chair. Neuros started. Resident's initial set of vitals: Oxygen 93, HR (heart rate) 88, temp 97.8, and blood pressure 102/79. Redness noted to right knee. Resident reports she hit the front of her forehead, but no markings noted. Resident c/o (complains of) headache. Pupil reaction normal. MD (medical doctor) notified of fall. No new orders at this time. A nurses progress note dated 5/25/23 at 7:15 PM revealed, Went to check resident's vitals for neuros and she was sleeping. Resident was hard to arouse. Blood pressure dropped to 95/78 and resident appears more confused. Resident reports being dizzy. Assisted resident with brief and clothing change in restroom. Notified MD via message regarding resident's condition and that resident is getting sent to ER for evaluation. On 6/4/24 at 12:09 PM, an observation was made of resident 18 sitting in her motorized wheelchair waiting for lunch to be delivered to her room. Resident 18 was not wearing her seatbelt. On 6/4/24 at 2:20 PM, an observation was made of resident 18 ambulating quickly through the hallway in her wheelchair. Resident 18 was not wearing her seatbelt. On 6/4/24 at 2:25 PM, an interview was conducted with CNA 6 who stated there were sheets at the nurse's station to provide the CNAs with information about each resident. CNA 6 also stated that CNAs received information verbally from the nurses about residents. CNA 6 stated the information at the nurses station would include if a resident was a fall risk or had a recent fall, including the date and time of the fall. CNA 6 stated the resident information at the nurse's station was updated daily and interventions to prevent falls would be on that list or the nurses would let them know if there was a new intervention. CNA 6 stated resident 18 was not a fall risk. On 6/4/24 at 2:[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that for 1 of 31 sample residents that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice and comprehensive person-centered care plan. Specifically, a resident experienced a change of condition (wound worsened) without the appropriate interventions and failed to notify the appropriate physician, as well as the facility did not monitor and reassess resident's vitals signs when they had changed. Resident Identifier: 57. Finding include: Resident 57 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that initially included morbid obesity, anemia, low back pain, malignant neoplasm of breasts, lymphedema, and pressure-induced deep tissue damage of right upper and left upper back. On 6/30/22, resident 57 was readmitted with diagnoses that included severe sepsis with septic shock, myositis of right thigh and pressure ulcers of left and right buttock. On 7/20/22, a review of resident 57's electronic medical record was completed. A hospital Discharge summary dated [DATE] revealed that resident 57 was admitted to the hospital for a urinary tract infection (UTI) and multiple pressure ulcers. Resident 57 was started on antibiotics during her hospital admission for her UTI and was discharged to the facility with a prescription for the antibiotic levofloxacin to be administered until 6/14/22. Progress notes revealed: a. Resident 57 was under the care of a primary care physician (PCP) and wound care physician while she resided at the facility and also had access to the facility in house provider. b. Nursing note on 6/14/22 at 1:12 AM, revealed resident 57 arrived to the facility after being treated for a UTI at the hospital. Documentation stated Discoloration and edema on bilateral lower legs is present. Skin breakdown is present in groin area, bilateral posterior calves, mid lower back, and right hip. Padded pups and silver cloth were placed where the skin breakdown is present. c. Nursing note dated 6/15/22 at 12:40 AM, stated, patient continues to be in pain despite her PRN (as needed) pain medication; I will reach out to [the facility's physician]. Mid back wound is leaking large amounts of purulent drainage. Pressure was placed on the wound for 20+ minutes and it was ineffective in stopping it from draining. The nurse manager on call was notified and I was told to keep the area CDI (clean, dry and intact). Frequent dressing changes throughout the shift took place; each time the dressing would be saturated. The area around the wound appears to be red. Patient remains afebrile. Wound doctor will be notified as well . Nineteen hours later, nursing progress notes revealed, [The wound doctor] gave a verbal order to have levothyroxine {LevoFLOXacin} to continue for one week. [Note: order for the antibiotic with a start date of 6/15/22 read as followed: levoFLOXacin Tablet 750 MG, Give 1 tablet by mouth at bedtime for Prophylaxis related to NON PRESSURE CHRONIC ULCER OF SKIN OF OTHER SITES LIMITED TO BREAKDOWN OF SKIN]. No documentation was found where resident 57's primary care physician was notified, only the in-house provider was notified. d. Nursing note on 6/16/22 at 1:40 AM stated, Resident is on levofloxacin for abscess. Received written order from [the pcp] for CMP, Lipid panel with 8 hour fast, CBC (complete blood count) with auto diff, Hgb (hemoglobin) A1c, Vitamin D25OH, PTH (Parathyroid hormone) level. Mid back wound is leaking large amounts of Serosanguineous drainage. No CO (complaints) of N (nausea) V (vomiting) D (diarrhea), No SOB (shortness of breath), wound nurse treated wounds today. Pt (patient) has co of pain, which is treated with oxycodone and has not been as effective as pt would like. Messaging [the facility's physician] because pt is requesting pain meds multiple times before it is due. Will continue to monitor. [Note: No documentation was found where resident 57's primary care physician was notified, only the in house provider was notified.] e. Nursing note on 6/17/22 at 11:43 AM, stated, Pt on abx (antibiotic) treatment for abscess. Abscess still draining at this time. No s/s of worsening infection. No adverse effects to the abx treatment. PA into see pt, no order changes at this time. Dressings to wounds changed, moderate amount of bloody drainage noted, pt to have labs drawn today. Pt continues on ABX for wound infection. f. A PCP note on 6/17 at 1:25 PM, revealed resident 57 was seen by the provider for her back abscess, malnutrition, depression and chronic pain. PCP stated in their note that resident 57 has a severe abscess with spontaneous drainage on mid back. 750 cc (cubic centimeters) pus and is being treated by the