**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management to a resident experiencing pain for 1 of 35 sampled residents (Resident #7) related to not providing pain medication per physician orders and not administering pain medication that met professional standards of practice resulting in Resident #7 having significant, untreated pain. Findings include: Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). Resident #7's 10/2/23 Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 10/2/23 reveals that s/he shows indicators of pain daily and is assessed to have a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness). Resident #7's care plan states that I have pain or have the potential in an alteration in my comfort r/t [related to] history of bladder and breast Cancer, Chronic Physical Disability r/t spastic CP [cerebral palsy], quadriplegia, polyneuropathy and bilateral knee pain created on 3/3/2020, with a goal that My pain will be managed daily, created on 3/3/2020. Interventions include Provide medication as ordered, created on 2/23/2023, and Assess characteristics of pain: location, severity on a scale of 0-10, type, frequency, precipitating factors, alleviating factors and vital signs or Non-verbal indications of pain as needed, created on 12/29/2021. Physician orders reveal that Resident #7 has orders to receive oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) Give 5 ml by mouth three times a day for pain, which began on 2/20/23. Per review of Resident #7's MAR (Medication Administration Record) for November 2023 and December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled oxycodone twice on 11/16/23 (afternoon and evening), three times on 12/8/23 (morning, afternoon, and evening) and two times on 12/9/23 (morning and afternoon) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses on 11/26/23 or 12/8/23 and was not notified until after the first missed dose on 12/9/23. On 12/21/23 at approximately 9:30 AM, the Unit Manager confirmed that neither s/he nor the physician were notified every time Resident #7 did not receive their oxycodone and should have been. Pain assessments during the above periods reveal the following: On 11/16/23, at the time medications were due, Resident #7 had pain assessments of 0 for the afternoon and a 5 for the evening; on 12/8/23, at the time medications were due, Resident #7 did not have pain assessments documented (morning, afternoon, and evening) but additional pain assessments for that day were documented as a 0; on 12/9/23, at the time medications were due, Resident #7 did not have pain assessments documented (morning and afternoon) but additional pain assessments for those times were documented as a 0 and a 4. However, the accuracy of these pain assessments are questionable based on the following interviews and record reviews. Record review and interview reveal that Resident #7 suffers greatly when his/her pain is not managed. Per interview on 12/21/23 at approximately 9:30 AM, the Unit Manager explained that Resident #7 is normally in pain. S/He explained that while Resident #7 is unable to communicate by speech, s/he can communicate clearly non-verbally. S/He explained that Resident #7's pain can be assessed with a numerical pain scale but sometimes staff use the PAINAD (an instrument for measurement of pain in noncommunicative patients). Weekly psychological service progress notes dated from 10/20/23 through 12/8/23 indicate that Resident #7 had been working on coping skills related to feeling frustrated with communication and being able to verbalize his/her pain. A 12/8/23 psychological services progress note Patient was alert and fully oriented. Patient reported she was in a lot of pain and was feeling uncomfortable. This note was from a day where Resident #7's pain was only documented as a 0 for the entire day. A 12/15/23 clinical treatment therapy plan of care note reveals, Patient reported depressive symptoms related to [his/her] situation, including pain. Ability to effectively communicate continues to be very frustrating for [him/her] Assessments from this visit indicated that Resident #7 had severe anxiety disorder and moderate depression; an increase from the previous 8/11/23 assessment. Per interview on 12/21/23 at 9:45 AM, Resident #7 indicated that s/he is in pain most of the time and the pain reaches a level of 10 often. S/he indicated that the pain medications do help a little but not completely. When asked about the two days in December when s/he did not receive her pain medication, s/he indicated that his/her pain was very bad. Per interview on 12/21/23 at 2:55 PM, the Regional Nurse Consultant confirmed that Resident #7 was not administered his/her oxycodone as ordered and a physician was not notified of each of the missing medication administrations and should have been. 2. Per observation on 12/19/23 at approximately 10:00 AM, Resident #7 was lying in bed with a red substance dripping from his/her mouth onto a towel placed on his/her chest. An unknown amount of the red substance was collected on the towel. Resident #7 was unable to reposition his/herself in the bed. Per interview on 12/19/23 directly following this observation, the Registered Nurse (RN) caring for Resident #7 explained that the red substance was oxycodone and it was normal for it to be dripping out of his/her mouth because s/he has difficulty swallowing. The two pain assessments recorded before and after this observation were documented as a 7 out of 10 for severity (10 being the highest severity) at 8:36 AM and a 6 out of 10 at 2:12 PM. Per facility policy titled Medications Administration Methods, last modified on 7/12/2022, and professional nursing standards, when administering medications, the nurse must watch each resident take the medication and ensure the medication is swallowed unless the resident has an order for self-administration. Per interview on 12/20/23 at 2:27 PM, the Unit Manager stated that Resident #7 is normally in pain. S/He confirmed that the nurse administering the medication should have stayed with Resident #7 to make sure that the pain medication was administered all the way. Reference: Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Nursing Skills [Internet]. Eau [NAME] (WI): [NAME] Valley Technical College; 2021. Chapter 15 Administration of Enteral Medications. Available from: https://www.ncbi.nlm.nih.gov/books/NBK593215/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Per interview and record review, the facility failed to provide medications as ordered by the prescriber to meet the needs of each resident for 4 of 35 sampled residents (Resident #7, #52, #102, and #81). Findings include: 1. Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). Resident #7's 10/2/23 Minimum Data Set (MDS; a comprehensive assessment used as a care- planning tool) dated 10/2/23 reveals that s/he shows indicators of pain daily. A 10/16/23 progress note indicates that Resident #7 has difficulties with oral secretions. Physician orders reveal that Resident #7 has orders to receive oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) Give 5 ml by mouth three times a day for pain, which began on 2/20/23. Per review of Resident #7's MAR (Medication Administration Record) for November 2023 and December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled oxycodone twice on 11/16/23 (afternoon and evening), three times on 12/8/23 (morning, afternoon, and evening) and two times on 12/9/23 (morning and afternoon) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses on 11/26/23 or 12/8/23 and was not notified until after the first missed dose on 12/9/23. On 12/21/23 at approximately 9:30 AM, the Unit Manager confirmed that neither s/he nor the physician were notified every time Resident #7 did not receive their oxycodone and should have been. Physician orders reveal that Resident #7 has orders to receive Scopolamine Transdermal Patch 72 Hour 1 MG/3DAYS (Scopolamine) Apply 1 patch transdermally every 72 hours for Secretions and remove per schedule, which began on 10/17/23. Per review of Resident #7's MAR (Medication Administration Record) for October through December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled scopolamine patch 9 out of the 21 scheduled times through 12/22/23 (10/29/23, 11/4/23, 11/13/23, 11/19/23, 11/22/23, 12/4/23, 12/13/23, 12/19/23, and 12/22/23) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses. As a result, Resident #7 experienced significant, untreated pain. See F760 for more information. Per interview on 12/21/23 at 2:55 PM, the Regional Nurse Consultant confirmed that Resident #7 was not administered his/her oxycodone and scopolamine as ordered and a physician was not notified of each of the missing medication administrations and should have been. 2. Per record review, Resident #52 was admitted to the facility on [DATE] with diagnoses that include post-traumatic stress disorder (PTSD), traumatic brain injury with impulsive behaviors, anxiety disorder, bipolar disorder, and psychotic disorder (other than schizophrenia). Resident #52 had a physician order for Invega Sustenna Suspension 234 MG/1.5ML (Paliperidone Palmitate; an atypical antipsychotic) Inject 1.5 ml intramuscularly one time a day every 28 day(s) for PTSD/BIPOLAR DISORDER, with an order date of 11/9/2023 and a start date of 11/13/2023. Per Resident #52's MAR, and confirmed by a 12/11/23 progress note, Resident #52 was scheduled to have this medication administered on 12/11/23, 28 days following the 11/13/2023 administration, but it was not administered because the medication was not available. As a result, Resident #52 was at increased risk for increased behavioral and mental health symptoms. See F760 for more information. A physician note dated 12/14/23 reveals [S/He] admits [his/her] depression has been a bit worse lately . At times, [s/he] has thoughts of suicide, but denies any active plan. This note continue paliperidone palmitate injection 234 mg IM monthly. This note does not address that Resident #52 did not receive their dose three days prior (12/11/23) when it was scheduled to be administered. Per interview on 12/21/23 at 11:30 AM, the Unit Manager stated that s/he was unaware that Resident #52 did not receive his/her Invega Sustenna as ordered and should have been notified. Per interview on 12/21/23 at 2:55 PM, the Director of Nursing was unaware that Resident #52 was not administered his/her Invega Sustenna as ordered. After bringing this medication omission to the facility's attention, the facility obtained the medication from the pharmacy and a new physician order. Resident #52 was administered the medication on 12/23/2023, twelve days after the scheduled order. 3. Per record review Resident #102 has diagnoses that include diabetes requiring daily insulin. A 12/11/23 Endocrinology consult note shows a new medication order for Ozempic related to diabetes management. Resident #102 has a physician order for Ozempic (0.25 or 0.5 MG/DOSE) 2 MG/3ML Solution pen-injector INJECT 0.25MG SUBCUTANEOUSLY EVERY MORNING FOR 7 DAYS; INJECT 0.5MG SUBCUTANEOUSLY EVERY MORNING FOR 7 DAYS;INJECT 1MG SUBCUTANEOUSLY EVERY MORNING FOR 7 DAYS, with a start date of 12/14/23. Per Resident #102's MAR and confirmed by a 12/14/23 progress note, Resident #102 did not receive their Ozempic on 12/14/23 because the medication was available. This order was discontinued on 12/19/23 and a new order for Ozempic was placed with a start date of 12/20/23. Per Resident #102's MAR, s/he received his/her first does of Ozempic, 6 days after the initial start date. There is no evidence in Resident #102's medical record that a physician was notified of the missed dose between 12/14/23 and 12/18/23. 4. Per record review Resident #81 has diagnoses that include acute transverse myelitis (inflammation of the spinal cord; symptoms may include pain), anxiety, and lower back pain. Physician orders reveal that Resident #81 has orders to receive New Age Naturals Advanced Hemp Gummies 100 MG Give 1 gummy by mouth three times a day for pain / anxiety, which began on 11/17/23. Per review of Resident #81's MAR for December 2023, and confirmed by MAR administration notes, Resident #81 did not receive their scheduled hemp gummies 1 time on 12/9/23, 1 time on 12/20/23, 3 times on 12/21/23, 3 times on 12/22/23, 3 times on 12/23/23, and 1 time on 12/24/23 because the medication was not available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 2 of 35 sampled residents (Residents #7 and #52) are free from significant medication errors related to missed medication administration. As a result, Resident #7 experienced significant, untreated pain and Resident #52 was at increased risk for increased behavioral and mental health symptoms. Findings include: 1. Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). Resident #7's 10/2/23 Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 10/2/23 reveals that s/he shows indicators of pain daily and is assessed to have a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness). Resident #7's care plan states that I have pain or have the potential in an alteration in my comfort r/t [related to] history of bladder and breast Cancer, Chronic Physical Disability r/t spastic CP [cerebral palsy], quadriplegia, polyneuropathy and bilateral knee pain created on 3/3/2020, with a goal that My pain will be managed daily, created on 3/3/2020. Interventions include Provide medication as ordered, created on 2/23/2023. Physician orders reveal that Resident #7 has orders to receive oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) Give 5 ml by mouth three times a day for pain, which began on 2/20/23. Per review of Resident #7's MAR (Medication Administration Record) for November 2023 and December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled oxycodone twice on 11/16/23 (afternoon and evening), three times on 12/8/23 (morning, afternoon, and evening) and two times on 12/9/23 (morning and afternoon) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses on 11/26/23 or 12/8/23 and was not notified until after the first missed dose on 12/9/23. On 12/21/23 at approximately 9:30 AM, the Unit Manager confirmed that neither s/he nor the physician were notified every time Resident #7 did not receive their oxycodone and should have been. Pain assessments during the above periods reveal the following: On 11/16/23, at the time medications were due, Resident #7 had pain assessments of 0 for the afternoon and a 5 for the evening; on 12/8/23, at the time medications were due, Resident #7 did not have pain assessments documented (morning, afternoon, and evening) but additional pain assessments for that day were documented as a 0; on 12/9/23, at the time medications were due, Resident #7 did not have pain assessments documented (morning and afternoon) but additional pain assessments for those times were documented as a 0 and a 4. However, the accuracy of these pain assessments are questionable based on the following interviews and record reviews. Record review and interview reveal that Resident #7 suffers greatly when his/her pain is not managed. Per interview on 12/21/23 at approximately 9:30 AM, the Unit Manager explained that Resident #7 is normally in pain. S/He explained that while Resident #7 is unable to communicate by speech, s/he can communicate clearly non-verbally. S/He explained that Resident #7's pain can be assessed with a numerical pain scale but sometimes staff use the PAINAD (an instrument for measurement of pain in noncommunicative patients). Weekly psychological service progress notes dated from 10/20/23 through 12/8/23 indicate that Resident #7 had been working on coping skills related to feeling frustrated with communication and being able to verbalize his/her pain. A 12/8/23 psychological services progress note Patient was alert and fully oriented. Patient reported she was in a lot of pain and was feeling uncomfortable. This note was from a day where Resident #7's pain was only documented as a 0 for the entire day. A 12/15/23 clinical treatment therapy plan of care note reveals, Patient reported depressive symptoms related to [his/her] situation, including pain. Ability to effectively communicate continues to be very frustrating for [him/her] Assessments from this visit indicated that Resident #7 had severe anxiety disorder and moderate depression; an increase from the previous 8/11/23 assessment. Per interview on 12/21/23 at 9:45 AM, Resident #7 indicated that s/he is in pain most of the time and the pain reaches a level of 10 often. S/he indicated that the pain medications do help a little but not completely. When asked about the two days in December when s/he did not receive her pain medication, s/he indicated that his/her pain was very bad. Per interview on 12/21/23 at 2:55 PM, the Regional Nurse Consultant confirmed that Resident #7 was not administered his/her oxycodone as ordered and there was no evidence that a physician was notified of each of the missing medication administrations and should have been. 2. Record review, interviews, and observations reveal that Resident #7 has trouble with oral secretions which began in October 2023. Due to Resident #7's diagnoses of spastic quadriplegic cerebral palsy and dysphagia, troubles managing oral secretions would put him/her at increased risk for aspiration and skin breakdown. A 10/16/23 progress note indicates that Resident #7 was having difficulty breathing. S/He had an oxygen saturation of 79% on room air, was tachycardic (fast heartrate), required oxygen, and suctioning due to mucus in his/her throat. The physician was made aware and Resident #7 was prescribed a scopolamine patch (used to reduce mucus and salvia production). A 12/19/23 nurse note states, Resident presenting with secretions, congestion, and a non-productive cough. Per interview on 12/20/23 at 2:27 PM, the Unit Manager revealed that Resident #7 has trouble with oral secretions. On 12/21/23 at 9:45 AM, Resident #7 was observed having a weak, mucous cough. A 12/21/23 physician note states [Resident #7] has difficulty with oral secretions. Physician orders reveal that Resident #7 has orders to receive Scopolamine Transdermal Patch 72 Hour 1 MG/3DAYS (Scopolamine) Apply 1 patch transdermally every 72 hours for Secretions and remove per schedule, which began on 10/17/23. Per review of Resident #7's MAR (Medication Administration Record) for October through December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled scopolamine patch 9 out of the 21 scheduled times through 12/22/23 (10/29/23, 11/4/23, 11/13/23, 11/19/23, 11/22/23, 12/4/23, 12/13/23, 12/19/23, and 12/22/23) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses. Per interview on 12/21/23 at 2:55 PM, the Regional Nurse Consultant confirmed that Resident #7 was not administered his/her scopolamine as ordered and a physician was not notified of each of the missing medication administrations and should have been. Per interview on 12/26/23 at approximately 1:45 PM, the Director of Nursing stated that s/he was unaware that Resident #7 did not receive his/her scopolamine patch on the above dates. S/He stated that s/he and the provider should have been notified because there was atropine (which can also be used to treat oral secretions) available in the facility and staff could have gotten an order for that while the medication was unavailable. 3. Per record review, Resident #52 was admitted to the facility on [DATE] with diagnoses that include post-traumatic stress disorder (PTSD), traumatic brain injury with impulsive behaviors, anxiety disorder, bipolar disorder, and psychotic disorder (other than schizophrenia). Per interview and observation on 12/18/2023 at 10:30 AM, Resident #52 stated that s/he was on medications for his/her mood swings. S/He expressed concerns about losing his/her independence and relying on staff who were inattentive and rough with his care needs. During this interview Resident #52 expressed feelings of sadness and became weepy and for a few moments, s/he withdrew from the conversation in tears. Resident #52 had a physician order for Invega Sustenna Suspension 234 MG/1.5ML (Paliperidone Palmitate; an atypical antipsychotic) Inject 1.5 ml intramuscularly one time a day every 28 day(s) for PTSD/BIPOLAR DISORDER, with an order date of 11/9/2023 and a start date of 11/13/2023. Per Resident #52's MAR, and confirmed by a 12/11/23 progress note, Resident #52 was scheduled to have this medication administered on 12/11/23, 28 days following the 11/13/2023 administration, but it was not administered because the medication was not available. A physician note dated 12/14/23 reveals [S/He] admits [his/her] depression has been a bit worse lately . At times, [s/he] has thoughts of suicide, but denies any active plan. This note continue paliperidone palmitate injection 234 mg IM monthly. This note does not address that Resident #52 did not receive their dose three days prior (12/11/23) when it was scheduled to be administered. Per interview on 12/21/23 at 11:30 AM, the Unit Manager stated that s/he was unaware that Resident #52 did not receive his/her Invega Sustenna as ordered and should have been notified. Per interview on 12/21/23 at 2:55 PM, the Director of Nursing was unaware that Resident #52 was not administered his/her Invega Sustenna as ordered. After bringing this medication omission to the facility's attention, the facility obtained the medication from the pharmacy and a new physician order. Resident #52 was administered the medication on 12/23/2023, twelve days after the scheduled order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 3 eligible residents (Residents #50, #270, and #80) on one unit received the influenza vaccine. As a result, one unvaccinated resident (Resident #50) developed influenza and required hospitalization for dehydration and abnormal lung sounds, and two residents (Resident #270 and #87) were at increased risk for contracting influenza and/or developing influenza complications. 1. Per record review, Resident #50 was admitted to the facility on [DATE] with diagnoses that include diabetes and severe kidney disease. S/He was recently assessed at the emergency room related to elevated kidney function labs and a urinary tract infection according to a 12/16/23 emergency visit note. Resident #50 is considered high risk for influenza complications because of his/her diagnoses and nursing home admission. An undated form titled Vaccination Review: Consent/Declination Resident Form, entered into Resident #50's medical record with the effective date of 11/20/23, reveals that his/her vaccination history was assessed for influenza, Covid-19, and pneumococcal. The form indicates that s/he did not receive a 2023 influenza vaccine. Under decision to vaccinate, the choices not eligible, consented, and declined are all left blank. The resident, nor their representative, did not sign off that they were provided education or that they consented or declined the administration of the influenza vaccine. There is no evidence that Resident #50 received the influenza vaccine in his/her medical record or that s/he had a medical contraindication to receive the vaccine. Per interview on 12/18/2023 at 9:07 AM, Resident #50 stated that s/he does not feel good at all and was needing to rest. A 12/18/23 physician visit note reveals that Resident #50 was complaining of a scratchy throat which started late the night before/earlier that morning. A 12/18/23 progress note reveals that Resident #50 had a rapid flu test and was positive for influenza A. A 12/21/23 physician note reveals the following: HPI [history of present illness]: Patient seen because of continued illness with influenza. When I saw the patient [s/he] was sleeping [s/he] was arousable [s/he] was alert. But [s/he] had a hard time staying awake. The patient has not been eating or drinking. Despite the staff efforts to constantly come in and give [him/her] fluids. [S/He] does not feel like eating or drinking [s/he] has been feeling quite sick. No ear pain no eye symptoms mild stuffy nose no sore throat no difficulty breathing but [s/he] does have a persistent cough. [S/He] feels nauseated no abdominal pain no. The nausea is the main reason [s/he] cannot eat or drink anything at this time . Physical Exam: This patient appears to be in mild to moderate distress. [S/He] was retching when I came in the room. After I woke [him/her]. It started within a few seconds. [S/He] does not have tenting but [his/her] mucous membranes are dry. [S/He] appears to be very tired. [S/He] is alert and oriented. Lungs have nonspecific coarse sounds throughout .Assessments/Plans: Influenza due to identified novel influenza A virus with other manifestations . Patient is dehydrated and also has abnormal lung sounds. And not able to take fluids we are not able to start an IV here. Patient will need to go to the ER [emergency room] for further evaluation and treatment. A 12/21/23 transfer form reveals that Resident #50 was transferred to the emergency room on [DATE] for the following reason: flu, n/v [nausea/vomiting], poor appetite, decreased fluid intake . Additional Relevant Information: poor kidney function, ID [infectious disease] patient, dx [diagnosed] w/ FLU. A 12/21/23 hospital admission note reveals the following: Assessment: Resident #50 is a 60 y.o. [year old] [gender] with a PMHx [past medical history] significant for T2DM [type 2 diabetes mellites] c/b [complicated by] neuropathy [nerve damage], retinopathy [disease of the retina] and CKD4 [stage 4 kidney disease]. HTN [hypertension], Seizure disorder (on Keppra [seizure medication]), left TMA [transmetatarsal amputation; removal of part of the foot] (2019) and recent hospitalization (10/20-11/6) for osteomyelitis [bone infection] as a result of a burn with course complicated by shock secondary to GBS bacteremia [bloodstream infection] (now s/p [status post] right BKA [below knee amputation]), as well as type II NSTEMI [heart attack] who presents with 3-5 days of increased confusion, poor PO [by mouth] intake in the setting of new diagnosis FluA and ongoing treatment for a UTI [urinary tract infection] with cefpodoxime [antibiotic]. Patient likely with multifactorial toxic/metabolic encephalopathy [brain disease that alters brain function or structure] due to infection, dehydration, and buildup of metabolites [substance resulting from the metabolism of a drug] with [his/her] PTA [prior to admission] medication in the setting of poor renal [kidney] function. In addition, chest x-ray results reveal possible pneumonia in the left lung base, very faint and appearance and visible only on the lateral view, therefore equivocal. Per interview on 12/21/23 at 9:07 AM, the Director of Nursing/Infection Preventionist explained that Resident #50 did not receive an influenza vaccine because s/he was on antibiotics and staff have been instructed not to vaccinate residents that are taking antibiotics. Per interview on 12/26/23 at approximately 9:30 AM, the Attending Physician stated that being on antibiotics is not a contraindication to receive vaccinations. 