Every finding on record at Adira Medical Resort

Based on record reviews and interview the facility failed to ensure physician orders were followed for 3 (#1, #2, and #5) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for wounds. The facility failed to ensure evidence that wound care was conducted as ordered. Findings:Review of undated policy titled Wound Treatment Management revealed, in part:Policy:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. Resident #1 Review of Resident #1's medical record revealed an admission date of 02/16/2026 with diagnoses that included, in part, burns involving 80-89% of body surface with 80-89% third degree burns, pressure ulcer of left heel stage, pressure ulcer of left hip unstageable, unspecified open wound of left back wall of thorax without penetration into thoracic cavity subsequent encounter, unspecified open wound of abdominal wall periumbilic region without penetration into peritoneal cavity subsequent encounter, morbid (severe) obesity due to excess calories, Type 2 diabetes mellitus without complications, anemia unspecified, chronic embolism and thrombosis of unspecified deep veins of left lower extremity, unspecified atherosclerosis of native arteries of extremities left leg, and unspecified diastolic (congestive) heart failure. Review of Resident #1's physician orders revealed:-03/05/2026 Left heel, cleanse with wound cleanser, apply collagen powder, apply Ca Alg (Calcium alginate), ABD (abdominal) pad, wrap with kerlix and secure with tape daily and prn (as needed) - every day shift for wound care. -03/24/2026 Right buttock - Cleanse with wound cleanser, apply collagen powder, Cal Alg, cover with border foam Q (every) day/prn - every day shift for wound care and as needed for wound care. -03/05/2026 (End date of 03/24/2026) Right buttock - Clean with wound cleanser, apply Santyl, Cal Alg, Cover with bordered gauze. Change daily/prn - every day shift for wound care. -03/24/2026 Left buttock - Cleanse with wound cleanser, collagen powder, Ca Alg, Cover with border foam Q day/PRN - every day shift for wound care and as needed for wound care. -03/05/2026 (End date of 03/24/2026) Left buttock - Cleanse with wound cleanser, apply Santyl, Cal Alg, Cover with bordered gauze. Change daily/prn every day shift for wound care. -03/24/2026 Left thigh- Cleanse with wound cleanser, apply collagen powder, cal alg, cover with bordered foam Q day/prn - Every day shift for wound care and as needed for wound care. -03/05/2026 (End date of 03/24/2026) Left thigh - Cleanse with wound cleanser, apply Santyl, Cal Alg, cover with bordered gauze, change daily/prn - every day shift for wound care. -03/24/2026 Back cleanse with wound cleanser, Collagen powder, Ca Alg, covered with border gauze change Q day/prn - Every day shift for wound care and as needed for wound care. -03/24/2026 Umbilical cleanse with wound cleanser, apply Santyl, Cal Alg, cover with bordered foam change Q day/prn - every day shift for wound care and as needed for wound care. -03/05/2026 (End date of 03/24/2026) Umbilical cleanse with wound cleanser, paint with Betadine, cover with bordered gauze, daily/prn every day shift for wound care. Review of Resident #1's Care Plan revealed potential for/actual impaired skin integrity and actual pressure ulcer development with interventions that included, in part, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly. Review of Resident #1's March 2026 TAR (Treatment Administration Record) revealed wound care was not documented as done for left heel wound, right buttock wound, left buttock wound, left thigh wound, and umbilical wound on 03/05/2026, 03/07/2026 to 03/12/2026, 03/14/2026 to 03/19/2026, 03/21/2026 to 03/25/2026, 03/27/2026, and 03/28/2026. Further review of Resident #1's TAR revealed wound care was not documented as done for back wound on 03/25/2026, 03/27/2026, and 03/28/2026. During an interview on 03/30/2026 at 11:30 a.m. S2 ADON (Assistant Director of Nursing)/Treatment Nurse reviewed Resident #1's March 2026 TAR and confirmed there were multiple times Resident #1's wound care was not documented as done. During an interview on 04/01/2026 at 09:20 a.m. S1 Administrator reviewed Resident #1's March 2026 physician orders and March 2026 TAR and confirmed there was no evidence wound care had been provided for Resident #1's left heel wound, right buttock wound, left buttock wound, left thigh wound, and umbilical wound on 03/05/2026, 03/07/2026 to 03/12/2026, 03/14/2026 to 03/19/2026, 03/21/2026 to 03/25/2026, 03/27/2026, and 03/28/2026. S1 Administrator further confirmed there was no evidence wound care had been provided for Resident #1's back wound on 03/25/2026, 03/27/2026, and 03/28/2026. Resident #2 Review of Resident #2's medical record revealed an initial admission date of 10/21/2025 and discharge date of 03/16/2026 with diagnoses including, in part, pressure ulcer of sacral region, essential (primary) hypertension, and paraplegia unspecified. Review of Resident #2's physician orders revealed:-01/12/2026 (end date of 02/24/2026) On Friday/Tuesday and prn Sacral Wound; cleanse wound with wound cleanser and pat dry. Apply adaptic, black vac (vacuum) foam to wound and seal with drape. Set at 120mmhg (millimeters of mercury) continuous. - every day shift every Tuesday, Friday for wound vac and as needed for dislodgement/leak. -02/24/2026 (end date of 03/05/2026) on Friday/Tuesday and prn Sacral Wound; cleanse wound with wound cleanser and pat dry. Apply adaptic, black vac foam to wound and seal with drape. Set at 125mmhg continuous. - every day shift every Tuesday, Friday for wound vac and as needed for dislodgement/leak Review of Resident #2's Care Plan revealed potential for impaired skin integrity and actual pressure ulcer development with interventions that included, in part, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly, and turn/reposition at least every 2 hours. Review of Resident #2's February 2026 and March 2026 TAR revealed wound care was not documented as done for Resident #2's sacral wound on 02/24/2026 and 03/03/2026. During an interview on 03/30/2026 at 11:30 a.m. S2 ADON/Treatment Nurse reviewed Resident #2's February 2026 and March 2026 TAR and confirmed wound care was not documented as done a couple of times. During an interview on 04/01/2026 at 10:05 a.m. S1 Administrator reviewed Resident #2's February 2026 and March 2026 physician orders and February 2026 and March 2026 TARs and confirmed there was no evidence wound care had been provided for Resident #2's sacral wound on 02/24/2026 and 03/03/2026. Resident #5 Review of Resident #5's medical record revealed an initial admission date of 02/13/2026 with diagnoses that included, in part, pressure ulcer of left heel unstageable, displaced bimalleolar fracture of right lower leg subsequent encounter for closed fracture with routine wound healing, Type 2 diabetes mellitus without complications, and essential (primary) hypertension. Review of Resident #5's physician orders revealed the following orders, in part:-03/24/2026 Left breast-Cleanse with wound cleanser, apply Betadine, Q day/prn - every day shift for wound care and as needed for wound care.-03/05/2026 (End date of 03/24/2026) Left breast-cleanse with wound cleanser, Ca. Alg., cover with bordered foam gauze. Change daily/prn - every day shift for wound care and as needed for wound care. -03/24/2026 Left heel cleanse with wound cleanser, apply calcium alg, boarder foam dressing. Q day/prn - every day shift for wound care and as needed for wound care. -03/05/2026 (stopped on 3/24/2026) Left heel cleanse with wound cleanser paint with Betadine, cover with bordered foam gauze. Change daily/prn - every day shift for wound care and as needed for wound care. -02/13/2026 Right lower leg/right foot sx site, clean around pin sites with chloraprep, place ABD pad to heel, wrap with cast padding and secure in place with ace wrap every M-W-F (Monday-Wednesday-Friday) - one time a day every Mon (Monday), Wed (Wednesday), Fri. (Friday). Review of Resident #5's Care Plan revealed potential impaired skin integrity and actual pressure ulcer development with interventions that included, in part, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing and turn/reposition at least every 2 hours. Review of Resident #5's March 2026 TAR revealed wound care was not documented as done for left breast wound and left heel wound on 03/05/2026, 03/07/2026, 03/09/2026, 03/10/2026, 03/12/2026, 03/14/2026 to 03/16/2026, 03/22/2026, 03/24/2026, 03/25/2026, 03/27/2026, and 03/28/2026. Further review of Resident #5's March 2026 TAR revealed wound care was not documented as done for Resident #5's right lower leg/right foot surgery site on 03/02/2026, 03/04/2026, 03/06/2026, 03/09/2026, 03/13/2026, and 03/27/2026. During an interview on 03/30/2026 at 11:30 a.m. S2 ADON/Treatment Nurse reviewed Resident #5's TAR and confirmed there were multiple times Resident #5's wound care was not documented as done. During an interview on 04/01/2026 at 9:20 a.m. S1 Administrator reviewed Resident #5's March 2026 physician orders and March 2026 TAR and confirmed there was no evidence wound care had been provided for Resident #5's left breast wound and left heel wound on 03/05/2026, 03/07/2026, 03/09/2026, 03/10/2026, 03/12/2026, 03/14/2026 to 03/16/2026, 03/22/2026, 03/24/2026, 03/25/2026, 03/27/2026, and 03/28/2026. S1 Administrator further confirmed there was no evidence wound care had been provided for Resident #5's right lower leg/right foot surgery site on 03/02/2026, 03/04/2026, 03/06/2026, 03/09/2026, 03/13/2026, and 03/27/2026.

Based on record reviews and interview, the facility failed to ensure CNA's were able to demonstrate competency in skills necessary to care for residents' needs as identified through resident assessments and described in residents' plans of care for 2 (S5, S6) of 5 CNA personnel records reviewed. Findings: Review of S5CNA's personnel record revealed a hire date of 01/14/2025. Further review of S5CNA's personnel record failed to reveal a skills competency had been conducted. Review of S6CNA's personnel record revealed a hire date of 10/22/2025. Further review of S6CNA's personnel record failed to reveal a skills competency had been conducted. During an interview on 01/21/2026 at 1:34 p.m., S1Administrator reviewed S5CNA and S6CNA's personnel files and confirmed the facility did not have documented evidence of skills competencies for S5CNA or S6CNA.

