Every finding on record at Alpine Skilled Nursing and Rehabilitation

Based on record reviews and interview, the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurses aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 2 of 13 weekends during Fiscal Year Quarter 4 2025. Findings:Review of the facility's PBJ Staffing Date Report for Fiscal Year Quarter 4 2025 (July 1 to September 30) revealed excessively low weekend staffing was triggered. Review of the Staffing Pattern Forms for weekends from Fiscal Year Quarter 4 2025 revealed on 07/06/2025 the facility provided 255.70 hours and were required to provide 260.85. Further review revealed on 08/24/2025 the facility provided 271.20 hours and were required to provide 282 hours. On 01/12/2026 at 3:45 p.m. interview with S1Administrator confirmed the facility did not provide the minimum required staffing hours on 07/06/2025 and 08/24/2025.

Based on observations and interviews the facility failed to store, prepare and distribute food in accordance with professional standards for food safety. This had the potential to affect the 117 residents served meals from the kitchen.Findings:Findings:On 01/11/2026 at 8:00 a.m. during the initial observation and tour of the kitchen, staff were currently serving breakfast. Observation of the staff serving breakfast revealed:S8Dietary was using his gloved hand to serve bacon, then touched fried eggs, then touched toast, biscuits and pancakes and the scoop handle for the scrambled eggs with the same gloved hand. At 8:09 a.m., an interview with S8Dietary confirmed he used the same gloved hand to touch the fried eggs, bacon, biscuits, toast and pancakes and scoop handle for the scramble eggs. At 8:10 a.m., observation of the refrigerator revealed the following items were undated: three salads, 22 sandwiches and two bowls of soup. At 8:15a.m., an interview with S7Cook confirmed the salads, sandwiches and bowls of soup were not dated. Further observation of the kitchen environment revealed there was a bag of pink lemonade for the drink dispenser that was sitting directly on the floor. At 8:20 a.m., an interview with S8Dietary confirmed the pink lemonade bag was lying directly on the floor. Further observation of the kitchen area revealed there was an open package of cleaner on the upper shelf above the food preparation table. S7Cook confirmed the package of cleaner was on the shelf above the food preparation table. Observation of the walk-in freezer revealed there was an undated bag of fish and two undated bags of chicken. Observation of the walk-in refrigerator revealed the following undated items: one pan of diced tomatoes, one pan of diced tomatoes with the lid open, one pan of diced green pepper and one bag of salad fixings. On 01/11/2026 at 8:40 a.m., an interview with S7Cook confirmed the above issues in the kitchen area. On 01/11/2026 at 11:21 a.m. observation of the steam table food temperatures taken by S7Cook revealed the pureed au gratin potatoes were 116 degrees Fahrenheit and the chopped pork loin was 127 degrees Fahrenheit. Further observation revealed S7Cook did not reheat the pureed au gratin potatoes or the chopped pork loin prior to serving. Observations revealed the pureed au gratin potatoes were served to residents #4, #9, #25, #47, #54, #87, #88, #99, #108 and #118 and the chopped pork loin was served to residents #2, #22, #30, #31, #38, #49, #53, #62, #68, #91, #100, #104, and #117. Further observation of the lunch meal revealed S8Dietary continued to use his gloved hand to touch the serving scoop handles and then pick up the rolls and place them on the resident's tray. During an interview on 01/12/2026 at 9:30 a.m. with S10Dietary Manager, S10Dietary Manager agreed with the above issues and reported they would be fixed.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment by 1) failing to follow EBP and infection control practices during urinary catheter care and bathing and 2) failing to store unused respiratory equipment in a sanitary manner when not in use for 3 (#10, #61, #91) of 4 residents reviewed for infection control. Findings: 1.Review of the Enhanced Barrier Precautions Cheat Sheet dated 03/2024 revealed in part: Enhanced Barrier Precautions (EBP)- Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. MDRO's may be indirectly transferred from resident-to resident during these high-contact care activities. Examples of EBP residents: Wounds- includes chronic wounds, but are not limited to pressure ulcers, diabetic ulcers, unhealed surgical wounds and venous stasis ulcers. Indwelling medical devices- include central lines, urinary catheters, feeding tubes, and tracheostomies/vents. EBP are indicated during: Dressing Bathing/showering in a shared/common shower room Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care; any skin opening requiring dressing. Implementation: Gowns and gloves are used during high-contact sessions. Before entering the resident's room: Gather all needed supplies and materials; Clean Hands; Correctly put on a gown and gloves; After care, throw away gown and gloves; clean hands again. Resident #10 On 01/12/2026 at 1:45 p.m. review of the record for Resident #10 revealed an admit date of 11/05/2025 with diagnoses in part of metabolic encephalopathy, mild protein calorie malnutrition, stage 3 pressure ulcer to the sacral region, hypertension, Dementia, chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and personal history of venous thrombosis and embolism. Further review of the record revealed Resident #10 had a PEG tube placed with an order for Isosource 1.5 at 70 ml/hour continuous and had a indwelling urinary catheter. Review of the quarterly MDS assessment dated [DATE] revealed Resident #10 had a BIMS of 8 indicating moderate cognitive impairment. Review of the functional abilities revealed Resident #10 was dependent on staff for all ADLs, dependent on staff to roll in bed, and was incontinent of bowel and bladder. On 01/13/2026 at 10:35 a.m. observation of the door to Resident #10's room revealed there was an Enhanced Barrier sign posted. On 01/13/2025 at 10:35 a.m. observation of a bed bath and catheter care performed by S5CNA and S6CNA revealed upon entering Resident #10's room, S5CNA and S6CNA did not put on a gown. Further observation revealed S5CNA performed catheter care without a gown on. Observation revealed S6CNA washed Resident #10's face without a gown on. S5CNA placed soap into the washbasin and cleaned the resident's penis with soap and water and then placed the washcloth back into the soapy water. S5CNA then retrieved the same washcloth that was just used to clean Resident #10's penis and wiped the resident's buttocks, then his legs and over an open blister on the resident's leg and then placed the same washcloth back into the soapy water. S5CNA then washed Resident #10's lower legs with the same washcloth that was used on the resident's penis, buttocks and legs. On 01/13/2025 at 11:09 a.m., an interview with S5CNA regarding the catheter care and bath revealed she agreed that she and S6CNA did not use a gown while performing the care and should have and that she did use the same washcloth to bathe the resident after she had cleaned the resident's penis. 2. Facility's Oxygen Administration policy revised February 2025 revealed in part: Steps in the Procedure 5. Oxygen cannula and tubing will be changed within 7-10 days or if visibly soiled. Store in a covered device (i.e. plastic bag, kangaroo pouch) between uses. Resident #61 Review of the record for Resident #61 revealed an admit date of 11/06/2025 with diagnoses in part of cerebral vascular accident, dysphasia, acute respiratory failure, protein calorie malnutrition, hypertension and muscle wasting and atrophy. On 01/11/2026 at 3:30 p.m., observation of Resident #61's room revealed a nebulizer mask was lying directly on the table next to the resident's bed and was not covered. Further observation revealed the Yankauer oral suction instrument was sitting directly on the suction machine and was not covered. On 01/11/2026 at 4:04 p.m., an interview with S4LPN confirmed the nebulizer mask was supposed to be placed in a black bag and the Yankauer oral suction instrument was supposed to be stored in a clear plastic bag. S4LPN confirmed the nebulizer mask and the Yankauer oral suction instrument were not stored correctly. Resident #91 Record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses including: interstitial pulmonary disease, unspecified; pulmonary fibrosis, unspecified; chronic pulmonary edema; and mild intermittent asthma, uncomplicated Review of Resident #91's annual Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 indicating that Resident #91 had moderate cognitive impairment. Review of Resident #91's active physician's orders revealed an order for the facility to administer oxygen at 2 liters per minute as needed for shortness of breath. On 01/11/2026 at 9:30 a.m., Resident #91 observed to have an oxygen concentrator in her room. Oxygen humidifying water bottle on concentrator was dated 12/16/2025. Oxygen tubing connected to the concentrator was not stored in a bag and was observed touching the floor. Resident #91 was not wearing the oxygen and concentrator was off. On 01/12/2026 at 8:42 a.m., Resident #91 observed lying in bed eating breakfast. Oxygen concentrator observed in room with oxygen tubing attached. Concentrator was turned off and the oxygen tubing observed laying on the floor. On 01/12/2026 at 2:38 p.m., an observation made with S2DON confirmed that Resident #91's oxygen tubing was not stored in a bag and agreed that staff should have stored the oxygen tubing in a bag.

