**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect 2 of 6 sampled residents (R3 and R6's) right to be free from abuse, neglect, or exploitation by a CNA I (Certified Nursing Assistant). R3 stated CNA I was rude to her, yelled at her, and refused to help her put her compression stockings on during morning cares (AM), resulting in a fall, and that she is terrified of CNA I. R6 stated CNA I mocks and belittles her, and often leaves her in a wet incontinence brief for over an hour. Evidenced by: Facility policy entitled Abuse/Neglect/Exploitation, undated, states, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or thing their hearing distance regardless of their age, ability to comprehend, or disability . Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Neglect meals [sic] failure of the facility, its employees, or service providers to provide good [sic] and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents . 3. The facility will provide ongoing oversight and supervision of staff in order to assure its policies are implemented as written . III. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation . and exploitation that achieves: H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . IV. Identification of Abuse, Neglect and Exploitation: B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse . 5. Verbal abuse of a resident overheard . 7. Psychological abuse of a resident observed. 8. Failure to provide care needs such as feeding, bathing, dressing . 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person . VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm . Examples include but are not limited to: C. Increased supervision of the alleged victims and residents; D. Room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation . Per the State operations Manual: Sections §§1819(c)(1)(A)(ii) and 1919(c)(1)(A)(ii) of the Social Security Act provide that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility must provide a safe resident environment and protect residents from abuse. Abuse may result in psychological, behavioral, or psychosocial outcomes including, but not limited to, the following: Fear of a person or place, of being left alone, of being in the dark, and/or disturbed sleep and nightmares; Example 1 R3 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 4, Hemiplegia and Hemiparesis following Cerebral Infarction (weakness and paralysis on one side of the body). R3's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/18/25, indicates R3 has a Brief Interview of Mental Status (BIMS) of 10 out of 15, indicating R3 has moderate cognitive impairment. R3's Care Plan includes, in part: Focus: I have a physical functioning deficit related to Mobility impairment, self-care impairment due to weakness, cancer, physical limitations, and need for staff assistance. Date initiated: 2/11/25 . Interventions: Dressing assistance of 1. Date initiated: 2/11/25 Personal hygiene assistance of 1. Date initiated: 2/11/25 . Toileting assistance of 1. Date initiated: 2/11/25. Transfer assistance of 1 with gait belt and walker. Date initiated: 2/11/25 . Alteration in elimination of bowel and bladder r/t (related to) functional incontinence due to weakness, physical limitations, and need for staff assistance. Date initiated: 2/11/25 . Interventions: Provide 1 assistance to toilet. Date initiated: 2/11/25 . On 3/20/25 at 11:06 AM, Surveyor interviewed CNA F. CNA F stated that when she came in that morning, she found CNA I and R3 in the lounge. R3 was in her wheelchair in the lounge wearing an incontinence brief and t-shirt but no pants. CNA I was telling R3 that she was disrespectful, that she was on her call light all the time, and that she was going to file a grievance against R3 with the facility. CNA I told R3 that if she would have stayed in bed she wouldn't have fallen, and told R3 she should not have come out to the lounge. R3 was crying and stated she would just go hide in my room. At this point CNA F intervened, telling CNA I she could go home, and she would help R3. R3 stated she was trying to put on her compression stockings and fell out of her wheelchair because no one would help her. CNA F said that R3 was terrified of CNA I. Surveyor asked CNA F if she would consider what happened this morning as abuse. CNA F stated yes, it was an allegation of abuse and that she followed the facility abuse policy by calling NHA A (Nursing Home Administrator) at home right away. Please note: CNA F indicated throughout this exchange, CNA I was loudly berating R3, who was crying and visibly upset. On 3/20/25 at 12:47 PM, Surveyor interviewed CNA E, who said she saw the incident that happened that morning between CNA F, CNA I and R3. CNA E stated that she observed CNA I say something to R3 and then CNA F told CNA I not to talk to R3 that way and that she should just go home since her shift was over. CNA E stated she did not hear what exactly CNA I said to R3, only CNA F intervening and telling CNA I not to talk to R3 that way. CNA E indicated that she would consider the way CNA I treated R3 as abuse. CNA E stated that R3 was afraid of CNA I and says that CNA I refuses to take her to the bathroom at night. Of note: CNA E was aware of R3 being afraid of CNA I and that R3 indicated CNA I refused to take her to the bathroom at night, yet CNA E did not report this to the facility. On 3/20/25 at 1:18 PM, Surveyor interviewed NHA A, who stated that he had received no reportable incident from today. On 3/20/25 at 1:24 PM, Surveyor called and left a message with CNA I regarding the incident that happened that morning. Surveyor did not receive a call back from CNA I. On 3/20/25 at 1:40 PM, Surveyor interviewed R3 who stated that she fell out of her wheelchair this morning while trying to put on her own compression stockings. Surveyor asked R3 if the staff normally help her in applying her compression stockings. R3 stated that normally they do, but that today they didn't. R3 indicated it was CNA I who was supposed to help her, but that she was afraid to say anything for fear of retaliation from CNA I and other staff members. Surveyor asked R3 if any staff had ever been rough with her. R3 replied, No comment, but stated, It will go right back to her and I'm afraid to say anything, but no one should be yelled at, and nobody should be treated that way. On 3/20/25 at 4:30 PM, Surveyor interviewed R3 who stated that she was concerned that CNA I would be working again tonight. R3 stated that when she even hears CNA I's voice in the hall, she becomes anxious and is so afraid that she can't sleep all night. R3 stated that she is afraid to put her call light on to go to the bathroom, for fear that CNA I will come in and yell at her. R3 stated that she has developed a UTI (urinary tract infection) due to being afraid of CNA I taking her to the bathroom. R3 said she is afraid that CNA I is going to come in her room at night and do something to her. R3 stated, I don't want to be here tonight. Every night I get anxious. I just want to run away and die. It's terrible, I shouldn't feel that way. (Of note: R3 is indicating that CNA I's presence is affecting her routine, such as becoming anxious and not being able to sleep. A reasonable person would not want to feel afraid of someone within their own home.) On 3/20/25 at 6:44 PM, Surveyor interviewed R3 who stated that everyone tells her not to be afraid of CNA I, but that they are afraid of her too. R3 stated that CNA I is mean to her, and that she starts shaking as soon as CNA I talks to her. Surveyor observed R3 was visibly trembling while discussing CNA I. R3 again stated that if CNA I is in the building that she is so anxious that she lays awake all night, unable to sleep from fear. (Of note: per R3's interview staff were aware R3 was afraid of CNA I, and telling R3 not to be afraid.) On 3/20/25 at 7:09 PM, Surveyor interviewed RN J (Registered Nurse) who stated that she saw the entire incident between CNA I and CNA F. RN J stated that CNA F and CNA I were raising their voices and getting R3 all worked up. RN J stated she would consider what happened to R3 as psychological abuse. Surveyor asked RN J if she had told anyone about the psychological abuse she had witnessed. RN J stated no, she hadn't because everyone saw what happened. (Of note: nurses are mandatory abuse reporters, and RN J did not report abuse to the facility or intervene even though she witnessed psychological abuse.) Example 2 R6 was admitted to the facility on 1/2325 with diagnoses that include Morbid Obesity, Type 2 Diabetes Mellitus, Insomnia, and Major Depressive Disorder. R6's most recent MDS, with an ARD of 1/30/25, indicates R6 has a BIMS of 15 out of 15, indicating R6 is cognitively intact. R6's Care Plan includes, in part: Focus: I have a physical functioning deficit related to Mobility impairment, self-care impairment due to morbid obesity, weakness, physical limitations. Date initiated: 1/20/25 . Interventions: Dressing assistance of 1. Date initiated: 1/20/25 Personal hygiene assistance of 1. Date initiated: 1/20/25 . Transfer assistance of 1 with gait belt and walker. Date initiated: 1/20/25 . Alteration in elimination of bowel and bladder r/t (related to) functional incontinence due to morbid obesity physical limitations and need for staff assistance. Date initiated: 1/20/25 . Interventions: Provide 1 assistance to toilet. Date initiated: 1/20/25 . On 3/20/25 at 10:19 AM, Surveyor spoke with R6 who stated that CNA I makes fun of her accent and the way she talks. R6 said she feels belittled by CNA I, and there are many nights she can't sleep and just lies awake in bed and cries because of her pain, immobility, and having CNA I make fun of her on top of everything else that she is experiencing. R6 stated that many nights she will put on her call light, and CNA I will turn off her call light and tell her she will come right back, but that she doesn't come back for over an hour, resulting in her being soaked and getting a rash. R6 stated that she had talked to NHA A on more than one occasion about CNA I, her lack of care, and how she made fun of her accent, but that nothing was ever done about it. On 3/20/25 at 1:18 PM, Surveyor interviewed NHA A, who stated that he had received no reportable incident from today. On 3/20/25 at 6:12 PM, Surveyor interviewed NHA A, who stated that CNA F told him that her and CNA I had an argument over cares for a resident. NHA A stated he did not know which resident it was. NHA A said that CNA F told him that she was going to call the state, that she didn't give a reason, but it was based on how CNA I treated the residents. Surveyor asked NHA A if a staff member saw another staff being disrespectful and rude to a resident, would he expect that to be reported to him right away. NHA A replied yes. NHA A stated that both CNA I and CNA F would be educated on not arguing in the building. NHA A stated it could have been an abuse situation if a resident was around. Surveyor pointed out that R3 was around and witnessed the incident between CNA I and CNA F. Surveyor asked NHA A if he would expect staff to report allegations of abuse. NHA A replied yes, if it truly was abuse. Surveyor asked if a staff member raising their voice and refusing to help them would be considered abuse. NHA A replied yes absolutely. Surveyor asked NHA A when should staff report allegations of abuse. NHA A replied staff should report allegations of abuse to him immediately. On 3/20/25 at 7:17 PM, Surveyor interviewed NHA A who stated that no one had ever reported concerns about CNA I. Surveyor asked NHA A if R6 had ever brought concerns to him about lack of care with CNA I and that CNA I makes fun of her accent. NHA A stated that he had talked to R6's sister, and that her memory has been going a little and she will say things happened that really didn't happen. Surveyor pointed out that R6 has a BIMS of 15 and no dementia diagnosis. Surveyor asked NHA A if he should take all allegations of abuse seriously. NHA A replied yes absolutely. Surveyor pointed out that R3 and R6 do not feel safe in their own home. NHA A agreed that R3, R6, and all the residents should feel safe in their home. (Of note: NHA A was aware that R6 had concerns.) The facility failed to protect two residents from verbal abuse, including belittling, mocking, yelling and withholding of cares, resulting in ongoing fear and anxiety. R3 was afraid to speak up for fear of retaliation, and R6's concerns of humiliation were not addressed. These residents, who trust and rely on facility staff to meet their needs, have the reasonable expectation to be safe in their home and to be treated with respect and dignity. Cross Reference F609.