wound care team. In regards to pain, PA reveals, that resident 57 had requested more pain meds even after doing much better following drainage of abscess. [Note: no wound culture order was located for resident 57's back abscess to determine the appropriate antibiotic to treat the abscess.] g. Skin/Wound note on 6/17/22 at 3:48 PM, stated, Resident admitted with multiple wounds. Resident seen by facility wound specialist P.A. (physician assistant) for assessment and new treatment orders on 6/15/22. Resident has abscess to back with two holes measuring 0.5cmx0.5cm. Large amounts of serosang and purulent drainage has been draining out of holes with each position change. Resident has had chux underneath her to help control wound drainage. Wound specialist P.A. drainage about 500CC of this fluid from abscess. Resident continues to have drainage from abscess and requires frequent dressing changes. h. On 6/18/22 and 6/19/22, nursing notes revealed that resident 57 continued to be on antibiotic due to her wound infection/abscess. i. Nursing note on 6/20/22 4:32 PM, stated, [pcp] notified of Results of [resident 57's] labs. Six hours later a new nursing note stated, Dressing changes were performed on her back wound due to the dressing being saturated with sanguineous drainage. The wound was cleaned with NS and an island dressing was placed. Will continue to monitor wounds. j. Registered Dietitian note on 6/21/22 at 2:19 PM, stated that wound RN reported that wounds had improved. k. PCP note on 6/21/22 11:21 PM, revealed resident 57's low back abscess had been treated by wound care aggressively but wound started to have more heavy bleeding from exit sites and remarkable significant blood on the chuks but appears to be getting better. No significant pus noted and defer to wound care team. Provider noted that resident 57 did not complain of dizziness or lightheadedness and did not present with a fever but was concerned with resident 57 low blood pressures and tachycardia. Stated to watch blood pressures and considered blood cultures. [Note: No vitals were documented for 6/21/22.] l. Nursing note on 6/21/22 at 4:54 PM, stated, Assisted wound nurse in wound dressing changes on patients back. There is blood coming out in clots saturating her pads and streams of blood coming out of her back. Pt was compliant but often exclaimed in pain. Pt was given pain medications and Lorazepam prior to change. Two hours later, the nurse sent the first MD communication to wound PA. [Note: No documentation was found where resident 57's pcp was notified.] m. Nursing note on 6/22/22 at 12:00 PM, stated, [wound PA] ordered resident to go to ER (emergency room) for emergency MRI (magnetic resonance imaging) of mid back abscess for excessive and constant bloody drainage over the last week. After resident 57 was sent to the ER, new orders written by PCP were received for senna twice a day and miralax as needed. Orders revealed that resident 57 was ordered have vitals taken twice a day with a start date of 6/13/22. Vitals signs were documented as followed: a. On 6/13, 6/14, and 6/16, resident 57's vitals were within normal limits and documented to be the exact same readings for all three days. Blood pressure was documented as 109/57 and heart rate as 87. Vitals signs were only obtained once throughout the day on 6/14 and 6/16 instead of twice as ordered. b. On 6/18 and 6/19, vitals signs were taken twice a day as ordered. Blood pressure readings ranged from 104/57 to 94/45. Resident 57's heart rate remained within normal limits, ranging from 82 to 86. c. On 6/20/22, vitals signs were only taken once throughout the day. Resident 57's blood pressure remained low at 96/54 and heart rate increased to 105. [Note: no documentation was found where any provider was notified of vital signs.] d. On 6/15/22 and 6/21/22, no vitals signs were documented. [Note: resident's PCP stated they were concerned about hypotension and tachycardia on 6/21/22 and would continue to monitor vitals.] e. On 6/22/22 vitals signs were taken during the morning shift and revealed a blood pressure of 78/42 and heart rate of 107. All other vitals remained within normal limits. Resident 57 was taken to the ER (emergency room) on this day. Resident 57's Medication Administration Record (MAR) for June revealed the following: a. Pain medication was increased on 6/17 from oxycodone 5 mg (milligrams) every 6 hours as needed for pain to oxycodone 7.5 mg every 6 hours as needed for pain. b. From 6/13/22 to 6/17/22 resident received pain meds 12 times out of 20 possible opportunities. Pain scores ranged from 2 to 7. c. From 6/18/22 through 6/22/22 resident received pain medication 13 times out of 17 possible opportunities. Pain scores ranged from 5 to 7 out of 10. On 6/22/22, the hospital H&P (history and physical) revealed Resident 57 was taken to the ER due to excessive drainage from her back wound and feeling ill. Resident 57 stated they reported symptoms of diaphoresis, fever and moderate back pain at the facility. An MRI (magnetic resonance imaging) was done in the ER and the results indicated Resident 57 had infectious myositis and cellulitis. Resident 57 was admitted to the ICU for septic shock. On 7/21/22 at 10:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that vitals were done at least twice a day unless there was a requirement to get them more often. If a resident were to have a change in condition, repeat vitals were obtained. CNA 4 stated some resident's vitals ran high while other ran low and every resident had their own set of normal vital signs. CNA 4 stated that a normal blood pressure was 120/80 and normal blood pressures fall either 10 points below that or 10 points above. On 7/21/22 at 10:26 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that vitals were taken every morning before meds pass. RN 3 stated that if vitals signs were outside of parameters, first they rechecked the vitals and then if they were still outside parameters, they held blood pressure medication or notified the MD. RN 3 stated that the blood pressure parameters were 100/60 and the Medical Doctor was notified if a blood pressure was below that parameter. RN 3 stated that they documented in their progress notes when they contacted the MD and if any new orders were received. RN 3 stated that signs and symptoms of an infection were redness, fever, confusion and pain. RN 3 stated that in regards to wounds, other signs of infections were purulent and excess