2. Record review reveals that Resident #270, who is [AGE] years old, was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (stroke), diabetes, and asthma. Resident #270 is considered high risk for influenza complications because of his/her age, diagnoses, and nursing home admission. Resident #270 also resides on a unit at the facility where there is an active case of influenza. An undated form titled Vaccination Review: Consent/Declination Resident Form, entered into Resident #270's medical record with the effective date of 12/6/23, reveals that his/her vaccination history was assessed for influenza, Covid-19, and pneumococcal. The form indicates that s/he did not receive a 2023 influenza vaccine. Under decision to vaccinate, the choices not eligible, consented, and declined are all left blank. The resident, nor their representative, did not sign off that they were provided education or that they consented or declined the administration of the influenza vaccine. There is no evidence that Resident #270 received the influenza vaccine in his/her medical record or that s/he had a medical contraindication to receive the vaccine. 3. Per record review, Resident #87, who is [AGE] years old, was admitted to the facility on [DATE] with diagnoses that include COPD (Chronic Obstructive Pulmonary Disease), diabetes, heart disease, and kidney disease. Resident #87 is considered high risk for influenza complications because of his/her age, diagnoses, and nursing home admission. Resident #87 also resides on a unit at the facility where there is an active case of influenza. A form titled Vaccination Review: Consent/Declination Resident Form, dated 12/14/23, reveals that Resident #87 vaccination history was assessed for influenza, Covid-19, and pneumococcal. The form indicates that s/he did not receive a 2023 influenza vaccine. Under decision to vaccinate, the choices not eligible, consented, and declined are all left blank. There is no evidence that Resident #87 received the influenza vaccine in his/her medical record or that s/he had a medical contraindication to receive the vaccine. Per interview on 12/26/23 at approximately 1:45 PM, the Director of Nursing/Infection Preventionist was unable to determine why Residents #270 and #87 did not receive the influenza vaccine by looking at their vaccination review forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide safe and effective skin and wound care consistent with facility policy and professional standards of practice for preventing and treating existing pressure ulcers for 7 of 37 sampled residents (Residents #50, #7, #1, #99, #43, #21, and #107), resulting in new or worsening pressure ulcers for all 7 residents. Findings include: Facility policy titled Pressure Ulcer, Pressure Injury & Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management (HAM, [NAME], SS, WAV, WMS [facility name initails]) SNF, last revised on 2/27/2023 reveals the following under procedures: Care Plan Development & Implementation: a baseline care plan will be developed by the IDT [interdisciplinary team] within 48 hours of admission identifying appropriate interventions to stabilize, reduce or remove underlying risk factors to prevent or treat skin conditions. The individualized care plan will be reviewed and revised as needed to meet the skin care needs of the resident based on assessment and risk factors. Medical providers are part of the IDT and will discuss, review, monitor and assess the progress of ulcers, pressure injuries or other skin conditions during routine visits and when necessary. Ongoing assessment of existing pressure ulcers, pressure injuries & other skin conditions will be conducted weekly by facility staff and/or a consultant who specialized in wound management. Progress, treatment, and care plan interventions are reviewed at that time and will be documented in the medical record. Wound consultant progress notes will be scanned into the medical record and may be used as the source document to meet the requirement of a weekly assessment. The assessment will include characteristics of the wound and surrounding tissue such as but not limited to presence of epithelial or granulation tissue, measurements, stage, presence of exudates, necrotic tissue such as eschar or slough and evidence of erythema or swelling around the wound. Staging of a pressure ulcer or pressure injury will be conducted according to professional standards of practice. Documentation also includes signs and symptoms of pain and intervention for pain related to the wound or treatment. Appendix F: Wound Care & Skin Product Formulary Guide, dated 2/19/2020, reveals the following formulary products for MASD: Thera Calazinc Body Sheild Cream (zinc product) and [NAME] Med Skin Protectant (aluminum hydroxide product); guidelines for use, Apply QS [every shift] & PRN [as needed] or as directed by MD order; considerations, Nurse to apply. 1. Per record review, Resident #50 was admitted to the facility on [DATE] for rehabilitation services following a below-knee amputation (BKA) with diagnoses that include diabetes, osteomyelitis (bone infection), hypertension, and severe kidney disease. A 11/20/23 form titled Braden Scale for Predicting Skin Ulcers, a tool used to identify the level of risk a resident has for developing pressure ulcers, reveals that Resident #50 is at risk. Review of an initial wound assessment dated [DATE] reveals that Resident #50 has an abrasion on his/her lower left leg 2.5 cm x 0.2 cm. There are 3 other skin conditions identified on this assessment: MASD (Moisture-associated skin damage, which can contribute to the formation of a pressure injury since the tissue has been compromised) on the groin, MASD on the coccyx, and a surgical incision on the right knee. There is no documentation of the size of these conditions. A second wound assessment dated [DATE] reveals that Resident #50 has a left lower leg abrasion that is 2.5 x 0.2 cm; a groin MASD that is marked healed; a coccyx MASD, 1 x 0.5 cm; and a right knee surgical incision, 16 x 0.1 cm. A third wound assessment dated [DATE] reveals that Resident #50 has groin MASD, no measurement; coccyx MASD, no measurement; and no assessments of abrasion or surgical incision from the previous assessment. Record review reveals that Resident #50 did not have a baseline care plan within 48 hours of admission related to his/her risk for impaired skin or for the skin conditions present on admission. The following care plan focus was created 25 days after admission SKIN INTEGRITY: I am at risk for impaired skin integrity related to 5 (or more) medications, Activity Intolerance, Deconditioning, Diabetes, Hx [history] of Pressure Ulcers, Immobility, Incontinence, Overall Physical Condition, initiated on 12/15/23. It does not address the actual condition of Resident #50's skin. Apply/administer treatments and barrier creams, as ordered, created 12/15/23. Per review of physician order and the medication and treatment administration records, Resident #50 does not have physician orders for any wound treatment or barrier creams and there is no evidence in their medical record that any wound treatment or barrier creams were provided. Per review of a 12/21/23 transfer form, Resident #50 was transferred to the emergency room on [DATE]. Review of a 12/21/23 hospital admission note reveals on physical exam Resident #50 has a purplish/erythematous (redness of the skin) ulcer per imaging, and has a wound consult planned related to Resident #50's sacral pressure wound. The note includes a small photograph of Resident #50's sacrum and coccyx area that is approximately 6 inches by 4 inches and dark purplish red. It is difficult to determine if the area is open based on just the photo. Review of a 12/22/2023 hospital wound care note reveals the following, Healing fungal rash notes to sacrum extending down bilateral buttocks. Superficial ulceration to left buttock and left coccyx, etiology likely moisture and friction. Linear, full thickness wound in gluteal cleft. Difficult to determine primary etiology as linear distribution tends to be due to moisture and friction however wound is located directly over coccyx so could likely have a pressure component. All wounds present on admission. Per interview on 12/26/23 at approximately 8:30 AM, the Unit Manager stated that it is very difficult to get a sense of the current status of the skin and current wounds with the skin assessment form that is used in the EMR (electronic medical record). S/He was unable to find any wound care orders for Resident #50 and confirmed that Resident #50 did not have a baseline care plan for skin and should have. 2. Per record review, Resident #1 has diagnoses that include diabetes, end stage renal disease requiring dialysis, malnutrition, and a history of pressure ulcers. A 7/10/23 MDS (Minimum Data Set; a comprehensive assessment used as a care-planning tool) assessment reveals that Resident #1 is at risk for developing pressure ulcers. Review of an 8/29/23 wound assessment reveals that Resident #1 has a stage 3 pressure left heel pressure ulcer that measures 3.9 cm length x 3.0 cm width x 0 cm depth. Review of a 10/25/23 wound assessment reveals that Resident #1's stage 3 pressure left heel pressure ulcer now measures 4.5cm length x 4.0 cm width x 0 cm depth, an increase from the previous 8/29/23 wound assessment. There are no weekly skin assessments completed between the two assessments above. Review of Resident #1's physician orders reveals the following order for his/her heel wound, Clean left heel wound with NS [normal saline], pat dry, skin prep around wound edges X2, apply solosite [wound gel] soaked gauze to WOUND BED ONLY and cover with two 4x4 gauze, apply tubigrip [bandage] daily until wound resolves. every evening shift for WOUND CARE, with a start date of 7/24/23. Per Resident #1's Treatment Administration Record, this order is not marked as complete for the time between 8/29/23 and 10/25/23 9 times during September 2023 and 4 times during October 2023. Per phone interview on 12/26/23 at 11:23 AM, the MDS Coordinator confirmed that Resident #1 did not have all their wound assessments completed weekly for their actual pressure ulcers and should have. 3. Per record review, Resident #99 has diagnoses that include diabetes, peripheral vascular disease, difficulty walking, and need for assistance with personal care. Resident #99 had a left great toe amputation on 6/15/23. Per record review, Resident #99 has the following care plan I am at risk for impaired skin integrity related to Diabetes and immobility, I have a left first toe partial amputation, revised on 6/19/23 with interventions that include, monitor skin daily and report any signs of skin breakdown, and conduct systemic skin inspection weekly and as needed. Document findings. Review of an 8/31/23 wound assessment reveals that Resident #99 has an unresolved, unchanged surgical incision from the left toe amputation site that measures 8 cm x 1 cm. Review of a 10/2/23 wound assessment reveals that Resident #99 continues to have an unresolved, unchanged surgical incision from the left toe amputation site. There are no measurements of this wound in this wound assessment. There are no weekly wound assessments from 9/1/23 through 10/1/23 in Resident #99's medical record. According to the facility's policy and professional standards, there should have been a minimum of four wound assessments during this time. Review of Resident #99's physician orders reveals the following order, Diabetic foot check q (every) day, report s/sx [signs and symptoms] of skin breakdown to MD [physician]. every evening shift every 7 day(s) for diabetes -Start Date 09/23/2023. Resident #99's Treatment Administration Record for September, October, November, and December 2023 reveal that diabetic foot checks were only completed only once a week. Per record review, a 12/1/23 progress notes state, writer was informed by resident in the AM that the three toes on the left foot (excluding little toe) were hurting and resident was concerned with