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 3 of 3 sampled residents (R49, R29, R63) and 1 supplemental resident (R5). (R29 is being cited at actual harm) R29 was identified to be at risk for PI development. R29 developed two stage 3 PI's and a stage 2 PI. The facility down staged R29's Pressure injury to a stage 2 when the PI contained slough. Facility staff reported they were not able to turn/reposition R29 every 2 to 3 hours as care planned. The facility failed to update R29's Care Plan with Physician recommendations for turning and repositioning every one to two hours. The facility utilized a bariatric air mattress and when the power source was partially interrupted staff noted R29 to be on a deflating air mattress for 30 to 60 minutes. Staff did not transfer R29 onto an offloading surface that was functioning. R49, R63, and R5 were identified to be at risk for PI development or have a current PI. R49, R63, and R5 were noted to be on deflating air mattresses for 30 minutes to an hour when the facility's power source was partially interrupted. Evidenced by: Facility policy, entitled Wound Management, undated, includes: it is the policy of the facility to provide evidence based treatments in accordance with current standards of practice and physician orders . treatment decisions will be based on a) etiology of the wound- pressure injuries will be differentiated from non pressure ulcers . b) characteristics of the wound- pressure injury stage or level of tissue destruction if not a pressure injury . size-including shape, depth, and presence of tunneling or undermining . volume and characteristics of exudate . presence of pain . presence of infection . condition of tissue in the wound bed . condition of peri wound skin . the effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: lack of progression towards healing, changes in characteristics of the wound, changes in the residence goals . National Pressure Injury Advisory Panel current standards of practice, titled Staging, dated 2016, includes: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Example 1 R29 admitted to the facility on [DATE] with the following diagnoses: schizotypal disorder (mental health condition characterized by a pervasive pattern of intense discomfort with and reduced capacity for close relationships, by distorted cognition and perceptions, and by eccentric behavior), altered mental status, contracture of muscle, and abscess of bursa left hip. R29's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/12/25, indicates R29 is dependent on staff assistance to meet his needs in toileting hygiene, dressing, bed mobility, and transfer. R29's MDS also indicates R29's cognition is severely impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. R29's Comprehensive Care Plan, initiated 1/22/21, includes: 1/22/21 Focus: I am at risk for skin breakdown related to limited mobility, history of pressure ulcers, and my need for extensive assistance with repositioning and mobility. I am also at risk due to bowel and bladder incontinence. Goal: I will have no signs and symptoms of skin breakdown through the review date of 5/13/25 . Interventions: 6/15/21 air mattress setting at 150 to 180 per patient weight and comfort. Settings to be checked every shift. 1/22/21 Complete Braden scale per living center policy. 10/13/22 I am incontinent of bladder and bowel. Please help me maintain good hygiene and skin integrity by providing me with incontinence care after each episode. 10/13/22 please report any new and abnormal skin concerns to licensed staff such as bruises, reddened areas, tender areas, cuts or abrasions so that they can update my physician. 12/9/21 I know that licensed staff will conduct a full body inspection per policy. 2/5/25 Wedge in bed for repositioning every two to three hours staff to reposition wedge as needed. 2/1/21 Focus: I have a physical functioning deficit related to mobility impairment, self-care impairment. Goal: I will improve my current level of functioning with target date of 5/13/25 . Interventions: 12/9/21 Bed mobility assistance: extensive 2 assist . 2/15/24 Transfer assistance- 2 assist with hoyer. Towel to be placed between right side strap and right leg to prevent rubbing skin injury . (It is important to note the facility had no evidence of R29's mattress settings being checked every shift.) (It is important to note R29 has an infection that set in around the hardware in his left hip. R29 had the hardware removed and his legs now lay in a frog leg position. The facility has accommodated this deformity by keeping R29 on a bariatric bed and mattress.) R29's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 11/13/24, indicates R29 is at high risk for PI development. R29's Body Check Form, dated 11/13/24, indicates R29 has a new skin disruption/open spot wound on his coccyx area. What kind of skin disruption was found? Open spot on bottom . open area on butt . R29's Physician Summary, dated 11/13/24, includes: Chief complaint: Patient has wound on his sacrum and a rash . Review of Systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Non-pressure Wound Sacrum Partial Thickness: etiology- moisture associated skin damage . Objective: healing . Wound size: 6.0cm x 0.5cm x 0.1cm . Exudate: light serosanguinous . Dermis: open areas exposed dermis . Dressing Treatment Plan: Primary- Zinc ointment apply every shift (3 times a day) for 30 days . Recommendations: Off-load wound, reposition per facility protocol . R29's Physician Summary, dated 11/20/24, includes: Chief complaint: Patient has wound on his sacrum . Review of Systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Non-pressure wound sacrum partial thickness: etiology- moisture Associated Skin Damage, objective- healing, wound size: 5.0cm x 0.5cm x 0.1cm . Exudate: light serosanguinous . Dermis: open area with exposed dermis . Dressing Treatment Plan: Primary: Zinc ointment apply every shift (3 times a day) for 23 days . Recommendations: Off-load wound; Reposition per facility protocol . R29's Physician Summary, dated 11/27/24, includes: Chief complaint: Patient has wound on his sacrum . Review of Systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 2.5cm x 0.7cm x 0.1cm . Additional Wound Details: Adjusting etiology given appearance of wound bed . Dressing Treatment Plan: Primary: Zinc ointment apply every shift (3 times a day) for 16 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . (Of note: R29's sacrum wound is now being identified as a pressure injury. Even though the physician ordered repositioning to offload the wound, there is no evidence R29's care plan was updated to include this intervention. R29's Physician Summary, dated 12/4/24, includes: Chief complaint: Patient has wound on his sacrum. Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 2.5cm (centimeter) x (by) 1.0cm x 0.2cm . Exudate: moderate serosanguinous . Dressing Treatment Plan: Primary: Alginate calcium apply three times per week for 30 days . Secondary: Dry dressing apply three times per week for 30 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . (It is important to note in this assessment there is no description of the wound characteristics, including color, tissue type or tissue percentage. Wound MD note indicates unstageable DTI within and around wound.) R29's Physician Summary, dated 12/11/24, includes: Chief complaint: Patient has a wound on his sacrum. Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 2.5cm x 0.7cm x 0.2cm . Exudate: moderate serosanguinous . Dressing Treatment Plan: Primary: Alginate calcium apply three times per week for 23 days . Secondary: Dry dressing apply three times per week for 23 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . R29's Body Check Form, dated 12/11/24, indicates R29 has a new skin disruption/old wound on his coccyx area. What kind of skin disruption was found? Open area on bottom . R29's Physician Summary, dated 12/18/24, includes: Chief complaint: patient has wound on his sacrum. Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 2.5cm x 0.7cm x 0.2cm . Exudate: moderate serosanguinous . Dressing Treatment Plan: Primary: Alginate calcium apply three times per week for 16 days . Secondary: Dry dressing apply three times per week for 16 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . R29's In House Assessment, dated 12/24/24, includes: Type of wound: non-pressure . Location of wound: coccyx . admitted or Acquired: in house acquired . Date identified: 11/13/24 . Measurements: 2.5cm x 1.5cm x 0.2cm . Treatment: Clean. Pat dry. Calcium alginate dry dressing . Frequency: 3 times per week and as needed . Care planned: yes . Orders up to date in (electronic health record): yes . (It is important to note in this assessment the PI is larger in width, there is no description of the wound including color, drainage description, drainage amount, drainage color, if there was an odor, description of wound edges, description of wound bed, or description of the surrounding area. It is important to note even though the physician is now identifying the area as an unstageable deep tissue injury, which is a pressure injury, the facility continues to identify it as non-pressure wound.) On 3/11/25 at 12:15 PM, Surveyor spoke with DON B, who indicated R29's coccyx/sacrum PI and non-pressure wound are the same wounds. DON B indicated R29 did not have two different wounds to the sacrum/coccyx area. R29's Physician Summary, dated 12/31/24, includes: Chief complaint: patient has wound on his sacrum. Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 3.0cm x 1.0cm x 0.2cm, exudate- light serosanguinous . Dressing Treatment Plan: Primary: Alginate calcium apply once daily for 30 days; Leptospermum honey apply once daily for 30 days . Secondary: Dry dressing apply once daily for 30 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . The physician continued to order repositioning and offloading. There is no evidence this intervention was added to the care plan to promote healing. R29's Physician Summary, dated 1/8/25, includes: Chief complaint: patient has wounds on his sacrum, right buttock, left buttock . Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Stage 3 Pressure Wound Sacrum Full Thickness: etiology- pressure, objective- healing, wound size: 4cm x 4cm x 0.2cm, Exudate- moderate serosanguinous, Granulation tissue- 70%, Skin- intact normal color 30% . Dressing Treatment Plan: primary- Alginate calcium apply once daily for 22 days, Secondary- dry dressing apply once daily for 22 days, Recommendations- reposition per facility protocol; offload wound; group 2 mattress . Stage 2 Pressure Wound of the Right Buttock Partial Thickness: Etiology- pressure, objective- healing, wound size- 4.0cm x 5.0cm x 0.1cm, Exudate- light serosanguinous, dermis- open areas with exposed dermis . Stage 2 Pressure Wound of the Left Buttock Partial Thickness: Etiology- pressure, objective-healing, wound size- 4.0cm x 5.0cm x 0.1cm . Additional wound details- multifactorial, reviewed need for dressings and for continued offloading of wounds . Dressing Treatment Plan: primary dressing- alginate calcium apply once daily for 22 days. Leptospermum honey apply once daily for 22 days, secondary- dry dressing apply once daily for 22 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . (It is important to note R29 now has three in house acquired PI, one stage 3 on the sacrum, a stage 2 on the right buttock, and a stage 2 on the left buttock. R29's Stage 3 pressure injury has increased in size. ) On 1/8/25, R29's Nursing advance skin check indicates additional skin issue education documentation: Staff for am also updated and will updated [sic] pm staff cop (change of position) q 2 hours, check for incont, only 1 sheet under him, check hob (head of bed) position. R29's Body Check Form, dated 1/12/25, staff circled coccyx area indicating R29 has a skin disruption on his coccyx area and handwritten note indicating wounds. R29's Physician Summary, dated 1/15/25, includes: Chief complaint: patient has wounds on his sacrum, right buttock, left buttock . Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Stage 3 Pressure Wound Sacrum Full Thickness: etiology- pressure, objective- healing, wound size: 3.0cm x 1.0cm x 0.2cm . Exudate- Moderate Serosanguinous, granulation tissue-100% . Stage 2 Pressure Wound of Right Buttock Partial Thickness: etiology- pressure, objective- healing, wound size- 3.0cm x 3.0 x 0.1cm . Exudate- moderate serosanguinous, dermis- open area with exposed dermis . Dressing Treatment Plan: primary dressing- collagen sheet apply once daily for 30 days, secondary- dry dressing apply once daily for 30 days, Recommendations- reposition per facility protocol; offload wound; group 2 mattress . Stage 2 Pressure Wound of Left Buttock Partial Thickness: etiology- pressure, objective-healing; wound size 2.0cm x 2.0cm x 0.1cm .; exudate- moderate sersanguinous[sic]; dermis- open areas with exposed dermis . Dressing Treatment Plan: primary- collagen sheet apply once daily for 30 days, secondary- dry dressing apply once daily for 30 days . Recommendations- reposition per facility protocol, offload wound, group 2 mattress . R29's Body Check Form, dated 1/19/25, indicates R29 has a new skin disruption on his coccyx area. What kind of skin disruption was found? (blank) . (It is important to note staff circled the coccyx area on the image indicating a new skin disruption noted, but then handwrote No when asked if new skin disruption found.) R29's Physician Summary, dated 1/23/25, includes: Chief complaint: patient has wounds on his sacrum, right buttock, left buttock . Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Stage 3 Pressure Wound Sacrum Full Thickness: etiology- pressure, objective- healing, wound size: 3.0cm x 0.8cm x 0.2cm . exudate- light serosanguinous, Thick adherent devitalized necrotic tissue- 80%, slough- 10%, granulation tissue- 10% . Dressing Treatment Plan- primary- Iodosorb gel, apply once daily for 30 days . secondary- gauze island with border apply once daily for 30 days . Peri wound treatment- Skin prep apply once daily for 30 days . Recommendations: cleanse with soap and water, turn side to side in bed every one to two hours if able, offload wound, group 2 mattress already on . surgical excisional debridement was performed today on this wound . surgical excisional debridement procedure: indication for procedure- remove necrotic tissue and establish the margins of viable tissue . procedure note: the wound was cleansed with normal saline and anesthesia was achieved by using topical benzocaine . then with clean surgical technique, 15 blade was used to surgically excise 2.16cm ^2 of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.3 centimeters and healthy bleeding tissue was observed. As a result of this procedure, the non viable tissue in the wound bed decreased from 90% to 0%. Hemostasis was achieved and a clean dressing was applied (Of note: R29's Sacrum/coccyx wound deteriorated from 100% granulation tissue to 80% necrotic tissue requiring debridement (removal of necrotic and devitalized tissue).) . Stage 3 Pressure Wound of the Right Buttock Full Thickness: etiology- pressure, objective- healing, wound size- 2.0cm x 2.0cm x 0.1cm, exudate- light serosanguinous, slough- 80%, granulation tissue- 20% . Dressing Treatment Plan- primary- Iodosorb gel, apply once daily for 30 days . secondary- gauze island with border apply once daily for 30 days . Peri wound treatment- skin prep apply once daily for 30 days, zinc ointment apply once daily for 30 days . Recommendations: offload wound, reposition per facility protocol, group 2 mattress, cleanse with soap and water, turn side to side in bed every one to two hours if able, changing schedule every two hours . Sharp Selective Debridement Procedure: indication for procedure-remove biofilm. Remove devitalized tissue at margins of a wound . procedure note: the wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to selectively remove biofilm, remove devitalized tissue at margins of a wound over the wound surface area of 4cm ^2. The wound was cleansed again and clean dressing was applied . Employing selective debridement of slough only. (Of note: R29's Right buttock PI deteriorated to a stage 3 pressure injury and required debridement.) . Stage 2 Pressure Wound of Left Buttock Partial Thickness: etiology-pressure, objective-healing, wound size- 2.0cm x 0.7cm x 0.1cm, exudate light serosanguinous, dermis- open areas with exposed dermis . Dressing Treatment Plan- Primary- zinc ointment apply once daily for 30 days, Iodosorb gel apply once daily for 30 days, Secondary- Gauze island with border apply once daily for 30 days, peri wound treatment- Skin prep apply once daily for 30 days . Recommendations: group 2 mattress, offload wound, repositioned per facility protocol, cleanse with soap and water, turn side to side in bed every one to two hours if able, changing schedule every two hours . (It is important to note R29 now has two in house acquired stage 3 pressure injuries and one stage 2 PI. The facility did not update R29's care plan to reflect the recommendations of turn side to side every one to two hours.) R29's Body Check Form, dated 1/26/25, indicates R29 has skin disruption on his coccyx area circled by staff. Are there any new skin disruptions found? No. What kind of skin disruption was found? (blank) . R29's Physician Visit Summary, dated 1/30/25, includes: Chief complaint: wound on sacrum, right buttock, left buttock . Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Stage 3 Pressure Wound Sacrum Full Thickness: etiology- pressure, objective- healing, Wound size (length x width x depth) - 2.5cm x 0.5cm x 0.2cm . periwound radius- macerated, exudate- light serosanguinous, Thick adherent devitalized necrotic tissue- 80%, slough- 10%, granulation tissue- 10% . Dressing Treatment Plan- primary- Iodosorb gel, apply once daily for 23 days . secondary- gauze island with border apply once daily for 23 days . Peri wound treatment- Skin prep apply once daily for 23 days . Recommendations- cleanse with soap and water; turn side to side in bed every one to two hours if able; offload wound; group 2 mattress already on . Stage 3 Pressure Wound of Right Buttock Full Thickness: etiology-pressure, Wound size- 1.0cm x 2.0cm x o.1cm, exudate- light serosanguinous, Slough- 80%, Granulation tissue- 20% . Dressing Treatment Plan- primary- Iodosorb gel, apply once daily for 23 days . secondary- gauze island with border apply once daily for 23 days . Peri wound treatment- Skin prep apply once daily for 23 days . Recommendations- offload wound, reposition per facility protocol, group 2 mattress, cleanse with soap and water, turn side to side in bed every one to two hours if able, changing schedule every two hours .Sharp Selective Debridement Procedure: indications for procedure- remove biofilm, remove dried exudates or debris . procedure note: the wound was cleansed with normal saline and anesthesia was achieved by using topical benzocaine . then with clean surgical technique, 15 blade was used to selectively remove biofilm, remove dried exudates or debris over the wound surface area of 2.0cm ^2. The wound was cleansed again and a clean dressing was applied . Stage 2 pressure wound of the left buttock: resolved . Of note: due to deterioration of the right buttock PI, the physician debrided the PI to remove debris and biofilm.) R29's Body Check Form, dated 2/2/25, includes: no new skin disruptions noted .In House Weekly Wound Roster, dated 2/5/25, includes: R29- Coccyx, non pressure, in house acquired, date identified 11/13/24, stage-3, measurement- 3.0cm x 1.0cm x 0.2cm . Treatment- Clean, pat dry, medi-honey, calcium alginate, dry dressing . frequency- daily and as needed . Care planned- yes . Orders up to date in electronic health record- yes .Right buttock, pressure, in house acquired, date identified 1/8/25, stage- 2, measurement- 3.0cm x 3.0cm x 0.1cm . Treatment- collagen sheet, dry dressing . frequency- daily and as needed . Care planned- yes . Orders up to date in electronic health record- yes .Left buttock, pressure, in house acquired, date identified 1/8/25, stage- 2, measurement- 2.0cm x 2.0cm x 0.1cm . Treatment- collagen sheet, dry dressing . frequency- daily and as needed . Care planned- yes . Orders up to date in electronic health record- yes . (It is important to note the facility continues to measure R29's left buttock wound after it was noted to be resolved on 1/30/25. There is no indication the facility notified R29's Medical Doctor when this area reopened. It is important to note the Facility down staged R29's wound to the sacral region from a stage 3 to a stage 2. The facility documents it as being non-pressure even though the physician indicates it's a stage 3 pressure injury.) On 2/5/25, R29's care plan was updated to include Wedge in bed for repositioning every two to three hours staff to reposition wedge as needed. This is the first time the care plan had been updated to include repositioning; however, the facility documented that repositioning should be done every 2-3 hours, when the physician actually ordered every 2 hour side to side repositioning. R29's Physician Note, dated 2/11/25, include: pressure ulcer sacral