Based on record reviews and interview, the facility failed to obtain a CNA registry verification prior to hire for 2 (S4CNA, S7CNA) of 5 CNA personnel records reviewed. Findings: Review of S4CNA's personnel record revealed a hire date of 09/20/2025. Further review of S4CNA's personnel record failed to reveal a CNA registry verification had been obtained. Review of S7CNA's personnel record revealed a hire date of 09/04/2025. Further review of S7CNA's personnel record failed to reveal a CNA registry verification had been obtained. During an interview on 01/21/2026 at 2:28 p.m., S1Administrator reviewed S4CNA and S7CNA's personnel files and confirmed the facility did not have documented evidence of CNA registry verification prior to hire for S4CNA or S7CNA.

Based on observation, interviews, and record review, the facility failed to honor and accommodate resident food allergies, intolerances, and preferences by failing to ensure a resident received meals that did not include food allergies for 1 (#20) of 1 (#20) resident reviewed for food. This deficient practice had the potential to affect all 20 residents who consumed meals from the kitchen. Findings:Review of Resident #20's medical record revealed an admit date of 11/21/2025 with diagnoses that included in part type 2 diabetes mellitus without complications, and urinary tract infection. Further review revealed Resident #20's allergies included tomatoes and potatoes. Review of Resident #20's meal ticket dated 01/19/2026 revealed in part: allergies: tomatoes, potatoes.Review of Resident #20's record revealed a Diet Requisition Form dated 11/21/2025 indicating New Admission, Allergies: potatoes, tomatoes. Signed by DON. Observation on 01/19/2026 at 12:30 p.m. revealed Resident #20's lunch food tray meal ticket: allergy-allergic to tomatoes. Further observation revealed tomatoes on lunch tray in tomato based shrimp etouffee. During an interview on 01/19/2026 at 12:30 p.m. Resident #20 confirmed she was allergic to tomatoes. During an interview on 01/19/2026 at 12:30 p.m. S2 CNA read Resident #20's meal ticket and confirmed Resident #20 was allergic to tomatoes. During an interview on 01/21/2026 at 9:15 a.m. S3 Dietary Manager reported the shrimp etouffee with a tomato base just got overlooked by accident. S3 Dietary Manager confirmed Resident #20 is allergic to tomatoes and should not have been served shrimp etouffee.

Based on record review, observations, and interviews, the facility failed to assess a resident upon readmission for the risk of elopement and failed to identify the need for supervision related to wandering tendencies displayed by a resident for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for elopement. The deficient practice resulted in an Immediate Jeopardy for Resident #1 on 06/10/2025 when Resident #1 walked out of the facility's locked front door with S1Medical Director and was left unattended on the facility's front porch. Resident #1 walked along a busy 4 lane road without supervision and entered a dental office business approximately 37 feet from the facility's parking lot. Resident #1 was last observed in the facility at approximately 9:00 a.m. when Resident #1 was observed sitting in the day area on the couch. The facility was notified by dental office staff of Resident #1 being in their office at approximately 9:10 a.m. Resident #1 was retrieved from the dental office business by S11Physical Therapy Assistant (PTA). Resident #1 was returned to the facility by S11PTA and S12Occupational Therapist (OT) at approximately 9:20 a.m. and S3Director of Nursing (DON) notified of elopement. The facility failed to assess Resident #1 as an elopement risk and did not supervise Resident #1 to prevent Resident #1 from eloping. This deficient practice had the likelihood to cause more than minimal harm to any residents residing in the facility at risk for elopement. S2Administrator and S3DON were notified of the Immediate Jeopardy on 06/18/2025 at 1:20 p.m. The Immediate Jeopardy was removed on 06/18/2025 at 8:40 p.m. when it was determined the facility had implemented an acceptable Plan of Removal (POR) as confirmed through onsite interviews and observations prior to the survey exit. Findings: Review of the facility's undated Elopement/Missing Resident policy revealed in part: Purpose: - Ensure a safe and secure environment for all residents. - In the event a resident is missing from the facility, the resident is located in a timely manner. - Ensure staff awareness of the importance of the resident safety and security. Procedure: 3. All residents will be assessed for risk of elopement, following admission, quarterly, with significant change in condition Minimum Data Set (MDS) assessments and when behaviors indicate. 7. This facility considers elopement to be a situation when a resident leaves the premises without the knowledge and supervision, when needed, of staff. A missing resident/elopement presents a risk to the resident's health and safety. Review of the facility's undated admission of Resident policy revealed in part: Purpose: - Process MDS Entry Tracking form in order to notify Centers for Medicare and Medicaid Services (CMS) Procedure: 7. When the resident has settled in a bit (no more than 2 hours after admission at most), the licensed nurse will begin the assessment of the resident's status upon admission, completing the Nursing Assessment/Data Collection or other nursing assessment form. Review of Resident #1's medical record revealed in part, Resident #1 was originally admitted to the facility on [DATE] and transferred/discharged to a local hospital on [DATE]. Further review of Resident #1's medical record revealed Resident #1 was readmitted to the facility on [DATE] with diagnoses including, but not limited to dementia, unsteadiness on feet, and generalized muscle weakness. Further review of Resident #1's medical record revealed Resident #1 was discharged during afternoon hours on 06/16/2025 to another local nursing home. Review of Resident #1's admission MDS with assessment reference date (ARD) of 03/31/2025 revealed in part, Resident #1 had a Brief Interview Mental Status (BIMS) score of 7 indicating severe cognitive impairment, wandering behavior did not occur during 7 day look back period, and Resident #1 received antipsychotic medication during 7 day look back period. Review of Resident #1's Comprehensive Care Plan dated 03/24/2025 revealed in part, Resident #1 was care planned for impaired cognitive function/thought processes and elopement risk/wanderer related to diagnoses of dementia. Further review of Resident #1's care plan failed to reveal updated interventions for increased supervision after Resident #1 demonstrated wandering tendencies. Review of Resident #1's medical record failed to reveal a risk for elopement assessment at time of Resident #1's 03/30/2025 readmission and/or prior to elopement on 06/10/2025. Review of Resident #1's physician orders failed to reveal any order(s) regarding wandering and/or elopement risk. Review of Resident #1's progress notes since admit on 03/30/2025 until 06/10/2025 revealed in part: 03/30/2025 at 9:23 p.m. by S6Licensed Practical Nurse (LPN): Resident #1 wandered to nurse's station and attempted to exit out front door. Explained that door was kept locked for everyone's safety . 05/16/2025 at 12:19 p.m. by S7LPN: Resident #1 was admitted on [DATE] .Level of consciousness noted as oriented to person .Behavioral problems are delusions, wanders throughout the facility and has to be redirected per staff. Resident #1 has delusions about the facility being his place of employment . 05/23/2025 at 10:27 a.m. by S3DON: Resident #1 was admitted on [DATE] . Level of consciousness noted as oriented to person . Behavioral problems are wandering, roams facility, into other's rooms at times. Will take food and drinks from other rooms/day spaces. Not exit seeking . 06/04/2025 at 7:15 a.m. by S7LPN: Resident #1was admitted on [DATE] .The resident has to be redirected to his room once or twice throughout the day when he accidentally enters another resident's room . 06/10/2025 at 10:35 a.m. by S7LPN: On the hall passing medication, resident #1 was observed walking up and down Hall A when Resident #1 was asked if he wanted to take his medication resident said no and continued walking. On the second attempt, resident was taken to get coffee in the dining area and took his meds. He proceeded to walk to the dining area. Later the social worker came and informed nurse resident was found outside facility. I immediately went to locate resident and found resident in the parking lot walking towards the entrance with several other staff members. Resident greeted nurse and smiled. Resident reported he was trying to go to his appointment and was trying to get a ride . An observation on 06/16/2025 at 7:46 a.m. revealed exit door at end of Hall A was unlocked. Further observation revealed Room A, immediately before Hall A exit door, had Resident #1's name on outside of the room door. During an interview on 06/16/2025 at 7:51 a.m., S8Assistant Administrator confirmed Hall A exit door was unlocked and should have been locked. During an interview on 06/16/2025 at 7:59 a.m., S9Maintenance reported all exit doors are supposed to remain locked except during an emergency. S9Maintenance reported someone on the night shift must have used the emergency key to unlock the Hall A exit door to go out and had not locked the door back. During an interview on 06/16/2025 at 9:44 a.m., S2Administrator confirmed Resident #1 was still a resident at the facility and resided on Hall A in Room A. S2Administrator further reported the facility does not have video surveillance inside or outside the facility. During an interview on 06/16/2025 at 12:15 p.m., Resident #1 reported he went outside the facility with staff and sat on porch. Resident #1 did not confirm he walked next door to the dental office building. During an interview on 06/16/2025 at 2:35 p.m., S2Administrator confirmed Resident #1 had eloped from the facility on 06/10/2025. S2Administrator reported she was not in the building at the time Resident #1 eloped. S2Administrator reported S3DON was in the facility at the time and S3DON had conducted the investigation. During an interview on 06/16/2025 at 2:40 p.m., S3DON reported no one witnessed Resident #1 elope from the facility. S3DON reported the facility was notified by the dental office staff next door at approximately 9:10 a.m. that Resident #1 had walked into their office. S3DON reported staff had seen Resident #1 sitting on couch near nurse's station approximately 10 minutes before the dental office staff called. S3DON reported facility staff immediately rushed over to the dental office and retrieved Resident #1. S3DON reported Resident #1 was brought back to the facility by staff and she was notified of the elopement at approximately 9:20 a.m. During an interview on 06/17/2025 at 9:20 a.m., S1Medical Director reported he let Resident #1 out the front door the day Resident #1 eloped from the facility. S1Medical Director reported he was talking with Resident #1 and Resident #1 walked out the front door with him and was standing outside the facility's front door. S1Medical Director reported he offered to open the locked door for Resident #1's reentry prior to leaving the facility, but Resident #1 reported he could push the button to get back in the facility. S1Medical Director reported he did not realize Resident #1 was an elopement risk. During an interview on 06/17/2025 at 9:33 a.m., S6LPN reported Resident #1 would constantly walk around the facility and would frequently sit at the nurse's station. During an interview on 06/17/2025 at 11:29 a.m., S10Certified Nursing Assistant (CNA) reported he was Resident #1's CNA while Resident #1 was a resident at the facility. S10CNA reported Resident #1 wandered the facility and stayed around the front of the facility the majority of the time. During an interview on 06/17/2025 at 12:57 p.m., S3DON confirmed a risk for elopement assessment was not conducted at Resident #1's readmission on [DATE] and should have been. S3DON reported the charge nurse would have been responsible for completing the admission assessment which includes the risk for elopement assessment. S3DON reported S6LPN was the nurse on 03/30/2025 who was responsible for performing Resident #1's admission assessment, including the risk for elopement assessment. During an interview on 06/17/2025 at 1:25 p.m., S13Social Services (SS) reported she was the staff member who completed Section E, behaviors of the MDS. S13SS reported she did not read Resident #1's progress notes. S13SS reported she relied on other staff members' verbal reports to gather information for the behaviors section of a Resident #1's MDS. S13SS reviewed Resident #1's nurse's progress note dated 03/30/2025 at 9:23 p.m. written by S6LPN and confirmed if she had read the progress note prior to completing Resident #1's behavior section on admission MDS with 03/31/2025 date, the section would have been completed differently. S13SS reported she would have answered the question regarding wandering to reflect Resident #1 displayed wandering behavior and exit seeking behavior. S13SS confirmed Resident #1 wandered around the facility every day. During an interview on 06/17/2025 at 3:15 p.m., S11Physical Therapy Assistant (PTA) reported he did go next door to the dental office on 06/10/2025 because the dental office staff had called and reported a resident of the facility was at their office. S11PTA reported he walked next door to the dental office and Resident #1 was in the dental office building. During an interview on 06/17/2025 at 3:45 p.m., S12Occupational Therapist (OT) reported she had just arrived at the facility the morning of 06/10/2025 when she saw S11PTA and Resident #1 standing outside the dentist office next door to the facility. S12OT reported she drove her car next door and brought S11PTA and Resident #1 back to the facility in her vehicle. During an interview on 06/18/2025 at 10:43 a.m., S7LPN reported she was Resident #1's nurse on 06/10/2025 when Resident #1 eloped. S7LPN reported she was giving medications and Resident #1 had refused morning medications. S7LPN reported when she left Resident #1, Resident #1 was near the nurse's station at the front door. S7LPN reported seeing S1Medical Director making rounds the morning of 06/10/2025 while she administered medications. During an interview on 06/18/2025 at 3:15 p.m., S6LPN confirmed an admission assessment which includes a risk for elopement assessment was not completed at time of Resident #1's readmission to the facility on [DATE]. The facility's POR submitted on 06/18/2025: Resident #1 and Resident #2 with risk assessment for elopements may be impacted by the noncompliance. Facility administration failed to have an adequate system in place to ensure Resident #1 was assessed for elopement risk when returning from the hospital. The process and systems for improvement were as follows: DON/Designee in serviced all nurses to report wandering to Administrator and/or DON, placed Resident on 1 on 1 on 06/10/2025 until further guidance from admin or DON, all completed on 06/18/2025. DON updated elopement risk assessments and binder at nurse's station on 06/10/2025. DON counseled the Medical Director on not letting any residents out the door without nursing staff on 06/18/2025. All nurses in-serviced on accurate elopement risk assessment for new admits and readmissions by DON/designee on 06/18/2025. DON/Designee to audit new admits and readmissions for elopement risk assessments 5 times a week for 4 weeks starting on 6/18/2025. Starting 06/18/2025, MDS will complete Section E of the MDS until new Social Services Director (SSD) is trained on elopement risk assessments and clinical documentation. Education/Training began immediately and was as follows: DON/Designee in-serviced all nurses to report wandering to Administrator and DON, place Resident on 1 on 1 until further guidance from Administrator or DON, all completed on 06/18/2025. Nurses in-serviced on accurate elopement risk assessment for new admits and readmissions by DON/Designee on 06/18/2025. S6LPN was in-serviced by DON/Designee on elopement precautions/wandering and when to complete a new elopement risk assessment on 06/18/2025. S6LPN in-serviced on proper procedure when a wandering resident is noted on 06/18/2025. The Medical director in-serviced by DON to not allow a resident to remain outside without nursing staff or to let a resident exit door with/behind him on 06/18/2025. DON/designee in serviced all staff to not use hall exit doors, except in an emergency on 06/18/2025. On 06/18/2025, DON and Administrator in serviced by corporate compliance consultant on elopement assessments, safety, and how to train staff. The monitoring of implemented actions was as follows: Starting on 06/18/2025 Maintenance will check exit doors twice a day, 7 days a week for 4 weeks and will report to quality assurance (QA) weekly on all findings until in compliance. Beginning 06/18/2025, DON/Designee to audit all admits/readmits for accurate elopement risk assessments and report to QA weekly until in compliance. On 06/18/2025 the wander guard system was activated, Resident #2 has been cared planned for wander guard and will be checked every shift with negative findings reported to DON and QA team until in compliance. Elopement Drills were performed 3 times over 3 days on 06/10/2025 at 9:10 a.m., 06/18/2025 at 10:13 a.m., and 06/13/2025 at 6:00 p.m. and will continue weekly for 4 weeks with all findings reported to the QA team weekly until in compliance. Date facility asserts the likelihood for serious harm to any recipient no longer exists: 06/18/2025.