drainage. RN 3 stated that any time they did a wound change, they always looked for any signs and symptoms of infection and would notify the doctor and wound nurse. On 7/21/22 at 10:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that if vitals were abnormal, they would notify the doctor and document in their process notes about the notification. LPN 1 stated that there are times they forget to document the MD notification in their progress notes. Abnormal vitals were considered any blood pressures lower than their given parameters of 100/60 or pulse rate lower than 60 or higher than 100. LPN 1 stated the physician was notified in two ways. Depending on how urgent the matter was, the physician was to be called/messaged immediately or staff wrote down their concerns in a book that was checked daily by the doctor. It was up to the nurse's discretion on how they wanted to notify the doctor. LPN 1 stated vitals were obtained once per shift by either the aid or the nurse and wouldn't get missed. LPN 1 stated that some signs of infection were redness, swelling, warmth/heat, green or pus drainage and foul smell. LPN 1 stated if they identified any of those signs on a resident's wound, they notified the wound nurse who would then notify the doctor. On 7/21/22 at 11:09 AM, an interview was conducted with RN 2. RN 2 stated that all resident's vitals were checked every shift and followed up as necessary. RN 2 stated the abnormal vitals signs were respirations of less than 10 or higher than 20, heart rate less than 60 or greater than 100 and any blood pressure less than 100/60. RN 2 stated that abnormal vitals depended on the resident and their circumstances. RN 2 stated if a resident had abnormal vitals with an unknown circumstance, they notified the doctor since it was a new finding. RN 2 stated that signs and symptoms of a generalized infection were an elevated heart rate and temperature, and respiratory difficulty. Signs and symptoms of a localized infection included redness, inflammation and unusual discharge to the area. RN 2 stated that if they discovered any of those signs or symptoms on a resident, they notified the provider. On 7/21/22 at 12:27 an interview was conducted with the Director of Nursing (DON). The DON stated that resident 57 was sent to the facility after being treated for a UTI at the hospital. The DON stated that resident was admitted to the facility with a bunch of wounds and there was one in particular on her back that drained. The DON stated that the resident was under the care of Physician Assistant (PA) and if needed the in house facility doctor. DON stated they had the wound doctor look at it. The DON stated that they thought the drainage eased up after her abscess had been drained and had purulent drainage come out at first which then turned to bloody drainage. The DON stated they weren't concerned about an infection at that time since her abscess had just been drained and all the icky drainage came out. The DON stated that the wound physician assistant was aware of the drainage coming from her abscess. The DON stated that because of the amount of drainage present, the wound PA ordered an MRI to get done on 6/16 but they were unable to get it done since outpatient MRI's were booked 2 weeks out. DON stated resident 57 was sent to the ER on [DATE] due to her back abscess increasing in size and the amount of drainage coming from it and needing a back MRI done promptly. The DON stated that before resident 57 went to the hospital, she was on antibiotics for her abscess. The DON identified signs and symptoms of infection such as malaise, redness, swelling, heat around wound, confusion, fever, increased pain, low blood pressure and a high heart rate. When asked about prescribing the correct antibiotic, the DON stated that normally a culture and sensitivity test was done and proceed to say that is how resident 57 was put on her levofloxacin while in the hospital. The DON stated they did not do a culture and sensitivity test on resident 57's wound since the doctor did not order it. The DON stated that resident 57's blood pressure ran on the lower side so they were not concerned about it since it was close to her normal. When this surveyor questioned the DON about resident 57 blood pressure on 6/22, DON replied that resident 57 was sent to the ER that day. On 7/21/22 at 2:18 PM, an interview was conducted with the wound physician assistant (pa). The PA stated that he was the wound specialist for the facility and had been taking care of resident 57 prior to her arrival at the facility on 6/13. The PA stated that resident 57 had a 2 cm by 1/2cm hole in her back that was draining due to an internal abscess she developed at her prior facility. The PA stated that he had drained resident 57 back abscess and wasn't sure how her body would react so he decided to keep resident 57 on the antibiotic she was prescribed from the hospital for a UTI. The PA stated that at the time he drained the abscess, resident 57 did not have any signs or symptoms of sepsis or a systemic infection. The PA stated there was a cautious wait and see about how her body reacted in terms of did her abscess improved or did resident 57 worsen due to an infection. The PA stated that after he had drained her abscess, he wanted to be notified if resident 57 experienced any signs and symptoms of an infection such as fevers, negative changes to the wound including an increase in size or weeping. The PA stated if he saw the wound hadn't improved, he would have acted on it. The PA stated what concerned him the most was when resident 57 had clots draining from her abscess and at that point decided something needed to be done since her abscess had not improved. The PA stated that he had ordered an MRI to give him an idea of what was going on but had trouble getting it done quickly and was unsure why. The PA stated that at the time he had not seen anything internal going on and the goal was to get her skin to heal. When asked about resident 57 decreased blood pressure, the PA responded that he was only concerned if it was causing resident 57 symptoms such as passing out or being unable to stand. If no symptoms were present, he referred to the physician to take care of it, especially if the residents presented with a high heart rate and low blood pressure due to the fact there may be something else going on within the body other than a wound. The PA stated that the scope of what resident 57 had was a surprise