region, measurements: 5.2cm x2.0cm x0.2cm . Stage 2, moderate exudate, serosanguineous, no odor, necrotic- (blank), granulation tissue: 0% .Tissue exposed- subcutaneous, periwound- non-blanchable, erythematous, macerated . Treatment Recommendations: the plan for the pressure ulcer is to cleanse the area with wound cleanser and the periwound area with vashe wound solution. Wound filler- Iodosorb Gel . Primary dressing- mepilex . This treatment will be done daily for 1 month. Today's treatment will be performed by the wound care team and other care performed by the staff of the facility . The pressure ulcer is to be offloaded using low air loss mattress . will be able to heal if offloading is able to continue in the setting of this acute illness. (It is important to note there are no weekly measurements or description for R29's left buttock PI or right buttock PI in this note or indication that the areas resolved. R29's sacrum (coccyx) PI has increased in length and is documented as a stage 2. Per standards of practice, a pressure injury should not be down staged.) R29's Braden Scale for Predicting Pressure Ulcer Risk, dated 2/12/25, indicates R29 is at high risk for developing pressure ulcers. On 2/15/25 the facility updated R29's care plan to include transfer assistance - 2 assist with Hoyer (full body lift) towel to be placed between right side strap and right leg to prevent rubbing skin injury. Physician Note, dated 2/18/25, includes: sacral region, wound type-pressure ulcer, measurements: 5.2cm x 2.0cm x 0.2cm . Tunnels- none, Stage 2, moderate exudate, serosanguineous, no odor, wound margins- well defined, necrotic material- over 50% .25% granulation tissue, scattered beefy red, pale . Tissue exposed- subcutaneous . Treatment Plan: The plan for the pressure ulcer-sacral region is to cleanse the area with wound cleanser and the periwound area with vashe wound solution . Wound filler- santyl . Primary dressing- mepilex . This treatment will be done twice a day for 1 month. The pressure ulcer was debrided using sharp debridement. The pressure ulcer is to be offloaded using a low air loss mattress . Left gluteal, wound type- abrasion, measurements- 1.5cm x 1.5cm x 0.1cm . Exudate amount- low, Exudate type- sanguinous, Odor-none, Wound Margins- poorly defined, periwound-denuded . Tissue exposed- partial thickness . Treatment Plan: The plan for the abrasion is to cleanse the area with vashe wound solution and the periwound area with vashe wound solution . Periwound Skin Treatment- SurePrep rapid dry, no sting barrier film . Primary dressing: Hydrocolloid dressing. This treatment will be done 3 times per week for 1 month. (Of note the Physician staged R29's sacral wound at a stage 2 but described the wound bed as having more than 50% necrotic tissue) On 2/23/25 at 2:40 PM LPN U (Licensed Practical Nurse) indicated the facility lost some power and then lost total power. LPN U indicated R29's air mattress was deflated for 30 minutes to an hour. LPN U indicated staff did not attempt to transfer R29 to a different surface or plug his bed into an emergency outlet. On 2/25/25 at 10:33 AM Surveyor observed R29's wound care with ADON C (Assistant Director of Nursing). ADON C indicated the sacral wound measures at 3.1cm x 0.6cm with 0.2cm. ADON C stated, There is some slough, 25 % granulation. Surveyor asked ADON C if there is slough in the wound how can it be a stage 2. ADON C stated, The slough is going away. Physician Note, dated 2/25/25, includes: wound- sacral region, wound type- pressure ulcer, measurements- 3.1cm x 0.6cm x 0.2cm . Stage- 2, Exudate amount- moderate, exudate type- serosanguinous, Odor- none, wound margins- well defined, peri wound- erythematous, necrotic material- 50%, granulation between 25% and 50% scattered, beefy red, pale, tissue exposes-subcutaneous . Treatment Plan: the plan for the pressure ulcer is to cleanse the area with wound cleanser in the peri wound area with Vashe wound cleanser . Wound filler- santyl . Primary dressing- mepilex . this treatment will be done twice a day for one month. The pressure ulcer was debrided using sharp debridement. The pressure ulcer is to be offloaded using low air loss mattress. Dressings can be changed as needed for soiling or if they are dislodged between scheduled dressing changes . wound- Left gluteal- healed Wound Type- abrasion . exudate amount- low, exudate type- sanguinous, wound margins- poorly defined, peri wound- denuded, tissue exposed- partial thickness . (Of note: During the dressing change on 2/25/25 ADON C and Surveyor both observed and noted slough in the wound bed while the physician does not mention slough. The left gluteal area is indicated as resolved.) On 2/25/25 at 2:38 PM, DON B (Director of Nursing) indicated the facility needed to provide education on emergency preparedness. DON B indicated staff should have transferred residents with pressure injuries whose bed was deflating/deflated to a support surface that was functioning appropriately. On 2/26/25 at 11:25 AM, CNA L (Certified Nursing Assistant) indicated they try to turn and reposition R29 every 2 to 3 hours, but there are times they are late doing this because they are busy with other residents. On 2/26/25 at 11:46 AM, RN G (Registered Nurse) stated, Staffing is a concern on this unit and to be honest, there have been times the staff was late to reposition and turn R29. It is very difficult for aides to get to him every 2 to 3 hours. On 2/26/25 at 4:36 PM, CNA S indicated staff turn and reposition R29 every 3 hours most days but they cannot get to him every 1 to 2 hours. CNA S indicated because of the acuity on the unit, they

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 4 sampled residents (R3 and R12). R3 had a change in condition on 5/8/24. R3's respiratory status was not fully assessed, there is no evidence of continuous monitoring of R3's condition or respiratory status, and R3's provider was not updated timely resulting in R3 being sent to the hospital on 5/10/24 for sepsis due to pneumonia. R12 had a change of condition following a fall including increased complaints of leg pain. The facility did complete a comprehensive assessment of R12 resulting in delay of treatment. Evidenced by: The facility's 'Notification of Changes Policy,' implemented 3/1/19, states in part: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate .all pertinent information will be made available to the provider by the facility staff.Overview of Components of the Policy. 1. Requirements for notification of resident, which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 3. A need to alter treatment significantly. (i) a significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments . Procedure. 1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list is not all inclusive) .c. a need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment . 2. the nurse will notify the resident, resident's physician, and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. 3. document the notification and record any new orders in the resident's medical record.6. Update the resident's care plan, transcribe, and implement the provider's orders. 7. communicate the changes to the rest of the care team and inform the supervisor. 8. communicate the changes to the staff on the oncoming shift . R3 was admitted to the facility for short term rehab and wound care. R3 had the following diagnoses: malignant neoplasm of bone and articular cartilage (cancer), acute respiratory failure with hypoxia (condition where the body's tissues don't have enough oxygen), paraplegia (chronic condition that causes the loss of muscle function and voluntary movement in the lower have of the body), pressure injury sacral (bottom of the spine that lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone) stage 4, combined systolic (congestive) and diastolic (congestive) heart failure (condition that occurs when the heart's left ventricle can't contract normally so the heart can't pump enough blood into circulation with enough force), Peripheral Vascular Disease (PVD; circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), anxiety disorder, and Urinary Tract Infection (UTI) diagnosed on [DATE]. R3's most recent Minimum Data Set (MDS) dated [DATE] documents a score of 15 on her Brief Interview of Mental Status (BIMS), which indicates R3 was cognitively intact. R3's Care Plan indicates the following: Impaired cardiovascular status related to congestive heart failure (CHF); peripheral vascular disease (PVD) date initiated 2/23/24 . interventions: Monitor intake and output (2/23/24), observe and report headaches, flushing, nosebleeds, nausea, shortness of breath (2/23/24), observe and report signs of chest pain, edema, shortness of breath (SOB) . (2/23/24). R3's Physician Orders indicates O2 (Oxygen) per NC (Nasal Cannula) PRN (as needed) to keep O2 Stats >92% (greater than 92%) one time a day for Hypoxia, start date 4/24/24, discontinued on 5/24/24. (This order was not on any of the Medication Administration Record/Treatment Administration Records (MAR/TARs) provided to Surveyor for April or May, therefore Surveyor is unable to see documentation of how often R3 was using the PRN oxygen order.) R3's MAR for March 2024 indicated R3 used her PRN (as needed) albuterol sulfate inhaler once on 3/12, twice on 3/13, and once on 3/15. R3's MAR for April 2024 indicated R3 did not use her PRN albuterol sulfate inhaler all month. R3's TAR for March, April, and May 2024, does not indicate any oxygen orders for R3. On 5/6/24 at 1:49 PM, R3's Nurses Note states in part: Advanced Skilled evaluation . Respiratory: no signs of difficulty breathing. No shortness of breath noted. Right lung clear. Left lung clear. Humidification: No. No oxygen. HOB (head of bed) is not elevated. No cough . On 5/7/24 at 9:41 AM, R3's Nurses Note with effective date of 5/7/24 indicates: Advanced Skilled evaluation: Vitals T (temperature) 97.1 5/8/2024 10:22 .BP (blood pressure) 107/62 - 5/8/2024 10:22 . P (pulse) 88 - 5/8/2024 10:22 type regular R (respirations) 20 - 5/8/2024 10:22. O2 (oxygen) 98% - 5/8/2024 10:22 Method: oxygen via Nasal cannula Mental status: Resident is alert & oriented x3, oriented to place. Oriented to time. Oriented to person. level of cognitive impairment: Alert. Resident is coherent. Speech is clear. Language barrier: No, Resident makes self-understood. Resident understands others .Respiratory: No signs of difficulty breathing. No shortness of breath noted. Humidification: Yes: oxygen via nasal cannula. HOB (head of bed) elevated. Head elevated at 30 degrees. No cough . On 5/8/24 at 8:37 AM, R3's eMAR - Medication Administration Note, indicates: Note text: Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 2 puff inhale orally every 4 hours as needed for wheezing, SOB (shortness of breath) Client complaints of SOB, O2 is 97% on 2 lts (liters). RR (respiratory rate) 22, HR (heart rate) 88 Author: RN Q (Registered Nurse) On 5/8/24 at 9:20 AM, R3's eMAR - Medication Administration Note, indicates: Note text: Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 2 puff inhale orally every 4 hours as needed for wheezing, SOB (shortness of breath). PRN Administration was: Effective Author: (RN Q) On 5/8/24 at 12:40 PM, R3's Nurses note states in part: Client (R3) was having episodes of SOB (Shortness