Based on observations, record reviews, and interviews, the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for resident needs by: 1.) S9LPN leaving prescription medications at Resident #80's bedside unattended and failing to remain with the resident until the medications had been taken and 2.) failing to have documentation of Resident #55's Lasix medication being administered as ordered for 2 (#80 and #55) of 3 residents reviewed for competent nursing staff.Findings: Review of the facility's Administering Oral Medications Policy (Revised April 2019) revealed in part: Steps in the Procedure 21. Remain with the resident until all medications have been taken. Resident #80 Review of the medical record revealed Resident #80 had an initial admission date of 06/03/2022. Resident #80 had diagnoses that included hemiplegia, muscle wasting, obesity, muscle weakness, pain, debility and hypokalemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #80 had intact cognition for daily decision making. On 01/11/2026 at 10:25 a.m. observation of Resident #80 revealed he was lying in the bed, a medication cup that contained 4 pills was located on his over bed table unattended. At this time, an interview with Resident #80 revealed the cup contained his morning medications that he did not take. On 01/11/2026 at 10:30 a.m. observation of Resident #80 with S9LPN revealed the medications were still at the bedside. At this time, interview with S9LPN confirmed the medications should not have been left at the bedside. S9LPN further confirmed she should have stayed with Resident #80 until he swallowed the medications. On 01/12/2026 at 3:30 p.m. S2DON confirmed the nurse should not have left the medications at the bedside unattended and the nurse should have stayed with the resident until the medications had been taken. Resident #55 Review of the record for Resident #55 revealed an admit date of 12/19/2025 with diagnoses of rhabdomyolysis, acute pulmonary edema, chronic kidney disease, heart failure, and atrial flutter. Review of the physician orders dated 12/31/2025 revealed: Lasix 10 mg/ml use 4 ml intravenous twice a day for edema for 3 days. Administer 1 dose today and then twice a day for 3 days. Review of the January 2026 Medication Administration Record revealed there was no documented evidence of Lasix administered as ordered on 01/01/2026 at 8:00 p.m., 01/02/2026 at 8:00 a.m. and 01/03/2026 at 8:00 p.m. During an interview on 01/13/2026 at 4:45 p.m., S2DON and S3Corporate Nurse confirmed there was no documented evidence of Lasix administered as ordered on 01/01/2026 at 8:00 p.m., 01/02/2026 at 8:00 a.m. and 01/03/2026 at 8:00 p.m.

Based on observation, record review, and interview the facility failed to ensure a resident's tube feeding bag had documentation including the resident's identifying information, type of formula, and date and time it was started for 1 (#61) of 1 resident reviewed for tube feeding. Findings:Review of the facility's Enteral Tube Feeding via Continuous Pump policy and procedure with a revised date of 08/04/2019 revealed in part:Purpose:The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings.General Guidelines:Check the enteral nutrition label against the order before administration. Check the following information:Resident name, ID and room number;Type of formula;Date and time formula was prepared;Route of delivery;Method (pump, gravity, syringe); andRate of administration (ml/hour)Review of the record for Resident #61 revealed an admit date of 10/31/2025 with diagnoses in part of cerebral vascular accident, dysphasia, malnutrition, and PEG tube placement.Review of the current physician's orders revealed an order for nothing by mouth and a tube feeding order of Isosource 1.5 at 55 ml/hour.On 01/11/2026 at 3:30 p.m., observation of the tube feeding bag that was currently infusing at 55 cc/hr with 150cc water bolus every 4 hours revealed the bag of tube feeding was not labeled with the resident's identifying information, type of formula that was infusing, or the date and time it was started.On 01/11/2026 at 4:00 p.m., an interview with S4LPN confirmed the tube feeding bag that was currently infusing for Resident #61 was not labeled with resident's identifying information, type of formula that was infusing, or the date and time it was started and should have been.

Based on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications for 1 (#1) of 1 sampled residents observed for medications available at the bedside. Findings:Facility's Self-Administration of Medications policy revised December 2016 revealed, in part: Policy StatementResidents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation1. As part of their overall evaluation, the staff with the assistance from the practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident.2. In addition to general evaluation of decision-making capacity, the interdisciplinary team will perform an assessment of Self Administration of Medications Form, or equivalent including (but not limited to) the resident's:a. Ability to read and understand medication labels;b. Comprehension of the purpose and proper dosage and administration time for his or her medications;c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medications; andd. Ability to recognize risks and major adverse consequences of his or her medications.4. If the resident is determined to self-administer, then he/she will be capable and willing to assume control and responsibility for his/her medication. The resident must sign the Consent for Administration of Medication Form regarding and agree to abide by the restrictions for handling and storage of medication according to one of the following plans. 6. All medication is kept in a locked cabinet (night stand) in the resident's room where it is not accessible by other residents. The resident is responsible for remembering to go to the cabinet at each time the medication is due, take the appropriate amount of medication, return the containers to the locked cabinet and keep the cabinet secure always. Resident must be instructed on the necessity of reporting each dose used to the nursing staff. Resident #1 Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including encephalopathy, unspecified; Parkinsonism, unspecified; essential tremor; chronic obstructive pulmonary disease, unspecified; and shortness of breath. Review of Resident #1's current Minimal Data Set (MDS) Assessment revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 indicating that Resident #1 was cognitively intact. Review of Resident #1's active physician's orders revealed an order dated 09/18/2025 for Flonase Allergy Relief Suspension 50 micrograms/actuation (Fluticasone Propionate (Nasal)) 1 inhalation in both nostrils two times a day. On 01/11/2026 at 10:48 a.m., 01/12/2026 at 8:47 a.m., and 01/12/2026 at 2:25 p.m., observations revealed a bottle of fluticasone was in Resident #1's room on top of a dresser at the foot of the bed. On 01/11/2026 at 10:48 a.m., an interview with Resident #1 revealed that she self-administers the fluticasone and facility staff bring her a new bottle when she needs one. On 01/12/2026 at 3:10 p.m., an observation made with S2DON confirmed that Resident #1 had a bottle of Fluticasone in the room. On 01/12/2026 at 3:40 p.m., an interview with S3Corporate RN confirmed that Resident #1 did not have an order to self-administer medications or medication self-administration assessment completed by the facility.

Based on observation, interviews, and record review the facility failed to ensure an accurate assessment was completed to reflect a resident`s condition. The failed practice was evidenced by 1 (#316) of 5 (#50, #62, #80, #102, and #316) residents reviewed for pressure ulcers not having an accurate wound assessment completed by a Registered Nurse (RN) upon discovery of skin breakdown. Findings: Resident #316 On 12/02/2024 at 4:06 p.m., observation revealed resident #316 was alert and oriented while sitting in a chair at his bedside. He reported he had a wound to his sacrum area. Record review revealed resident #316 was admitted to the facility on [DATE] with diagnoses that included idiopathic pulmonary fibrosis, chronic cough, hypotension, hypokalemia and mild protein malnutrition. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated no cognitive impairment. Review of active physician orders for December 2024 revealed the following: Sacrum: Clean stage 3 wound with wound cleanser, pat dry, paint wound bed with betadine, cover with Calcium Alginate and foam dressing every other day and as needed for dislodgement until resolved. Record review of a body assessment completed on 11/19/2024 revealed no record of skin issues related to resident #316. Review of a nurse`s note dated 11/23/2024 at 10:11 a.m., revealed the following; LATE ENTRY: On 11/22/2024, it was reported to S3Licensed Practical Nurse (LPN)/ Wound Care Nurse (WCN) that resident #316 had skin breakdown noted. S3 LPN/WCN assessed resident #316 and found skin to sacrum to be moist, soft, and boggy. No broken skin was noted. New physician orders were obtained for the sacrum to be cleaned with wound cleanser, pat dry, apply foam dressing every 3 days for preventative measures. Review of the wound assessments revealed the following: On 11/27/2024 a wound assessment was completed for resident #316 and signed by S2Director of Nurses (DON). The assessment revealed the wound was first assessed by a RN on 11/27/2024. Further review of the wound assessments revealed no record of a wound assessment being completed by a registered nurse when the skin breakdown was discovered on 11/22/2024. On 12/04/2024 at 9:15 a.m. an interview with S2DON confirmed the first wound assessment was completed by a registered nurse for resident #316` s pressure ulcer to the sacrum on 11/27/2024. S2DON further confirmed an initial wound assessment was not completed by a registered nurse on 11/22/2024 when the skin breakdown was first identified. On 12/04/2024 at 10:55 a.m. an interview with S2LPN/WCN confirmed the skin breakdown to resident #316`s sacrum was identified on 11/22/2024. S2LPN/wound care nurse confirmed she assessed the wound, notified the physician, obtained and implemented physician orders, she further confirmed an initial wound care assessment was not completed and signed by a RN on 11/22/2024.