getting an infection; toes were red and warm to touch, and Writer spoke with therapy regarding getting a bed extender for resident's bed; writer sees that resident is touching the foot of bed and it may be contributing to pressure on the resident's toes. Per a Physician note dated 12/1/23, Resident #99 was seen for left foot pain. The provider describes examination of the left toe to have a small amount of scab that the patient notes has improved. This note does not assess the wound completely; there are no measurements or documentation that the pervious incision has fully healed. Record review reveals the following physician order, Apply telfa [cotton pad] and kerlix [gauze] to left foot every other day until steri stips fall off. every evening shift every Wed, Sun for Wound care, with a start date of 9/10/23. This is marked as complete as scheduled on the TAR on all but three days scheduled (missing 9/20/23, 10/4/23, and 11/29/23). The continuation of wound care implies that the wound has not healed and still needs treatment. A Physician progress note dated 12/13/23 reveals .Patient has a stage 3 (full thickness skin loss) non-inflamed ulcer over his/her distal amputated first toe The note indicates that the patient's pain in his/her left foot is consistent with cellulitis will be treated with Keflex. The infected toe is Resident #99's left toe and his/her great left toe has an ulcer. A 12/13/23 wound assessment reveals a stage 2 pressure ulcer (Partial-thickness skin loss) on Resident #99's left great toe 1 cm x 0.5 cm in size and his/her left second toe has an area of trauma. There are no weekly wound assessments of this area between 10/2/23 and this note dated 12/13/23 in Resident #99's medical record. According to the facility's policy and professional standards, there should have been a minimum of ten wound assessments during this time since the last skin assessment. During a phone interview on 12/21/23 at 12:02 PM with the MDS Registered Nurse Coordinator, he/she confirmed that the weekly skin assessments were not completed consistently for Resident #99. Per interview on 12/26/23 at 10:35 AM, the Regional Nurse Consultant reviewed Resident #99's weekly skin assessments and was unable to produce skin assessments of Resident #99's left toe wound for the missing weeks mentioned above. 4. Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), and is at risk for developing pressure ulcers according to a 10/2/23 MDS (Minimum Data Set; a comprehensive assessment used as a care-planning tool). Resident #7 has the following care plan focus, I am at risk for fungal infections and/or impaired skin integrity related to Deconditioning, Immobility, Overall Physical Condition, Poor Nutritional Status, created on 3/3/2020. A 11/17/23 progress note reveals Writer was made aware of unstageable pressure area [full thickness tissue loss in which the base of the ulcer is covered by slough (non-viable tissue) and/or eschar (dry, non-viable tissue) in the wound bed] on residents right buttock. Resident states pressure area is painful. New tx [treatment] order to apply santyl [an ointment that removes dead tissue from wounds so they can start to heal] everyday shift and cover with allevyn [brand] foam dressing. Resident #7's care plan was revised to include the following focus, I have an alteration in skin integrity r/t decreased mobility. Unstageable pressure area on right buttock, created on 11/17/23 with an intervention for Assess and document status of wound/skin site(s) weekly and as needed, created on 11/17/23. Review of an initial wound assessment (Skin Assessment form in the electronic medical record) dated 11/17/23 reveals that Resident #7 has an in-house acquired unstageable pressure ulcer on the right buttock that is 3 cm X 2 cm in size. This assessment does not include characteristics of the necrotic tissue. There are no weekly wound assessments or evidence that progress, treatment, and care plan interventions were reviewed for the existing pressure ulcer from 11/18/23 through 12/14/23 in Resident #7's medical record. According to the facility's policy and professional standards, there should have been a minimum of three wound assessments during this time. Review of a 12/15/23 skin assessment form reveals that Resident #7 has a stage 3 pressure ulcer (full thickness skin loss) on the right buttock that is 3 cm x 2.8 cm in size. This assessment does not include characteristics of the wound and surrounding tissue. While it was expected that treatment would expose at least a stage 3 pressure ulcer following treatment, the wound did increase in size. There is no evidence that a medical provider was informed of the change of status of Resident #7's pressure ulcer. Because of this, there is no evidence in Resident #7's medical record that progress, treatment, and care plan interventions were reviewed at the time of the 12/15/23. There are no weekly wound assessments or evidence that progress, treatment, and care plan interventions were reviewed for the existing pressure ulcer from 12/16/23 through 12/26/23 in Resident #7's medical record. According to the facility's policy and professional standards, there should have been a minimum of one wound assessment during this time. Review of Resident #7's physician orders reveal the following, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Right Buttock topically every evening shift for Wound Care, with a start date of 11/18/2023, and Right Buttock: Cleanse with NS, pat dry. Apply Santyl nickel thick to wound bed only. Cover with alleyvn foam dressing. every evening shift for Wound Care, with a start date of 11/18/2023. While the first order for Santyl is documented as complete in Resident #7's MAR, the second treatment order, which describes how the Santyl ointment is to be applied, and what type wound care is to be used, including cleaning and dressings, is not marked as complete for 12/6/23, 12/8/23, 12/12/23, 12/15/23, 12/17/23, 12/18/23, and 12/26/23. Per interview on 12/21/23 at approximately 9:30 AM, the Unit Manger confirmed that the above wound treatment orders were not documented as administered for Resident #7 for the above times. S/He indicated that s/he was unsure why there were no wound assessments completed between the 11/17/23 and the 12/15/23 assessments. 5. Record review reveals that Resident #107 was admitted to the facility on [DATE] and has diagnoses that include diabetes, obesity, and abnormalities of gait and mobility. Per Resident #107's MDS dated [DATE], s/he requires a mix of partial, substantial. and complete assistance for most ADLs excluding eating, is at risk for developing pressure ulcers, and does not have any unhealed pressure ulcers at the time of the assessment. Review of an admission skin assessment dated [DATE] skin reveals that Resident #107 has only a surgical incision on their chest which was present on admission. No other skin conditions are identified. There are no weekly skin assessments or wound assessments for the existing surgical incision from 7/26/23 through 8/21/23 in Resident #107's medical record. According to the facility's policy and professional standards, there should have been a minimum of three wound assessments during this time. Review of Resident #107's MAR shows a physician order for Left Heel: skin prep every shift for Deep Tissue injury [closed wound where the tissues beneath the surface have been damaged], with a start date of 8/10/23. There is no evidence that this wound was assessed when it was first discovered. An 8/22/23 skin assessment reveals that Resident #107 has an in-house acquired left heel pressure ulcer that measures 3 cm x 4 cm x 0 cm. There is no staging information or date for when this wound was acquired. Review of an 8/26/23 skin assessment reveals that Resident #107 has a newly identified in-house acquired pressure ulcer on the left lower leg. There is no staging information or measurements of this wound. Review of an 8/29/23 skin assessment reveals that Resident #107's left lower leg is now being documented as an abrasion that measures 3.5 cm x 1 cm x 0 cm and the left heel is measured to have the same area and is still not staged. Record review reveals that between 8/30/23 and 10/11/23 Resident #107 was missing two wound assessments and two wound assessments did not have the completed information. Review of a 10/12/23 skin assessment reveals that Resident #107's left lower leg abrasion has worsened to an unstageable left calf pressure ulcer that measures 4 cm x 3 cm x 1 cm and their left heel has worsened to a suspected deep tissue pressure injury that measures 2.5 cm x 1.5 cm x 0 cm. The following weekly wound assessments reveal that on 11/6/23 the pressure injury to Resident #107's heel increased in size to 5.5 cm x 3.5 cm x 0 cm, and on 11/16/23, Resident #107's left calf pressure ulcer has worsened to a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) that measures 3.9 cm x 3.1 cm x 2.8 cm. Resident #107's care plan was not revised to reflect his/her actual skin conditions related to his/her calf until 11/2/23, 68 days after it was first assessed, and heel until 11/2/23, 72 days after it was first assessed. Per interview on 1/10/24 at 4:07 PM, the Director of Nursing confirmed that Resident #107 had incomplete and missing wound assessments and their care plan was not revised to reflect existing wounds when they were first identified. The facility wound management policy was requested on 1/9/24 at 10:20 AM. On 1/9/24 at approximately 3:00 PM, both the Director of Nursing and the Asisstant Director of Nursing were unable to produce an up to date wound management policy. On 1/11/24 at 8:10 AM, when asked to produce the current wound policy, the Unit Manager was only able to find a policy that was not applicable to the facility's wound assessment procedure. The policy that was available referred to using a photograph system to document wound progress which had stopped being used in the Spring of 2023. On 1/11/24 at 3:07 PM, the Chief Nursing Officer confirmed that the facility policy titled Pressure Ulcer, Pressure Injury & Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management (HAM, [NAME], SS, WAV, WMS) SNF, last revised on 2/27/2023, was the wound policy that the facility should be using for wound management even though the title does not include the facility's initials. 6. Record review reveals that Resident #43 has diagnoses that include diabetes, peripheral vascular disease, and reduced mobility. Per Resident #43's MDS dated [DATE], s/he is dependent on staff for all ADLs, is at risk for developing pressure ulcers, and does not have any unhealed pressure ulcers at the time of the assessment. Resident #43 has the following care plan focus, I have an alteration in skin integrity r/t pressure injury on right foot r/t impaired mobility, initiated on 11/2/23 with interventions to apply treatments as MD/NP orders and assess and document status of wound/skin site(s) weekly and as needed, initiated on 11/2/23. Review of a 11/6/23 skin assessment reveals that Resident #43 has an in-house acquired stage 2 right foot pressure ulcer measuring 1 cm x 1.5 cm x 0.1 cm and wound progress is described as improving. Review of a 11/15/23 skin assessment reveals that Resident #43's stage 2 right foot pressure ulcer measuring 1.1 cm x 1.7 cm x 0.1 cm and wound progress is described as worsening. There are no weekly wound assessments for the existing pressure ulcer from 11/16/23 through 11/29/23 in Resident #43's medical record. According to the facility's policy and professional standards, there should have been a minimum of one wound assessment during this time. Review of a 11/30/23 skin assessment reveals that Resident #43's right foot wound is now a stage 3 pressure ulcer measuring 6.5 cm x 4.5 cm x 0.5 cm and wound progress is described as worsening. Review of Resident #43's physician orders reveal the following, Medihoney Wound/Burn Dressing External Gel (Wound Dressings) Apply to Right Lateral Foot topically every day shift for Wound Care, started on 11/9/23 and discontinued on 11/15/23. Per the MAR, this order is not marked as complete for 2 of the 7 days ordered (11/14/23 and 11/15/23). There are orders for cleaning or dressing the right foot wound in the MAR or TAR from 11/9/23 through 11/15/23. Medihoney Wound/Burn Dressing External Gel (Wound Dressings) Apply to Right Lateral Foot topically every day shift for Wound Care Cleanse with wound cleanser, pat dry. Apply medihoney to wound bed only. Cover with allevyn foam dressing, with a start date of 11/16/23. Per the MAR, this order is not marked as complete for 3 of the 15 remaining days in November (11/18/23, 11/20/23 and 11/29/23). Per interview on 1/10/24 at 4:07 PM, the Director of Nursing confirmed that Resident #43 had incomplete and missing wound assessments and their care plan was not revised to reflect existing wounds when they were first identified. Per interview on 1/11/24 at 8:51 AM, the Regional Nurse Consultant confirmed that Resident #43's treatment orders for their right