and that it was a fully unanticipated situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 52 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, generalized anxiety, hypertension, and major depression. A record review for resident 52 was conducted on 1/7/2020 and revealed the following progress notes. a. A progress note dated 12/22/19 at 2:50 PM, documented Patient has abrasion/skin tear on the back of her left leg. Injury occurred during transfer treated and will follow up for wound care orders. b. A progress note dated 12/22/19 at 7:35 PM, documented Resident's left leg abrasion is approximately 5 inch half circle. Do to continues oozing and checking injury site with the 2 other nurses, it was agreed the injury needed sutures. Family notified and resident was sent to the emergency room via Gold Cross ambulance. Vital signs within normal. Afebrile. No complaint of pain except at wound site. c. A progress note dated 12/22/19 at 9:51 PM, documented Resident returned from emergency room. Wound dressed, clean and dry with 3 sutures. Afebrile 98.2, blood pressure 113/80, pulse 72, respirations 16. No complaint of pain or signs and symptoms distress. Is a 2 person in activities of daily living. Presently sleeping. [Note: The facility did not have an incident report or investigation of the incident.] d. A progress note dated 12/24/19 at 12:34 PM, documented alert to self only. Eats meals in assisted dining room. Incontinent of bowel and bladder. Wheelchair used for ambulation with assistance. 1 person extensive with late loss activities of daily living. NO signs and symptoms of nausea, vomiting, diarrhea, shortness of breath or pain. Wound care to left lower leg applied. Vital signs within normal limit, afebrile. Attends activity. Safety precautions in place. Will continue to monitor. e. A progress note dated 12/31/19 at 5:36 PM, documented alert to self only. Wound care applied to left lower leg skin tear .Safety precautions in place. f. A progress note dated 1/2/2020 at 10:32 PM, documented This writer was called to replace the dressing on her lower left extremity. The wound is moist and macerated draining a moderate amount of serosanguinous exudate. The skin is sloughing. The sutures remain intact but the areas between the sutures are open. The wound looks like hamburger with a red swollen area surrounding the wound which is warm to the touch. Will contact wound nurse and wound clinic for follow up. Will continue to monitor. [Note: there is a 100 hour delay in physician notification from the initial assessment that the wound has deteriorated.] g. A progress note dated 1/6/2020 at 2:56 PM, documented Doctor [name removed] office called and ordered for the resident to see a wound clinic, noted and transport informed. h. A progress note dated 1/6/2020 at 9:46 PM, documented Resident's dressing dry and intact on left lower leg will continue to monitor for bruises for healing and monitor for skin for any further bruises or breakdown. A review of resident 52 care plan was reviewed and revealed the following. a. Focus: Ms. [name removed] has potential impairment to skin integrity related to fragile, skin, incontinence, decreased mobility, and dementia. Date initiated 12/13/2018. Revision on 6/17/2019 b. Goal: Ms. [name removed] will maintain or develop clean and intact skin by the review date. Date initiated 12/6/2018. Revision date 6/17/2019. c. Tasks: a. Encourage good nutrition and hydration in order to promote healthier skin. Date initiated 12/13/2018 b. Identify/document potential causative factors and eliminate/resolve where possible. Date initiated 12/13/2018. [Note: The facility did not identify or investigate the causative factor of the skin tear on 12/26/19 to eliminate/resolve where possible.] c. Keep skin clean and dry. Use lotion on dry skin. Date initiated 12/12/2018. d. Use draw sheet or lifting device to move resident. Date initiated 12/13/2018. [Note: No care plan update was completed after the skin tear occurred on 12/26/19.] e. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against sharp or hard surface. Date initiated 12/13/2018. On 1/7/19 at 2:52 PM and observation was made of resident 52. Resident 52 was sitting in her wheelchair in the TV room. Resident 52 had a dressing on her left lower extremity. Resident 52's wheelchair had long brake handles sticking up on wheelchair, the ends of the brakes were round, and metal with a hollow inside. Nothing was covering the hard metal ends. An interview was conducted with Certified Nursing Assistant (CNA) 3 on 1/8/20 at 9:25 AM. CNA 3 stated that resident 52 would be considered an extensive assist. CNA 3 stated that when they transfer her they raise the bed, put the wheelchair next to the bed, then assist patient to her feet, and assist her with weight bearing and balance. CNA 3 states resident 52 is a one person transfer unless she is combative then they will use 2. An interview was conducted on 1/8/20 at 9:32 AM with CNA 9. CNA 9 stated that the facility is a no lift facility. CNA 9 stated that meant that they don't really lift anyone that they can do stand by assistance but not do weight bearing transfers, and if a resident needed weight bearing assistance they would use the sit to stand or Hoyer for transfer. CNA 9 stated that resident 52 would help stand up when being transferred. CNA 9 stated she is a kind of pivot, stand and pivot transfer. An interview was conducted with Registered Nurse (RN) 1 on 1/8/20 at approximately 10:00 AM. RN 1 stated that physicians should be notified of falls, refusal of medications, injuries and skin issues. RN 1 stated that physicians can be notified by fax or a phone call. RN 1 stated that she did not know if an incident report would be done on a skin tear. An interview was conducted with Licensed Practical Nurse (LPN) 2 on 1/8/20 at 10:59 AM. LPN 2 stated that resident 52 had a skin tear on her leg that required stitches. LPN 2 stated that the wound looked fine and the dressing was being changed daily, and then it just started falling apart. LPN 2 stated that last time she saw the wound it looked tough and that the stitches were removed per the wound nurse, and she signed the treatment record for her. LPN 2 stated that the wound was the like a half dollar, round with a pink and brownish wound bed, LPN 2 stated that some areas look like hamburger meat. LPN 2 stated that the facility did incident reports for falls, but she did not know if they did incident reports