Based on record review and interview, the facility failed to conduct Quality Assessment and Assurance meetings at least quarterly. Findings: Record review revealed the Quality Assessment and Assurance meetings revealed the past four meetings were held on 10/18/2023, 04/09/2024, 07/10/2024, and 10/30/2024. There was no record of a meeting between the dates of 10/18/2023 and 04/09/2024. On 12/04/2024 at 5:36 p.m., an interview with S1Administrator confirmed there was no record of a quarterly meeting in January 2024.

Based on observations, record reviews and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from side rails prior to the installation of side rails for 5 (#22, #40, #50, #55, #104) of 5 (#22, #40, #50, #55, #104) residents reviewed for side rails. The facility failed to complete the Side Rail Utilization Assessment and consent for side rails prior to implementation for resident #22. Findings: Review of the facility's Proper Use of Side Rails policy and procedure, revised August 2024, revealed the following, in part: General Guidelines 3. Upon admission, readmission, with routine quarterly or significant change MDS and prn, therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When use for mobility or transfer, the assessment will include a review of the resident's: c. risk for entrapment from the use of side rails 4. Consent for use of side rail will be obtained from the resident or legal representative, after presenting potential benefits and risks 5. The resident's care plan will reflect the use of side rails and updated as necessary; 9. The resident will be checked at least every shift for safety and proper functioning of the side rail use; Resident #40 Review of the medical record for resident #40 revealed an admitted [DATE] with diagnoses including muscle wasting and atrophy, diabetes mellitus, chronic obstructive pulmonary disease, convulsions, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was a 4 which indicated severe cognitive impairment for daily decision making. Resident #40 required extensive assistance with bed mobility, toileting and transfers. Review of resident #40's December 2024 Physician's Orders revealed no order for side rails. On 12/02/2024 at 4:12 p.m. and 12/03/2024 at 2:10 p.m., observations of resident #40 revealed he was in the bed, quarter side rails were in the raised position on both sides of the bed. Review of the Side Rail Utilization assessment dated [DATE] for resident #40 revealed no documentation that risks of entrapment were assessed prior to the implementation of the side rail. On 12/04/2024 at 2:00 p.m. interview with S2Director of Nursing (DON) confirmed the side rail assessment for resident #40 did not address the assessment for risk of entrapment prior to installation. Resident #55 Review of the medical record for resident #55 revealed an admitted [DATE] with diagnoses of muscle wasting and atrophy, muscle spasm, heart failure, anxiety, and diabetes mellitus. Review of the quarterly MDS dated [DATE] revealed resident #55 had a BIMS score of 15 which indicated no cognitive impairment and she required assistance with bed mobility and transfers. Review of resident #55's December 2024 Physician's Orders revealed no order for side rails. On 12/02/2024 at 2:00 p.m., and 12/04/2024 at 7:45 a.m. observations of resident #55's bed revealed quarter side rails were in the raised position on both sides of the bed. Review of the Side Rail Utilization assessment dated [DATE] for resident #55 revealed no documentation that risks of entrapment were assessed prior to the implementation of the side rail. On 12/04/2024 at 2:00 p.m. interview with S2DON confirmed the side rail assessment for resident #55 did not address the assessment for risk of entrapment prior to installation. 41829 Resident #50 Record review revealed resident #50 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysphagia, aphasia, essential hypertension, chronic pain, diabetes mellitus, generalized muscle weakness, muscle wasting and atrophy multiple sites, encounter for attention gastrostomy, acquired absence of right leg and left leg above the knee, and major depressive disorder. Review of quarterly MDS assessment dated [DATE] revealed BIMS score of 99 which indicated resident #50 was unable to complete due to severe cognitive impairment. Further review revealed resident #50 was dependent on staff assistance with all activities of daily living. On 12/02/2024 at 9:30 a.m., an observation of resident #50 revealed she was lying in bed with head of bed elevated up 30 degrees. The quarter side rails on each side of the bed were in the upright position. On 12/03/2024 at 9:50 a.m., an observation of resident #50 revealed she was lying in bed with head of bed elevated up 30 degrees. The quarter side rails on each side of the bed were in the upright position. Review of active care plans revealed resident #50 had an activities of daily living self-care performance deficit. An intervention listed included resident #50 used side rails to maximize independence with turning and repositioning. On 12/04/2024 at 2:28 p.m., S2DON provided surveyor with resident #50's side rail utilization assessment that had an effective date of 09/30/2024 included a consent for bilateral side rails. Further review of the side rail utilization assessment form revealed resident #50 was not assessed for entrapment. S2DON confirmed there was no documentation of resident #50 being assessed for entrapment prior to the use of side rails. 43405 Resident #22 Review of resident #22's record revealed and admitted [DATE] with diagnoses including fibromyalgia, chronic kidney disease stage 3, type 2 diabetes mellitus with diabetic neuropathy, spinal stenosis, other sequelae of cerebral infarction, adjustment disorder with depressed mood, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, and major depressive disorder. Review of resident #22's December 2024 Physician's Orders revealed no orders for side rails. Review of resident #22's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Observations on 12/02/2024 at 3:30 p.m., 12/03/2024 at 4:00 p.m., and 12/04/2024 at 9:15 a.m. of resident #22 revealed resident had half side rail to one side of the bed in the up position. Review of resident #22's Side Rail Utilization Assessment revealed an effective date 10/01/2024 with the assessment and consent signed and dated on 12/04/2024. Further review of the assessment revealed no documentation that risks of entrapment were assessed prior to the implementation of the side rail. An interview on 12/04/2024 at 2:10 p.m. with S2DON confirmed the facility did not complete the Side Rail Utilization Assessment or consent prior to the implementation of the side rails. S2DON further confirmed there was no documentation of risks of entrapment assessed prior to the installation of side rails. Resident #104 Review of resident #104's record revealed an admission record of 08/02/2024 with diagnoses including hypertension, atrial fibrillation, and shortness of breath. Review of resident #104's December 2024 Physician's Orders revealed no order for use of side rails. Review of resident #104's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. Observations of resident #104 on 12/02/2024 at 2:25 p.m., 12/03/2024 at 4:15 p.m., and 12/04/2024 at 9:05 a.m. revealed resident had bilateral half side rails in place in the up position. Review of resident #104's Side Rail Utilization assessment dated [DATE] revealed no documentation of identifying risks of entrapment prior to the installation of side rails. An interview on 12/04/2024 at 2:35 p.m. with S2DON confirmed there was no documentation of assessing risks of entrapment prior to the installation of side rails on resident #104.