of Breath) throughout the shift while writer was in room. Client (R3) sats were holding 98-97% on 2lt (liters) no s/x (signs or symptoms) or respiratory distress, RR (respiratory rate) 18 - 20. No barrel chested or nasal flares. During these episodes (sic), writer would stay in room and do breathing exercises and do education of anxiety and ways to control. (sic) Writer visually observed client several times during shift when walking by clients (R3) room and seen client resting comfortable with no s/sx of SOB. Client (R3) took noon medication with 240ml (milliliters) of water through a straw with no difficulty or SOB. Client refused all cares due to her SOB and refused therapy. Author (RN Q) . (No lung assessment is documented for R3 or any further documentation of monitoring R3's respiratory status on 5/8/24 or 5/9/24 is noted in R3's record. No documentation indicating R3's provider was updated regarding her shortness of breath on 5/8/24, when on 5/7 and 5/6, R3 was not experiencing SOB per nurses' notes and R3 was not using oxygen on 5/6 but is using it on 5/7 and 5/8. R3 does not have an order for oxygen on her MAR or TAR.) On 5/10/24 at 11:06 AM, R3's Nurses Note indicates: Resident called c/o (complaint of) SOB this morning. Pain med given, antianxiety med given, and albuterol given thru out am. NP R (Nurse Practitioner) contacted and stated to send resident to ED (emergency department) if SOB does not resolve. At this time resident and family are deciding on the options. Will monitor. On 5/10/24 at 11:15 AM, R3's Nurses Note indicates: Advanced Skilled evaluation: Lookback: Vitals temperature 97.1, blood pressure 107/62, pulse 88, respirations 20 and oxygen 96% on room air. Pain: indicators of pain: none. Neurologic (blank) EENT (eyes, ears, nose, throat): (blank) Mental status: Resident is alert & oriented x3, oriented to time, oriented to place, oriented to person. Mood and behavior: (blank) Cardiovascular: (blank) Respiratory: (blank) (of note, no indication if R3's lungs were assessed for abnormal lung sounds) Gastrointestinal: (blank) Nutrition: (blank) Genitourinary: Urinary catheter intact. Skin: Skin issues . Special care: (blank) Safety: (blank) Functional: (blank) Education/notification: (blank) Completed clinical suggestions: (blank) On 5/10/24 at 11:18 AM, R3's Nurses Note indicates: Advanced Skilled evaluation: Vitals temperature 97.1, blood pressure 107/62, pulse 88, respirations 20 and oxygen 96% on room air. Pain: indicators of pain: none. Neurologic (blank) EENT: (eyes, ears, nose, throat) (blank) Mental status: (blank) Mood and behavior: (blank) Cardiovascular: (blank) Respiratory: (blank) (of note, no indication if R3's lungs were assessed for abnormal lung sounds) Gastrointestinal: (blank) Nutrition: (blank) Genitourinary: Urinary catheter intact. Skin: . Special care: (blank) Safety: (blank) Functional: (blank) Education/notification: (blank) Completed clinical suggestions: (blank) On 5/10/24 at 11:51 AM, R3's Nurses Note states in part: Resident called on light and requested to be sent to the ED (emergency department) for evaluation because SOB was getting worse. 911 called and report called to (Hospital staff name) in ED at (Hospital name). On 5/10/24 at 1:55 PM, R3's Nurses Note indicates in part: Situation: Change in condition shortness of breath (SOB), outcome of physical assessment, respiratory status evaluation shortness of breath. Nursing observations, evaluation, and recommendations are SOB and anxious, feeling like she can't catch her breath at this time. Primary care Provider feedback: send to ED (emergency department) if no relief after albuterol and medications. R3's MAR for May 2024 indicated R3 only used her PRN albuterol sulfate inhaler on 5/8/24, this medication is not signed out on 5/10/24 as being given. (There is no evidence that a nurse assessed R3's lung sounds and R3's PRN albuterol medication is not signed out on the MAR for 5/10/24.) On 5/10/24 R3's Hospital Paperwork indicates: Emergency documentation service date/time: 5/10/2024 at 2:19 PM . Time seen: 5/10/24 at 12:42 (PM). Chief complaint: SOB for the past couple days. Not eating or drinking. History of present illness: .complains of 3 days history of shortness of breath. She complains of a little wheezing but denies any fever, URI (upper respiratory infection) symptoms, cough, chest pain, abdominal pain, vomiting or diarrhea . (heart rate) 121. (Blood pressure) 93/50, (respiratory rate) 23 SPO2: 98% nasal cannula 3 L/min. constitutional: Alert, interactive, appears pale. Respiratory: bilaterally wheezing, tachypneic (breathing that is faster and shallower than normal), mild respiratory distress . Medication decision making: .patient presented to the ED with complaint of shortness of breath. Patient is always on 2l of nasal cannula. Her initial pulse ox was 90%. Her initial blood pressure was in the 70's over 40s. Her heart rate was in the 120s. patient was treated with 2 DuoNeb's (breathing treatment) and a liter of normal saline IV (intravenous). Afterwards, she appeared improved. She still has bilateral wheezing. Her heart rate is in the 1 teens. Her blood pressure is in the 90s over 50s. Chest x-ray revealed bibasilar pneumonia. Due to patient's tachycardia (rapid heart rate), hypotension (low blood pressure) and bilateral pneumonia. She will be admitted for IV antibiotics . On 5/10/24 R3's Hospital Paperwork indicates: History and Physical 5/10/2024 at 3:45 PM, Chief complaint SOB for the past couple days. Not eating or drinking. History of present illness: .presents to the ED today for new onset SOB. Pt is accompanied by son breathing difficulty began about 3 days prior and has been progressively worsening. She is fatigued from the breathing efforts. Has a nonproductive cough and feels like something is stuck in her chest. Notes she is nauseated. Not normally on oxygen is now requiring 5 L NC (Nasal cannula) . physical exam: .Resp (respiratory): diffuse rhonchi but L>R (left greater than right), fast shallow breathing, on nasal cannula, breath sounds bilaterally vitals & measurements .(heart rate) 119bpm (beats per minute) .(blood pressure) 94/55, SPO2% (oxygen) 85% O2 therapy: nasal cannula O2 flow rate: 5l/min .diagnostics: XR chest 1 view: XR chest 1 view (05/10/24 12:43) chest Xray portable . impression: bibasilar airspace opacities pneumonia versus atelectasis. Favor Pneumonia. Assessment/Plan: 1. Sepsis due to pneumonia continue on IV antibiotics: Cefepime. 2. Bilateral Pneumonia .admit to inpatient .bilateral pneumonia/sepsis. 3. COPD exacerbation, acute COPD exacerbation brought on by PNA (pneumonia) . On 5/15/24 at 11:22 AM, R3's Hospital Discharge/Transfer information, states in part: Discharge diagnoses: 1. Bacteremia. 2. Sepsis due to pneumonia. 3. COPD exacerbation. 4. Acute Respiratory failure with hypoxia. 4. Acute respiratory failure/hypoxia 5. Pulmonary hypertension .Hospital course/treatment rendered: presented to the ER (hospital name) with 3 days of SOB, CXR shows BL (bilateral) PNA and was septic with hypotension needing levophed after sepsis protocol fluid resuscitation. Pt was started on cefepime + vancomycin. (Sepsis is a life-threatening medical emergency that occurs when the body's immune system overreacts to an infection, which damages its own tissues and organs. Levophed is a medication used to treat low blood pressure and heart failure. Cefepime and vancomycin are antibiotics used to treat bacterial infections.) On 6/13/24 at 11:29 AM, Surveyor interviewed DON B (Director of Nursing) regarding R3. Surveyor asked DON B to read 5/8 and 5/10/24 documentation/notes. DON B indicated he would expect a lung assessment to be completed to see if there were any changes, update the provider with R3 having SOB. DON B indicated he is not able to tell how long RN Q was in R3's room with R3, and that he would expect that to be documented. DON B indicated he would expect follow up monitoring/assessments to be done on R3. DON B indicated R3 should have had monitoring on 5/8 and 5/9. DON B indicated he would expect a lung assessment to be completed on 5/10/24 as well. DON B indicated he would expect PRN breathing medications to be offered as ordered. On 6/13/24 at 1:40 PM, Surveyor interviewed NP R (Nurse Practitioner), regarding R3. Surveyor read R3's note from 5/8/24 to NP R. NP R indicated she would expect a call from the facility with any change and with a SBAR (Situation, Background, Assessment, and Recommendation). NP R indicated she would expect nursing staff to monitor R3 for a few days for further signs/symptoms. Surveyor asked NP R, if staff would have monitored R3's lung sounds and assessed her respiratory status on 5/8 and 5/9, if R3's pneumonia could have been treated sooner. NP R referred Surveyor to Medical Director and would not give an answer to the question. On 6/13/24 at 4:51 PM, Surveyor interviewed RN Q (Registered Nurse) regarding R3. RN Q indicated she recalled R3 having complaints of shortness of breath on a night shift and with her on another shift. (Unable to remember dates.) RN Q indicated if someone is saying they're SOB she would get vitals, check their oxygen, check for respiratory distress and if they are having respiratory distress you would need to call the provider and administer as needed medications. Surveyor asked RN Q if she would do a lung assessment. RN Q replied yes, you would do a full assessment like a head to toe. Surveyor asked RN Q if she did a full assessment on R3 on 5/8/24? RN Q indicated she is unable to say without reviewing documentation and indicated she no longer works at the facility. Surveyor read RN Q's note from 5/8/24 to her. RN Q indicated she should have done a lung assessment and charted it. RN Q indicated R3 should have been monitored for SOB if it was passed on in report. R3 experienced a change in condition on 5/8/24 per documentation and was put on 2 L of oxygen. R3's provider was not updated regarding the SOB or oxygen use. R3 was not monitored any further until 5/10/24 when R3 was sent out to the hospital and was admitted with sepsis due to pneumonia which required IV antibiotics to be provided. Example 2 R12 had a change in condition on 6/5/24 following a fall out of bed. R12 began complaining of pain and staff did not assess despite a known fall. There is no evidence of continuous monitoring of R12's condition despite obvious signs of increased pain. R12 was later found to have a hip fracture. The facility's 'Falls Management Process,' undated, states in part: In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident .Resident is NOT to be moved until assessed for injury by a nurse unless life-threatening situation exists. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating, and examining all areas for breaks in the skin and/or other abnormal findings. If no obvious injury or only minor injury move resident to a comfortable position. If significant injury, severe pain, or abnormal assessments observed, call 9-1-1. The facility's 'Notification of Changes Policy,' implemented 3/1/19, states in part: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate .all pertinent information will be made available to the provider by the facility staff.Overview of Components of the Policy. 