for skin tears. An interview was conducted on 1/8/20 at 1:59 PM, with the director of nursing (DON). The DON stated that the wound nurse round on the wound weekly and will do measurements and document on the wounds. The DON stated that if a physician needs called after hours the staff can call her and she will call the medical director. The Director of nursing had no additional information regarding resident 52 wounds or physician notification delay of the wounds. The DON stated they did not have an incident report for resident 52's skin tear and had no further information about the cause of the skin tear. An interview was conducted with the wound nurse on 1/9/20 at 8:58 AM. The wound nurse stated that she assessed wounds one time a week, and she measures, and documents on the wounds. The wound nurse stated that she communicated with the wound clinic and the physicians if needed. The wound nurse stated that her assessments are documented in the progress notes but that she is behind because it's been crazy. The wound nurse said she assesses pressure ulcers, surgical wounds and bad skin tears like resident 52'. The wound nurse stated that when she notified the physician of wound changes she will fax them, and she notifies the physician of new wounds, if there is a drastic change in the wound, if the wound orders needs to change, if they need to be seen in the wound clinic, if the wound has a smell, is warm, or needs and antibiotic. The wound nurse stated that she removed the stitches for resident 52 on 1/4/20. The wound nurse stated that she had assessed the wound on 12/28/19 and the wound was fine, and that on 1/4/20 she was notified that it had gotten bad. The wound nurse stated that when she assessed the wound there was black and green tissue, the stitches almost fell out when taken out, it was very moist, it's beyond what they could do there. The wound nurse stated that the peri wound was macerated, and was warm. The wound nurse stated that she left a voicemail on the medical assistant's phone on 1/4/20 that the wound has worsened. The wound nurse stated that sometimes an on call physician can be called for a change of condition but they don't really call back. The wound nurse stated that she had received notification that resident 52 missed he wound clinic appointment. On 1/9/20 at 9:58 AM CNA 1 was observed transferring resident 52 into bed with the assistance of another CNA, patient required 50% or more of weight bearing assistance with a pivot transfer. CNA 1 stated that resident 52 sheets had to be changed this morning due to weeping from her lower extremity wound and also weeping from her elbow wound. On 1/9/20 at 10:08 AM an observation was made of the wound nurse changing a dressing to resident 52 left lower extremity. It was observed that the resident's wound was a round, full thickness wound. Resident 52 had 2 wounds to her right elbow. One of the wounds on the right elbow was scabbed and the other was open. The Wound nurse stated that she did not know about the wounds on resident 52's right elbow, but after assessing it she thought it was a skin tear. On 1/9/20 at 11:03 AM, an interview was conducted with resident 52's family member. The family member stated that she was not notified of the incident when resident 52 received the skin tear to her lower extremity. The family member stated she was notified when she was visiting the resident when she noticed a dressing to her leg and asked what had happened. The family member stated she was not notified that resident 52's wound had worsened and that was the reason for the wound clinic appointment. The family member stated when the facility staff member called her about the appointment they did not know the reason for the appointment. 4. Resident 118 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include pneumonitis, type 2 diabetes, unspecified dementia without behavioral disturbance, history of falling and major depressive disorder. A record review was conducted for resident 118 on 1/8/20 and revealed the following. a. A progress note dated 11/8/19 at 12:47 PM, documented .Gave resident glucagon for blood sugar of 65. Continue on IV antibiotics as noted. Will continue to monitor. b. A physician order dated 11/8/19, Use 1000 milliliters (ml) intravenously every 24 hours as needed for supplement low blood sugar 75ml/hour. c. A physician order dated 10/30/2019: Glucose <70 dl and responsive give 4 ounces of clear glucose containing liquid, 40-70 mg/dl and unresponsive or NPO give 50% dextrose 25 ml IV over 3 minutes STAT. <40 and unresponsive or NPO give 50% dextrose 50ml IV over 3 minutes after treatment & notify provider for glucose 70mg/dl or less after 2 treatments. d. A progress note dated 11/11/19 at 1:05 AM, documented PM nurse reported patients NG tube was clogged. At about midnight patient was diaphoretic and blood glucose was 27. Called 911, paramedics administered IV meds to raise blood glucose and were unable to unclog NG tube. Feeding running at 80ml/hr. Pt tolerating well. Placement checked, residual 10 cubic centimeters (CC). Blood glucose rechecked periodically and within normal limits. An interview was conducted with Registered Nurse (RN) RN 1 on 1/9/19 at 8:42 AM. RN 1 stated that she worked and documented the progress note on 11/11/19 at 1:05 AM. RN 1 stated that she had received report at 10:00 or 10:30 PM on 11/11/19, but she did not know how long resident 118 NG tube had been clogged prior to that. RN 1 stated she remembered the nurse who gave her report telling her she had given resident 118 insulin. RN 1 stated that she had entered resident 118 room to administer and IV antibiotic when she noticed that he was diaphoretic. RN 1 stated that because resident 118 was diaphoretic she checked his blood sugar, and it was 27 so she called 911. RN 1 stated that resident 118 was NPO. RN 1 stated that after the event she reviewed orders and noted that resident 119 had order for IV Dextrose for hypoglycemia. RN 1 stated that prior to the event she had only ever had residents that could take stuff by mouth for hypoglycemia. An interview was conducted with the Director of Nursing (DON) on 1/9/19 at approximately 12:00 PM. The DON stated if a resident had orders related to hypoglycemia she would expect those orders to be followed. 