Based on record review and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #1) of 3 (#1, #2, #3) sampled residents reviewed for elopement. S3Director of Nursing (DON) failed to ensure the nursing staff conducted a risk for elopement assessment for Resident #1 at the time of readmission to the facility and failed to implement elopement precautions. The deficient practice resulted in an Immediate Jeopardy for Resident #1 on 06/10/2025 when Resident #1 walked out of the facility's locked front door with S1Medical Director and was left unattended on the facility's front porch. Resident #1 walked along a busy 4 lane road without supervision and entered a dental office business approximately 37 feet from the facility's parking lot. Resident #1 was last observed in the facility at approximately 9:00 a.m. when Resident #1 was observed sitting in the day area on the couch. The facility was notified by dental office staff of Resident #1 being in their office at approximately 9:10 a.m. Resident #1 was retrieved from the dental office business by S11Physical Therapy Assistant (PTA). Resident #1 was returned to the facility by S11PTA and S12Occupational Therapist (OT) at approximately 9:20 a.m. and S3Director of Nursing (DON) notified of elopement. The facility failed to assess Resident #1 as an elopement risk and did not supervise Resident #1 to prevent Resident #1 from eloping. This deficient practice had the likelihood to cause more than minimal harm to any residents residing in the facility at risk for elopement. S2Administrator and S3DON were notified of the Immediate Jeopardy on 06/18/2025 at 1:20 p.m. The Immediate Jeopardy was removed on 06/18/2025 at 8:40 p.m. when it was determined the facility had implemented an acceptable Plan of Removal (POR) as confirmed through onsite interviews and observations prior to the survey exit. Findings, Cross Reference F689: During an interview on 06/17/2025 at 10:00 a.m., S3DON reported if a resident was gone from the facility over 48 hours, an admission MDS should be done and a risk for elopement assessment would be completed at that time. S3DON reported a risk for elopement assessment is built into an admission assessment. S3DON further reported a risk for elopement assessment should be performed at the time of admission, with quarterly and significant change MDS, and if a resident was actively trying to get out of the facility. During an interview on 06/17/2025 at 12:57 p.m., S3DON confirmed a risk for elopement assessment was not conducted at Resident #1's readmission on [DATE] and should have been. S3DON reported the charge nurse would have been responsible for completing the admission assessment which includes the risk for elopement assessment. S3DON reported S6LPN was the nurse on 03/30/2025 who was responsible for performing Resident #1's admission assessment, including the risk for elopement assessment. During an interview on 06/18/2025 at 3:15 p.m., S6LPN confirmed an admission assessment which includes a risk for elopement assessment was not completed at time of Resident #1's admission to the facility on [DATE]. S6LPN further reported she did not know a risk for elopement needed to be done at the readmission on [DATE]. During an interview on 06/23/2025 at 2:35 p.m. S2Administrator reported herself and S3DON were responsible for the oversite of facility policies and ensuring staff were educated on said policies. During an interview on 06/23/2025 at 2:38 p.m. S3DON confirmed she and the administrator were responsible for the oversite of facility's policies and ensuring staff were educated on facility policies. S3DON further confirmed she was responsible for the oversite of staff training including admission assessments, elopement assessments, and when assessments should be performed. The facility's POR submitted on 06/18/2025: Resident #1 and Resident #2 with risk assessment for elopements may be impacted by the noncompliance. Due to a lack of administrative oversight, S3DON failed to ensure S6LPN implemented elopement precautions for Resident #1 when he was readmitted . The process and systems for improvement were as follows: Resident #1 was placed on 1 on 1 on 6/10/2025 through 6/11/2025 till 10 p.m. and then hourly checks on 6/11/2025 to 6/13/2025 until 5:45 p.m. On 06/18/2025 at approximately 9:30 a.m. the facility's wander guard system was serviced by a 3rd party vendor and is functional on front door in order for the facility to be able to utilize ankle bracelets. Beginning 06/16/2025 doors will be checked by Maintenance or designee twice a day for 7 days for 4 weeks and report to quality assurance (QA) weekly until in compliance. Resident #1 was discharged to another facility on 06/16/2025 around 2:30 p.m. Elopement drills were performed times 3 starting on 06/13/2025 for 1st and 2nd shift, will do one weekly for 4 weeks and report to QA weekly. Wander guard placed on Resident #2 on 06/18/2025 around 1:45 p.m. to 2:15 p.m. Starting 06/18/2025, DON/Designee will review all new admissions for accurate elopement risk assessments. DON in-serviced MDS staff on 06/18/2025 to complete section E of the MDS until new Social Services Director (SSD) is trained on elopement risk assessments and clinical documentation. All doors have been serviced and checked and were in compliance by 6/18/2025 around 10:30 a.m. Education/Training began immediately and was as follows: DON/designee in-serviced all staff to not use hall exit doors except in an emergency to be completed on 6/18/2025. On 06/10/2025 elopement drills started and continued over 3 days until 06/13/2025 with a total of 3 drills, will continue weekly elopement drills for 4 weeks and reported to QA weekly until in compliance. On 06/18/2025, DON and Administrator were in-serviced by corporate compliance consultant on the facility must have written policies and procedures that include training new and existing nursing home staff and in-service training on wandering or elopement-type behaviors; the facility policies should clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement that can help to minimize the risk of a resident leaving a safe area without the facility's awareness and/or appropriate supervision; all new admissions, readmissions, and those residents with changes in condition that can present as wandering, exit seeking behavior or statements, improved mobility, mental status changes and other changes should be assessed/reassessed for elopement risk; residents identified to be an elopement risk should have interventions in their comprehensive plan of care to address the potential for elopement; furthermore, the facility's disaster and emergency preparedness plan should include a plan to locate a missing resident; facilities are responsible for identifying and assessing a resident's risk for leaving the facility without notification to staff and developing interventions to address this risk; the facility must implement care plan interventions to monitor a resident with a known history of elopement attempts, which can result in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death; this is to ensure the facility provides adequate supervision and necessary devices to each resident to prevent elopement; this includes identifying hazard(s) and risk(s); evaluating and analyzing hazard(s) and risk(s); implementing interventions to reduce hazard(s) and risk(s); monitoring for effectiveness and modifying interventions when necessary. The Corporate Compliance Nurse is responsible for the oversight and monitoring of the DON and Administrator with weekly scheduled conference calls for compliance. Starting 6/18/2025 Corp Compliance Nurse will monitor weekly for 4 weeks and report to Ownership and Compliance officer all negative findings and continue reporting to ensure continued compliance. The monitoring of implemented actions was as follows: Starting on 06/18/2025 Maintenance will check exit doors twice a day, 7 days a week for 4 weeks and will report to QA weekly on all findings until in compliance. Wander Guard will be checked every shift starting 6/18/2025 and ongoing by nursing staff and all negative findings reported to DON and QA team until in compliance. Drills performed by DON/SSD weekly for 4 weeks starting 06/18/2025 and turned into QA team. Drills started 06/13/2025, will report all findings to QA team weekly until in compliance. DON/Designee to audit all admits/readmits for accurate elopement risk assessments starting 06/18/2025 for 4 weeks with all findings reported to QA weekly until in full compliance. Corporate Compliance Nurse is responsible for the oversight and monitoring of the DON and Administrator with weekly schedule conference calls for compliance. Starting 06/18/2025, Corporate Compliance Nurse will monitor weekly for 4 weeks and report to Ownership and Compliance officer all negative findings and continue reporting to ensure continued compliance. Any negative findings will be reported in the morning meeting to the compliance officer for the next 4 weeks and to be reported to Corporate Compliance Nurse. All findings and monitoring started on 6/18/2025 will be reported in our next schedule QA meeting with our Medical Director and Interdisciplinary Team (IDT). Date facility asserts the likelihood for serious harm to any recipient no longer exists: 06/18/2025.

