Every finding on record at Anberry Post Acute

Number of residents sampled: 6Number of residents cited: 2Based on observation, interview, and record review, the facility failed to provide needed care and services in accordance with professional standards of practice for two of six sampled residents (Resident 25 and Resident 74) when Resident 25 and Resident 74's fingernails and toenails were thick, long and had jagged edges.These failures placed Resident 25 and Resident 74 to experience discomfort and pain when wearing footwear and risk of skin breakdown which could lead to skin infection. During a concurrent observation and interview of 6/16/26 at 11:24 a.m. during initial tour in Resident 74's room, Resident 74 was observed sitting up in his wheelchair at bedside. Resident 74 observed fingernails and toenails thick, long with jagged edges. Resident 74 stated he did not remember the last time his nails were cut. Resident 74 stated he wanted his toenails cut because he could not wear his shoes or socks because his nails got caught in the socks. Resident 74 stated he wanted his fingernails cut because they were too long and could also scratch himself. During a concurrent observation and interview on 6/19/26 at 10:15 a.m. with Resident 25 and Administrator (ADM) in the hallway, Resident 25 was observed sitting up in her wheelchair and propelling self in hallway. Resident 25 was wearing open-toed footwear and her toenails were observed to be thick and long. Resident 24 stated she had not had her toenails trimmed for a while. The ADM stated, The podiatrist was in the facility a month ago. Resident 25 stated she had not seen the podiatrist for a while and was difficult to wear her new shoes because her toenails are too long. The ADM stated he will follow up with the podiatrist.During an interview on 6/17/26 at 3:09 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated nail care is provided on resident's shower days which was twice a week. CNA 3 stated CNAs only cut or trim nails of non-diabetic residents, licensed nurses trim or cut nails of diabetic residents. CNA 3 stated she usually let the nurse know if a diabetic resident needs their nails trimmed. During an interview on 6/17/26 at 4:16 p.m. with CNA 1, CNA 1 stated nail care is provided on resident shower days. CNA1 stated CNAs are only allowed to trim or cute non-diabetic residents and not allowed to trim toenails. CNA 1 stated she usually let the charge nurse know when residents needed their toenails trimmed. CNA 1 stated she did not remember seeing a podiatrist (foot doctor) providing services to residents in the facility.During a concurrent observation and interview on 6/18/26 at 1:55 p.m. with Licensed Vocational Nurse (LVN) 1 and Resident 74, observed Resident 74 sitting in his room at bedside. LVN 1 checked Resident 74's fingernails and toenails. LVN 1 stated, His nails are long and needed to be trimmed. LVN 1 asked Resident 74 if he preferred his nails long and Resident 74 stated, No, I want my nails trimmed. Resident 74 stated he could not wear his shoes and socks because of his long toenails. LVN 1 stated nursing staff are responsible in trimming and cutting residents' nails. LVN 1 stated the podiatrist takes care of resident's toenails. LVN 1 stated she did not remember the last time she saw the podiatrist come in the facility and when Resident 74 was last seen by podiatrist. During an interview on 6/19/26 at 10:30 a.m. with Social Services Director (SSD), the SSD stated there was a new podiatrist providing services at the facility and the last time podiatrist was in the facility was 5/2/26. The SSD stated the podiatrist only saw 10 residents and Resident 25 and Resident 74 were not seen. The SSD stated the podiatrist will be going to the facility once a month on Saturdays. The SSD stated the licensed nurses usually give her a resident list of resident that need to be seen. During an interview on 6/19/26 at 11:21 a.m. with the Director of Staff Development (DSD), the DSD stated nail care is provided to residents on shower days and as needed. The DSD stated CNAs are not allowed to trim toenails. The DSD stated CNAs are expected to let the charge nurse know when a resident needs to be seen by a podiatrist and the nurse would then let the SSD know. During an interview on 6/19/26 at 1:55 p.m. with the Director of Nursing Services (DNS), the DNS stated her expectation was for CNAs to provide nail care to residents who are not diabetic on their shower days and licensed nurse to provide nail care to diabetic residents. The DNS stated, The podiatrist comes in once a month to take care residents toenails.' The DNS stated they send residents out to the local podiatrist if unable to wait for the next podiatry visit. During an interview on 6/19/26 at 2:30 p.m. with the ADM, the ADM stated he knew the podiatrist was in the facility in May. The ADM stated he did not know Resident 25 and Resident 74 were not seen. The ADM stated he talked to the podiatrist and agreed to increase the number of residents seen every month. The ADM stated, The podiatrist is local and we could send residents in his clinic for any emergencies.During a review of facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, revised date 2/18, the 'P&P indicated, .1. Nail care includes daily cleaning and regular trimming. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 6. Stop and report to the nurse supervisor if there is evidence of ingrown toenails, infections, pain, or if nails are too hard or too thick to cut with ease.