foot wound from 11/9/23 through 11/15/23 did not include instructions for cleaning and dressing the wound and should have. 7. Record review reveals that Resident #2 has diagnoses that include diabetes, severe obesity, and abnormalities of gait and mobility. Per Resident #2's MDS dated [DATE], s/he is dependent on staff for all ADLs excluding eating, is at risk for developing pressure ulcers, and does not have any unhealed pressure ulcers at the time of the assessment. Resident #2 has the following care plan focus, I am at risk for impaired skin integrity related to Diabetes, Incontinence, decreased mobility with hemiplegia [paralysis on one side of the body] s/p cva [status post stroke] and obesity related to skin folds, revised on 4/29/21, with interventions that include, Appy/administer treatments and barrier creams, as ordered, and conduct systemic skin inspections weekly and as needed. Document findings, initiated on 6/10/19. Review of a 11/24/23 skin assessment reveals that Resident #2 has a newly identified in-house acquired stage 2 pressure ulcer on the right buttock that measures 0.2 cm x 0.3 cm x 0.1 cm. There are no weekly wound assessments for the existing pressure ulcer from 11/26/23 through 12/12/23 in Resident #2's medical record. According to the facility's policy and professional standards, there should have been a minimum of two wound assessments during this time. Review of a 12/13/23 skin assessment reveals that Resident #2's right buttock stage 2 pressure ulcer has increased in size to 3 cm x 1 cm x 0.1 cm. This wound assessment is incomplete as it does not include characteristics of the wound. Resident #2's care plan does not reflect existing wounds until 12/18/2023, 25 days after the wound was first assessed. Per interview on 1/10/24 at 4:07 PM, the Director of Nursing confirmed that Resident #2 had incomplete and missing wound assessments and their care plan was not revised to reflect existing wounds when they were first identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to update a care plan following a fall, to prevent further falls and/or reduce the risk of injury for one of five residents included in the investigation sample (Resident #1). Findings include: Per record review, Resident #1 was an [AGE] year-old-person admitted to the facility from the acute care hospital with admission diagnosis including Parkinson's disease, Alzheimer's dementia, diabetes type 2, glaucoma, muscle weakness, chronic kidney disease and repeated falls. Approximately one week after Resident #1 was admitted to the facility s/he sustained a fall while attempting to use the bathroom without assistance. A review of the care plan revealed Resident #1 required the assist of one person and his/her walker for ambulation (walking). The care plan review also revealed no updates with new interventions following this fall, to prevent further falls or reduce the risk of injury from falls. On 5/1/23 Resident #1 sustained another fall, was transported to the hospital emergently and found to have significant trauma sustained during the fall. Problems managed by the hospital included cervical spine fracture of C1 and C2, acute minimally displaced fracture of right occipital condyle (the bony segment on the back of the skull that articulates with the neck allowing the skull to move side-side, up and down and rotate), multiple minimally displaced fractures of the bony nasal septum and nasal bones, a short segment right vertebral artery dissection (a flap like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain). During an interview on 5/15/23 at 11:30 AM with the Director and Assistant Director of Nursing they agreed the care plan had not been updated following the 4/21/23 fall until 5/1/23 which was following the traumatic second fall. See also F689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 2 of 4 residents sampled (Residents #1, and #2) received appropriate supervison to reduce accident hazards and risks, and to assess interventions for effectiveness. Findings include: 1. Resident #1 was an [AGE] year-old-person admitted to the facility from an acute care hospital where s/he had been hospitalized following several falls at home. Resident #1 had diagnosis that included Parkinson's disease, Alzheimer's dementia, glaucoma, generalized muscle weakness and repeated falls. Approximately one week after Resident #1 was admitted to the facility s/he sustained a fall while attempting to use the bathroom without assistance. A review of the care plan revealed Resident #1 required the assist of one person and his/her walker for ambulation (walking). The care plan review also revealed no updates with new interventions following this fall. On [DATE] Resident #1 sustained another fall while in the bathroom unsupervised. Resident #1 was transported to the hospital emergently and found to have significant trauma sustained during the fall. Problems managed by the hospital included cervical spine fracture of C1 and C2, acute minimally displaced fracture of right occipital condyle (the bony segment on the back of the skull that articulates with the neck allowing the skull to move side-side, up and down and rotate), multiple minimally displaced fractures of the bony nasal septum and nasal bones, a short segment right vertebral artery dissection (a flap like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain). A review of the record of hospitalization stated Resident #1 died while hospitalized . During an interview on [DATE] at 11:30AM with the Director and Assistant Director of Nursing it was confirmed that there had been no interdisciplinary team meeting to discuss care plan revisions and aside from attaching a sign stating call don't fall to Resident #1's walker no additional measures to provide supervision to ensure safety, or to reduce risk of injury from falls had been implemented. 2. Resident #2 was admitted to the facility with diagnoses to include multiple sclerosis, anxiety, chronic depression, quadriplegia, and muscle spasticity which puts him/her at risk of falling out of bed. Resident #2 had a recorded (Brief Interview of Mental Status) BIMS score of 14 indicating intact cognition. Resident # 2 was reliant on a blow bell to summon assistance as he/she was unable to use his/her upper extremities to push a call bell button for assistance. Per record review, on [DATE] at 5:42 AM Resident #2 was found on the floor and was emergently sent to the local emergency room for evaluation and returned to the facility without significant injury. Further review reveals a Physicians order dated [DATE] stating Nurse must visualize blow call light placement every hour while (Resident) is in bed. D/T (due to) muscle spasms moving his/her body away from blow straw. Every hour for safety checks while in bed visually verify blow call light is in correct placement, this order is to be signed off in the MAR hourly as a safety measure. On [DATE] at approximately 11:34 AM the DNS was interviewed regarding the circumstances and outcome of the facility investigation. The DNS stated and provided documentation providing the nurse on duty had falsified the documentation by signing off the hourly checks at 0300, 0400 and 0500 on [DATE] although he/she admitted to not having done the checks because of a nurse call-out s/he was trying to find coverage for. As a result of this Resident #2 reported the fall from bed took place at 0300, the documentation indicates that he/she was found on the floor at 0542. The Director of Nursing confirmed at 11:34 AM on [DATE] that the nurse on duty the night of this incident did not ensure this resident's safety or prevent the fall by failing to follow physician orders and further s/he incorrectly documented on the MAR that s/he had performed these tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Per interview and record review, the facility failed to provide treatment to an existing pressure injury for 3 applicable residents [Residents #1, #2 and #4] consistent with facility policy and professional standards of practice. Facility policy titled Skin Conditions, Wounds and Pressure Ulcers (Assessment and Monitoring Program), last modified on 2/3/2023 states Identified skin conditions and/or wounds will be reassessed weekly by a registered nurse until the presence of the condition is resolved, and The medical provider will review and assess the progress of skin conditions and/or wounds during required visits, or when necessary, and document in the medical record. 1. Record review reveals Resident #4 was readmitted to the facility with diagnoses that include congestive heart failure, end stage renal disease (ESRD), type 2 diabetes, history of spinal fusion, emphysema, and need for assistance with personal care on 9/14/22 following a hospital stay related to septic shock and pneumonia. Resident #4's care plan includes the following care plan focus: Skin integrity: I [Resident #4] am at risk for impaired skin integrity related to Activity Intolerance, Deconditioning, Immobility, actual skin breakdown r/t [related to] decline in status/refusal of repositioning 9/6/22, initiated on 6/13/2022. Interventions include conduct systemic skin inspections weekly and as needed. Document findings, initiated on 07/26/2022, and monitor skin condition daily and report any signs of skin breakdown, initiated on 06/13/2022. Review of Resident #4's wound evaluations on 11/23/2022 reveal a stage 2 pressure ulcer [partial-thickness skin loss with exposed dermis] on the right ischial tuberosity [sit bone located in the buttock] measuring 1.1 cm x 0.5 cm and an abscess on the spine [surface intact] measuring 1.9 cm x 0.6 cm. Resident #4's Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool), dated 12/3/2022, reveals that Resident #4 is at risk for developing pressure ulcers/injuries and has one stage 2 pressure ulcer. Review of Resident #4's wound evaluations on 12/6/2022 reveal a stage 2 pressure ulcer on the right ischial tuberosity measuring 2.5 cm x 1.3 cm. There are no additional wounds identified during this evaluation. There are no wound evaluations for Resident #4 from 12/7/2022 through 1/5/2023. Review of Resident #4's wound evaluations on 1/6/2023 reveal a stage 2 pressure ulcer on the right buttock measuring 2.5 cm x 1.3 cm, a stage 2 pressure ulcer on the left buttock measuring 5.1 cm x 2.6 cm, and a stage 2 pressure ulcer on the left buttock measuring 3.9 cm x 3.3 cm. Resident #4's discharge MDS, dated [DATE], reveals that Resident #4 has one stage 2 pressure ulcer, one stage 3 pressure ulcer [full thickness skin loss], and one stage 4 pressure ulcer [full thickness skin and tissue loss]. There is no evidence in Resident #4's medical record that the provider was notified of the worsening and/or developing of Resident #4's pressure ulcers and no documentation that the medical provider reviewed and assessed Resident #4's skin condition and/or wounds. Review of Resident #4's physician's orders reveal the following: Cleanse right ischial tuberosity wound with NSS [normal saline solution], pat dry, cover with Allevyn foam [foam dressing] every shift for skin condition start date 11/26/22. There are no treatment orders for the other two identified pressure ulcers from readmission on [DATE] through hospital transfer on 1/9/2023, or evidence that wound care was completed. A hospital note dated 1/10/2023 states that Resident #4 is found to be in likely septic shock from acute [and] chronic SSTI [skin and soft tissue infections] of [his/her] back/buttocks in setting of baseline chronic hypotension. The provider note reveals the following about Resident #4's clinical condition: Over the past 24 hours, there has been a high probability of sudden, clinically significant or life threatening deterioration in the patient's condition, which include the following diagnoses which I have managed: Active problems: ESRD, septic shock, decubitus skin ulcer [bedsore], wound infection complicating hardware, sequela, delirium. 