Based on record review and interviews, the facility failed to assess a resident for the risk of elopement and failed to ensure an assessment accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement, impaired cognition and/or a diagnosis which may increase the risk of elopement by failing to: 1. Ensure a nursing assessment and elopement risk assessment were completed for Resident #1 at the time of readmission on [DATE]. 2. Ensure Resident #1's behavioral section on Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/31/2025 was completed accurately. Findings: Review of the facility's undated Elopement/Missing Resident policy revealed in part: Purpose: - Ensure a safe and secure environment for all residents. - In the event a resident is missing from the facility, the resident is located in a timely manner. - Ensure staff awareness of the importance of the resident safety and security. Procedure: 3. All residents will be assessed for risk of elopement, following admission, quarterly, with significant change in condition Minimum Data Set (MDS) assessments and when behaviors indicate. Review of the facility's undated admission of Resident policy revealed in part: Purpose: - Process MDS Entry Tracking form in order to notify Centers for Medicare and Medicaid Services (CMS) Procedure: 7. When the resident has settled in a bit (no more than 2 hours after admission at most), the licensed nurse will begin the assessment of the resident's status upon admission, completing the Nursing Assessment/Data Collection or other nursing assessment form. Review of Resident #1's medical record revealed in part, Resident #1 was originally admitted to the facility on [DATE] and transferred/discharged to a local hospital on [DATE]. Further review of Resident #1's medical record revealed Resident #1 was readmitted to the facility on [DATE] with diagnoses including, but not limited to: dementia, unsteadiness on feet, and generalized muscle weakness. Review of Resident #1's admission MDS with ARD of 03/31/2025 revealed in part, Resident #1 had a Brief Interview Mental Status (BIMS) score of 7 indicating severe cognitive impairment and wandering behavior did not occur during 7 day look back period. Review of Resident #1's medical record failed to reveal a nursing assessment and risk for elopement assessment was completed at the time of Resident #1's 03/30/2025 readmission. Review of Resident #1's progress notes revealed in part: 03/30/2025 at 9:23 p.m. by S6Licensed Practical Nurse (LPN): Resident #1 wandered to nurse's station and attempted to exit out front door. Explained that door was kept locked for everyone's safety . 06/10/2025 at 10:35 a.m. by S7LPN: On the hall passing medication, Resident #1 was observed walking up and down Hall A when Resident #1 was asked if he wanted to take his medication, resident said no and continued walking . Later the social worker came and informed nurse (S7LPN) Resident #1 was found outside facility. I (S7LPN) immediately went to locate Resident #1 and found Resident #1 in the parking lot walking towards the entrance with several other staff members . During an interview on 06/17/2025 at 10:00 a.m., S3Director of Nursing (DON) reported if a resident is gone from the facility over 48 hours, an admission MDS and a risk for elopement assessment should be completed. S3DON reported a risk for elopement assessment is built into the admission assessment. S3DON further reported a risk for elopement assessment is performed at time of admission, with quarterly and significant change MDS, and if a resident is actively trying to get out of the facility. During an interview on 06/17/2025 at 12:57 p.m., S3DON confirmed a risk for elopement assessment was not conducted at Resident #1's readmission on [DATE] and should have been. S3DON reported S6LPN was the charge nurse on 03/30/2025 who was responsible for performing Resident #1's admission assessment. During an interview on 06/17/2025 at 1:25 p.m., S13Social Services (SS) reported she was the staff member who completed Section E, behaviors of the MDS. S13SS reported she did not read Resident #1's progress notes prior to completing Section E. S13SS reported she relied on other staff members' verbal reports to gather information for the behaviors section of Resident #1's MDS. S13SS reviewed Resident #1's nurse's progress note dated 03/30/2025 at 9:23 p.m. written by S6LPN and confirmed if she had read the progress note prior to completing Resident #1's behavior section on admission MDS with ARD of 03/31/2025, the behavioral section would have been completed differently. S13SS reported she would have answered the question regarding wandering to reflect Resident #1 displayed wandering behavior and exit seeking behavior. During an interview on 06/17/2025 at 1:35 p.m. S3DON confirmed S13SS should have read Resident #1's progress notes prior to completing section E, behaviors on Resident #1's MDS with ARD of 03/31/2025. During an interview on 06/18/2025 at 3:15 p.m., S6LPN confirmed an admission assessment which includes a risk for elopement assessment was not completed at time of Resident #1's readmission to the facility on [DATE]. S6LPN further reported she did not know a risk for elopement assessment needed to be completed at the time of Resident #1's readmission on [DATE].

Based on record review and interview the facility failed to implement the plan of care to meet the needs of 1 (#1) out of a total of 3, (#1, #2, #3) sampled residents by failing to complete an x-ray as ordered by the physician. Findings: Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses of but not limited to acute respiratory failure with hypercapnia, pneumonia, type 2 diabetes mellitus without complications, spinal stenosis cervical region, cognitive communication deficit, spinal stenosis lumbar region without neurogenic claudication, essential (primary) hypertension and dysphagia. Review of Resident #1's physician's orders revealed an order for a STAT (immediately or right now) Chest x-ray on 04/18/2025. Review of Resident #1's medical record revealed a chest x-ray report with a completion date of 04/19/2025. Review of Resident #1's progress notes revealed an entry on 04/19/2025 at 4:05 p.m. stating, Resident #1's chest x-ray was completed at 1:15 p.m. and results were sent to the provider. During an interview on 05/13/2025 at 8:30 a.m. S2LPN (licensed practical nurse) confirmed Resident #1's chest x-ray should have been done on 04/18/2025 instead of 04/19/2025 because it was ordered STAT which meant it should have been done on the same day it was ordered by Resident #1's physician. S2LPN further confirmed failing to notify Resident #1's physician that Resident #1's STAT chest x-ray was not completed until the next day. During an interview on 5/13/2025 at 9:00 a.m. S1DON (Director of Nurses) confirmed Resident #1's chest x-ray should have been completed on the same day it was ordered and Resident #1's physician should have been notified of its completion on the next day.

Based on observation and interviews the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1( #3) resident out of 3 (#1,#2, #3) sampled residents. The facility failed to ensure a resident request for toileting assistance was answered in a timely manner. Findings: Review of Resident #3's medical record revealed an admitted [DATE] and a readmitted [DATE] with diagnoses of but not limited to unspecified fracture of left femur, hyperlipidemia, essential hypertension, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, irritable bowel syndrome, parkinsonism, major depressive disorder, esophageal obstruction, gastronomy and dysphagia. Review of Resident #3's MDS (Minimum Data Set) revealed Resident #3 was assessed to require assistance with using the toilet. Review of Resident #3's Care Plan revealed a problem of: ADL (activities of daily living) self-care performance deficit related right sided hemiplegia and required total assistance by staff with toileting. Observation on 05/12/2025 at 1:45 p.m. revealed Resident #3 in the restroom calling out for help, while hovering over the toilet attempting to sit down without assistance. Observation also revealed the emergency call light was activated and lit up outside of Resident #3's room door with an audible beeping at the nurse's station. Further observation failed to reveal staff on the hallway and no staff at the nurse's station monitoring the call system. Observation revealed staff failed to respond to Resident #3's emergency call light and request for assistance for 15 minutes. During an interview 05/12/2025 at 2:00 p.m. S3 LPN confirmed the assigned certified nursing assistants were not on the hall when Resident #3's emergency call light was activated. During an interview on 05/12/2025 at 2:01p.m. S1 DON confirmed Resident #3's request for assistance should have been answered in a timely manner. S1 DON further confirmed there should have been a staff member at the nurse's station answering resident request for assistance with call light system.