1. Requirements for notification of resident, which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 3. A need to alter treatment significantly. (i) a significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments . Procedure. 1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list is not all inclusive) .c. a need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment . 2. the nurse will notify the resident, resident's physician, and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. 3. document the notification and record any new orders in the resident's medical record.6. Update the resident's care plan, transcribe, and implement the provider's orders. 7. communicate the changes to the rest of the care team and inform the supervisor. 8. communicate the changes to the staff on the oncoming shift . This is evidenced by: R12 was admitted to the facility on [DATE] with diagnoses including, but not limited to, the following: displaced spiral fracture of shaft of left femur, alcohol abuse, Wernicke's encephalopathy, urinary retention, metabolic encephalopathy, hyperosmolality, and hypernatremia. R12's admission BIMS (Brief Interview of Mental Status) demonstrates that R12 is severely cognitively impaired. R12 has an APOAHC (Activated Power of Attorney for Healthcare). R12's comprehensive care plan documents the following: Focus: Needs pain management and monitoring related to surgically repaired hip fracture, and generalized pain. (Date Initiated: 4/22/24) Goal: Patient will achieve acceptable pain level goal 4. Interventions/Tasks: Administer Pain medication as ordered; Evaluate and establish level of pain on numeric scale/evaluation tool; Evaluate characteristics and frequency/pattern of pain; Evaluate need for bowel management regimen; Evaluate need for routinely scheduled medications rather than PRN (as needed) pain med administration; Evaluate need to provide medication prior to treatment or therapy; Evaluate what makes the patient's pain worse; Repositioning for comfort as needed (All interventions with Date Initiated: 4/22/24) R12's comprehensive care plan documents, in part, the following: I have a physical functioning deficit related to: Mobility impairment, self-care, impairment r/t (related to) weakness, physical limitations, need for staff assistance, hip fx (fracture) and cognitive deficits. Goal: R12 will improve my current level of physical functioning. Interventions/Tasks: Bed mobility assistance of 1, Dressing assistance of 1, Locomotion assistance of 1 in w/c (wheelchair), Monitor and report changes in physical functioning ability, Personal hygiene assist assistance of 1, Toileting assistance of 1, Transfer assistance of 2 with full body lift (Date Initiated 4/24/24) At risk for falls related to cognitive deficits, weakness, physical limitations, and need for staff assistance. Actual fall on 4/30/24, 5/16/24 Goal: No serious Fall related injuries Interventions: Bolster mattress placed on bed (Date Initiated: 4/24/24), Dysom (sic) on wheelchair seat (Date Initiated: 4/20/24), Encourage participation in activities to improve strength or balance (Date Initiated: 4/19/24, Revised 4/24/24), Encourage rest periods if feeling fatigued (Date Initiated: 4/19/24, Revised 4/24/24), Encourage use of a chair with arm rests (Date Initiated: 4/19/24, Revised 4/24/24), Footwear to prevent slipping (Date Initiated: 4/21/24, Revised 4/24/24), Keep bed locked (Date Initiated: 4/21/24, Revised 4/24/24), Keep environment well-lit and free of clutter (Date Initiated: 4/21/24, Revised 4/24/24), Keep personal items within reach (Date Initiated: 4/21/24, Revised 4/24/24), Nonskid socks/slippers (Date Initiated: 4/19/2 Revised 4/24/24), Resident is not to be left in the dining room alone (5/17/24), Staff to set up an activity table for resident if appearing restless (Date Initiated: 5/11/24, Revised 5/13/24), Therapy to work with DON on positioning calf pad on wc (wheelchair) between leg rests. (Date Initiated: 5/1/24), On 6/5/24 at 5:00 PM, R12 sustained an unwitnessed fall from bed. On 6/5/24 at 5:35 PM, LPN D (Licensed Practical Nurse) documented the following progress note: R12 found on floor, no injuries, Neuro checks started. BP (Blood Pressure) 124/88, resp (Respirations): 22, Temp (Temperature): 98.1, Pulse: 52 Spo2 (oxygen concentration) 98% room air. MD (Medical Doctor) notified, ADON (now Interim Director of Nursing), IDON CC notified. Significant other notified. On 6/5/24 at 5:45 PM, LPN D documented the following Fall Risk: History of falls (past 3 months): 3 or more falls in past 3 months. Level of consciousness/mental status: Intermittent confusion. Resident is chairbound/incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 3 or more present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait/balance: N/A (not applicable) - not able to perform function. medication: Takes 3-4 these medications (or medication classes) currently and/or within the last 7 days. Fall Risk Score: 19 (Note, R12 is at risk of falls as he was admitted to the facility with a fracture.) LPN D (Licensed Practical Nurse) documented the following Post Fall Evaluation: Fall Details Date/Time of Fall: 6/5/24 at 5:00 PM Fall was not witnessed. Fall occurred bedside. Activity at the time of fall: Attempting to self-transfer - The reason for the fall was not evident. Did an injury occur as a result of the fall: No Did fall result in ER visit/hospitalization: No Provider: Physician AA Time Notified: 6/5/24 Notified of fall with no injury. Contributing Factors: Resident change in environment: No Was fluid spilled on floor: No Clutter present on the floor: No Floor mat was on floor: No Poor lighting in the area: No Bed was at an improper height: No Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall. No Foot wear at the time of fall: Non-skid shoes/socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen at the time of fall. Resident was using incontinent supplies at the time of the fall. Incontinent at time of fall: No Bedside call light on when Resident was found: No Bathroom call light on when Resident was found: No Personal alarm sounding when Resident found: No Other Residents were not involved in fall. Medication Changes: No Vitals at 6:01 PM: T (Temperature): 98.2 BP (Blood Pressure): 128.86, P (Pulse: 56, R (Respirations) 20, Oxygen: 98% Method: Room Air Pain: Indicators of pain: None Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Physical Findings: Change in diagnosis status: No Recent diagnosis of stroke, TIA (Trans ischemic Accident/mini stroke) or arrhythmia: No Decrease in fluid intake: No Change in blood glucose levels: No Change in blood pressure: No Change in behaviors: No Change in mobility status: No Recent weight loss: No Sensory impairment: No Resident does not have orthostatic BP (blood pressure) changes. Actioned Clinical Suggestions: Blank On 6/5/24 at 5:45 PM, LPN D documented the following progress note: Type: Skin Only Evaluation - Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. On 6/5/24 at 8:09 PM, LPN D documented the following progress note: R12 c/o (complained of) pain right hip after fall, Physician AA ordered an x-ray, x-ray company called, and they are expected to come tomorrow morning. LPN D did not document R12's pain level, administer pain medication, complete range of motion, or do an assessment of R12's lower extremities. R12's MAR (Medication Administration Record) documents the following order: Tylenol Oral Tablet 325 mg (milligram) - Give 650 mg by mouth every 4 hours as needed for pain. Order Date: 6/5/24 11:12 PM The MAR indicates LPN BB (Licensed Practical Nurse) administered Tylenol to R12 at 3:05 AM with a documented pain rating of 5. LPN BB did not follow up with R12 to ensure the Tylenol was effective. The oncoming shift marked the medication with an I indicating ineffective on 6/6/24 at 8:45 AM with a pain rating of 6. On 6/6/24 at 3:05 AM, LPN BB (Licensed Practical Nurse) documented the following progress note: upon start of shift, R12 with visible pain and reporting butt and legs hurting, sitting in broda chair at time of arrival. Writer and CNA (Certified Nursing Assistant) transferred resident to bed via Hoyer. Resident yelling and hollering my leg. R12 with severe pain to right leg/hip with transferring/repositioning. Notified Physician AA of yelling and hollering, gave order for Tylenol 650 mg (milligram) Q4H (every 4 hours) PRN (as needed). It is important to note, LPN BB entered the order for Tylenol PRN in the MAR at 11:12 PM. It is important to note despite R12's known fall, yelling my leg, there was no assessment of R12's right leg or hip and no continuous monitoring of R12. On 6/6/24, there is no documentation from LPN BB or any staff after 3:05 AM until 8:41 AM to indicate if the Tylenol was effective or not. There is no follow up pain assessment or continued monitoring documented until 8:41 AM (over 5 1/2 hours). On 6/6/24 at 8:41 AM, staff document in the progress notes: Tylenol Oral Tablet 325mg - Give 650 mg by mouth every 4 hours as needed for pain. PRN (as needed) Administration was: Ineffective Follow up Pain Scale was: 6. On 6/6/24 at 10:41 AM, staff documented the following progress note: Xray of right hip post fall one time only for diagnostic for 30 days. Resident was sent to the hospital for X-ray of his right hip. Called x-ray company and talked to (name omitted) to cancel the X-ray. On 6/6/24 at 10:55 AM, IDON CC (Interim Director of Nursing) documented the following eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers. At the time of the evaluation resident/patient vital signs, weight and blood sugar were: Pulse P 56 6/5/24 6:01 PM RR R 20.0 6/5/24 at 6:01 PM Temp T 98.2 6/5/24 6:01 PM Weight 134.0 lb. (pounds) 6/2/24 Pulse Oximetry O2 98.0 6/5/24 at 6:01 PM Note, these vitals are not current. (The most recent vitals documented on the Neuro Checks indicates the last vitals were obtained on 6/6/24 at 7:00 AM. The vitals were as follows: Temperature: 90 (type-o), Pulse: 97, Respirations: 20, Blood Pressure: 106/64.) Outcomes of Physical Assessment: Positive findings reported on the resident/patient for evaluation for this change in condition were: Functional Status Evaluation: Fall Pain Status Evaluation: Does the resident/patient have pain: Yes. Nursing observations, evaluation, and recommendations are: R12 with unwitnessed fall out of bed last evening with no apparent injury noted. Resident developed pain overnight and increased swelling to R (right) hip joint. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: Send to ED (Emergency Department) for eval if the condition has worsened and pain has increased. On 6/6/24 at 4:17 PM, R12's hospital report documents, in part, as follows: Pt (patient) brought in by medic. Per report Pt fell yesterday afternoon and is c/o (complaining of) back pain and right hip pain. Pt hypotensive upon arrival to ER (emergency room). Patient with longstanding history of alcohol abuse (now with Wernicke's encephalopathy/dementia), chronic urinary retention with indwelling Foley, and a history of a multitude of fractures from multiple falls . He reportedly fell out of bed yesterday (details not available since unwitnessed) and presented to the ER today due to pain Imaging confirms a right intertrochanteric hip fracture no other acute injuries (multiple old various healed fractures noted along with the recently healed distal L (left) spiral femur fx (fracture). R12's right hip x-ray documents the following findings: Bones: Comminuted, displaced, right proximal femoral intertrochanteric fracture. Left hip arthroplasty in position. Remote right pubic rami fractures. The facility has three (3) staff statements related to R12's fall on 6/5/24. On 6/6/24, CNA Z (Certified Nursing Assistant) documented the following statement: I was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure quality end of life care was provided to 2 Residents (R) (R6 and R5) of 11 sampled residents. R6's hospice plan of care, related to pain management and comfort, was not consistently followed from the time R6 was admitted to hospice services on 4/14/23 until R6 passed away on 4/23/23. On 4/21/23, R6 was prescribed liquid morphine every 4 hours and liquid lorazepam every 6 hours. The orders were not transcribed in R6's medical record and the medications were not administered. In addition, R6's medical record did not contain hospice visit notes and the facility did not follow up on hospice staff concerns reported on 4/15/23. This example is being cited at a level G (Actual Harm/Isolated). R5 was diagnosed with edema and had physician orders to complete daily weights indefinitely and put compression stockings on in the AM and remove in the PM. R5 also had a physician order to place a wedge provided by the facility or R5 to elevate R5's legs while in bed. The orders were not consistently followed. Findings include: The facility's Hospice Services Facility Agreement, dated 3/1/19, contained the following information: It is the facility's responsibility to .meet the resident's personal care and nursing needs in coordination with the hospice representative . 1. R6 was admitted to the facility on [DATE] with diagnoses to include a stroke, hypertension, insomnia, bipolar disorder, anxiety disorder, major depressive disorder, and a chronic venous ulcer of the left foot. R6's most recent Minimum Data Set (MDS) assessment, dated 3/26/23, indicated R6's cognition was not assessed and R6 required the assistance of one to two staff for activities of daily living (ADLs), including bed mobility, toileting, bathing, transferring, and personal hygiene. R6's plan of care, revised 4/17/23, stated R6 would be comfortable and have needs met. Interventions included: coordinate care plan with hospice, evaluate effectiveness of medications/interventions to address comfort, and notify hospice of any change in condition or medication changes. R6's hospice plan of care (POC), dated 4/14/23, stated R6 was admitted to hospice services for terminal diagnoses of aspiration pneumonia, sepsis, metabolic encephalopathy, and acute respiratory failure with hypoxia. The POC listed the following goals and interventions: -The facility will support R6's needs along with hospice services' support for end of life care, including but not limited to, pressure rotation every 1-2 hours in bed, incontinence cares, oral cares, and symptom relief medication administration for pain/shortness of breath. -R6's pain will be 4 or less on a scale of 0-10 as evidenced by resting peacefully, not calling out, and not moaning when touched or turned. R6's medical record contained the following hospice orders, dated 4/14/23: - Atropine Opthalmic solution 1% - 4 drops by mouth every 15 minutes as needed for terminal congestion. - Morphine Sulfate Oral tab 15 mg (milligrams) - give ½ tablet by mouth every 30 minutes as needed for pain or dyspnea (difficulty breathing) by mouth/sublingual, may crush. Give for mild symptoms. - Morphine Sulfate Oral tab 15 mg - give 1 tablet by mouth every 30 minutes as needed for pain or dyspnea by mouth/sublingual, may crush. Give for moderate to severe symptoms. - Lorazepam 1 mg by mouth at bedtime for agitation/anxiety. - May crush oral medications with instruction from hospice nurse or pharmacist. - Small sips/bites as tolerated and for pleasure. R6's medical record contained the following hospice order, dated 4/19/23: - Scopolamine Transdermal Patch 72 hour - apply 1 patch every 72 hours as needed for mild/moderate airway secretions. On 6/14/23, Surveyor requested all hospice documentation from Nursing Home Administrator (NHA)-A. Included in the documentation were the following signed orders, dated 4/21/23: - Morphine Concentrate 20 mg/ml (milliliter) oral - give 1 ml every 4 hours. - Lorazepam 2 mg/ml liquid - give 0.25 ml every 6 hours. On 6/14/23, Surveyor reviewed R6's medical record, including Certified Nursing Assistant (CNA) charting, Treatment Administration Record (TAR), Medication Administration Record (MAR), and vital signs. CNA charting did not include documentation that incontinence cares and repositioning were completed on the 4/14/23, 4/17/23, 4/18/23, and 4/21/23 night shifts. In addition, CNA charting did not contain any documentation regarding the completion of oral cares. R6's MAR indicated one dose of morphine sulfate 7.5 mg was administered on 4/21/23 at 5:20 PM by Licensed Practical Nurse (LPN)-G for a pain rating of 8 out of 10. R6's MAR and TAR did not indicate any other comfort medications were administered by facility staff. R6's pain assessments indicated pain was to be monitored each shift. Staff completed the following pain assessments using the numeric scale (0-10 out of 10) versus the Pain Assessment in Advanced Dementia (PAINAD) unless otherwise specified: 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, and 4/22/23 Night shifts - 0 4/15/23, 4/18/23, and 4/22/23 AM shifts - not assessed 4/16/23 AM shift - 0 (PAINAD); 4/19/23, 4/20/23, and 4/21/23 AM shifts - 0 4/15/23, 4/16/23, and 4/17/23 PM shifts - not assessed 4/18/23, 4/19/23, 4/20/23, and 4/22/23 PM shifts - 0 4/17/23 AM shift - 2 (PAINAD) 4/21/23 PM shift - 8 R6's medical record contained the following respiratory assessments: 4/16/23 at 12:58 PM: O2 sat (oxygen saturation level) 91% on oxygen (did not indicate how many liters); Respiratory Rate (RR) 16 (normal range is 12-20 breaths per minute (bpm)). 4/17/23 at 10:57 AM: O2 sat 89% on oxygen (did not indicate how many liters); RR 22 bpm 4/17/23 at 3:52 PM: O2 sat 89% on oxygen (did not indicate how many liters); RR 22 bpm 4/20/23 at 8:05 AM: O2 sat 90% on oxygen (did not indicate how many liters); RR 20 bpm R6's medical record did not contain any additional assessments or vital signs. On 6/14/23, Surveyor reviewed R6's hospice visit notes which contained the following information: 4/14/23 - Hospice admission Visit 12:35 PM: Hospice Registered Nurse (HRN)-J noted R6 was breathing heavily and had wet sounding respirations with O2 sat of 81% on 5 liters (L). HRN-J opened medication from a comfort pack and administered atropine drops as ordered. HRN-J noted R6's tongue was extremely dry and cracking in several spots and provided oral and incontinence care. HRN-J assessed R6, obtained vital signs and then administered a second dose of atropine drops. R6's respirations went from 26 to 21. HRN-J educated facility staff on the need for repositioning and oral cares every 2 hours. 4/15/23 - Hospice Nurse Visit 12:00 PM: HRN-K spoke with NHA-A regarding R6's dry oral mucosa, including thick sloughing layers of dry tissue on (R6's) tongue, lips, and inside of cheeks. HRN-K also informed NHA-A that an unknown facility CNA stated oral care, incontinence care, and repositioning was not being done every two hours. NHA-A stated the concerns would be addressed. HRN-K asked NHA-A how R6 took medications due to concerns about R6's ability to swallow. NHA-A was unable to provide the information and HRN-K was unable to find a facility nurse to discuss the concern. At 3:43 PM, HRN-K called the facility and spoke with LPN-R who stated R6 took medications without concern. HRN-K instructed the facility to contact hospice with any concerns related to comfort/swallowing. 4/17/23 - Hospice Nurse Visit 12:00 PM: HRN-L noted R6 felt short of breath. R6's RR was 22 and O2 sat was 80% on 6 L. R6's pain was assessed as 4 (moderate pain) out of 10 using the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Pain Scale. 4/20/23 - Hospice Nurse Visit 10:45 AM: HRN-M noted R6 had a RR of 44. HRN-M requested R6's morphine. LPN-F stated the facility did not have R6's comfort medications. HRN-M verified R6's comfort pack was delivered on 4/14/23. LPN-F found R6's medications after approximately twenty minutes. LPN-F crushed and administered one ½ tab of morphine with water in a syringe. R6 began to cough and R6's O2 sat dropped to 72% on 8 L. HRN-M instructed LPN-F to stop when LPN-F tried to administer additional water via syringe and educated LPN-F on the proper administration of R6's crushed medication. HRN-M requested R6's atropine drops when R6 became restless. LPN-F stated the facility did not have atropine drops. HRN-M again verified all medications in the comfort pack were delivered on 4/14/23. LPN-F found the atropine drops after approximately 15 minutes. HRN-M administered two doses of lorazepam, three doses of morphine, and one dose of atropine to bring R6 back to baseline. HRN-M instructed LPN-F to administer comfort medications every four hours and as needed. 4/21/23 - Hospice Nurse Visit 4:40 PM: HRN-L and LPN-G reviewed R6's comfort medications and why they were not administered since hospice's visit on 4/20/23. LPN-G stated the medications were tablets. HRN-L educated LPN-G on how to administer crushed comfort medications with a small amount of water in a syringe. HRN-L noted R6 had labored breathing and a RR of 48 with an O2 sat of 75% on 10 L of oxygen. HRN-L obtained orders for liquid morphine and liquid lorazepam so facility staff would feel comfortable administering medications. HRN-L instructed LPN-G to administer morphine 7.5 mg and lorazepam 0.5 mg with a small amount of water. Hospice sent orders for liquid comfort medications to the pharmacy to be delivered the following day. 4/22/23 - Hospice Nurse Visit 11:30 AM: HRN-N arrived at the facility with liquid morphine and liquid lorazepam. LPN-I signed and accepted the medications. 