2. Resident 24 was admitted to the facility on [DATE] with diagnoses which included palliative care, hypertension, gastro-esophageal reflux disease, and edema. On 1/7/20 from approximately 8:35 AM to 8:45 AM, resident 24 was observed as she ate her breakfast. Resident 24 was in her room in her bed in a seated position and legs extended in front of her in the bed. During the approximate 10 minute observation, resident 24 was observed to cough several times. Her cough was observed to be wet, and she was clearing her throat extensively. On 1/9/20 at 7:45 AM it was observed that resident 24 was resting in bed and was coughing. The resident's cough was notably wet. Resident 24 was noted to be on room air. On 1/9/20 at 9:26 AM, a phone interview was conducted with resident 24's family member. Resident 24's family member not aware that resident 24 had a cough. On 1/9/20 at 10:13 AM an interview with the Assistant Director of Nursing (ADON) stated that the resident had always had a dry cough but that she has never heard resident 24 have a wet cough. The ADON stated that the dry cough happened mostly in the morning and she hasn't noticed any increase in coughing with food or fluids. On 1/9/20 at 10:19 AM, Certified Nurse Assistant (CNA) 1 stated that resident 24 had a cough on and off throughout the day. CNA 1 stated that she didn't know if it sounded wet or dry or if it get worse with food or fluids. On 1/9/20 at 10:21 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 2 has had a dry cough since admit, that the cough is random and didn't know if it was wet or dry. On 1/9/20 at 10:42 AM, an interview was conducted with the dietary aid. The dietary aid stated that she hasn't seen resident 24 coughing during meal time. On 1/9/20 at 10:57 AM, a record review revealed that no doctor had been contacted regarding resident 24's wet or dry cough. Based on interview and record review, the facility did not ensure that 3 of 25 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not seen by a physician for approximately 9 days after falling and experiencing a change in condition, a resident with a cough had not been assessed by the physician, and a wound had not been treated timely. The findings for resident 118 were cited at a harm level. Resident identifiers: 24, 52 and 118. Findings include: 1.Resident 118 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, diabetes mellitus, pneumonitis, aneurysm of renal artery, peripheral vascular disease, dementia without behavioral disturbance, history of falling, and major depressive disorder. Resident 118's medical record was reviewed on 1/6/20. Progress notes and skilled daily notes for resident 118 revealed the following: a. On 9/26/19, a progress note indicated that at 4:30 AM patient fell out of his bed. It was unseen, therefore cause is unknown. Language barrier prevented understanding of how he fell. Nurse found him laying supine on the floor with his head by the foot of the bed, holding on to the bottom of the bed frame. Patient was alert and vitals were within normal range, BP (blood pressure) =136/80, HR (heart rate) =91, O2 (oxygen saturations) =90, Temp (temperature) 98.0, and Resp (respirations) =20. Skin check=negative for bruises, skin tears, nor any new wounds. Patient had no pain with passive range of motion. Slight difficult standing up, but was assisted with two male staff with transferring (sic). Pupils are equal billateraly (sic), brisk, and both dilated at 3 mm. Called daughter from patients (sic) phone two times, and from the facilities (sic) phone once, but she did not answer. Left a message on her phone. Will continue to monitor patient throughout the shift. [Note: The nurse did not indicate in his/her note that resident 118's physician had been contacted regarding the fall.] b. On 9/26/19 a progress note indicated that the Interdisciplinary Team (IDT) review of resident 118 ' s fall had been conducted. Resident had an unwitnessed fall in his room around 0430 am. Resident was not able to state exactly how or why he fell. Resident was found lying in supine position on the floor, his head was by the foot of his bed and he was holding onto the bottom of the bed frame. Resident was assessed by nurse, no apparent injuries were noted. Able to range extremities without pain. MD and daughter notified of fall. Will continue to monitor resident for changes and have CNA's (Certified Nursing Assistants) offer toileting during last rounds. c. On 9/26/19 at 2:46 PM a progress note was entered that the resident . seemed disoriented this morning, difficult for him to follow simple instructions. With patience he was cooperative . d. On 9/26/19 a skilled nursing assessment indicated that resident 118 . had a fall at 4:30am, He seemed more confused this morning and unable to follow simple commands. Pt (patient) seemed disoriented this morning, difficult for him to follow simple instructions. With patience he was cooperative . e. On 9/28/19 a progress note indicated that Resident is sleepy looking but able to follow instructions . f. On 9/28/19 at 5:31 PM, a progress note indicated that the resident had a blood glucose (BG) . reading of 469 at check before dinner. [Name of physician] ' s office is contacted and voicemail left for request to review BG history and address possible changes to sliding scale. BG history is faxed to the office. g. On 9/28/19 at 10:41 PM, a progress note indicated that the resident was complaining of . pain on rt (right)side from former fall. No bruising noted. Strength and mobility lessened. h. On 9/28/19, a skilled nursing assessment indicated that the resident was having a change in level of consciousness as evidenced by him being sleepy. i. On 9/29/19 at 11:18 AM, a progress note indicated that resident 118 was .alert and verbally responsive, with confusion. j. On 9/29/19 at 10:12 PM, a progress note indicated that the resident had . difficulty comprehending instructions even with translation. Communication problems. B.S. (blood sugar) 369 this noc (evening). k. On 9/30/19 a weekly nursing summary indicated that resident 118 had been experiencing Increased sleepiness that week. l. On 9/30/19 at 3:50 PM, a progress note indicated that .Resident has had an overall decline, has been sleeping most of the day, is easy to arouse, but falls right back to sleep. Resident has required extensive assistance with eating during both breakfast and lunch. Resident was up in activity room after breakfast and lunch for activities, but was seen sleeping. Resident did not want to be removed from the activity room, so he stayed in the activity per his request. Resident lungs were clear upon