Based on record reviews and interviews, the faciity failed to implement the care plan for 2 (#2, #3) of 3 (#1, #2, #3) sampled residents reviewed. The facility failed to administer antibiotic for Resident #2 and provide wound care for Resident #3 as ordered. Findings: Resident #2 Review of Resident #2's medical records revealed an admitted [DATE] with the following diagnoses, including in part: dependence on renal dialysis, type 2 diabetes mellitus without complications and myalgic encephalomyelitis/chronic fatigue syndrome. Review of Resident #2's Physician's orders revealed an order dated 03/27/2025 for Levofloxacin oral tablet 250 mg (milligram) give 1 tablet by mouth one time a day for UTI (urinary tract infection) for 10 Days. Review of Resident #2's March and April 2025 Medication Administration Records (MAR) failed to reveal Levofloxacin tablet 250 mg give 1 tablet by mouth one time a day for 10 days was administered on 03/28/2025, 03/31/2025, 04/02/2025 and 04/04/2025. During an interview on 04/16/2025 at 1:30 p.m. S2 LPN (Licensed Practical Nurse) acknowledged Resident #2 did not receive Levofloxacin tablet 250 mg give 1 tablet by mouth one time a day for 10 Days on 03/28/2025, 03/31/2025, 04/02/2025 and 04/042025 as ordered. During an interview on 04/16/2025 at 2:30 p.m. S1 Interim DON (Director of Nursing) acknowledged Resident #2 did not receive Levofloxacin ablet 250 mg give 1 tablet by mouth one time a day for 10 days on 03/28/2025, 03/31/2025, 04/02/2025 and 04/04/2025 and should have. Resident #3 Review of Resident #3's medical records revealed an admitted [DATE] with the following diagnoses, including in part: pressure ulcer of sacral region, muscle wasting and atrophy/multiple sites, other spondylosis with myelopathy lumbar region, dependence on wheelchair and chronic pain syndrome. Review of Resident #3's Physician's orders revealed an order dated 04/01/2025 to clean left hip with wound cleanser and pat dry, apply calcium alginate to wound bed and cover with a dry dressing every other day and as needed. Further review revealed orders dated 03/15/2025 for 1) sacrum - cleanse with wound cleanser, pat dry, apply skin prep to peri area; apply medihoney to slough and then calcium alginate then cover with dry dressing daily until resolved and prn (as needed); 2) left hip - cleanse with wound cleanser, pat dry, apply skin prep to peri area, apply betadine to eschar and cover with a dry dressing daily until resolved. (discontinued on 03/30/2025). Review of Resident #3's March and April 2025 MAR/TARs (Treatment Administration Record) failed to reveal left hip and sacrum wound care was completed on 03/18/2025, 03/24/2025, 03/28/2025, 04/01/2025, 04/07/2025, and 04/09/2025. During an interview on 04/16/2025 at 2:30 p.m. S1 Interim DON acknowledged Resident #3 did not receive wound care to left hip and sacrum on 03/18/2025, 03/24/2025, 03/28/2025, 04/01/2025, 04/07/2025, and 04/09/2025 and should have.

Based on observation and interview, the facility failed to ensure the nurse staffing data was posted on a daily basis at the beginning of each shift. Findings: Observation on 04/16/2025 at 8:30 a.m. revealed staffing posted was dated 04/12/2025. During an interview on 04/16/2025 at 9:05 a.m. with S2 Interim DON (Director of Nursing)/Director of Clinical Operations acknowledged the staffing posted was dated 04/12/2025 and should have been posted daily.

Based on observation, interviews, and record reviews, the facility failed to ensure medications were available for administration for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. The facility failed to ensure a controlled drug was available and administered to Resident #1. Findings: Policy: Pharmacy Services: (no revision date) Purpose: Ensure accurate and safe provision or obtaining of pharmaceutical services, including the provision lot routine and emergency medications and biologicals as well as the services of a licensed pharmacist to meet the needs of the resident. Procedure: The facility must: 2. Provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 3. Employ or obtain the services of a licensed pharmacist who b. Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. c. Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Review of Resident #1's medical record revealed an initial admitted [DATE] with the following diagnoses, in part: Type 2 diabetes mellitus, acute osteomyelitis, difficulty walking, prosthetic heart valve and generalized anxiety disorder. Review of Resident #1's Admission MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. Review of Resident #1's physician order dated 03/05/2025 revealed an order for Temazepam (a controlled drug) 7.5 mg (milligrams), give 1 capsule by mouth at bedtime for anxiety. Review of Resident #1's 2025 March and April MAR (Medication Administration Record) revealed Tamazepam 7.5mg was not administered on 03/30/2025, 03/31/2025 and 04/01/2025 due to (9) other - See Notes: Not available. During an interview on 03/31/2025 at 4:00 p.m. Resident #1 reported the nurse told her she did not receive her Temazepam the night of 03/30/2025 because the pharmacy had not filled her medication and she did not have any Temazepam left. During an interview on 04/02/2025 at 10:50 a.m. S3 LPN (Licensed Practical Nurse) reported prescriptions should be ordered before the resident runs out of their medication. An observation on 04/02/2025 at 11:41 a.m. with S5 RN (Registered Nurse) revealed Temazepam was not available for Resident #1 on the medication cart and should have been. During an interview on 04/02/2025 at 11:41 a.m. S5 RN reported medications should be refilled 7 days before they run out. S5 RN confirmed Resident #1 was not administered Temazepam 7.5 mg at bedtime on 03/30/2025, 03/31/2025, and 04/01/2025 and should have been.

Based on record review and interview the facility failed to immediately notify the resident's representative after an incident with an injury for 1 (#2) of 3 (#1, #2, #3) sampled residents reviewed. Findings: Review of the facility's Condition Change of the Resident policy (no revision date) revealed: Procedure: After all resident falls, possible injuries or changes in physical or mental function: 6. Notify Resident's Responsible Party. Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses which included, in part: Type 2 diabetes mellitus, unspecified dementia, muscle weakness, difficulty walking, cognitive communication deficit and chronic kidney disease. Review of Resident #2's Admission MDS (Minimum Data Sets) assessment dated [DATE] revealed Resident #2 had a BIMS (Brief Interview for Mental Status) score of 11 indicating moderately impaired cognition. Review of the facility's incident log revealed Resident #2 had an incident which involved an injury on 03/16/2025. Review of Resident #2's medical record revealed a progress note dated 03/16/2025 at 11:40 p.m. which documented Resident #2 was transported via stretcher per EMS (Emergency Medical Services) to a local hospital. Further review revealed the facility was not able to contact the family of the incident due to no family contact listed on Resident #2's face sheet. Review of Resident #2's medical record failed to reveal Resident #2's family was notified immediately after an incident on 03/16/2025. Review of Resident #2's medical record revealed a progress note dated 03/17/2025 at 3:18 a.m. which documented Resident #2 returned to the facility from the hospital. Review of Resident #2's medical record revealed a progress note dated 03/17/2025 at 7:55 a.m. which documented Resident #2's family/RP (Responsible Party) was contacted. Further review revealed the RP asked, Why wasn't I notified last night? RP was informed at this time of no contact listed on the face sheet in the computer or chart. During an interview on 04/01/2025 at 4:15 p.m. S1 Administrator confirmed Resident #2's family was not notified of the incident on 03/16/2025 until his return from the hospital on 03/17/2025. S1 Administrator further confirmed contact information was not located on Resident #2's profile page at the time of the incident.

Based on record review and interviews the facility failed to ensure a baseline care plan was developed for 1 (#2) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure a baseline care plan was developed for Resident #2. Findings: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses which included, in part: Type 2 diabetes mellitus, unspecified dementia, muscle weakness, difficulty walking, cognitive communication deficit and chronic kidney disease. Review of Resident #2's Admission MDS (Minimum Data Sets) assessment dated [DATE] revealed Resident #2 had a BIMS (Brief Interview for Mental Status) score of 11 indicating moderately impaired cognition. Review of Resident #2's medical record failed to reveal a baseline care plan had been completed. During an interview on 04/01/2025 at 1:30 p.m. S3 LPN (Licensed Practical Nurse) confirmed Resident #2 did not have a baseline care plan and should have. During an interview on 04/01/2025 at 2:15 p.m. S1 Administrator acknowledged a baseline care plan was not done for Resident #2 and should have been.

Based on record review and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day 7 days per week. This deficient practice had the potential to affect all 24 residents residing in the facility. Findings: Review of the Nursing/Ancillary Personnel Staffing Pattern Reporting Form for the week days of 03/09/2025 to 03/22/2025 completed by S4 Human Resource Director revealed there were no staffing hours for an RN on 03/21/2025. Review of the facility's Employee Hours Per Day record, provided by S4 Human Resource Director, dated 03/21/2025 revealed no RN hours were clocked on 03/21/2025. During an interview on 04/01/2025 at 2:15 p.m. S1 Administrator reviewed the Personnel Staffing Pattern report from 03/02/2025 to 03/22/2025 and confirmed the facility did not have RN coverage on 03/21/2025.