Based on observations, record reviews, and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice by not having signage on the outside of the residents' room door to indicate oxygen was in use for 3 (#29, #104, #316) of 5 (#17, #29, #67, #104, #316) residents reviewed for oxygen. Findings: Review of the facility's Oxygen Administration policy and procedure, revised October 2010, revealed the following, in part: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure 2. Place an Oxygen in Use sign in a designated place outside resident room. Resident #29 Review of the medical record for sampled resident #29 revealed an admitted [DATE] with diagnoses of idiopathic peripheral autonomic neuropathy, pulmonary edema, diabetes mellitus, dysarthria, depression, dysphagia, cardiomyopathy, heart failure, and dementia. Review of the physician's orders dated 11/20/2024 revealed administer continuous oxygen at 2 liters per nasal cannula. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #29 had a Brief Interview for Mental Status (BIMS) scored of 3 which indicated the resident had severe cognitive impairment for daily decision making. Review of the current care plan for resident #29 revealed the resident had oxygen therapy related to ineffective gas exchange, respiratory illness, give medications as ordered by the physician, and observe for signs and symptoms of respiratory distress. On 12/02/2024 at 9:45 a.m., and 12/03/2024 at 12:31 p.m., observations of resident #29 revealed she was in the bed and received oxygen at 2 liters per nasal cannula. Observations of the outside of the resident's door revealed there was no sign to indicate the resident received oxygen therapy. On 12/04/2024 at 2:15 p.m. observation of the outside of resident #29's door with S2Director of Nursing (DON) revealed there was no signage to indicate the resident was on oxygen. S2DON confirmed the signage for oxygen use was not on the outside of the door. 40238 Resident #316 Record review revealed resident #316 was admitted to the facility on [DATE] with diagnoses that included idiopathic pulmonary fibrosis, chronic cough, hypotension, hypokalemia and mild protein malnutrition. Review of the most recent MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated no cognitive impairment. Review of the plan of care revealed resident #316 was to receive Oxygen at 2 liters per minute via nasal cannula. On 12/02/2024 at 4:06 p.m., observation revealed resident #316 was alert and oriented while sitting in a chair at his bedside. He was observed wearing a nasal cannula that was providing Oxygen at 2 liters per minute via an Oxygen concentrator located in the corner of the room. There was no signage observed at the entrance of the room that indicated oxygen was in use. 43405 Resident #104 Review of resident #104's record revealed an admitted [DATE] with diagnoses including hypertension, atrial fibrillation, shortness of breath, and gastroesophageal reflux disease. Review of resident #104's December 2024 Physician's Orders revealed an order dated 08/02/2024 for continuous Oxygen at 2 liters per nasal cannula. Observations on 12/02/2024 at 2:25 p.m., 12/03/2024 at 4:15 p.m., and 12/04/2024 at 9:05 a.m. of resident #104 revealed resident had Oxygen in use, but there was no Oxygen in use sign posted on the outside of the resident's door. An interview on 12/04/2024 at 2:25 p.m. with S2DON confirmed resident #104 had Oxygen in use without an Oxygen in use sign posted on the outside of the resident's door.

Based on record review and interview, the facility failed to ensure resident's drug regimens were free from unnecessary psychotropic medications for 1 (#22) of 5 (#4, #17, #22, #55, and #78) residents reviewed for unnecessary medications. The facility failed to ensure a psychotropic medication was used only when there was an acceptable diagnosis documented in the medical record for resident #22. Findings: Review of resident #22's record revealed an admitted [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, other sequelae of cerebral infarction, adjustment disorder with depressed mood, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, and major depressive disorder. Review of resident #22's current Electeronic Health Records (EHR) revealed an order dated 11/12/2024 for Quetiapine Fumarate oral tablet give 50 milligrams (mg) by mouth (po) 2 times a day for mood related to adjustment disorder with depressed mood. An interview on 12/04/2024 at 2:00 p.m. with S2Director of Nursing (DON) confirmed resident #22 has an order for Quetiapine Fumarate with the a diagnosis of adjustment disorder with depressed mood. S2DON confirmed resident #22 does not have an appropriate diagnosis for the use of Quetiapine Fumarate (antipsychotic medication).

Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#22) of 5 (#4, #17, #22, #55, and #78) residents reviewed for unnecessary medications. Findings: Review of the facility's Pharmacy Services- Role of the Consultant Pharmacist policy and procedure, revised April 2007, revealed the following in part: 4. The Consultant Pharmacist will provide specific activities related to medication regimen review including: b. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. Review of resident #22's record revealed and admitted [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, spinal stenosis, other sequelae of cerebral infarction, adjustment disorder with depressed mood, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, and major depressive disorder. Review of resident #22's current Electeronic Health Records (EHR) revealed an order dated 11/12/2024 for Quetiapine Fumarate oral tablet give 50 milligrams (mg) by mouth (po) 2 times a day for mood related to adjustment disorder with depressed mood. Review of the monthly drug regimen review revealed the phamacist reviewed resident #22 on 11/22/2024, but no documented evidence that the pharmacist identified an irregularity on regarding the use of Quetiapine Fumarate without an appropriate diagnosis. An interview on 12/04/2024 at 2:00 p.m. with S2Director of Nursing (DON) confirmed the pharmacist did not notify the facility, DON, or physician regarding resident #22 not having an appropriate diagnosis for the use of Quetiapine Fumarate (antipsychotic medications).

Based on record reviews and interviews, the facility failed to ensure routine medications were administered to each resident for 3 (#18, #34, and #69) of 4 (#18, #34, #69, and #101) residents reviewed for pharmceutical services. The facility failed to have documented evidence as to the reason why the residents were not administered their medications in accordance with the physician's orders. Findings: Resident #18 Review of the medical record revealed resident #18 was admitted to the facility on [DATE]. Her diagnoses included in part, dry eye syndrome of unspecified lacrimal gland, constipation, chronic obstructive pulmonary disease, asthma, exocrine pancreatic insufficiency, restless leg syndrome, psoriatic arthopathy, rheumatoid arthritis, and fibromyalgia. Review of the Minimum Data Set, dated dated dated [DATE] revealed resident #18 had a brief interview for mental status score of 15. A score of 13-15 indicated that resident #1 was cognitively intact with daily decision making. On 11/27/2023 at 10:45 a.m., during an interview with resident #18, she revealed that she was supposed to have gotten Systane Complete (Over-the-counter medication used to treat dry eyes), because she had extremely dry eyes. Further interview revealed it had been approximately two weeks since the medication had been ordered and she had not received the medication to date. Review of the November 2023 physician orders revealed resident #18 was ordered the following medications: 11/08/2023: Systane Complete; give one drop four times a day (7:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m.). Review of the November 2023 MAR revealed no documented evidence of the medication being administered on 11/17/2023 at 9:00 p.m. and on 11/28/2023 at 4:00 p.m. 11/08/2023: Flonase Allergy RLF (Relief) 50 micrograms spray; give two puffs in each nostril daily (8:00 a.m.,). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on 11/25/2023 at 8:00 a.m. 10/24/2023: Creon 3,000 unit-9,500 unit capsule; give one capsule by mouth three times daily (8:00 a.m., 2:00 p.m., and 8:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence on the MAR of the medication being administered on 11/04/2023 at 8:00 a.m., 2:00 p.m. and 8:00 p.m., on 11/22/2023, 11/23/2023, and 11/24/2023 at 2:00 p.m. 10/24/2023: Ropinirole HCL (Hydrocloride) 0.25 mg tablet; take one tablet by mouth at bedtime (8:00 a.m. and 8:00 p.m.). Further review revealed there was no documented evidence on the MAR of the medication being administered on 11/22/2023, 11/23/2023, and 11/24/2023 at the schedule 2:00 p.m. 10/26/2023: Hydrocortisone 1% topical cram apply topically to area on back three times daily (8:00 a.m., 2:00 p.m., and 8:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the date of 11/22/2023, 11/23/2023, and 11/24/2023 at 2:00 p.m. Review of the November 2023 nurse's notes revealed no documented evidence of the reason why resident #18 was not administered the medications as ordered by the physician. Resident #34: Review of the EHR (Electronic Health Record) revealed resident #34 was admitted to the facility on [DATE] with diagnoses including in part, Parkinsonism, primary osteoarthritis, muscle wasting and atrophy, Type 2 diabetes mellitus with diabetic nephropathy, allergy, constipation, and anxiety disorder. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed resident #34 had a brief interview for mental status score of 10. A score of 8-10 indicated resident #34 was moderately cognitively impaired with daily decision making. Review of the November 2023 physician orders revealed resident #34 was ordered the following medications: 03/15/2023: Nystatin 100,000 unit/gram powder; apply powder to affected area three times daily until healed, may keep at beside or use (8:00 a.m., 12:00 p.m., and 4:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates of 11/02/2023, 11/08/2023, 11/21/2023, and 11/22/2023 at 12:00 p.m. 04/24/2023: Gabapentin 600 mg tablet; take one by mouth three times daily (8:00 a.m., 2:00 p.m., and 8:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates of 11/02/2023, 11/08/2023, 11/10/2023, 11/21/2023, and 11/22/2023 at 2:00 p.m. 11/10/2023; Prednisone 10 mg tablet; take one tablet mouth once daily for 5 days (9:00 a.m.). Review of the November 2023 MAR revealed there was documented evidence of the medication being administered on the dates of 11/21/2023 and 11/22/2023 at 9:00 a.m. 03/11/2022: Clotrimazole-betamethasone cream; apply to affected area bid (8:00 a.m. and 8:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the date of 11/18/2023 at 8:00 a.m. 01/20/2023: Docusate Sodium 100 mg capsule take one capsule by mouth once daily (8:00 a.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates of 11/04/2023, 11/11/2024, and 11/18/2023 at 8AM. 03/10/2023: Zyzal 5 mg tablet give on tablet by mouth every morning (8:00 a.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the date of 11/18/2023 at 8:00 a.m. 07/25/2023: Spiriva Respimat 1.25 mg micrograms; inhale two puffs daily (8:00 a.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the date of 11/18/2023 at 8:00 a.m.) 11/07/2023: Isosorbide Mononit Extended Release 60 mg; take one by mouth every morning. Review of the November 2023 MAR revealed no documented evidence of the medication being administered on the date of 11/08/2023 at 8:00 a.m. 02/02/2023: Hydralazine 50 milligram tablet take on tablet by mouth three times daily (8:00 a.m., 1:00 p.m., and 8:00 p.m.). Review of the November 2023 MAR revealed no documented evidence of the medication being administered on the dates of 11/02/2023, 11/08/2023, 11/21/2023, and 11/22/2023 at 1:00 p.m. 10/06/2023: Pataday twice daily 0.1% daily drops apply one drop in each three times a day for 7 days (6:00 a.m., 2:00 p.m., and 10:00 p.m.). Review of the November 2023 MAR revealed no documented evidence of the medication being administered on the dates of 11/02/2023, 11/08/2023, 11/10/2023, 11/21/2023, and 11/22/2023 at 2:00 p.m., 11/09/2023 and 11/16/2023 at 6:00 a.m., 11/12/2023, 11/17/2023, and 11/25/2023 at 10:00 p.m. Review of the nurse's noted dated November 2023 revealed no documented evidence of the reason why resident #34 did not receive her medications as ordered by the physician. Resident #69: Review of the medical record revealed resident #69 was admitted to the facility on the date of 06/16/2023. Resident #69's diagnoses included in part, pain, unspecified dementia, unspecified severity and without behaviors, Addisonian crisis, pain, muscle wasting and atrophy, multiple sites, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed resident #69 had a brief interview for mental status score of 15. A score of 13-25 indicated that resident #69 was cognitively intact with daily decision making. Review of the November 2023 physician orders revealed the following: 10/20/2023: Neurontin 100 mg capsule; take one capsule by mouth three times daily (6:00 a.m., 2:00 p.m., and 10:00 p.m.) until end of November then will evaluate effectiveness. Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates of 11/06/2023, 11/21/2023 and 11/22/2023 at 2:00 pm, 11/08/2023, 11/16/2023, and 11/25/2023 at 6:00 a.m., and 11/25/2023 at 10:00 p.m. 06/22/2023: Klonopin 0.5 mg tablet take one by mouth once daily at 2:00 p.m. Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates 11/22/2023 and 11/24/2023 at 2:00 p.m. Review of the nurse's noted dated November 2023 revealed no documented evidence of the reason why resident #69 did not receive her medications as ordered by the physician. On 11/19/2023 at 4:15 p.m., S3Corporate Nurse was notified of the findings. S2Director of Nursing was present. After a review of the medical records for residents #18, #34, and #69, S2Corporate confirmed there was no documented evidence as to the reason why the residents did not receive their medications in accordance with the physician's orders.