Based on observation, interview and record review, the facility failed to ensure pharmaceutical services were being met according to facility's policy and procedures when:1. Emergency medication kit was opened on 4/13/26 and had not been replaced by the pharmacy for over two months. This failure resulted in medication not being available in the e-kit (emergency medication container) and had the potential not to meet the needs of the residents during emergencies.2. Resident 75's medication brought by the family was not verified by the facility's licensed pharmacist. Resident 75's medication bottle of Lamotrigine (an antiepileptic medication uses to treat epilepsy [a seizure -a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness]) 200 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) was stored in the medication cart and was available for use.This failure had the potential for medication error and had the potential to result in the administration of unverified medications, placing Resident 75 at risk of receiving unnecessary or inappropriate treatment. Findings:1. During a concurrent observation and interview on 6/18/26 at 10:17 a.m. with the Director of Staff Development (DSD), in medication room [ROOM NUMBER], the refrigerator e-kit was checked. The refrigerator e-kit had a red lock and white slip inside the container. The refrigerator e-kit indicated, .Brand Name (insulin lispro-a fast-acting type of insulin [one of many hormones that helps the body turn the food we eat into energy] one vial QTY (Quantity) 1. The e-kit slip indicated, .Name of Drug: insulin lispro injection Date: 4/13/26 E-kit Opened. The DSD stated the refrigerator e-kit had a red lock which indicated that the e-kit was open. The DSD stated the e-kit slip was opened on 4/13/26. The DSD stated licensed nurses will fax to the pharmacy the completed e-kit slip for replacement. The DSD stated an opened e-kit should be replaced by the pharmacy the following day or within 72 hours. The DSD stated it was more than two months and had not been replaced. The DSD stated she would notify the pharmacy.During an interview on 6/18/26 at 1:26 p.m. with the Director of Nursing (DON), the DON stated it was her expectation for the pharmacy to replace opened e-kit with 48 hours. The DON stated licensed nurses were checking the medication room including the medication fridge daily and stated, it was missed. The DON stated maintaining complete e-kits was important to ensure medications were available during emergencies.During a review of facility's P&P titled, Emergency Pharmacy Service and Emergency Kits, the P&P indicated, Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special orders from the provider pharmacy. An emergency supply of medications, including emergency drugs, antibiotics, controlled substances and products for infusion is supplied by the provider pharmacy in limited quantities in portable, sealed containers, in compliance with applicable state regulations. G. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the kit by transmitting the entire order for the resident and indicating that the first dose was used from the kit. The nurse flags the kit with a red color-coded lock to indicate need for replacement of kit. K. If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening. If replacing used medications, the replacement doses are added to the kit within 72 hours of opening. 