34708 Based on interviews and record reviews, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure: 1. Resident's medical records accurately reflected the residents' wishes for emergency basic life support for 8 (#1, #15, #9, #76, #77, #126, #127, #175 ) residents; 2. Failed to document residents and/or resident's representative were given information on Advanced Directives on admission for 12 (#9, #76, #77, #126, #127, #175, #4, #11, #12, #20, #75, #125) residents, of 19 (#9, #77, #11, #75, #12, #76, #125, #126, #1, #127, #4, #20, #15, #175, #2, #8, #22, #24, and #18) residents reviewed for Advanced Directives. Total facility census was 23. Findings: Review of the Facility's Advance Directive Policy dated ,d+[DATE] revealed in part: It is the policy of the Facility to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on behalf of the resident when the resident lacks the capacity to do so. 2. Upon admission the Facility will provide each resident medically deemed competent or resident's representative, who does not have an existing Advanced Directive, with written information and instruction regarding the right to make Advance Directives prior to the initiation of care or at any requested time. c. The resident's instructions, the resident's receipt of written information, and the existence or non-existence of the resident's Advance Directive must be documented in the resident's record. Review of the Facility's Do Not Resuscitate (DNR) Policy dated ,d+[DATE] revealed in part: It is the policy of the Facility to respect the resident's right of self-directed care . This also includes the ability to initiate a DNR directive. -Responsibility: All Facility Employees, Monitored by Social Services Director and Executive Director -DNR Orders: 1. Residents with Capacity: To enter a DNR order for an adult resident who has decision-making capacity: a. Discuss the order with resident and inform resident about his/her condition, risks and benefits or CPR (Cardiopulmonary Resuscitation), and consequences of DNR order. b. Seek the resident's oral or written consent: -Oral consent must be witnessed by two (2) adults, one of whom is a physician affiliated with the Facility. -Written consent must be signed by two (2) adult witnesses. c. Record decision in electronic medical record d. Enter DNR order in medical record 2. Residents Who Lack Capacity: To enter a DNR order for an adult resident without capacity who has appointed a health care agent by written Power of Attorney for Health care: b. Seek health care agent's oral or written consent: -Oral consent must be witnessed by two (2) adults, one of whom is a physician affiliated with the Facility. -Written consent must be signed by two (2) adult witnesses. c. Record decision in medical record. 4. Residents Who Lack Capacity (Surrogate Decision) To enter a DNR order for an adult who lacks capacity and has not appointed a health care agent: d. Inform surrogate about resident's condition, risks, and benefits of CPR and consequences of DNR order. e. Seek surrogate decision maker's oral or written consent: -Oral consent must be witnessed by two (2) adults, one of whom is a physician affiliated with the Facility. -Written consent must be signed by the surrogate before one (1) adult witness. f. Inform resident, if resident is capable of understanding information g. Enter DNR order in medical record. During an interview on [DATE] at 3:00 p.m., S9 Admissions and S8 Admissions reported the Admissions staff complete the admissions packet. S9 Admissions and S8 Admissions reported the completed admission packet should be given to the floor nurses. If a resident chooses DNR status, the order form should be taken out of the admission packet and placed at the nurses' station to be signed by the physician. After the DNR order is signed then the order should then go to medical record to be scanned in the residents' EHR (Electronic Health Record). 1. Resident #1 Review of Resident #1's medical record revealed Resident #1 was admitted [DATE] with diagnoses which included osteomyelitis unspecified, disorders of plasma-protein metabolism, and paraplegia. Review of Resident #1's [DATE] physician orders failed to reveal an order for code status. Review of Resident #1 care plan revealed a focus dated [DATE] and revised on [DATE] with a code status of full code. Further review revealed Resident #1's care plan interventions included: resident will have advanced directive followed, discuss directives with resident and/or resident RP (responsible party), and initiate CPR (cardiopulmonary resuscitation) if needed. During an interview on [DATE] at 3:30 p.m., S4 DOCO (Director of Clinical Operations) reviewed Resident #1's record and acknowledged there was not an order for Resident #1's code status. Resident #15 Review of Resident #15 medical record revealed Resident #15 was admitted on [DATE] with diagnoses which included non-rheumatic aortic (valve) stenosis, unspecified systolic (congestive) heart, acute on chronic diastolic (congestive) heart failure, acute respiratory failure with hypoxia, chronic obstructive respiratory failure. Review of Resident # 15's [DATE] physician orders dated [DATE] revealed code status: Full code. Review of Resident #15's baseline care plan dated [DATE] revealed code status: Full code. Review of Resident #15's DNR Order form was signed by Resident #15's responsible party on [DATE] and attending physician on [DATE]. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #15's medical record and acknowledged Resident # 15's code status did not match throughout Resident #15's medical record. S4 DOCO reported Resident #15's physician orders should have been changed to a DNR after the DNR order was signed by the physician. 1. and 2. Resident #9 Review of Resident #9's medical record revealed Resident #9 was admitted on [DATE] with a re-admitted [DATE]. Resident #9's diagnoses included Parkinson's disease without dyskinesia, congestive heart failure, chronic kidney disease, and unspecified atrial fibrillation. Review of Resident #9's [DATE] physician orders revealed, in part, an order dated [DATE] for Do Not Resuscitate that was not signed by a physician. Review of Resident #9's care plan revealed a focus initiated [DATE] and revised [DATE] with a code status of DNR. Further review revealed Resident #9's care plan interventions included: resident will have advanced directive followed; discuss advance directives with resident and/or resident's Responsible Party (RP) on admit, quarterly or as needed; DNR status posted in medical record; and physician order for DNR. Further review of Resident #9's admission packet information failed to reveal Resident #9 and/or the resident representative received written information regarding advance directives. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #9's record and acknowledged Resident #9 had a care plan for DNR and an unsigned physician's DNR order. S4 DOCO further reviewed Resident #9 record and acknowledged there was no documentation Resident #9 and/or the resident representative received written information regarding advance directives. Resident #76 Review of Resident #76's medical record revealed Resident #76 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic atrial fibrillation unspecified, essential (primary) hypertension, heart failure unspecified, chronic kidney disease unspecified, prediabetes, chronic pain and insomnia. Review of Resident #76's [DATE] physician orders failed to reveal a code status. Review of Resident #76's current care plan revealed he was a full code. Review of Resident #76's advance directive acknowledgement form failed to reveal documentation Resident #76 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #76's record and acknowledged the physician orders did not reveal a code status and there was no documentation Resident #76 and/or the resident representative received written information regarding advance directives. Resident #77 Review of Resident #77's medical record revealed Resident #77 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #77's [DATE] physician orders revealed an order dated [DATE] for a Full Code. Further review revealed Resident #77 signed a DNR [DATE] and his physician signed the DNR [DATE]. The DNR Physician Order form was found in another resident's electronic record on [DATE]. Review of Resident #77's care plan revealed he was a full code. Review of Resident #77's advance directive acknowledgement form failed to reveal documentation Resident #77 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #77's record and acknowledged Resident #77's [DATE] Physician Orders was full code, DNR order was not scanned in the electronic system after it was signed by the physician and the code status was not updated. S4 DOCO reported there was no documentation Resident #77 and/or the resident representative received written information regarding advance directives. Resident #126 Review of Resident #126's medical record revealed Resident #126 was admitted [DATE] with diagnoses which included in part metabolic encephalopathy and type 2 diabetes mellitus with diabetic amyothrophy and diabetic neuropathy. Review of Resident #126's [DATE] Physician Orders failed to reveal an order for code status. Review of Resident #126's admission packet information revealed a State of Louisiana Declaration dated [DATE] with Resident #126's name at the top of the page and signed by Resident #126 at the bottom of the page with no indications of Resident #126's wishes. Further review of Resident #126 admission packet failed to reveal Resident #126 and/or the resident representative received written information regarding advance directives. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #126's record and acknowledged there was not an order for Resident #126's code status and there was no documentation Resident #126 and/or the resident representative received written information regarding advance directives. Resident #127 Review of Resident #127's record revealed Resident #127 was admitted on [DATE] with diagnoses including encephalopathy and Alzheimer's disease. Review of Resident #127's [DATE] physician orders failed to reveal documentation of an order for code status. Review of Resident #127's admission packet information revealed an undated State of Louisiana Declaration page with no indications of wishes signed per Resident #127's RP and a DNR Do Not Resuscitate order page with the date [DATE] with no name or signature. Further review of Resident #127's admission packet failed to reveal Resident #127 and/or the resident representative received written information regarding advanced directives. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #127's record and acknowledged there was not an order for Resident #127's code status and there was no documentation Resident #127 and/or the resident representative received written information regarding advanced directives. Resident #175 Review of Resident #175's medical record revealed Resident #175 initial admitted was [DATE] and a re-entry admit on [DATE] with diagnoses which included orthostatic hypotension and chronic atrial fibrillation. Review of Resident #175's [DATE] physician orders failed to reveal a code status. Review of Resident # 175's medical record failed to reveal advance directive acknowledgment form. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #175's medical record and acknowledged Resident #175 did not have physician order for a code status and there was no documentation Resident #175 and/or the resident representative received written information regarding advanced directives. 2. Resident #4 Review of Resident #4's medical record revealed Resident #4 was admitted on [DATE] with diagnoses which included unspecified systolic (congestive) heart failure, chronic kidney disease, stage 3, acute respiratory failure with hypoxia, and acute respiratory failure with hypercapnia. Review of Resident #4's advance directive acknowledgement form failed to reveal documentation Resident #4 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #4's record and acknowledged there was no documentation Resident #4 and/or the resident representative received written information regarding advance directives. Resident #11 Review of Resident #11's medical records revealed Resident #11 was admitted on [DATE] with diagnoses that include cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, polyneuropathy, muscle weakness, acute kidney failure and cognitive communication deficit. Review of Resident #11's advance directive acknowledgement form failed to reveal documentation Resident #11 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident # 11's record and acknowledged there was no documentation Resident #11 and/or the resident representative received written information regarding advance directives. Resident #12 Review of Resident #12's medical record revealed Resident #12 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, generalized anxiety disorder, type 2 diabetes mellitus without complication, difficulty walking and muscle weakness. Review of Resident #12's advance directive acknowledgement form failed to reveal documentation Resident #12 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #12's record and acknowledged there was no documentation Resident #12 and/or the resident representative received written information regarding advance directives. Resident #20 Review of Resident # 20's medical record revealed Resident #20 was admitted on [DATE] with diagnoses which included chronic diastolic (congestive) heart failure, failure of cardiac pacemaker, cardiomyopathy, unspecified essential (primary) hypertension, chronic kidney disease, stage 4 severe pneumonia. Review of Resident #20's advance directive acknowledgement form failed to reveal documentation Resident #20 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #20's record and acknowledged there was no documentation Resident #20 and/or the resident representative received written information regarding advance directives. Resident #75 Review of Resident #75's medical record revealed Resident #75 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus due to underlying condition with diabetic polyneuropathy, hyperlipidemia. Review of Resident #75's advance directive acknowledgement form failed to reveal documentation Resident #75 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #75's record and acknowledged there was no documentation Resident # 75 and/or the resident representative received written information regarding advance directives. Resident #125 Review of Resident #125's medical record revealed Resident #125 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #125's advance directive acknowledgement form failed to reveal documentation Resident #125 and/or the resident representative received written information regarding advance directives. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #125's record and acknowledged there was no documentation Resident #125 and/or the resident representative received written information regarding advance directives. During an interview on [DATE] at 4:38 p.m., S7 LPN (Licensed practical Nurse) reported all residents were a full code until the doctor signed the DNR. S7 LPN reported the DNR order and advance directives should be scanned into EHR. S7 LPN reported she would look in the resident's orders and under miscellaneous tab for the advance directives. During an interview on [DATE] at 4:43 p.m., S6 LPN reported the resident's code status is located on the dashboard information in the resident's EHR. S6 LPN reported if it was not on the dashboard the other places to locate code status would be in the orders and in the admission information. S6 LPN reported the information should be easily accessible because in an emergency there would not be time to do a search for status. During an interview on [DATE] 8:05 a.m., S7 LPN and S6 LPN reported the advance directive form that should be on admission should be kept in the resident chart and in the electronic chart. S7 LPN reported residents are a full code until the DNR order is signed by the physician. After the DNR order is signed by the physician; the floor nurse or the admission coordinator inputs the DNR order in the computer and places the form on the paper chart or scan the DNR order in the electronic health record under the miscellaneous tab. During a telephone interview on [DATE] at 11:37 a.m., S11 Medical Director reported he signed DNR orders when he made weekly onsite visits. S11 Medical Director reported the nurse practitioner will notify him when a DNR order needs to be signed during his weekly visits. S11 Medical Director reported during his weekly onsite visits the floor nurse just hands him the DNR orders that need to be signed. S11 Medical Director reported the facility also has the option to fax over DNR orders that need to be signed. S11 Medical Director reported he recently checked the residents' EHR and found there were discrepancies with code status. S11 Medical Director then confirmed residents' code status should match what the family wants. During an interview on [DATE] at 10:20 a.m., S16 NP (Nurse Practitioner) reported she did not sign DNR orders only S11 Medical Director signed them. S16 NP reported she has a binder that she checks when she comes into the facility that the DNR orders that need to be signed would be placed in. S16 NP reported she comes to the facility 3 to 4 times a week and S11 Medical Director comes every Thursday. S16 NP reported she would notify S11 Medial Director if there was a DNR order in the binder that required a signature. When asked if there had been any DNR orders for signature in her binder in the last couple weeks S16 NP reported there were 2 that she could recall. S16 NP reported she had not had any in September that she could recall. During an interview on [DATE] at 3:30 p.m., S4 DOCO acknowledged admission packets were not entered into residents' EHR in a timely manner leading to resident's wishes for emergency basic life support not accurately being documented in their record and accessible to all staff. S4 DOCO also reviewed a sampling of resident records and confirmed the advance directives information in the residents' records was inaccurate and incomplete. 36921

Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and received a written order from the physician for bed rails prior to installation for 7 (#4, #20, #125, #22, #75, #9, #126) of 7 (#4, #20, #125, #22, #75, #9, #126) residents reviewed for accident hazards. Findings: Review of the Facility's Restraint Evaluation & Restraint Reduction Policy dated 07/2024 revealed in part: -Definition: Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Responsibility: All members of the interdisciplinary team (as appropriate to individual resident needs) and monitored by the Director of Nursing. -Procedure: 1. The following devices are considered physical restraints and require evaluation (Category I is considered most restrictive with Category IV being the least restrictive): -Category I: wrist, Pelvic, Full Body -Category II: Chest/vest, Waist, Poncho, Hand Mitt, Roll Belt -Category III: Seat belts, Wheelchair lab [NAME], Geri-chair with or without tray, Wheelchair with lap tray, Roll bar, Lap buddy -Category IV: Wedge Cushion, Recliner/Beanbag --side rails that restrict freedom of movement and cannot be easily removed are considered a restraint. 2. All residents using a restraint are to be evaluated utilizing the Physical Restraint Evaluation assessment and/or the Side Rail Evaluation assessment for side rails. Restraint use is to be re-evaluated approximately every quarter. The evaluation is to be conducted by a licensed nurse and reviewed by a physical therapist and or occupational therapist and/or physician and/or rehab certified RN (Registered Nurse), as appropriate. 4. A specific physician's order is to be entered in the resident's Medical Record which details the medical reason, type of restraint and when to be used. 8. Care Plan updates are to occur approximately every quarter and/or as a goal or approach direction changes. Findings: Resident #4 Review of Resident #4's medical record revealed Resident #4 was admitted on [DATE] with diagnoses which included lymphedema, generalized muscle weakness, and difficulty in walking. Review of Resident #4's most recent MDS (Minimum Data Set) asssessment dated 10/08/2024 revealed Resident #4 had a BIMS (Brief Interview for Mental Status) of 11 indicating moderately impaired cognition. Further review of Resident #4's most recent MDS revealed Resident #4 was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #4 revealed Resident #4 was in bed with quarter side rails in use. Review of Resident #4's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #4's care plan revealed Resident #4 had an ADL (Activity of daily living) self-care deficit. Review of Resident #4's medical record failed to reveal documentation Resident #4 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #20 Review of Resident #20's medical record revealed Resident #20 was admitted on [DATE] with diagnoses which included cellulitis of right lower limb, congestive heart failure, cardiomyopathy, hypertension, and difficulty in walking. Review of Resident #20's most recent MDS dated [DATE] revealed Resident #20 had a BIMS of 9 indicating moderately impaired cognition. Further review of Resident #20's most recent MDS revealed Resident #20 was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #20 revealed Resident #20 was in bed with quarter side rails in use. During an interview on 10/14/2024 at 9:00 a.m. Resident #20's son reported the quarter side rails were used to assist Resident #20 with positioning. Review of Resident #20's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #20's medical record failed to reveal documentation Resident #20 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #125 Review of Resident #125's medical record revealed Resident #125 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, bilateral primary osteoarthritis of knee, lack of coordination, difficulty in walking, and generalized muscle weakness. Review of Resident #125's most recent MDS assessment dated [DATE] revealed Resident #125 had a BIMS of 4 indicating severely impaired cognition. Further review of Resident #125's most recent MDS assessment revealed Resident #125 was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #125 revealed Resident #125 was in bed with quarter side rails to the head of the bed bilaterally. Review of Resident #125's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #125's care plan revealed Resident #125 had an ADL self-care performance deficit. Review of Resident #125's medical record failed to reveal documentation Resident #125 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #22 Review of Resident #22's medical record revealed Resident #22 was admitted on [DATE] with diagnoses which included encounter for surgical aftercare following surgery on the digestive system, scoliosis, low back pain, restless leg syndrome, generalized muscle weakness, difficulty in walking, and lack of coordination. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #22 revealed Resident #20 was in bed with quarter side rails in use. Review of Resident #22's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #22's medical record failed to reveal documentation Resident #22 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #75 Review of Resident #75's medical record revealed Resident #75 was admitted on [DATE] with diagnoses including the following, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes, hypertension, difficulty walking and heart failure. Review of Resident #75's admission MDS assessment dated [DATE] revealed in progress (not completed). During an observation on 10/14/2024 at 08:30 a.m. revealed Resident #75's bed was observed to have bilateral assistive devices (bed rails) attached to the bed. During an interview on 10/16/2024 at 11:30 a.m. Resident #75 reported the bed rails help her turn and position while in bed. Review of resident #75's current Physician Orders fail to reveal documentation of an order for the use of side rails. Review of resident #75's medical record failed to reveal documentation Resident #75 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #9 Review of Resident #9's medical record revealed Resident #9 was admitted on [DATE] with a re-admitted [DATE]. Resident #9's diagnoses included Parkinson's disease without dyskinesia, congestive heart failure, chronic kidney disease, unspecified atrial fibrillation, lack of coordination, generalized muscle weakness, and difficulty walking. Review of Resident #9's most recent MDS assessment dated [DATE] revealed Resident #9 had a BIMS score of 15 indicating intact cognition. Further review of Resident #9's most recent MDS revealed Resident #9 was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #9 revealed Resident #9 was in bed with grab bars to the head of the bed bilaterally. Review of Resident #9's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #9's care plan revealed Resident #9 had an ADL self-care performance deficit. Review of Resident #9's medical record failed to reveal documentation Resident #9 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #126 Review of Resident #126's medical record revealed Resident #126 was admitted on [DATE] with diagnoses which included in part metabolic encephalopathy and type 2 diabetes mellitus with diabetic amyothrophy and diabetic neuropathy, generalized muscle weakness, lack of coordination, and difficulty walking. Review of Resident #126's most recent MDS assessment dated [DATE] revealed assessment in progress. Further review of Resident #126's record revealed Resident #126's admission functional abilities and goals assessment indicated Resident #126 had independent cognition and was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #126 revealed Resident #126 was in bed with quarter rails to the head of the bed bilaterally. Review of Resident #126's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #126's medical record failed to reveal documentation Resident #126 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. During an interview on 10/17/2024 at 10:09 a.m. S2 DON (Director of Nursing) reviewed Resident #4, #20, #125, #22, #75, #9, #126's records and confirmed there was no documentation of an order for use of bed rails. S2 DON further confirmed there was no documentation of an assessment for risk of entrapment from bed rails for #4, #20, #125, #22, #75, #9, and #126 prior to instillation and use of bed rails. 34708 36921