4/23/23 - Hospice Nurse Visit 7:35 AM: HRN-O arrived after the facility reported R6 passed away. HRN-O asked facility staff how R6's night went, when R6 received the last dose of medication(s) and when staff last rounded on R6. RN-Q stated R6 did not receive any medications during the night. HRN-O asked why the liquid morphine and liquid lorazepam orders were not transcribed or administered after they were delivered on 4/22. RN-Q stated RN-Q did not know. On 6/14/23 at 9:55 AM, Surveyor interviewed Hospice Director (HD)-P who verified several hospice staff reported concerns regarding R6's condition and the fact facility staff did not provide comfort medications. HD-P stated R6 likely had a very rough end of life. HD-P stated that (named hospice company) chose to no longer work with the facility due to poor communication and lack of follow through on hospice orders/treatments. On 6/14/23 at 2:20 PM, Surveyor interviewed Regional Director (RD)-C who verified medication orders should be transcribed and administered as ordered. On 6/14/23 at 3:05 PM, Surveyor interviewed NHA-A who could not recall any concerns regarding R6, including any concerns expressed by hospice staff. Surveyor noted the grievance binder contained no concerns related to R6. On 6/15/23 at 9:31 AM, Surveyor interviewed CNA-D who worked with R6 on the 4/15/23 AM and PM shifts and the 4/20/23 PM shift. CNA-D stated R6 appeared to be in pain because R6 moaned when R6 was repositioned and appeared to have labored breathing. On 6/15/23 at 9:35 AM, Surveyor interviewed RN-E who was the charge nurse on the 4/14/23 AM shift. RN-E verified staff had to assess R6 for pain because R6 could not verbally report pain. RN-E confirmed RN-E did not administer any comfort medications due to R6's swallowing concerns. On 6/15/23 at 9:42 AM, Surveyor interviewed LPN-F who worked with R6 on 4/19/23 and 4/20/23 AM shifts. LPN-F stated the last time LPN-F worked with R6, R6 appeared to be in respiratory distress as evidenced by the use of accessory muscles, gasping, and low O2 sat. LPN-F stated LPN-F administered comfort medications under the direction of hospice staff. On 6/15/23 at 9:49 AM, Surveyor interviewed LPN-G who worked with R6 on the 4/19/23, 4/21/23, and 4/22/23 AM shifts and the 4/21/23 PM shift. LPN-G verified R6 appeared restless and uncomfortable. LPN-G stated R6 could not verbally report pain and staff had to determine R6's pain level via assessment/non-verbal scale. On 6/15/23 at 12:47 PM, Surveyor interviewed HRN-N who verified both liquid medications and a copy of the signed orders were delivered to LPN-I during R6's hospice visit on 4/22/23. HRN-N told LPN-I the medications were scheduled and R6 needed them right away. On 6/15/23 at 10:04 AM, Surveyor interviewed LPN-I who verified HRN-N delivered the medications in the early afternoon. LPN-I stated LPN-I put the medications (in their original bag) in the 400 wing medication cart and added them to the narcotic book. LPN-I stated LPN-I assumed R6 already had orders for the medications and did not look in the medication bag for orders. 2. On 6/13/23, Surveyor reviewed R5's medical record. R5 was admitted to the facility with diagnoses to include hemiplegia/hemiparesis following a cerebrovascular accident, morbid obesity and seizures. R5's Quarterly MDS assessment, dated 4/28/23, documented R5's cognition was 15 out of 15 (the higher the score, the more cognizant). R5 did not ambulate, was dependent on staff for transfers with a full-body lift, and required extensive assistance of two staff for bed mobility. R5's plan of care, initiated 7/27/21, stated R5 was at risk for altered nutrition related to current condition, alcohol abuse, and history of weight gain. Weights to be obtained per orders. A progress note, dated 5/12/23 at 1:47 PM, indicated R5's physician was notified that R5 had four (4) plus edema to the left foot. New orders were obtained to weigh and notify the physician. A physician order, dated 5/12/23, stated daily weights to start on 5/13/23 on the day shift. A progress note, dated 5/12/23 at 5:06 PM, indicated R5 was to be administered 20 mg of Lasix every day with daily weights. Lasix 20 mg was administered as ordered. R5's weight summary indicated R5 weighed 345.6 pounds on 5/3/23. R5 was weighed on 5/15/23 and weighed 357.8 pounds (a weight gain of 12.2 pounds). Surveyor noted that was the only documented weight after the physician ordered daily weights to start on 5/13/23. R5 had a physician order, dated 5/23/23, for compression stockings to lower extremities-measure and fit, on in AM, off in PM, every day and evening shift. R5 also had a physician order, dated 5/23/23, for facility to supply wedge to R5-place at foot of bed to elevate legs or allow to use own (wedge). R5 did not have a plan of care or a CNA [NAME] (modified care plan used by nursing staff) related to compression stockings or the use of a wedge. R5 had a physician order, dated 5/31/23, to send R5 to the emergency department (ED) per family request due to concerns of increased edema and a question of possible sepsis. A progress note, dated 5/31/23 at 5:55 PM, indicated R5 was sent to the ED to be evaluated per family request for increased edema and possible sepsis. R5 was evaluated at the ED on 5/31/23 at 6:29 PM. The chief complaint was increased edema and shortness of breath. Morbid obesity was an ongoing problem. R5's weight was obtained. R5 weighed 390.88 pounds. R5 was prescribed compression socks, but R5 stated the facility did not provide compression wraps. R5 was diagnosed with dependent edema, 40 mg = 4 milliliters was administered to R5 intravenously (IV) at the ED. R5 was discharged back to the facility on 5/31/23 at 8:02 PM with an order to increase Lasix to 40 mg daily as the ED physician suspected the ongoing edema was likely due to R5's weight, immobility and a prior left leg deep vein thrombosis (DVT). The ED physician indicated to please apply compression stockings to both legs as prescribed. On 6/13/23 at 12:50 PM, Surveyor observed R5 in bed with stretched out (loose) Tubigrips (not compression stockings) on both legs, and without a wedge to elevate R5's legs. R5 stated staff do no put on R5's compression stockings and verified the Tubigrips were loose. R5 also stated staff do not elevate R5's legs with the wedge, but should do so because of R5's edema. Additionally, R5 stated R5 was not weighed in a long time. On 6/13/23 at 1:02 PM, R5 requested CNA-S and CNA-T put compression stockings on R5's legs and elevate R5's legs with the wedge in R5's room. CNA-S stated R5 did not ask for and did not wear compression stockings for the entire nine (9) months CNA-S worked at the facility. CNA-T stated R5 refused to wear compression stockings because the stockings were too tight. R5 stated R5 wanted to wear the compression stockings, but there was not a pair of stockings in R5's room. R5 then asked for the wedge under R5's legs. CNA-S and CNA-T placed the wedge under R5's legs, but did not feel the wedge was safe to use because it did not look comfortable or safe and R5 ordered the wedge on R5's own. CNA-T removed the wedge from under R5's legs and stated CNA-T would ask therapy if R5 could use the wedge. CNA-T verified the compression stockings and wedge were not on R5's plan of care or CNA [NAME]. CNA-T left R5's room to get compression stockings and discuss the use of the wedge R5 ordered with therapy. On 6/13/23 at 1:27 PM, CNA-T returned to R5's room with brown and white compression stockings. R5 declined the brown stockings, but allowed CNA-T to put the white stockings on. CNA-T also elevated R5's legs. On 6/14/23 at 4:05 PM, Surveyor interviewed LPN-G regarding R5's weights, compression stockings and wedge. LPN-G verified R5 had an order for daily weights indefinitely, but stated the order should have been for daily weights times three (3) days and update the physician. LPN-G confirmed the only weight documented was on 5/15/23. Additionally, LPN-G verified R5 had a physician order for compression stockings to be placed on R5's legs daily and R5 had an order to use R5's own wedge to elevate legs while in bed. LPN-G verified R5 should be offered the stockings and wedge. LPN-G stated if R5 refused, the nurse should be notified so the physician could be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure dressing changes were completed as ordered for 1 Resident (R) (R2) of 2 residents reviewed. R2 had a physician order to change a central line dressing every 72 hours. The dressing was not changed for 11 days. On 4/27/23, R2 was transferred to the emergency room (ER) with signs of infection and was prescribed antibiotic treatment. Findings include: The facility's Catheter Insertion and Care: Central Venous Catheter Dressing Changes policy, revised July 2011, contained the following information: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .Dressing changes will include: removal of the old dressing, observation and evaluation of the catheter-skin junction and surrounding tissue, cleansing with an approved antiseptic solution, replacement of any stabilization device, and application of a sterile dressing .Apply sterile transparent dressing to area .label with initials, date and time. R2 was admitted to the facility on [DATE] with diagnoses to include femur (hip) fracture, osteomyelitis (bone infection), diabetes, and depression. R2's most recent Minimum Data Set (MDS) assessment, dated 3/31/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. R2's most recent care plan, dated 3/31/23, stated R2 had the potential for infection/complication related to intravenous (IV) use via central line and contained a goal that R2 would remain free from signs and symptoms of infection. Care plan interventions included: Change IV tubing, dressings, and caps according to order or more frequently as needed; Monitor site for signs and symptoms of infection: redness, inflammation, drainage, irritation to the vein. On 5/9/23, Surveyor interviewed R2 regarding R2's central line dressing changes. R2 verified staff missed some of R2's dressing changes before R2 was transferred to the hospital on 4/27/23. R2 stated the area became infected a few weeks ago and was very painful to the touch. On 5/9/23 at 12:29 PM, Surveyor noted R2's central line dressing was clean and intact; however, the dressing did not contain initials or a date. On 5/9/23, Surveyor reviewed R2's medical record, including physician orders, Treatment Administration Record (TAR) and hospital notes. R2 had a physician order, dated 4/10/23, to change the central line dressing every 72 hours. Per R2's TAR, the treatment was completed on 4/10/23, 4/13/23, 4/16/23, 4/19/23, and 4/25/23. R2's TAR did not contain initials or indicate the treatment was completed on 4/22/23. On 5/10/23 at 10:15 AM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should date and initial dressings when applying a new dressing. DON-B was not aware of any concerns related to R2's central line dressing changes, but verified R2 was treated for an infection at the central line site. A nursing progress note, dated 4/27/23 at 7:53 AM, indicated R2's central line was red and warm around the site and stated R2 had pain even when blankets touched the site. A nursing progress note, dated 4/27/23 at 8:22 AM, contained the following information: (R2) complaining of pain in right chest where central line is placed. Area is red, warm to the touch and an angry red orders to send to the ER to evaluate and treat. An ER visit note, dated 4/27/23, contained the following information: Central line dressing not intact. Gauze underneath saturated with yellow drainage. Skin around site is reddened and excoriated (skin damage). Appears dressing has not been changed since 4/16/23. On 5/11/23 at 7:02 AM, Surveyor interviewed ER Registered Nurse (RN)-H who stated upon R2's arrival to the ER on [DATE], R2's central line dressing was dated 4/16. RN-H stated the central line site was infected and R2 was prescribed Clindamycin (antibiotic) 450 mg (milligrams) three times daily for five days. On 5/11/23 at 7:42 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who initialed the central line dressing change in R2's TAR on 4/19/23. LPN-F stated LPN-F had never done a dressing change on R2's central line, but recalled assessing the area around the dressing. LPN-F verified LPN-F did not complete R2's central line dressing change on 4/19/23. On 5/11/23 at 9:26 AM, Surveyor interviewed LPN-G who initialed the central line dressing change in R2's TAR on 4/25/23. LPN-G stated LPN-G could not recall ever completing a central line dressing change for R2.