Based on record review and interviews, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for a resident's need by not having a controlled medication available and administered in accordance with physician orders for 1 (#8) of 5 (#7, #8, #34, #72, and #86) residents reviewed for unnecessary medications. Findings: On 11/27/2023 at 4:17 p.m., an interview with Resident #8 was conducted in her room. She reported she did not receive her Lyrica (controlled medication) on the morning of 11/27/2023 or on 11/26/2023 as scheduled. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included left hip fracture, diabetes, adjustment disorder with depressed mood, and presence of artificial hip and artificial knee. Review of most recent Minimum Data Set, dated dated dated [DATE] revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated she had no cognitive impairment. Review of active physician orders for the month of November 2023 included an order for Lyrica 150 milligrams (mg) by mouth to be administered three times daily. Review of November 2023 Medication Administration Record (MAR) revealed Lyrica 150 mg was not given on 11/25/2023 at 8:00 p.m., 11/26/2023 at 8:00 a.m., 2:00 p.m. and 8:00 p.m., and 11/27/2023 at 8:00 a.m. and 2:00 p.m. Review of the current facility`s policy and procedure related to ordering controlled medications revealed re-orders for controlled substances should be made allowing for appropriate time for the pharmacy to obtain the prescription and to assure an adequate supply is on hand. On 11/27/2023 at 9:30 a.m., an interview with S10Licensed Practical Nurse (LPN) revealed Resident #8 did not receive her Lyrica as ordered on 11/25/2023, 11/26/2023 and 11/27/2023 because it was not available. On 11/28/2023 at 2:26 p.m., an interview with S2 Director of Nurses (DON) confirmed Resident # 8 should not have missed doses of Lyrica due to the medication not being available. S2DON revealed the nursing staff should have ordered the Lyrica for Resident #8 ahead of the scheduled times in accordance with their policy on re-ordering controlled medications to ensure Resident #8 did not miss a dose of the scheduled medication.

Based on record review and interview, the facility failed to ensure a performance review was completed at least once every 12 months for 3 (S4 Certified Nursing Assistant (CNA), S6CNA, S8CNA ) of 5 (S4CNA, S5CNA S6CNA, S7CNA, and S8CNA) personnel records reviewed. Findings: Review of S4CNA, S6CNA, and S8CNA personnel records revealed there was no documentation that an annual performance review was completed in the past 12 months. On 11/29/2023 at 3:24 p.m., an interview with S1Administrator revealed he could not provide annual performance reviews for S4CNA, S6CNA, and S8CNA. S1Administrator confirmed S4CNA, S6CNA, and S8CNA should have annual performance reviews completed in the past 12 months.

Based on observations, interviews, and record reviews, the facility failed to provide assistance for residents who were unable to carry out activities of daily living (ADL) by failing to maintain good grooming and personal hygiene for 3 (#7, #29, and #39) of 4 (#7, #29, #39, and #72) residents reviewed for activities of daily living. Findings: Resident #7 Review of the medical record for resident #7 revealed the resident was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, peripheral autonomic neuropathy, pain in right shoulder, lack of coordination, dysarthria following cerebral infarction, muscle weakness, pain, atrial fibrillation, insomnia, dyspnea, major depression disorder, seizures, aphasia following cerebral infarction, and hemiplegia following cerebral infarction affecting left dominant side. Review of the Yearly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognitive skills for daily decision making. The resident required one person limited assistance with personal hygiene. Review of the care plan revealed self-care deficit related to inability to perform own activities of daily living (ADLs) independently. Further review revealed the following approaches: assist with ADLs as needed, nail care when necessary and weekly, monitor/trim toenails and fingernails, bathing, dressing, and hygienic needs (shaving per one person assist). Observation on 11/27/2023 at 12:26 p.m. revealed the resident's facial hair was unkempt and he needed to be shaved. Further observation revealed the resident had long dirty fingernails. Interview at this time revealed that he wanted to be shaved and a Certified Nursing Assistant told him that he would shave him but hasn't yet. Further interview revealed he would like his fingernails trimmed. Observations on 11/28/2023 at 1:10 p.m. and 11/29/2023 at 11:00 a.m. revealed the resident's facial hair was unkempt and he needed to be shaved. Further observation revealed the resident had long fingernails. Observation of resident #7 with S9Licensed Practical Nurse (LPN) on 11/29/2023 at 1:10 p.m. confirmed the resident's facial hair needed to be shaved and his nails were in need of trimming. Observation of resident #7 with S2Director of Nursing (DON) on 11/29/2023 at 2:25 p.m. confirmed the resident's facial hair needed to be shaved and his nails were in need of trimming. Interview with the resident at this time revealed he would like his face shaved and nails filed. Resident #29 Review of the medical record for resident #29 revealed the resident was admitted on [DATE] with diagnoses of chronic atrial fibrillation, encephalopathy, congestive heart failure, arthritis, pain in left shoulder, rotator cuff tear left shoulder, gout, sleep disorder, hypertension, and pain in knee. Review of the Admission MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required maximal assistance for personal hygiene. Review of the care plan revealed the resident was at risk for falls with an approach to assist the resident as needed with transfers and activities of daily living. Observation on 11/27/2023 at 12:30 p.m. revealed the resident's facial hair was unkempt and he needed to be shaved and his teeth needed to be brushed. Further observation revealed the resident had long fingernails. Interview at this time with the resident revealed he had not been shaved or had his teeth brushed since admit. Further observation revealed there was not a toothbrush in his room. Observation on 11/29/2023 at 11:10 a.m. revealed the resident's fingernails are long with one fingernail jagged. Interview at this time revealed he would like his fingernails and toenails trimmed. Further interview revealed he had not received oral care and he doesn't have a toothbrush. Observation of the resident on 11/29/2023 at 1:15 p.m. with S9LPN confirmed the resident's nails were in need of trimming. Interview with the resident at this time revealed he needed his fingernails and toenails trimmed and he also needed a toothbrush. Interview on 11/29/2023 at 2:30 p.m. with resident #29 and S2DON confirmed the resident needed his fingernails and toenails trimmed. Further interview at this time with the resident revealed he had not received oral care since he has been here. Observation by S2DON confirmed there was not a toothbrush in his room. Resident #39 Review of the medical record for resident #39 revealed the resident was admitted on [DATE] with diagnoses of fractured right femur, muscle wasting and atrophy, diabetes, Chronic Obstructive Pulmonary Disease, convulsions, insomnia, depression, Alzheimer's, Transient Ischemia Attack and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required maximal assistance for personal hygiene. Review of the care plan revealed the resident required staff assistance for all activities of daily living. Further review of the approaches revealed hygienic needs/grooming and shaving, the resident required 1 person assist, and weekly nail care per nursing to my fingernails and my toenails. Observations on 11/27/2023 at 9:19 a.m., 11/28/2023 at 12:30 p.m., and 11/29/2023 at 11:05 a.m. revealed the resident's facial hair was unkempt and he needed to be shaved. Further observations revealed the resident had long dirty fingernails. Observation of resident #39 with S9LPN on 11/29/2023 at 1:19 p.m. confirmed the resident's facial hair needed to be shaved and his fingernails needed to be trimmed. Observation of resident #39 with S2DON on 11/29/2023 at 2:35 p.m. confirmed the resident's facial hair needed to be shaved and his fingernails needed to be trimmed.