2.During a medication storage observation on 6/18/26 at 2:46 p.m. in the hallway of nursing station 200, medication cart 200 was checked. Resident 75's medication bottle indicated, Lamotrigine 200 mg Take 3 tablets by mouth daily.QTY (Quantity):90.During a concurrent interview and record review on 6/18/26 at 3:02 p.m. with Licensed Vocational Nurse (LVN) 6, Resident 75's medication bottle of Lamotrigine 200 mg was checked. LVN 6 stated Resident 75's medication bottle of Lamotrigine 200 mg was from outside pharmacy and was brought in by the family. LVN 6 stated she cannot validate if Resident 75's medication bottle of Lamotrigine 200 mg was verified by the facility's licensed pharmacist. LVN 6 stated licensed nurses should document Resident 75's progress notes when medications are brought in by the family. LVN 6 stated it is important for licensed nurses to ensure the medications are verified by licensed pharmacist before administering. LVN 6 stated medications brought by the family should be verified before administration to ensure the medication bottle contained the right medication as written on the medication label. LVN 6 stated Resident 75 has an active order of Lamotrigine 200 mg.During a concurrent interview and record review on 6/19/2026 1:30 p.m. with LVN 8, Resident 75's medication bottle of Lamotrigine 200 mg was checked and counted. Resident 75's medication bottle indicated, Lamotrigine 200 mg Take 3 tablets by mouth daily.QTY (Quantity):90. LVN 8 stated Resident 75's medication bottle of Lamotrigine 200 mg contained 27 tablets. LVN 8 stated Resident 75's medication bottle of Lamotrigine 200 mg was not from the facility's pharmacy. LVN 8 stated that medications brought by family should not be used and should be returned to the family. During an interview on 6/19/26 at 2:10 p.m. with the DON, the DON stated it was her expectation for all licensed nurses to follow the P&P for medications brought to the facility by the resident or family to prevent medication errors. The DON stated the facility discouraged the use of medications brought by the family unless the medications were verified by the facility's licensed pharmacist. The DON stated medications brought by the family or resident should be verified by the facility's licensed pharmacist prior to administration to ensure the right medication was being administered to the resident. The DON stated medications brought by the family should be kept in the medication room and should not be stored in the medication cart. The DON stated medications stored in medication carts are available for use.During a review of Resident 75's Order Summary Report dated 6/19/26, indicated, . [Brand Name] 200 mg (Lamotrigine) Give 1 tablet by mouth three times a day for Seizure Disorder (abnormal electrical activity in the brain).During a review of Resident 75's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/19/26, the AR indicated Resident 75 was admitted to the facility on [DATE] with diagnosis of epilepsy.During a review of Resident 75's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/9/26, the MDS section C indicated Resident 75 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 7 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 75's cognition was severely impaired.During a review of facility's P&P titled, Medications Brought to the Facility by the Resident/Family. The facility shall ordinarily not permit residents and families to bring medications into the facility. 1. Residents and families must report to the nursing staff any medications that they want to bring or have brought into the facility. 3. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, heath, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the attending Physician and Consultant and Pharmacist, shall check to ensure that: a. State law and regulations allow such use; .d. The contents of each container have been verified by a licensed pharmacist. 5. Medications brought into the facility that are not approved for the resident's use shall be returned to the family. If the family does not pick up those medications within thirty (30) days, the facility may destroy the in accordance with established policies.