Based on record reviews and interviews, the facility failed to ensure each resident's drug regimen was free of unnecessary medications for 4 (#9, #11, #76, #175) of 5 (#9, #11, #76, #127 and #175) residents reviewed for unnecessary medications. The facility failed to ensure adequate monitoring of: Resident #9 for edema related to the use of diuretic Bumex. Resident #11 for edema related to the use of the diuretic Furosemide (Lasix). Resident #11 for bleeding related to the use of an anticoagulant Apixaban (Eliquis). Resident #76 for edema related to the use of the diuretic Furosemide. Resident #175 for bleeding related to the use of the anticoagulant Dabigatran Etexillate Mesylate. Findings: #9 Review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included, in part, Parkinson's disease, systolic (congestive) heart failure, essential (primary) hypertension, and chronic kidney disease. Review of Resident #9's 5-day MDS (minimum data set) with ARD (assessment reference date) of 10/08/2024 revealed Resident #9 had a BIMS (Brief Interview Mental Status) score of 15, which indicated Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed the following orders: 10/09/2024 Bumex Oral Tablet 2 mg (milligram) - give 1 tablet by mouth two times a day for edema. 10/02/2024 (discontinued on 10/11/2024) Bumex Oral Tablet 1 mg - Give 1 tablet by mouth two times a day for edema. 09/19/2024 (discontinued on 10/02/2024) Bumex oral tablet 2 mg - give 1 tablet by mouth two times a day for CHF (congestive heart failure). Review of Resident #9's October 2024 MAR (medication administration record) failed to reveal monitoring for edema had been conducted for Resident #9 who was receiving Bumex. Review of Resident #9's Care Plan revealed Resident #9 was on diuretic therapy (Bumex) with interventions that included, in part, administer Bumex as ordered by physician; monitor for side effects and effectiveness every shift; monitor edema 0, +1, +2, +3, +4; notify MD (medical doctor) if +3 or greater X 3 consecutive days; and monitor/document/report PRN (as needed) adverse reactions to diuretic therapy. During an interview on 10/16/2024 at 1:40 p.m. S7 LPN (Licensed Practical Nurse) reviewed Resident #9's MAR and reported monitoring for edema had not been conducted for Resident #9. #11 Review of Resident #11's medical records revealed an admitted [DATE] with diagnoses that included, in part, cerebral infarction dues to unspecified occlusion or stenosis of left middle cerebral artery, generalized muscle weakness, dysphagia, difficulty walking, and cognitive communication deficit. Review of Resident #11's October 2024 Physician orders revealed the following orders: 09/30/2024 Apixaban (Eliquis) oral tablet 5 mg. Give one by mouth one time a day for blood thinner. 09/30/2024 Furosemide (Lasix) oral tablet 20 mg. Give 1 tablet by mouth one time a day for edema. Review of Resident #11 - 5 Day MDS with ARD 10/07/2024 revealed section N, high-risk drug classes anticoagulant and diuretic. Review of Resident #11's Care Plan revealed the following problems with some of the interventions: 1. The resident is on anticoagulant therapy Apixaban (Eliquis) status post CVA (cerebral vascular accident). Some of the interventions are to administer anticoagulant Apixaban (Eliquis) as ordered by physician. Monitor for side effects and effectiveness every shift. Observe, document and report any adverse reactions of anticoagulant therapy. 2. The resident is on diuretic therapy Furosemide (Lasix). Some interventions are administer diuretic medications as ordered by physician. Monitor for side effects (edema, light-headiness, ringing in the ears, and increase thirst and effectiveness every shift. Observe, document, and report any adverse reactions to diuretic therapy. During an interview on 10/16/2024 at 1:00 p.m. S5 LPN reviewed Resident #11's medical records including the October 2024 Physician orders and MAR and reported there was no monitoring being done for bleeding related to the use of anticoagulant Apixaban (Eliquis) and no monitoring for edema related to the use of Furosemide (Lasix). #76 Review of Resident #76's medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses that included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential (primary) hypertension, heart failure unspecified, and chronic kidney disease. Review of Resident #76's 10/09/2024 Admission 5-day MDS revealed Resident #76 had a BIMS score of 15, which indicated Resident #76 was cognitively intact. Review of Resident #76's physician orders revealed a 10/02/2024 order for Furosemide tablet 20mg - give 20mg by mouth one time a day for edema. Review of Resident #76's October 2024 MAR failed to reveal monitoring for edema had been conducted for Resident #76 who was receiving Furosemide. During an interview on 10/16/2024 at 1:25 p.m. S6 LPN reviewed Resident #76's MAR and reported monitoring for edema had not been conducted for Resident #76. #175 Review of Resident #175's medical record revealed Resident #175 was admitted to the facility on [DATE] with diagnoses that included, in part, type 2 diabetes mellitus, chronic atrial fibrillation, and essential hypertension. Review of Resident #175's medical record revealed Resident #175 had a BIMS score of 14, which indicated Resident #175 was cognitively intact. Review of Resident #175's physician orders revealed the following orders: 10/10/2024 Dabigatran Etexillate Mesylate Oral Capsule 150mg - Give 1 capsule by mouth two times a day for blood thinner. 09/27/2024 (discontinued on 10/02/2024) Dabigatran Etexillate Mesylate Oral Capsule 150mg - Give 1 capsule by mouth two times a day for atrial fibrillation. Review of Resident #175's October 2024 MAR failed to reveal monitoring for bleeding had been conducted for Resident #175 who was receiving Dabigatran Etexillate Mesylate. Review of Resident #175's Care Plan revealed Resident #175 was care planned for anticoagulant therapy with interventions that included, in part, administer anticoagulant medications as order by physician , monitor for side effects and effectiveness every shift, and observe/document/report any adverse reactions of anticoagulant therapy. During an interview on 10/16/2024 at 1:35 p.m. S5 LPN reviewed Resident #175's MAR and reported monitoring for bleeding had not been conducted for Resident #175. 40015

Based on record reviews and interviews, the facility failed to ensure each resident's drug regimen was free of unnecessary medications for 2 (#9, #175) out of 5 (#9, #11, #76, #127, #175) residents reviewed for unnecessary medications. The facility failed to ensure monitoring of side effects and behaviors had been conducted for Resident #9 and Resident #175 who were each receiving a psychotropic. Findings: #9 Review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] and had diagnoses that included, in part, Parkinson's disease, systolic (congestive) heart failure, essential (primary) hypertension, chronic kidney disease, and generalized anxiety disorder. Review of Resident #9's 5-day MDS (minimum data set) with ARD (assessment reference date) of 10/08/2024 revealed Resident #9 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed the following orders: 10/04/2024 Buspirone HCl (hydrochloride) oral tablet 7.5mg (milligram) - Give 1 tablet by mouth two times a day for anxiety. Review of Resident #9's October 2024 MAR (medication administration record) failed to reveal monitoring for side effects and behaviors had been conducted for Resident #9 who was receiving Buspirone. Review of Resident #9's care plan revealed the following care plan, in part: Resident uses anti-anxiety medications with interventions that included, in part, administer anti-anxiety medications as ordered by physician; monitor for side effects and effectiveness every shift; and observe, document, and report any adverse reactions to anti-anxiety therapy. During an interview on 10/16/2024 at 1:40 p.m. S7 LPN (Licensed Practical Nurse) reviewed Resident #9's MAR and reported monitoring for side effects and behaviors had not been conducted for Resident #9 who was receiving Buspirone. #175 Review of Resident #175's medical record revealed Resident #175 was admitted to the facility on [DATE] with diagnoses that included, in part, bipolar II disorder, major depressive disorder recurrent unspecified, type 2 diabetes mellitus, chronic atrial fibrillation, and essential hypertension. Review of Resident #175's medical record revealed Resident #175 had a BIMS score of 14, which indicated Resident #175 was cognitively intact. Review of Resident #175's physician orders revealed a 10/10/2024 order for Cymbalta Oral Capsule Delayed Release Particles 30mg (Duloxetine HCl) - Give 1 capsule by mouth two times a day for depression. Review of Resident #175's October 2024 MAR failed to reveal monitoring for side effects and behaviors had been conducted for Resident #175 who was receiving Cymbalta. Review of Resident #175's care plan revealed: Resident uses antidepressant medication with interventions that included, in part, administer antidepressant medications as ordered by physician and monitor, document, and report any adverse reactions to antidepressant therapy. During an interview on 10/16/2024 at 1:35 p.m. S5 LPN reviewed Resident #175's MAR and reported monitoring for side effects and behaviors had not been conducted for Resident #175 who was receiving Cymbalta.

Based on record reviews and interviews the facility failed to comply with Federal, State, and Local Laws, and Professional Standards by: 1. Failing to ensure CNA (Certified Nursing Assistant) staff had undergone and passed criminal background checks prior to working in the facility for 2 CNAs (S12, S14) of 5 CNA personnel records reviewed. 2. Failing to ensure the nurse aide registry/adverse action list was searched monthly for 3 CNAs (S12, S13, S14) of 5 CNA personnel records reviewed. Findings: Review of S12 CNA's personnel record revealed S12 CNA was hired on 05/17/2024 with a criminal background check performed on 09/06/2024. Further review of S12 CNA's personnel record failed to reveal monthly nurse aid registry/adverse action list searches. Review of S13 CNA's personnel record revealed S13 CNA was hired on 01/05/2018. Further review of S13 CNA's personnel record failed to reveal monthly nurse aid registry/adverse action list searches. Review of S14 CNA's personnel record revealed S14 CNA was hired on 07/23/2023 with a criminal background check performed on 09/06/2024. Further review of S14 CNA's personnel record failed to reveal monthly nurse aid registry/adverse action list searches. During an interview on 10/17/2024 at 12:36 p.m. S15 Human Resources reviewed S12 CNA, S13 CNA, and S14 CNA's records and confirmed there was no documentation of criminal background checks prior to hire for S12 CNA and S14 CNA. S15 Human Resources further confirmed there was no documentation of monthly nurse aid registry/adverse action list searches for S12 CNA, S13 CNA, and S14 CNA.