auscultation, heart rate was regular, bowel sounds active, last BM (bowel movement) was 9/29/19. Resident able to follow simple commands, able to take medications without difficulty. Contacted MD to notify him of resident condition, requested UA (urinalysis) and xrays of right ribs and right hip/pelvis per daughter's request. Awaiting for MD response. [Note: A review of resident 118 ' s lab and radiology results was completed. No documentation could be located to indicate resident 118 had the UA or the xrays ordered or completed per the family request. In addition, no documentation could be located to indicate that resident 118 ' s physician returned the nurse ' s phone call regarding the resident ' s apparent change in condition, until 10/4/19.] m. On 10/1/19 a progress note indicated that Resident is alert to verbal stimuli, sleepy but rousable. Resident is able to make some needs known but struggles because of language barrier. Resident was sitting with other residents at the television then resting in bed. Daughter in to help with cares and all medication and treatments given with no ASE (adverse side effects) and no refusals. Resident is resting in bed with call light within reach. n. On 10/2/19 a progress note indicated that Resident is alert to verbal stimuli. Resident is very tired. Rousing only enough to take pills and get eye drops. o. On 10/3/19 at 5:46 PM, a progress note indicated that Resident has been very lethargic today. Difficult to arouse in a.m . p. On 10/3/19 at 10:26 PM, a progress note indicated that Resident resting in chair and in bed. Able to take meds without difficulty. Blood sugar 303. Insulin given as ordered. VSS (vital signs stable). Resident sleepy tonight. q. On 10/3/19 a skilled nursing assessment indicated that the resident was experiencing notable changes in LOC (level of consciousness). as evidenced by Does not respond when spoke (sic) to. r. On 10/4/19 a skilled nursing assessment indicated that The past few days resident has been lethargic, hard to arouse. Primary physician notified. s. On 10/4/19 a progress note indicated that the resident was discharged to the hospital for further evaluation and treatment. [Note: After falling on 9/26/19, the resident ' s physician was not in contact with the facility staff until 10/4/19, approximately 8 days later, when the resident was sent to the emergency room and subsequently admitted .] On 10/30/19, the resident was readmitted to the facility from the hospital, where he had stayed approximately 26 days. The hospital History and Physical dated 10/4/19 indicated that resident 118 was diagnosed with a liver laceration and adjacent fluid/hematoma measuring 6.3 x 4 cm (centimeters). On 1/8/20 at 3:00 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that resident 118 fell on 9/26/19 when he was trying to get out of bed. The DON stated that there were no apparent injuries right away. The DON then stated that a few days later the resident ' s daughter was concerned about the resident ' s decline and asked the DON to do an assessment. The DON stated that she completed the assessment and resident 118 was okay, but that then there was a decline. The DON stated that they had contacted the physician on 9/30/19 due to the level of pain that the resident was in, and confirmed that the physician had not responded to the notification of the resident ' s change in condition. The DON stated that the physicians were difficult to get a hold of sometimes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents that the facility did not ensure the residents were free of significant medication errors. Specifically, a resident's anticoagulant medication was not started on admission resulting in an outcome of an extensive iliofemoral deep vein thrombosis to the right lower extremity. This occurred at a harm level. Resident identifier 21. Findings include: Resident 21 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which include Sepsis, type 2 diabetes, acute and chronic respiratory failure, multiple sclerosis, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, and use of long term (current) use of anticoagulants. On 1/6/20 at 3:57 PM an interview was conducted with resident 21. Resident 21 stated that he had been hospitalized for pneumonia, a blood clot, or DVT in his leg, and for a urinary tract infection. A review of resident 21's medical record was conducted on 1/7/20 and revealed that resident 21 was readmitted to the facility on [DATE] following a hospitalization. A review of resident 21's discharge diagnoses from the hospital to the facility on [DATE] revealed diagnoses to include. a. Atrial Fibrillations with RVR b. History of deep vein thrombosis c. And history of ischemic vetebrobasilar artery thalamic stroke A review of resident 21's discharge medication orders from the hospital to the facility on [DATE] revealed the following orders. a. Rivaroxaban (Xarelto 20mg tablet) 1 tab orally every evening. A review of resident 21's admission orders at the facility and medication administration record reflected resident 21 did not reflect that resident had received Xarelto 20mg from 11/7/19-12/29/19. [Note: Resident 21 was receiving Xarelto 20 mg I tablet orally in the evening for preventions of pulmonary embolism and deep vein thrombosis prior to discharge on [DATE] to the hospital.] A review of resident 21's medical record conducted on 1/7/20 revealed the following progress notes. a. A progress note dated 12/26/19 at 10:27 AM documented Patient has been complaining of pain in his right inner thigh, there is warmth to the touch and some swelling, previous nurse reported some redness in that area . I contacted doctor [name removed] assistant and her and the doctor will be coming by today to see the patient. b. A progress note dated 12/26/19 at 4:41 PM, documented Note Text: Doctor [name removed]'s Physician Assistant (PA) came in to see patient. Ordered Doppler ultrasound (US) of right upper thigh/groin/popliteal to rule out blood clot. Order faxed to [name of imaging company]. c. A progress note dated 12/28/19 at 10:21 AM, documented Note Text: reviewed results for venous Doppler done to right lower extremity on 12/26/19. Called office of doctor [name removed] and was able to leave a message on his medical assistant's phone. Awaiting call back. Patient had no change in loc. No nausea, vomiting or diarrhea. No complains of feeling unusual. No complaints of feeling short of breath. Call light within