Based on record reviews and interviews, the facility failed to ensure an entry in the Emergency (ER) Transfer Log was completed and the Ombudsman was notified of the transfer for 1 (#64) of 1 (#64) residents reviewed for Notice Requirements Before Transfer/Discharge. The failed practice was made evident by the facility failing to ensure emergency transfer logs were completed and the ombudsman was notified when resident #64 was transferred to the emergency roiagnom on the dates of 07/05/2023 and 11/03/2023. Findings: Review of the electronic health record revealed resident #64 was admitted to the facility on [DATE] with diagnoses that included in part, hemiplegia, spondylolysis, cervical region, aphasia following cerebral infarction and dysarthria following cerebral infarction, and transient ischaemic attack. Review of the nurse's notes dated 11/03/2023 at 5:19 p.m., revealed in part, resident #64 was sent to the emergency room for evaluation and treatment due to having trouble gathering words and making sentences. Review of the ER (Emergency) transfer logs presented by S1Administrator revealed there were no documented logs noted after the month of June 2023. On 11/29/2023 at 1:30 p.m., an interview with S1Administrator revealed that S11Social Services (Previous Employee), had been responsible for completing the emergency transfer logs prior to ending her employment with the provider in August of 2023. S1Administrator further reported that after S11Social Service's employment was terminated with the nursing facility, he, (S1Administrator) assumed the position and was currently responsible for completing the emergency transfer logs. S1Administrator confirmed there was no documented evidence of the ER transfer logs being completed and the ombudsman being notified of any transfer/discharge after the month of June 2023. Further review of the nurse's notes revealed that on the date of 07/05/2023 at 6:13 p.m., resident #64 had facial drooping and was sent to the emergency room for evaluation. On 11/29/2023 at approximately 4:45 p.m., S1Administrator was notified of the additional findings regarding resident #64 being transferred to theER on the date of 07/05/2023. S1Adminsistrator further confirmed that he had not completed the ER transfer log to reflect resident #64's transfer to the ER and he had not notified the ombudsman of the transfer.

Based on observations, record review and interviews, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#83) of 1 residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving device while in the wheelchair for resident #83. Findings: Resident #83 Review of the medical record for resident #83 revealed the resident was admitted on [DATE] with diagnoses of aphasia, muscle wasting and atrophy, obesity, and abnormality of gait and mobility. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had independent cognitive skills for daily decision making. The resident required maximal assistance with transfers and toileting hygiene. The resident was frequently incontinent of bowel and bladder. Review of the Wound assessment dated [DATE] revealed a stage II pressure ulcer on the coccyx identified on 11/17/2023 and resolved on 11/20/2023. Review of the physician orders for November 2023 revealed an order dated 10/27/2023 - may have pressure relieving cushion to wheelchair every shift as tolerated and monitor for placement. Observation of resident #83 on 11/27/2023 at 3:30 p.m., 11/28/2023 at 12:40 p.m., and 11/29/2023 at 10:55 a.m. revealed the resident was up in her wheelchair in her room. The wheelchair did not have a pressure relieving device. An interview with S9Licensed Practical Nurse (LPN) on 11/29/2023 at 1:22 p.m. confirmed the resident should have a pressure relieving device in her wheelchair and the resident did not have one at this time. An interview with S2Director of Nursing (DON) on 11/29/2023 at 2:32 p.m. confirmed resident #83 should have a pressure relieving device in her wheelchair.

Based on observation, review of policy and procedure, and interview, the facility failed to ensure that residents environment remains free of accident hazards as is possible by 1) staff leaving unidentified medications at bedside for 1(#6) of 6 (#1,#2,#2,#4,#5,#6) sampled residents and 2) leaving medication cart, unlocked and unattended with unidentified medications and cigarette lighters on top of cart and accessible to residents. Findings: 1. Review of the Facility's Policy for Administering Oral Medications revealed in part: Steps in the Procedure 21. Remain with the resident until all medications have been taken. Review of the medical record for resident #6 revealed an admitted [DATE] with diagnoses including fibromyalgia, muscle wasting, diabetes mellitus, vascular dementia, hypertension, hypothyroidism, depression, hyperlipidemia, and neuralgia. Review of the annual Minimum Data Set, dated dated dated [DATE] revealed the resident was independent with cognition for daily decision making and required assistance with activities of daily living. On 08/09/2023 at 8:30 a.m., observation of resident #6 revealed she was sitting on the side of the bed and two unidentified pills were observed in a medication cup on the bedside table. Further observation revealed the pills were unattended and accessible to the resident. On 08/09/2023 at 8:30 a.m. S4 Licensed Practical Nurse (LPN) was notified and she went into resident #6's room to retrieve the two unidentified pills. She confirmed the pills should not have been left at the bedside unattended. On 08/09/2023 at 9:00 a.m. S2 Director of Nursing (DON) was informed of the two unidentified pills left at the bedside. S2 DON revealed the pills should not have been left at the bedside unattended. 2. On 08/09/2023 at 8:33 a.m., observation of the 400 Hall medication cart revealed two medication cups of unidentified pills, totaling four pills on top of unlocked cart. Further observation revealed 2 cigarette lighters sitting on top of the medication cart. Observation revealed the unlocked cart, pills, and cigarette lighters were unattended and accessible to residents. On 08/09/2023 at 8:37 a.m., interview with S3 LPN confirmed that she was out of view of the medication cart and that the pills and cigarette lighters should not be accessible to residents when out of view of cart. Further interview with S3 LPN confirmed that the medication cart must be locked when out of view. On 08/09/2023 at 9:05 a.m. S2 DON was informed of the unlocked medication cart and the unidentified pills and cigarette lighters on top of the cart. S2 DON revealed that cart is to be locked and that pills are not to be accessible.