Based on observation, interview, and record review, the facility failed to ensure medications used were labeled and stored in accordance with professional standards when:1. A [Brand name] topical gel ointment (a topical gel ointment for external use only to relieve joint pain, stiffness and swelling 1.7 oz [ounce - unit of measurement]) with no medication label and no opened date was stored with other liquid and oral medication in front medication cart 300.This failure had the potential for cross contamination (a transfer of harmful bacteria from one object to another) and improper storage of medication.2. Resident 122's [Brand name] Ophthalmic Solution (an eye drops to lubricate, soothe dry burning or irritated eyes) had no open date and no used by date.This failure had the potential for Resident 122 to be administered expired medications had the potential to experience a negative outcome including decreased effectiveness of medication.3. Resident 19's [Brand name] (a nasal spray to treat both seasonal and year-round allergy symptoms) was labeled only with a resident's room number.This failure had the potential for Resident 19 to be administered expired medications had the potential to experience a negative outcome including decreased effectiveness of medication.4. Resident 75's medication of Ondansetron Hydrochloride (a medication used to prevent nausea [a queasy or unsettled feeling in the stomach that creates an urge to vomit) and vomiting) 4 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) had an expiration date of 6/9/26 and was available for use.This failure resulted in medication errors when Resident 75 received an expired medication on 6/18/26 and had the potential to experience a negative outcome including decreased effectiveness of medication. Findings: 1. During a concurrent observation and interview on 6/18/26 at 11:10 a.m. with the Registered Nurse (RN) in Station 300, the front medication cart 300 was checked for medication storage and labeling with the RN. On the bottom shelf of the medication cart a [Brand name] topical gel ointment with no medication label and no open date was found stored together with other oral and liquid medications. The RN stated, the [Brand name] topical gel ointment is over-the-counter medication (a medication that can be bought directly from a pharmacy or store without a doctor's prescription) but should still be labeled with an open date and used-by date. The RN stated topical gel ointment should be stored separately from oral and liquid medication to prevent cross-contamination. During an interview on 6/18/26 at 1:40 p.m. with the DON, the DON stated [Brand name] topical gel ointment was an over-the-counter medication but should have been properly labeled with date opened and used-by date to monitor the medication's effectiveness. The DON stated all licensed nurses were expected to label over-the-counter medications with the date opened and the use-by date. The DON stated oral and topical medications, or external medications must be stored separately to prevent cross-contamination and for proper medication storage. During a review of the facility's policy and procedures (P&P) titles, Medication Storage in the Facility, dated March 2018, the P&P indicated, . Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. 2. During a concurrent observation and interview on 6/18/26 at 11:25 a.m. with the RN in Station 300, the front medication cart 300 was checked for medication storage and labeling with the RN. Resident 122's [Brand name] Ophthalmic Solution had no open date and used by date. The RN stated medication should have been labeled with both the date it was opened and the use-by date. The RN stated dates were important to determine when the medication was first started and when it should be discarded. The RN stated the licensed nurses should always check the date open and the use-by date to avoid medication errors and administering medications past their use-by date. During a review of Resident 122's Order Entry (OE) dated 6/18/26, the OE indicated, [Brand name] Tears Ophthalmic Solution.in both eyes.1 drop.three times a day.dry eyes. During an interview on 6/18/26 at 1:50 p.m. with the DON, the DON stated the expectation for the licensed nurses was to ensure that eye drops were properly labeled with the date opened and the use-by date. The DON stated it was important to check the open date and use-by date to ensure the eye drop was safe and effective to use. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, . The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions. 3. During a concurrent observation and interview 6/18/26 at 2:43 p.m. with Licensed Vocational Nurse (LVN) 6 in Station 200, the back medication cart 200 was checked for medication storage and labeling with LVN 6. Resident 19's [Brand name] was labeled only with resident's room number. LVN 6 stated [Brand name] should have been properly labeled with the resident's name, room number, date opened and used by date. LVN 6 stated it was important to properly label medications to avoid medication errors and cross-contamination. During a review of Resident 19's Order Summary Report (OSR) dated 6/18/26, the OSR indicated, . [Brand name] Allergy Relief Nasal Suspension.1 spray in both nostrils one time a day for nasal congestion one spray in each nostril. During an interview on 6/18/26 at 3:15 p.m. with the DON, the DON stated all licensed nurses should have used patient identifiers (a specific pieces of medication healthcare providers use to verify the resident's identity such as full name and date of birth ) and checked whether medications were properly labeled with resident's name, room number, date opened and used by date during medication administration. The DON stated the failure to label medications correctly could contribute to medication errors and cross-contamination. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, . The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions. 4.During a medication storage observation on 6/18/26 at 2:25 p.m. in the hallway of nursing station 200, medication cart 200 was checked. Resident 75's medication card indicated, Ondansetron HCL (Hydrochloride) 4 mg tablet Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting.QTY (Quantity):16 .12/9/25. EXP (Expiration): 6/9/26. During a concurrent interview and record review on 6/18/26 at 2:55 p.m. with LVN 6, Resident 75's medication card for Ondansetron HCL 4 mg was reviewed. The medication card indicated, Ondansetron HCL 4 mg tablet Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting.QTY (Quantity):16 .EXP (Expiration): 6/9/26. LVN 6 stated Resident 75's medication Ondansetron had expired on 6/9/26. LVN 6 stated she administered the expired medication to Resident 75 today (6/18/26). LVN 6 stated she did not check the expiration date prior to administering the medication to Resident 75. LVN 6 stated she should check the expiration date before administering the medication. LVN 6 stated expired medication should be removed from the medication cart for destruction. LVN 6 stated expired medication may not be as effective. During a concurrent interview and record review on 6/19/26 at 9:35 a.m. with the Minimum Data Set Nurse (MDSN), Resident 75's Electronic Medication Administration Record (EMAR, a daily electronic documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2026 was reviewed. The EMAR indicated, Ondansetron HCL 4 mg tablet Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting Ordered Date: 12/9/25. initialed GM 0830. The MDSN stated the medication Ondansetron HCL 4 mg was administered by LVN 6 on 6/18/26 at 8:30 a.m. During a concurrent interview and record review on 6/19/26 at 9:38 a.m. with the MDSN, Resident 75's care plan dated 1/15/26, indicated Resident 75 is at risk for nausea and vomiting related to medication side effects. During a review of Resident 75's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/19/26, the AR indicated Resident 75 was admitted to the facility on [DATE] with diagnosis of encounter for surgical aftercare following surgery on the circulatory system, hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (the blood supply to part of the brain is blocked or reduced), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), essential (primary) hypertension (abnormally high blood pressure [the amount of force the heart uses to pump blood through the arteries] that is not the result of a medical condition), and nausea and vomiting. During an interview on 6/19/26 at 11:15 a.m. with the DON, the DON stated it was her expectation for all licensed nurses to follow the facility's policy and procedures (P&P) for Medication Labeling and Storage and Medication Administration to ensure no expired medications were stored in the medication cart and medication room to prevent medication errors such as administration of expired medication. The DON stated licensed nurses should check expiration dates of medication before administering the medication to prevent medication errors. The DON stated expired medication has less effectiveness. During a review of facility's P&P titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated, . Medication Storage. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During a review of facility's P&P titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed. 12. The expiration/beyond use date on the medication label is checked prior to administering.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for three of seven sampled residents (Residents 21, 97, and 8) when:1. Licensed Vocational Nurse (LVN) 5 did not wear appropriate personal protective equipment (PPE- specialized clothing, equipment, and supplies worn by healthcare workers to protect residents and themselves from potential infectious hazards) when LVN 5 accessed Resident 21's gastrostomy tube (GT, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) on 6/16/26. Resident 21 was on enhanced barrier precaution (EBP- measures used in healthcare settings to prevent the spread of infections) due to presence of GT. 2. Certified Nursing Assistant (CNA) 5 did not wear appropriate PPE when CNA 5 provided direct care to Resident 97 who was on EBP on 6/18/26. 