2. Record review reveals Resident #2 was admitted to the facility on [DATE] with diagnosis that include end stage renal disease, chronic pressure ulcers, type 2 diabetes, osteomyelitis [bone infection], history of MRSA [Methicillin-resistant Staphylococcus aureus; antibiotic resistant infection] infection, paraplegia, and need for assistance with personal care. A 12/14/2023 provider note reveals that Resident #2 is complaining of heel wounds. The provider exam reveals a left heel PU [pressure ulcer] and left lateral distal foot PU noted and significant. These notes also reveal additional known pressure ulcers and a recent wound infection. Review of Resident #2's wound evaluations show the last wound evaluations for December 2022 were completed on 12/14/2022. There are multiple entries in the SWIFT system [wound photograph evaluation documentation system] prior to 12/14/2022. These entries are not labeled, and some wounds are tracked on multiple wound assessment entries. There is no way to accurately determine a comprehensive report of Resident #2's skin based on review of the SWIFT evaluations and there is no comprehensive skin evaluation documentation in Resident #2's medical record. Physician orders reveal that Resident #2 was being treated for skin injuries of the left heel, coccyx, left thigh, and right shin in December 2022. The treatment administration record reveals the following order: skin examination report to RN and document in Medical Record if new skin condition is identified every day shift every Tuesday start date 10/25/2022. The treatment record reveals that Resident #2's skin assessment was not completed between 12/14/2022 and 12/27/2022 as ordered. A 12/27/2023 progress note reveals that Resident #2 was transferred to the hospital due to showing signs of sepsis. There is no documentation of the condition of his/her skin at this time. A 1/26/2023 transfer of care note from the hospital reveals that Resident #2 was admitted to the hospital on [DATE] related to heel ulcers and ultimately septic shock. The provider writes that Resident #2 presented from the facility with AMS [altered mental status] and fever. In the ED [s/he] was found to have worse LE [left extremity] ulcers and a known sacral ulcer. Orthopedics evaluated the patient with concerns for osteomyelitis due to bedside debridement with probing to bone of his L [left] calcaneus [heel bone] . was started on cefepime and vancomycin for osteomyelitis causing septic shock and was admitted to the MICU. 3. Record review reveals Resident #1 was admitted to the facility on [DATE] with diagnoses that included complete paraplegia [paralysis of the legs and lower body], type 2 diabetes, morbid obesity, and a bed confinement status. Resident #1's care plan includes the following care plan focus: Skin integrity: I [Resident #1] am at risk for impaired skin integrity related to 5 (or more) medications, DM [diabetes], cardiac disease, paralysis, Immobility and an ostomy [surgical opening in the abdomen to allow stool to exit the body], initiated on 4/27/2021 with an intervention to monitor skin condition weekly and report any signs of skin breakdown, initiated on 4/27/2021. Resident #1's care plan does not address an actual wound until 1/25/2023. Review of Resident #1's wound evaluations on 12/14/2022 reveal a stage 2 pressure ulcer on the right calf measuring 1.0 cm x 0.6 cm. Resident #1's 1/27/2023 wound evaluations on reveal a stage 2 pressure ulcer on the right calf measuring 1.4 cm x 0.7 cm. There are no wound evaluations for this wound from 12/15/2022 through 1/26/2023. Review of Resident #1's physician's orders reveal the following: cleanse right calf lateral wound with NSS, pat dry, apply bacitracin and cover with Allevyn border foam every evening shift, with a start date of 11/25/2022. Resident #1's treatment administration record reveals that wound care was not documented as complete or refused for 12 days between 12/14/2022 through 1/19/2023. 4. On 3/21/2023 at approximately 3:00 PM, the Director of Nursing stated that there is no way to find comprehensive documentation of a Residents' skin injuries and/or wounds after a weekly skin assessment. Nursing staff check that it has been completed on the treatment record and any new wounds will be documented in a wound assessment. S/He stated s/he became aware of these problems in January 2023 and confirmed that the skin assessment and monitoring policy had not been followed for Residents #1, #2, and #4. Record review and interview with the Director of Nursing on 3/21/2023 at 3:30 PM reveal that the facility implemented corrective action for the above deficiencies. The facility completed a house wide audit of skin to ensure all wounds were identified and all wounds had treatment orders, hired new staff including a Registered Nurse to review wound evaluations weekly, implemented a new admission check list to ensure wound assessments were documented, and completed education with direct care staff. The facility continues to review skin and wound conditions for all residents with wounds weekly at a customer at risk meeting. Based on corrective actions completed by 2/17/2023, prior to the onsite investigation, this citation is designated as past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents were free from neglect for 1 of 5 residents reviewed (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital following a small bowel obstruction (SBO) necessitating an exploratory laparotomy secondary to a perforated stercocolitis. The resident has a long-standing diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). This condition was treated with Levothyroxine 100mcg a day (a medication replacing the missing thyroid hormone Thyroxine and is taken indefinitely, although the dose may change over time). Upon admittance to the facility the Transition of Care (TOC) from the hospital indicated the resident should continue to take the Levothyroxine. On 3/23/2022 the facility physician saw the resident for an admission visit and noted the Hypothyroidism Diagnosis and indicated the condition was well-managed, and there were currently no symptoms of thyroid disease present. The physician ordered a Thyroid Stimulating Home (TSH) test to be draw on the next laboratory (lab) draw and will adjust dosing of Levothyroxine as needed based on lab value and will continue to follow with periodic lab work. The resident did have lab work including a TSH drawn on 3/29, 5/18 and 5/23/2022, and none of those labs were indicative of levels within the therapeutic range and finally a lab draw on 6/15/2022 did indicate the therapeutic level had been reached. The resident went out to the hospital on 7/21/2022 returning on 7/29/2022. When the resident returned to the facility the TOC indicated Levothyroxine 100mcg a day for only 30 days. The facility has a system in place that 2 nurses are to verify that orders are correct before placing them into the resident record, neither nurse noted anything about the fact that the Levothyroxine for only prescribed for a 30-day period of time despite the fact that treatment with Levothyroxine is lifelong. On 7/29/2022 a nurse documented that all TOC medications were entered into the system and the Nurse Practitioner (NP) stated s/he had seen the TOC and to go ahead with the order, but clarification was needed for the Intravenous Therapy (IV) Protonix (a medication used to treat gastroesophageal-reflux-disease - GERD) since the facility does not provide that medication as an IV. There was no mention of the fact that the Levothyroxine was only ordered for 30 days. On 8/1/2022 the NP saw the resident for a readmission visit and documented incorrectly under the current medications list - Levothyroxine 150mcg a day. The NP also documented that a medication reconciliation had been completed and that diagnostic testing had been reviewed. During this visit the resident requested to return to the hospital for continued issues with constipation and recurrent episodes of SBO and the resident was transported to the hospital. The resident returned on 8/6/2022 and again the TOC indicated Levothyroxine 100mcg for 30 days only. On 8/6/2022 a nurses reviewed the orders from the TOC over the phone with the on-call provider and no changes to the orders were made at that time, despite the fact that the Levothyroxine was only ordered for 30 days from the previous 7/29/2022 date of discharge from the hospital. A second nurse also reviewed the orders for accuracy. On 8/29/2022 the resident received her last dose of the Levothyroxine 100mcg per the 30-day physician order on the TOC from the hospital and the medication dropped off the Medication Administration Record (MAR) at that time. There is no evidence in the Electronic Health Record (EMR) of anyone questioning why the medication, that is required to be taken indefinitely, was no longer ordered. On 9/30/2022 the NP saw the resident for a regular visit and again documented incorrectly that the current medications included Levothyroxine 150mcg a day. Again, the NP documented that a medication reconciliation had been completed and that diagnostic testing had been reviewed. On 8/11, 9/7, 10/6, 11/8 and 12/5/2022 the consultant pharmacist conducted the required Medication Regime Review and on each of these dates documented no recommendations at this time, despite the fact the TOC incorrectly listed only 30 days of Levothyroxine in July 2022 and the resident was no longer receiving Levothyroxine as of 8/30/2022, and that treatment with Levothyroxine is lifelong. The resident went without Levothyroxine for 2 days in August 2022, 30 days in September 2022, 31 days in October 2022, 30 days in November 2022 and 19 days in December 2022. The physician at the hospital for the 12/19/2022 inpatient admittance, indicated that endocrine was consulted because the resident was found to be overtly hypothyroid. Laboratory tests showed a very high TSH level and an undetectably low Thyroxine level (Free T4). While at the hospital there was concern that there was no evidence on her medication list from the facility that she was taking Levothyroxine, as she had previously been taking when being seen at the hospital. The December 2022 hospitalization also showed the resident was diagnosed with Parainfluenza and Pericardial Effusion which was likely in the setting of inflammatory state given viral infection versus overt hypothyroidism. S/he was found to be bradycardic likely a reflection of his/her hypothyroidism. Levothyroxine was restarted and a request for follow up laboratory testing be done to monitor the Thyroxine levels. The resident was returned to the facility on 12/20 and remains in the facility at present and laboratory testing has been done to monitor Thyroxine levels. Per interview with the physician who treated the resident at the hospital, had this lack of Levothyroxine continued it could have been life threatening and quite possibly had the resident's Thyroxine been in the therapeutic range the December hospitalization could have been avoided. Per interview on 12/27/2022 at approximately 12:15pm the acting Director of Nursing (DNS) confirmed that there were opportunities for both the NP and the pharmacist to realize that the Levothyroxine was no longer being given and that there was a system failure that led to medical neglect. Per review of this record, and multiple interviews, there was a facility multi-system failure to prevent medical neglect of Resident #1, and there was harm as a result. See citations at F711, F756, and F760 for more detail and confirmations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the physician failed to ensure that the onsite review of the resident's total program of care included accurate medication reconciliation and monitoring of medications for 1 of 5 residents (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital following a small bowel obstruction (SBO) necessitating an exploratory laparotomy secondary to a perforated stercocolitis. The resident has a long-standing diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). This condition was treated with Levothyroxine 100mcg a day (a medication replacing the missing thyroid hormone Thyroxine and is taken indefinitely, although the dose may change over time). Upon admittance to the facility the Transition of Care (TOC) from the hospital indicated the resident should continue to take the Levothyroxine. On 3/23/2022 the facility physician saw the resident for an admission visit and noted the Hypothyroidism Diagnosis and indicated the condition was well-managed, and there were currently no symptoms of thyroid disease present. The physician ordered a Thyroid Stimulating Home (TSH) test to be draw on the next laboratory (lab) draw and will adjust dosing of Levothyroxine as needed based on lab value and will continue to follow with periodic lab work. The resident did have lab work including a TSH drawn on 3/29, 5/18 and 5/23/2022, and none of those labs were indicative of levels within the therapeutic range and finally a lab draw on 6/15/2022 did indicate the therapeutic level had been reached. The resident went out to the hospital on 7/21/2022 returning on 7/29/2022. When the resident returned to the facility the TOC indicated Levothyroxine 100mcg a day for only 30 days. On 7/29/2022 a nurse documented that all TOC medications were entered into the system and the Nurse Practitioner (NP) stated s/he had seen the TOC and to go ahead with the order, but clarification was needed for the Intravenous Therapy (IV) Protonix (a medication used to treat gastroesophageal-reflux-disease - GERD) since the facility does not provide that medication as an IV. There was no mention by the NP of the fact that the Levothyroxine was only ordered for 30 days. On 8/1/2022 the NP saw the resident for a readmission visit and documented incorrectly under the current medications list - Levothyroxine 150mcg a day. The NP also documented that s/he had spent 40 minutes on patient care and that a medication reconciliation had been completed and that diagnostic testing had been reviewed. The note also indicates that the plan of care