reach. Continuing to monitor resident. [Note: this was 41 hours after the order for the Doppler ultrasound was ordered.] d. A progress note dated 12/28/19 at 12:01 PM, documented Note text: called pager on doctor [name removed] profile but not answer, unable to leave voice message. Continuing to monitor resident. No change in level of consciousness. Afebrile. No nausea, vomiting, and diarrhea. No complaints feeling shortness of breath. Call light within reach. e. A progress note dated 12/28/19 at 5:00 PM, documented Note Text: spoke to doctor [name removed] medical assistant and reported the deep vein thrombosis. Awaiting call back. f. A progress note dated 12/28/19 6:27 PM, documented Note text: spoke to nurse practitioner [name removed], gave new order for: Xarelto 20mg once a day, will follow up with further interventions. [Note: Xarelto for resident 21 was documented for initial administration on 12/29/19 at 8:00 PM. This is 25.5 hours after the order was received from the medical doctor.] A review of the Venous Doppler Ultrasound of the Right Lower Extremity revealed the following results on 12/26/19. a. Findings: There is extensive occlusive clot within all the visible deep veins of the right lower extremity through upper visible portion of the right common femoral vein. b. Impression: Extensive iliofemoral deep vein thrombosis right lower extremity. Occlusive illiofemoral clot with significant symptoms is often best treated with catheter directed thrombolytic therapy. Consider interventional radiology consultation. A review of documentation received from the third party diagnostic company revealed that the ultrasound results were faxed to the facility on [DATE] at 7:26 PM. There is a delay of the initial contact to a medical doctor of 39 hours. A review of resident 21 care plan revealed the following care plan. a. Focus: Mr. [name removed] is on anticoagulant therapy Xarelto related to atrial fibrillation. b.Goal: Mr. [name removed] will be free from discomfort or adverse reactions related to anticoagulant use through the review date. c. Interventions/tasks: a. Administer anticoagulant as ordered by physician. Monitor for side effects and effectiveness every shift. b. Monitor for adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. A follow up interview was conducted with resident 21 on 1/8/20 at 9:10 AM. Resident stated that when his deep vein thrombosis was discovered it was because it was painful, very painful that he left the staff know and they did an ultrasound. Resident 21 stated that it was still painful but not as much as it was. An interview was conducted with Registered Nurse (RN) 1 on 1/8/20 at approximately 10:00 AM. RN 1 stated that on admission the medical records department or the administrative nurses put in the admit medication orders. RN 1 stated they are just there for us. RN 1 stated that the diagnostic company send the results by fax to the facility and the doctor, and when facility receives the results they fax it to the doctor. RN 1 stated that if results are abnormal a call would be made to the physician to ensure the results were received. RN 1 stated that if the abnormal results were received after normal business hours they would call the on call physician. RN 1 stated that if the results do not come by the end of a shift, it would be passed onto the next shift by verbal report and or in the progress notes. An interview was conducted with Licensed practical nurse (LPN) 2 on 1/8/20 at 10:59 AM. LPN 2 stated that she thought the diagnostic company faxed results to the physicians. LPN 2 stated that she did not know how quickly results would come back and that they sometimes go directly to the doctor and then we wait for the doctor orders. LPN 2 stated she did not know how physician would be notified of abnormal results after hours. LPN 2 stated that she thinks medical records puts in new orders for medications on admission. LPN 2 stated then the nurse has to click to confirm them all. LPN 2 stated she thinks they get a list of papers that include the hospital medication orders. An interview was conducted with Nurse Practitioner (NP) 1 on 1/8/20 at 11:16 AM. NP 1 stated that the resident 21 was put on Xarelto in the hospital and that in the transition from the hospital it got lost in translation. NP 1 sated that when the ultrasound results were reported to her she reviewed resident 21's record and noted that it had been ordered on discharge from the hospital to the facility but had not been started. NP 1 stated that the deep vein thrombosis for resident 21 occurred as a direct correlation of not being on the Xarelto medication. NP 1 stated that for someone with deep vein thrombosis she would recommend heat to the affected area, that resident does not sit up in a flex position, and some light movement to the area for general circulation health. NP 1 stated that she believes she told the nurse that when she ordered the Xarelto. [Note: nothing could be found in patient medical record progress notes, care plan, ect to reflect these instructions.] NP 1 stated that she did not receive a copy of the ultrasound report, and it was not reported to her that the impression included occlusive iliofemoral clot with significant symptoms is often best treated with catheter directed thrombolytic therapy. Consider interventional radiology consultation. NP 1 stated that those results were super shocking and really important, and that she might still consider the recommendations to get the rest of the clot taken care of. On 1/8/20 at 1:59 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that diagnostic results typically get faxed to us and the physician, usually within 24 hours. The DON stated that sometimes there is an issue and I have to call and and say that we have not gotten the results. The DON stated that the results should be received within 24 hours, and abnormal results should be called into the physician. The DON stated that if it's an urgency abnormal result and after hours the staff can call she and she will call the facility medical director. The DON stated that either a nurse or the medical records department will initiate orders into the system. The DON stated that the floor nurse is responsible to verify the final orders that come with the patient to what's in point click care. The DON had no additional information to provide concerning resident 21's significant medication error, or delay in reporting of the ultrasound results to the physician.