3. CNA 5 and CNA6 left two used PPE (gowns) at the foot of Resident 8's bed after transferring Resident 8 from bed to the wheelchair on 6/16/26. Resident 8 was on EBP due to presence of surgical wound.These failures had the potential to cause cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) to other residents and staff potentially causing health complications, and facility outbreak of infection (a sudden increase or clustering of disease cases beyond what's normally expected in a specific time, place, or population, often involving common exposure).Findings: 1. During a concurrent observation and interview on 6/16/26 at 10:09 a.m. with Resident 21, in Resident 21's room, Resident 21 was self-propelling her wheelchair from the bathroom to her bed. Resident 21 was pleasant, clean, and well groomed. Resident 21 was alert and oriented to person, time, place and situation or event. Resident 21 stated her stomach was growling and was showing her GT. During a concurrent observation and interview on 6/16/26 at 10:09 a.m. with Resident 21, in Resident 21's room, Resident 21 was lying in her bed, awake. Resident 21 stated she was still waiting for the nurse to give her formula feeding in her tube. Resident 21 stated she cannot have oral food and only gets her food through her GT. During an observation on 6/16/26 at 10:37 a.m. with LVN 5, outside Resident 21's room, LVN 5 was preparing the GT formula on top of the medication cart. LVN 5 went inside Resident 21's room with the GT formula, and the privacy curtains were pulled around the bed. LVN 5 did not wear PPE.During a concurrent observation and interview on 6/16/26 at 10:50 a.m. with LVN 5, in Resident 21's room, LVN 5 came out of the room and opened the computer on top of the medication cart. LVN 5 stated she administered Resident 21's enteral feeding and did not wear a PPE. LVN 5 stated she should wear a PPE including a gown when she accessed Resident 21's GT to protect her from infection. LVN 5 stated Resident 21's name had a yellow triangle sign beside her name which indicated Resident 21 was on EBP.During a concurrent interview and record review on 6/17/26 at 11:35 a.m. with the Unit Nurse Manager (UNM), Resident 21's care plan for EBP dated 5/15/26 was reviewed. The care plan for EBP indicated, Patient meets criteria for enhanced barrier precautions. Goal. Patient will allow enhanced barrier precautions for duration of meeting criteria and will have no [NAME] avoidable complications related to infection. Interventions. Gloves and Gowns worn in extended high contact resident care activities. The UNM stated Resident 21 had a stoma opening (surgically created opening on the abdomen) related to the GT. The UNM stated licensed nurses should wear gowns and gloves when accessing GT to prevent the spread and transmission of an infection. The UNM Resident 21's care plan for EBP should be followed and implemented by staff.During an interview on 6/18/26 at 10:03 a.m. with the Infection Preventionist (IP), IP stated it was her expectation for all staff to follow the facility's policy and procedures (P&P) for EBP to prevent cross contamination and spread of infection. The IP stated it was her expectation for licensed nurses and CNAs to wear appropriate PPE during high contact activities such as brief change, linens change, and accessing the GT, and wound care to protect residents and staff from acquiring and transmitting bacteria. The IP stated the use of PPE was important to prevent cross contamination. During an interview on 6/19/2026 at 11:01 a.m. with the Director of Nursing (DON), the DON stated it was her expectation for all staff to follow and implement the facility's P&P for EBP to prevent cross contamination and prevent the spread of an infection. The DON stated licensed nurses should wear appropriate PPE such as gowns and gloves when accessing the GT to protect residents from acquiring an infection and prevent the staff from transmitting an infection.During a review of Resident 21's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/19/26, the AR indicated Resident 21 was admitted to the facility on [DATE] with diagnosis encounter for surgical aftercare following surgery of digestive system, and gastrostomy status (refers to the presence of a surgically created artificial opening in the stomach).During a review of facility's P&P titled, Enhanced Barrier Precaution, dated 8/2022, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 3. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, 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 a dressing.During a review of the professional reference (PR), found on https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html an article titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, the PR indicated, . [Multi Drug Resistant organisms] (MDROs - germs which have become resistant to medications) may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds . are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs).Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, 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 a dressing. 