was reviewed, and s/he agreed with the plan. During this visit the resident requested to return to the hospital for continued issue with constipation and recurrent episodes of SBO and the resident was transported to the hospital. The resident returned on 8/6/2022 and again the TOC indicated Levothyroxine 100mcg for 30 days only. On 8/6/2022 a nurses reviewed the orders from the TOC over the phone with the on-call provider and no changes to the orders were made at that time, despite the fact that the Levothyroxine was only ordered for 30 days from the previous 7/29/2022 date of discharge from the hospital. On 8/29/2022 the resident received her last dose of the Levothyroxine 100mcg per the 30-day physician order on the TOC from the hospital and the medication dropped off the Medication Administration Record (MAR) at that time. There is no evidence in the Electronic Health Record (EMR) of anyone questioning why the medication, that is required to be taken indefinitely was no longer ordered. On 9/30/2022 the NP saw the resident for a regular visit and again documented incorrectly that the current medications included Levothyroxine 150mcg a day. Again, s/he documented that they had spent 40 minutes on patient care and that a medication reconciliation had been completed and that diagnostic testing had been reviewed and that the plan of care was reviewed, and s/he agreed with the plan. The resident went without Levothyroxine for 2 days in August 2022, 30 days in September 2022, 31 days in October 2022, 30 days in November 2022 and 19 days in December 2022, when the resident returned to the hospital and laboratory tests showed a very high TSH level and an undetectably low Thyroxine level (Free T4). While at the hospital there was concern that there was no evidence on his/her medication list from the facility that s/he was taking Levothyroxine, as she had previously been taking when being seen at the hospital. The December 2022 hospitalization also showed the resident was diagnosed with Parainfluenza and Pericardial Effusion which was likely in the setting of inflammatory state given viral infection versus overt hypothyroidism. S/he was found to be bradycardic likely a reflection of his/her hypothyroidism. Levothyroxine was restarted and a request for follow up laboratory testing be done to monitor the Thyroxine levels. The resident was returned to the facility on 12/20 and remains in the facility at present and laboratory testing has been done to monitor Thyroxine levels. Per interview with the physician who treated the resident at the hospital, had this lack of Levothyroxine continued it could have been life threatening and quite possibly had the resident's Thyroxine been in the therapeutic range the December hospitalization could have been avoided. Per interview on 12/27/2022 at approximately 12:15pm the acting Director of Nursing (DNS) confirmed that the NP had incorrectly documented the dose of Levothyroxine on 2 occasions and appeared unaware that the Levothyroxine had dropped off the MAR and that the resident was no longer receiving this medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the Licensed Pharmacist failed to ensure that an irregularity was identified and reported to the facility for 1 of 5 residents reviewed (Resident #1) Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital following a small bowel obstruction (SBO) necessitating an exploratory laparotomy secondary to a perforated stercocolitis. The resident has a long-standing diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). This condition was treated with Levothyroxine 100mcg a day (a medication replacing the missing thyroid hormone Thyroxine and is taken indefinitely, although the dose may change over time). Upon admittance to the facility the Transition of Care (TOC) from the hospital indicated the resident should continue to take the Levothyroxine. On 3/23/2022 the facility physician saw the resident for an admission visit and noted the Hypothyroidism Diagnosis and indicated the condition was well-managed, and there were currently no symptoms of thyroid disease present. The physician ordered a Thyroid Stimulating Home (TSH) test to be draw on the next laboratory (lab) draw and will adjust dosing of Levothyroxine as needed based on lab value and will continue to follow with periodic lab work. The resident did have lab work including a TSH drawn on 3/29, 5/18band 5/23/2022, and none of those labs were indicative of levels within the therapeutic range and finally a lab draw on 6/15/2022 did indicate the therapeutic level had been reached. The resident went out to the hospital on 7/21/2022 returning on 7/29/2022. When the resident returned to the facility the TOC indicated Levothyroxine 100mcg a day for only 30 days. On 7/29/2022 a nurse documented that all TOC medications were entered into the system and the Nurse Practitioner (NP) stated s/he had seen the TOC and to go ahead with the order, but clarification was needed for the Intravenous Therapy (IV) Protonix (a medication used to treat gastroesophageal-reflux-disease - GERD) since the facility does not provide that medication as an IV. There was no mention of the fact that the Levothyroxine was only ordered for 30 days. The resident once again went to the hospital on 8/1/2022 and returned on 8/6/2022 again the TOC indicated Levothyroxine 100mcg for 30 days only. On 8/6/22 a nurses reviewed the orders from the TOC over the phone with the on-call provider and no changes to the orders were made at that time, despite the fact that the Levothyroxine was only ordered for 30 days from the previous 7/29/2022 date of discharge from the hospital. On 8/29/2022 the resident received her last dose of the Levothyroxine 100mcg per the 30-day physician order on the TOC from the hospital and the medication dropped off the Medication Administration Record (MAR) at that time. There is no evidence in the Electronic Health Record (EMR) of anyone questioning why the medication, that is required to be taken indefinitely was no longer ordered. The consultant pharmacist conducted the required Medication Regime Review on 8/11, 9/7, 10/6, 11/8 and 12/5/2022. Part of the Medication Regime Review is to review the resident's medical chart including current medications and report irregularities. On each of these dates the pharmacist documented no recommendations at this time, despite the fact the TOC incorrectly listed only 30 days of Levothyroxine in July 2022 and the resident was no longer receiving Levothyroxine as of 8/30/2022, and that treatment with Levothyroxine is lifelong. The resident went without Levothyroxine for 2 days in August 2022, 30 days in September 2022, 31 days in October 2022, 30 days in November 2022 and 19 days in December 2022, when the resident returned to the hospital and laboratory tests showed a very high TSH level and an undetectably low Thyroxine level (Free T4). While at the hospital there was concern that there was no evidence on her medication list from the facility that she was taking Levothyroxine, as she had previously been taking when being seen at the hospital. The December 2022 hospitalization also showed the resident was diagnosed with Parainfluenza and Pericardial Effusion which was likely in the setting of inflammatory state given viral infection versus overt hypothyroidism. S/he was found to be bradycardic likely a reflection of his/her hypothyroidism. Levothyroxine was restarted and a request for follow up laboratory testing be done to monitor the Thyroxine levels. The resident was returned to the facility on 12/20 and remains in the facility at present and laboratory testing has been done to monitor Thyroxine levels. Per interview with the physician who treated the resident at the hospital, had this lack of Levothyroxine continued it could have been life threatening and quite possibly had the resident's Thyroxine been in the therapeutic range the December hospitalization could have been avoided. Per interview on 12/27/2022 at approximately 12:15pm the acting Director of Nursing (DNS) confirmed that the pharmacist did not report any irregularities to the facility for the 5 monthly Medication Regime Reviews that were conducted during the time that the Levothyroxine was not being given to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 5 applicable residents (Resident #1) are free of significant medication errors. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital following a small bowel obstruction (SBO) necessitating an exploratory laparotomy secondary to a perforated stercocolitis. The resident has a long-standing diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). This condition was treated with Levothyroxine 100mcg a day (a medication replacing the missing thyroid hormone Thyroxine and is taken indefinitely, although the dose may change over time). Upon admittance to the facility the Transition of Care (TOC) from the hospital indicated the resident should continue to take the Levothyroxine. On 3/23/2022 the facility physician saw the resident for an admission visit and noted the Hypothyroidism Diagnosis and indicated the condition was well-managed, and there were currently no symptoms of thyroid disease present. The physician ordered a Thyroid Stimulating Home (TSH) test to be draw on the next laboratory (lab) draw and will adjust dosing of Levothyroxine as needed based on lab value and will continue to follow with periodic lab work. The resident did have lab work including a TSH drawn on 3/29, 5/18, and 5/23/2022, and neither of those labs were indicative of levels within the therapeutic range and finally a lab draw on 6/15/2022 did indicate the therapeutic level had been reached. The resident went out to the hospital on 7/21/2022 returning on 7/29/2022. When the resident returned to the facility the TOC indicated Levothyroxine 100mcg a day for only 30 days. The facility has a system in place that 2 nurses are to verify that orders are correct before placing them into the resident record, neither nurse noted anything about the fact that the Levothyroxine for only prescribed for a 30-day period of time despite the fact that treatment with Levothyroxine is lifelong. On 7/29/2022 a nurse documented that all TOC medications were entered into the system and the Nurse Practitioner (NP) stated s/he had seen the TOC and to go ahead with the order, but clarification was needed for the Intravenous Therapy (IV) Protonix (a medication used to treat gastroesophageal-reflux-disease - GERD) since the facility does not provide that medication as an IV. There was no mention of the fact that the Levothyroxine was only ordered for 30 days. On 8/1/2022 the NP saw the resident for a readmission visit and documented incorrectly under the current medications list - Levothyroxine 150mcg a day. The NP also documented that a medication reconciliation had been completed and that diagnostic testing had been reviewed. During this visit the resident requested to return to the hospital for continued issue with constipation and recurrent episodes of SBO and the resident was transported to the hospital. The resident returned on 8/620/22 and again the TOC indicated Levothyroxine 100mcg for 30 days only. On 8/6/2022 a nurses reviewed the orders from the TOC over the phone with the on-call provider and no changes to the orders were made at that time, despite the fact that the Levothyroxine was only ordered for 30 days from the previous 7/29/2022 date of discharge from the hospital. A second nurse also reviewed the orders for accuracy. On 8/29/2022 the resident received her last dose of the Levothyroxine 100mcg per the 30-day physician order on the TOC from the hospital and the medication dropped off the Medication Administration Record (MAR) at that time. There is no evidence in the Electronic Health Record (EMR) of anyone questioning why the medication, that is required to be taken indefinitely was no longer ordered. On 9/30/2022 the NP saw the resident for a regular visit and again documented incorrectly that the current medications included Levothyroxine 150mcg a day. Again, the NP documented that a medication reconciliation had been completed and that diagnostic testing had been reviewed. On 8/11, 9/7, 10/6, 11/8 and 12/5/2022 the consultant pharmacist conducted the required Medication Regime Review and on each of these dates documented no recommendations at this time, despite the fact the TOC incorrectly listed only 30 days of Levothyroxine in July 2022 and the resident was no longer receiving Levothyroxine as of 8/30/2022, and that treatment with Levothyroxine is lifelong. The resident went without Levothyroxine for 2 days in August 2022, 30 days in September 2022, 31 days in October 2022, 30 days in November 2022 and 19 days in December 2022, when the resident returned to the hospital and laboratory tests showed a very high TSH level and an undetectably low Thyroxine level (Free T4). There was concern that there was no evidence on her medication list from the facility that she was taking Levothyroxine, as she had previously been taking when being seen at the hospital. The December 2022 hospitalization also showed the resident was diagnosed with Parainfluenza and Pericardial Effusion which was likely in the setting of inflammatory state given viral infection versus overt hypothyroidism. S/he was found to be bradycardic likely a reflection of his/her hypothyroidism. Levothyroxine was restarted and a request for follow up laboratory testing be done to monitor the Thyroxine levels. The resident was returned to the facility on 12/20 and remains in the facility at present and laboratory testing has been done to monitor Thyroxine levels. Per interview with the physician who treated the resident at the hospital, had this lack of Levothyroxine continued it could have been life threatening and quite possibly had the resident's Thyroxine been in the therapeutic range the December hospitalization could have been avoided. Per interview on 12/27/2022 at approximately 12:15pm the acting Director of Nursing (DNS) confirmed that the resident did not receive the required dose of Levothyroxine from August 30th until s/he was readmitted to the hospital on [DATE].