Based on record review and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (#1, #3) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This was evidenced by 1) a licensed practical nurse administering a thyroid medication at the wrong time and with other medications to Resident #3 and, 2) a licensed practical nurse administering a medication to treat low blood pressure to Resident #1 within 3 hours of previous administration of the same medication. Findings: 1. Review of Resident #3's medical record revealed an admitted [DATE] with diagnoses that included in part .Hypothyroidism, Muscle Wasting and Atrophy. Review of Resident #3's August 2023 physician's orders revealed an order dated 06/09/2022 for Synthroid (medication used to treat low thyroid) 175 micrograms (mcg), take one tablet by mouth every day at 8:00 a.m. Observation of medication administration for Resident #1 on 08/07/2023 at 11:58 a.m. revealed S4 LPN (licensed practical nurse) administered Synthroid 175 mcg, 1 tablet, in addition with 10 other oral medications. Review of Resident #3's August 2023 Medication Administration Record (MAR) revealed S4 LPN documented that the Synthroid 175 mcg, 1 tablet, was administered on 08/07/2023 at 8:00 a.m. Interview on 08/07/2023 at 12:25 p.m. with S6 Nurse Practitioner revealed she was unaware that the Synthroid medication was being administered with other medications. She further stated that the Synthroid was ordered to be administered separately from other medications. 2. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included in part .Orthostatic Hypotension, Secondary Hypertension, Adjustment Disorder with Depressed Mood and History of Falls. Review of Resident #1's August 2023 physician's orders revealed an order dated 07/19/2023 for Midodrine HCL (medication used to treat low blood pressure) 10 mg tablet, take one tablet by mouth three times a day. (DO NOT HOLD) Review of Resident #1's August 2023 Medication Administration Record (MAR) revealed Resident #1 is to receive Midodrine, 10mg by mouth three times per day at 6:00 a.m., 12:00 p.m., and 8:00 p.m. Review of the MAR for Resident #1 revealed on 08/09/2023 the 6:00 a.m. dose of Midodrine was recorded as administered by S6 LPN at 5:04 a.m. Review of the MAR for Resident #1 revealed on 08/09/2023 the 12:00 p.m. dose of Midodrine was recorded as administered by S3 LPN at 8:00 a.m. Interview on 08/09/2023 at 8:37 a.m., S3 LPN confirmed that she administered Midodrine 10mg at 8:00 a.m. and that the medication was not to be administered until 12:00 p.m. Interview on 08/09/2023 at 9:05 a.m. with S2 DON confirmed that resident's #1 Midodrine should not have been administered at 8:00 a.m.