2.) Resident #16 required emergent care related to having the retention balloon of the Foley catheter overfilled. Per record review Resident #16 has diagnosis including unspecified dementia and neuromuscular dysfunction of the bladder requiring the use of a Foley catheter. A Foley catheter is a semi-rigid but flexible tube used to drain the bladder while blocking the urethra. A practitioner inserts the catheter through the urethra to the bladder then inflates the circumferential collar (located at the tip of the catheter) called the retention balloon to keep the catheter from being expelled. On 11/12/22 it was noted that Resident #16 had bloody urine in the Foley catheter collection bag. Two nurses attempted to remove the catheter to change it but due to resistance they were unable to remove it, per instructions from the physician Resident #16 was sent to the emergency room. The emergency department notes stated, There was resistance to deflating the catheter balloon, but with some pressure and patience it was able to start being emptied. Shockingly, there ended up being over 90 cc of water in the balloon. Once this was fully emptied, the catheter was able to be removed. New catheter was placed, and urine analysis did show evidence of infection. This could have contributed to the dysfunction, though the large amount of fluid in the balloon certainly was part of the issue. Facility procedure protocol entitled Catheterization, Insertion of Indwelling Catheter for [gender removed] Residents with an approval date of 01/23/2018 reviewed. Step 15 states .insert catheter an additional 1 to 2 inches beyond the point at which urine began to flow and inflate balloon lumen of catheter with sterile water. USE WATER AMOUNT SPECIFIED IN PHYSICIANS'S ORDER. Step 23 states Nurse: Document required or pertinent information in appropriate records, and consult immediate supervisor, if necessary. DOCUMENT SIZE OF CATHETER, CONDITION OF GENITAL AREA, TYPE OF DRAINAGE SYSTEM. NOTE AMOUNT, COLOR AND ODOR OF URINE. Per record review Resident #16 had the following provider order: 16 French (#16 refers to the size of the catheter to be used) to gravity for neurogenic bladder, change monthly for maintenance, bladder scan if UOP (urinary output) < 200 cc, notify provider if residual =/> 200 cc or if UOP <100 cc. It is noted the order does not contain an amount of water to be used to inflate the balloon. Further record review revealed there was no documentation from the nurse as required by the facility's written procedure protocol. On December 7, 2022, at approximately 2 PM a facility #16 French foley catheter and catheter insertion kit was requested for viewing, the RN Supervisor provided the requested catheter and confirmed this was the type used throughout the facility. In addition to being marked with 16 Fr (#16 French) it was also marked 30mL/cc which indicates how much fluid the retention balloon should be filled with. The contents of the insertion kit were viewed a syringe prefilled with 30 mL/cc was included in the kit to be used when inflating the retention balloon. Without a complete Provider order and with the lack of nursing documentation the standard of care as outlined in the Facility Procedure Protocol was not met resulting in an emergent transport of Resident #16. 3.) Review of Res. #198's medical record revealed on 7/10/22 the resident suffered a fall at 4:55 PM. The next morning, on 7/11/22, Nursing Notes record Resident complaining of aching right hip pain, 10/10 [on a scale of 0 to 10, 0= no pain, 10 = worst pain] . Resident unable to stand on her right leg due to her right hip pain. She did not want to attempt range of motion with writer because it hurts too much. Nursing Notes later the same day record Resident was seen by Nurse Practioner status post fall related to nursing reports of right hip pain and decreased ability to bear weight on right side. New order received and entered to obtain x-ray 2 views of right hip and pelvis. Further review of Nurses Notes reveal no further notes regarding the ordered x-ray for Res. #198's hip pain on 7/11, 7/12, and 7/13/22. Review of orders for Trident Care, the facility's Radiology service, reveal an order for a radiology exam dated 7/14/22, 3 days after the Nurse Practioner order for an x-ray was entered. A notation on the Trident Care order reads not done. Nurses Notes on 7/14/22 record Writer spoke with Nurse Practioner to update on resident status .Order received to send to emergency room for evaluation and treatment if unable to obtain right hip x-ray today related to decreased ability to bear weight status post fall. Review of Res. #198's medical record regarding the emergency room visit reveals the resident was diagnosed with 'a closed, non-displaced greater trochanteric fracture' [bony protrusion on the femur (thighbone)]. An interview was conducted with the acting Director of Nursing [DON] on 12/7/22 at 12:38 PM. The DON confirmed there was no documentation regarding why the x-ray ordered on 7/11/22 was not completed for 3 days until the resident was sent to the Emergency Department, and no documentation that the Nurse Practioner was notified that the x-ray was not completed as ordered for 3 days after the order was written. Based on staff interview and record review, facility staff failed to ensure that 3 applicable residents (Resident # 35, Resident #16, & Resident #198) received treatment and care in accordance with professional standards of practice. Findings include: Facility staff did not document the provision of care for Resident # 35's Foley catheter as ordered by the physician. There is a physician order dated 8/1/22 for urinary Foley catheter care every shift for infection control and as needed. Per review of the Treatment Record (TAR), catheter care was not documented as done on 7 occasions in October 2022 and on 7 occasions in November 2022. There is a physician order for urinary output - verify documentation and notify provider if output is less than 100 ml (milliliter) per shift every shift for output. Review of the TAR indicates that urinary output was not documented as done on 25 occasions in October and 23 occasions in November 2022. The above was confirmed by the Unit Manager on 12/6/22 at 3:36 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to properly manage the care of a Foley catheter for one applicable resident (Resident #16). Resident #16 is an [AGE] year old person with diagnosis including unspecified dementia and neuromuscular dysfunction of the bladder requiring the use of a Foley catheter. A Foley catheter is a semi-rigid but flexible tube used to drain the bladder while blocking the urethra. A practitioner inserts the catheter through the urethra to the bladder then inflates the circumferential collar (located at the tip of the catheter) called the retention balloon to keep the catheter from being expelled. Physician orders include an order to flush the catheter twice daily with 120 cc of normal saline to maintain patency and prevent urine related debris from collecting and resulting in a blockage. A Foley catheter has two ports that are accessable to the practitioner. One port is used to inflate the balloon with water using the syringe provided in the catheritization kit, the other port is to be used to irrigate the catheter. The irrigant is pushed via a syringe into the specified port, the irrigant then drains into the collection bag along with the urine being drained from the bladder. On 11/12/22 Resident #16 was emergently sent to the hospital after two facility nurses were unable to remove the catheter for replacement. The emergency department notes stated, There was resistance to deflating the catheter balloon, but with some pressure and patience it was able to start being emptied. Shockingly, there ended up being over 90 cc of water in the balloon. Once this was fully emptied, the catheter was able to be removed. New catheter was placed, and urine analysis did show evidence of infection. This could have contributed to the dysfunction, though the large amount of fluid in the balloon certainly was part of the issue. Per record review Resident #16 had the following provider order: 16 French (#16 refers to the size of the catheter to be used) to gravity for neurogenic bladder, change monthly for maintenance, bladder scan if UOP (urinary output) < 200 cc, notify provider if residual =/> 200 cc or if UOP <100 cc. It is noted the order does not contain an amount of water to be used to inflate the balloon. Further record review revealed there was no documentation from the nurse as required by the facility's written procedure protocol. On December 7, 2022, at approximately 2 PM a facility #16 French foley catheter and catheter insertion kit was requested for viewing, the RN Supervisor provided the requested catheter and confirmed this was the type used throughout the facility. In addition to being marked with 16 Fr (#16 French) it was also marked 30mL/cc which indicates how much fluid the retention balloon should be filled with. The contents of the insertion kit were viewed a syringe prefilled with 30 mL/cc was included in the kit to be used when inflating the retention balloon. On 12/7/22 at 12:10 PM the DON confirmed knowledge of this event and revealed it was suspected that someone had attempted to flush the catheter using the incorrect access port resulting in the balloon being significantly overfilled. Refer also to F684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to provide pain management in accordance with the resident's preferences for 1 of 27 sampled residents [Resident #302]. Findings include: Findings include: Per record review, Resident #302 was admitted to the facility on [DATE] for subacute rehab with multiple orthopedic injuries and fractures following a motor vehicle accident. Resident #302 has a physician order for OxyCODONE HCl Tablet 15 MG Give 1 tablet by mouth every 4 hours as needed for pain -Start Date-11/30/2022. Resident #302's care plan does not include a care area focus for pain, pain management goals, or interventions for pain management. Per observation and interview on 12/5/2022 at 09:35 AM, Resident #302 reported that his/her pain is not being managed. S/he stated that s/he has asked the nursing staff to wake him/her up at night to give administer his/her PRN [as needed] oxycodone but they won't wake him/her up to give it to him/her and because of that, s/he is unable to manage their pain throughout the rest of the day. Resident #302 reported to have a 9/10 pain level during interview and was observed moaning with a distorted face multiple times during the interview. A provider note dated 12/5/22 states Patient endorses chronic discomfort, moderately well managed with current regimen. Patient verbalizes pain at baseline today mildly increased with movement secondary to acetabular fracture, however, a social service note dated 12/5/22 states [Patient]states that [his/her] pain meds are still not right. Feels [s/he] is not being given in a timely manner. Worried that [s/he] won't get if falls asleep as they are prn. Per interview on 12/6/2022 at 3:00 PM, a Licensed Practical Nurse [LPN] stated s/he was aware the resident #302 wanted to be woken up for his/her PRN medication at night but nursing staff won't wake him/her up for PRN medications because there is a policy not to wake up residents and s/he has a history of drug seeking. Per interview on 12/07/22 at 7:40 AM, the Unit Manager stated that Resident #302 should have a care plan for pain and that nursing staff should not wake up a resident to administer PRN medications, even if they ask. Per interview on 12/7/2022 at 8:20 AM, the Director of Nursing [DON] stated that there was not a policy prohibiting nursing staff from waking up a resident on request for PRN medications and nursing should follow his request to wake him up. The DON confirmed that there should be a care plan for pain.