Based on observation, interview, and record review, the facility failed to ensure residents receive quality of care based on their comprehensive assessments, and received treatment and care in accordance with professional standards of practice for 2 (Resident #1 and Resident #2) of 5 (Residents #1-5) residents reviewed out of a total sample of 5 residents. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 12/31/18 at 1:46PM when S7LPN (Licensed Practical Nurse) was notified by a CNA (Certified Nursing Assistant) that Resident #1's foot did not look right. The resident was found to have an open wound to the right foot which was unstageable due to eschar. During the period of 12/31/18 to 01/02/19, the wound to the resident's right foot was not assessed by a RN (Registered Nurse) and there was no monitoring or treatment of [REDACTED]. The Administrator was notified of the Immediate Jeopardy on 01/15/19 at 12:45PM. The Immediate Jeopardy was removed on 01/02/19 at 7:28PM for Resident #1 when the resident was transferred to an acute care hospital with an admitting [DIAGNOSES REDACTED]. The Immediate Jeopardy was removed on 01/16/19 at 3:00PM when the facility submitted the following Plan of Removal which included: A. DON (Director of Nursing) was in-serviced by the Director of Clinical Operations on 01/15/19, nurse managers and staff nurses were in-serviced by DON on 01/15/19 regarding wound assessments, documentation of wounds, receipt of physician's orders [REDACTED]. Competency evaluated with post-test to be completed by 01/18/19. DON or designee will be responsible for ongoing monitoring through review of clinical record documentation during morning clinical meeting 5 days a week. (In-Service on 01/15/19 included: 1. A head to toe body evaluation will be completed on every resident upon admission or re-admission and weekly thereafter. The weekly evaluation will be documented on the Weekly Skin Check UDA in PCC. If skin is intact, no further action is required. If skin is compromised: Pressure injuries, venous ulcers and arterial ulcers, surgical wounds, and diabetic ulcers will be documented in the EMR. An RN assessment must be done and documented within 24 hours of wound identification in the EMR on the Weekly Wound Progress UDA in PCC. Wound progress must be documented every 7 days in EMR (UDA in PCC). Treatments are also documented in EMR on MAR/TAR. (Assess all residents for pain and act accordingly). MD is to be notified of skin issue and treatment orders obtained. RP is to be notified of skin issue and MD orders pertaining to skin issue. Documentation of notification should be in EMR. (Order for wound care consult is not appropriate treatment order .facility could monitor area until consult for example). All other skin issues will be documented in EMR. MD notified, treatment orders obtained and RP notified (all should be documented in EMR). Care plan will be updated for each resident skin issue with treatment orders/interventions. 2. CNA's will note any alteration in skin integrity during routine care using STOP N WATCH and reported to charge nurse responsible for the resident at that time for their attention. 3. Braden UDA will be completed upon admission, readmission, weekly X3weeks, with change in condition and then quarterly thereafter in EMR. Interventions will be noted on the resident care plan. 4. Refer to Protocol for Pressure Ulcers by AMT, and / or AMT binder, for assistance with wound identification, staging and recommended treatments. Contact physician for treatment recommendation approval. 5. Refer to Senior Care Centers Nutritional Support Protocol for Pressure Areas for recommendations. Notify RD. Contact MD for approval. 6. Follow Joerns bed algorithm should a specialty bed be needed. 7. DON responsible to establish a system to monitor and assure skin management system compliance. (Use system evaluation tools to audit/monitor). B. Training will be completed by 01/15/19, except for 4 licensed nurses who were unavailable for training on this date, they will not be allowed to return to work until training is complete. Expected date of completion for training 01/17/19. At the completion of training for these nurses competency will also be evaluated with post-test by 01/18/19 and DON or designee will be responsible for ongoing monitoring by thorough review of clinical record documentation during morning clinical meeting 5 days a week. C. Nursing administration will review 24-hour report, which includes resident changes of condition and new physician orders, during morning meeting 5 days a week. Any concerns identified during the morning clinical will be addressed immediately with responsible parties for correction. D. A full head to toe body audit for residents in house will be completed by AM of 01/16/19. These audits will be completed and documented by executive staff nurses (____LPN, ____RN,___LPN,____RN, ____LPN) and any new skin conditions will be documented in the clinical record, assessment done by RN if required, the physician notified, orders obtained, care plan updated, and resident representative notified. Weekly skin checks will be completed by executive nurses going forward and documented in the clinical record. CAN training on what to observe, look for and report in regards to resident skin will be completed quarterly. E. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. TO BE COMPLETED BY 01/16/19. The DON will complete skin system audit tool on a monthly basis and report findings to QAPI team along with any concerns identified in monitoring for this plan of removal monthly times 3 and then as directed by QAPI team. The deficient practice continued at more than minimal harm for 23 diabetic residents at high risk for impaired skin integrity. Findings: Record review of Resident #1 revealed the resident was admitted in (YEAR) and had [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status dated 10/31/18 revealed a score of 7, indicating severe cognitive impairment. Review of the care plan problems initiated in (MONTH) (YEAR) for Resident #1 revealed, in part, the following: 1- Diabetes Mellitus with complications of [MEDICAL CONDITION] and history of diabetic foot wounds with remote history of right great toe with interventions of: check all of body for breaks in skin and treat promptly as ordered by doctor and observe for peripheral neuropathies, decrease in pedal pulse, decreased sensation or coolness in lower extremities, and encourage resident to practice good general health practices, lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care, and, 2- Resident is at risk for pressure ulcer and interventions noted to: assess resident for risk weekly with skin audit, skin assessment upon admission and at a minimum weekly thereafter, and turn and reposition resident per facility protocol. Review of a nurses' note in Resident #1's record revealed documentation dated 12/31/18 at 1:46PM by S7LPN which noted, in part, wound to the bottom of resident's right foot on the ball of foot beneath pinky toe. Wound is un-stageable due to eschar. Wound is 0.5 by 0.5. Skin is sloughing around wound bed. Two pustules noted to top of resident's foot. Right foot is reddened and warm. Resident voices no complaint of pain or discomfort at this time. Notified FNP (Family Nurse Practitioner) and ordered to schedule appointment with wound care as soon as possible. Appointment scheduled for 01/02/19 at 11AM. Attempted to notify RP (responsible party) of new orders. Unable to reach at this time. Will continue to attempt. Further review of the nurses' notes revealed no other documentation of the wound to Resident #1's right foot until 01/02/19 at 2:45PM when S4LPN documented, in part, out of facility to appointment in stable condition. On 01/02/19 at 4:00PM, S4LPN documented Resident #1 returned to facility in stable condition and is scheduled for surgery on right foot for wound on 01/03/19. NPO (nothing by mouth) after midnight. RP notified. On 01/02/19 at 7:28PM, S4LPN noted new order to send resident to ER (emergency room ) for direct admit per Doctor ____. Family is with resident. Resident transported via stretcher by ambulance in stable condition. A telephone interview with the complainant (RP) on 01/11/19 at 3:45PM revealed the following: RP reported that the resident had not been able to walk for a long time. He reported that she did not like to get out of bed to the wheelchair. He stated that the resident required assistance with bathing and grooming. He further indicated that when he saw Resident #1 on 12/24/18 and on 12/25/18, she was fine. On 01/02/19, the RP received a call from S4LPN informing him the resident was going to be having surgery on the next morning. The RP said that he informed S3ADON/RN that he was on his way to the facility. Upon the RPs arrival to the facility, the RP found Resident #1 sitting in a wheelchair. The RP requested to see the wound on the resident's right foot. The RP said that when he saw the open wound on the resident's right foot, he immediately thought the resident's foot would have to be amputated. The RP said that he told S3ADON/RN that he wanted the resident to go to the ER. S3ADON/RN called the resident's physician and the resident was transferred to the ER around 6:30 to 6:45PM by ambulance. The RP reported that the resident was admitted to ICU that night, 01/02/19. As the telephone interview with RP continued, he indicated that on 01/03/19, the resident had surgery on 01/03/19 [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED] of the right foot. He reported that the surgeon removed an infected bone from the resident's foot. He further indicated that during the resident's hospitalization , the resident's WBC continued to climb and the resident's kidneys started to fail due [MEDICAL CONDITION]. On 01/05/19, the resident was intubated and on 01/06/2019, the resident passed away. On 01/14/19 at 3:35PM, an interview with S2DON reported that when the wound was found on Resident #1's foot that it looked bad. S2DON reported that it got worse before the resident was transferred out. When asked if she assessed Resident #1's foot, she reported that she had not actually seen the resident's foot. When asked if wound treatment was initiated after the wound was discovered, S2DON stated that she wasn't aware. On 01/15/19 at 11:00AM, an interview with S3ADON/RN (Assistant Director of Nursing) reported that she saw the open wound on Resident #1's right foot on 12/31/18. She stated that is was a significant wound. She stated that the resident got a bath on Monday, Wednesday, and Friday and possibly nobody looked at her foot from 12/28/18 until 12/31/18. S3ADON/RN reported that when she interviewed the CNAs that worked with Resident #1 on 12/27/18 and 12/28/18, both reported that they did not see an open area to the resident's right foot. S3ADON/RN stated that she told the nurse to inform the doctor, the family and the oncoming shift about the open wound to the resident's right foot When asked if she completed a wound assessment at the time of discovery, she confirmed that she did not. S3ADON/RN reported that she saw the resident's foot again on 01/02/19 and it was terrible. She stated there was drainage coming from the wound. When asked if the resident was high risk for wounds, she stated that all diabetics are high risk. When asked if she had completed an assessment of the wound on 01/02/19 when she saw it again and found that the wound had significantly deteriorated, she confirmed that she had not. She stated that the resident left the facility to go to the wound clinic on 01/02/19 and returned without seeing the doctor and a new appointment was scheduled for 01/10/19. She stated that she called the doctor and the resident was sent out again on the same day and saw the doctor on 01/02/19. On 01/15/19 at 11:15AM, an interview with S2DON reported that when Resident #1 was found to have a significant wound to the foot on 01/02/19 that they completed skin audits on all diabetics in the building at the time. On 01/15/19 at 11:35AM, S2DON provided a list that noted 2 residents had skin audits on 01/07/19, seven days after Resident #1 was found to have a significant wound to the right foot. Eleven residents had skin assessments on 01/09/19 and 01/10/19, nine and ten days later and nine residents were assessed on 01/15/19, 15 days later which was also the day a determination of Immediate Jeopardy was made in the facility. S2DON confirmed that there had been no staff in-services after the wound was discovered on 12/31/18 for Resident #1. S2DON confirmed that all residents should have skin assessments weekly. On 01/15/19 at 12:25PM, a telephone interview with Resident #1's PCP (primary care physician) revealed, in part, that he did not recall being notified that Resident #1 had been found to have an open wound to the right foot. PCP reviewed his electronic record and stated that the only documentation was that the resident had seen Dr _____ on 01/02/19. On 01/15/19 at 12:35PM, a telephone interview with nurse practitioner revealed, in part, that she was notified Resident #1 had a bad wound on her foot on 12/31/18. She stated that she told the nurse to make an appointment for the resident with the wound care doctor. When asked if she had given treatment orders, she stated if they didn't get an appointment right away, they will usually let me know so I can give them some treatment orders. On 01/16/19 at 10:42AM, a telephone interview with the wound care surgeon revealed, in part, that he examined Resident #1's foot on 01/02/19. He reported that the nursing home had canceled the appointment on 01/02/19 and re-schedule it for 01/10/19 because the resident didn't feel good and had some diarrhea. He reported that S3ADON/RN called him later that day and said it wouldn't wait until 01/10/19 and he told them to bring the resident to the clinic. He stated that the resident had [MEDICAL CONDITION] and infection in the foot and he felt like there was osteo[DIAGNOSES REDACTED] (infection of the bone) also. He reported a large area of black eschar (dead tissue) on the right foot and stated that he was able to palpate bone just under the eschar. The wound care surgeon was asked about his opinion of the wound and he stated that while a wound can progress quickly there had to have been something on the resident's foot for a long time, even if it was like a callus (thickened or hardened part of the skin) that maybe got knocked off. He added an open wound can sit stagnant for a long time until it got infected, which would make the wound progress. He reported that the resident had eaten lunch already when he saw her in clinic so he couldn't do surgery that day (01/02/19). He reported that he packed her foot wound with [MEDICATION NAME] gauze and scheduled her for surgery the next morning (01/03/19). He stated that it was difficult to admit a patient the night before surgery. He stated that he knew he was going to admit her after surgery so he sent her back to the nursing home to try to save her a hospital day. He stated that when the resident arrived at the emergency room later that evening, he realized how sick she was when he reviewed her lab results. Review of the hospital record for Resident #1 dated 01/02/19 at 7:38PM revealed an admitting [DIAGNOSES REDACTED]. Review of the History and Physical completed by the doctor revealed the following under the heading, Assessment: 1. Right foot wound with possible osteo[DIAGNOSES REDACTED] 2. Bilateral pneumonia 3.[MEDICAL CONDITION]. Review of the POS [REDACTED]. Review of the hospital death summary dated 01/06/19 revealed eight [DIAGNOSES REDACTED]. Septic shock secondary to infected gangrene of the right lower extremity. 2. Staphylococcus aureus bacteremia (bacterial infection in the bloodstream). On 01/16/19 at 2:00PM, an interview with S2DON confirmed that the facility had a breakdown with communication. S2DON reported that all wounds and skin breakdown should have a wound assessment within 24 hours of discovery. Resident #2 Record review revealed Resident #2 was admitted in 04/2017 with [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status dated 12/06/18 revealed a score of 99, which indicates unable to assess. Resident #2 required extensive to total assistance with activities of daily living and mobility. Total dependence on staff for personal hygiene and the resident was incontinent of bowel and bladder. On 01/14/19 at 12:20PM, a full body skin audit was completed with S9LPN and S8CNA, Resident #2's CNA. During the skin inspection, an area of moist, pink, macerated, and peeling skin about 4 inches by 2 inches was observed under Resident #2's left breast. S9LPN documented the smell of yeast was present. An interview with S8CNA at the time confirmed that she had observed the area of reddened, peeling skin this morning while she was providing AM (morning) care for the resident. S8CNA stated that the area of skin breakdown had been there 'a few days to a week'. Surveyor clarified with S8CNA that the area of skin breakdown had been there today during AM care. Surveyor asked if the area was there the day before on 01/13/19 and S8CNA confirmed that it was. S8CNA stated that she wasn't sure about 01/12/19 because she was off. When asked if she had reported the area of skin breakdown that she had first noticed yesterday on 01/13/19, S8CNA reported that she had not told anybody. On 01/14/19 at 1:00PM, S2DON was informed that S8CNA reported that she had known about an area of skin breakdown for two days on Resident #2 and had not informed anyone.