2.During a concurrent observation and interview on 6/18/26 at 8:50 a.m. with Resident 97 and CNA 5, in Resident 97's room, Resident 97 was lying on one side bed, awake, alert and oriented to person, places, and situation. Resident 97 stated she had a bowel movement and was looking for CNA 5. CNA 5 stated she will get her supplies and she will change Resident 97's brief and linen.During a concurrent observation and interview on 6/18/26 at 8:55 a.m. with CNA 5, outside of Resident 97's room, CNA 5 was holding linens, a gown and went inside Resident 97's room without wearing appropriate PPE. During a concurrent observation and interview on 6/18/26 at 9:02 a.m. with CNA 5, in Resident 97's room, CNA 5 was walking out of the room holding a clear plastic bag. CNA 5 stated the clean plastic bag containing Resident 97's soiled and dirty brief. CNA 5 stated she provided brief change and linen change for Resident 97. CNA 5 stated Resident 97 had a bowel movement. CNA 5 stated she did not notice the yellow triangle sign at the door which indicated Resident 97 was on EBP. CNA 5 stated she should have checked prior to entering her room. CNA 5 stated she should have worn a gown when she provided brief and linen change to Resident 97 to prevent cross contamination and spread of infection.During an interview on 6/18/26 at 10:03 a.m. with the IP, the IP stated it was her expectation for all staff to follow the facility's policy and procedures (P&P) for EBP to prevent cross contamination and spread of infection. The IP stated it was her expectation for licensed nurses and CNAs to wear appropriate PPE during high contact activities such as brief changes, linen changes, accessing GT, and wound care to protect residents and staff for acquiring and transmitting the bacteria. The IP stated the use of PPE was important to prevent cross contamination. During an interview on 6/19/2026 at 11:01 a.m. with the DON, the DON stated it was her expectation for all staff to follow and implement the facility's P&P for EBP to prevent cross contamination and prevent the spread of an infection. The DON stated CNAs should wear appropriate PPE such as gowns and gloves when providing brief changes and linen changes to protect residents and staff from acquiring and transmitting an infection.During a review of Resident 97's AR dated 6/12/26, the AR indicated Resident 97 had an admitting diagnosis of encounter for orthopedic aftercare following surgical amputation and acquired absence of left leg above the knee .During a review of Resident 97's care plan for EBP dated 6/13/26, indicated, . is on Enhanced Barrier Precaution related to left AKA (Above the Knee Amputation - A surgical procedure where the leg is removed above the knee joint) Goal Resident will remain free from new or secondary infections.During a review of facility's P&P titled, Enhanced Barrier Precaution, dated 8/2022, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 3. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, 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 a dressing.During a review of the professional reference (PR), found on https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html an article titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, the PR indicated, . [Multi Drug Resistant organisms] (MDROs - germs which have become resistant to medications) may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds . are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs).Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, 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 a dressing. 3. During an observation on 6/16/26 at 9:43 a.m. with Resident 8, in Resident 8's room, two crumpled pale-yellow gowns were lying at the foot part of Resident 8's bed. Resident 8 was not in the room. During a concurrent observation and interview on 6/16/26 at 10:01 a.m. with CNA 6, in Resident 8's room, CNA 6 was pointing her finger on two crumpled pale-yellow gowns lying at the foot part of Resident 8's bed. CNA 6 stated CNA 5 and her used those two gowns when care was provided to Resident 8 today (6/16/26). CNA 6 stated the two used gowns should not be left at Resident 8's bed. CNA 6 stated the two used gowns should be bagged using a clear transparent bag and disposed in soiled linen room to prevent infection.During a concurrent observation and interview on 6/16/26 at 10:06 a.m. with CNA 5, in Resident 8's room, CNA 5 was pointing her finger on two crumpled pale-yellow gowns lying at the foot part of Resident 8's bed. CNA 5 stated CNA 6 assisted her in transferring Resident 8 from bed to wheelchair this morning (6/16/26). CNA 5 stated used gowns should not be left at the resident's bed and should be placed in clear plastic bag and disposed in soiled linen room to prevent infection. During a concurrent observation and interview on 6/17/26 at 9:42 a.m. with Resident 8, in Resident 8's room, Resident 8 was lying in bed, alert and orientated to names, time, places, and situation, pleasant, clean, and well groomed. Resident 8 stated he had spinal surgery and came to the facility for therapy. Resident 8 stated he needed help getting out of bed with the use of a sit to stand machine. Resident 8 stated two CNAs transferred him from bed to wheelchair with the use of machine yesterday morning (6/16/26).During a concurrent interview and record review on 6/18/26 at 10:03 a.m. with the IP, the facility's in-service (a professional development or training program provided to employees while they are actively employed) for Enhanced Barrier Precautions dated 5/12/26 and 6/12/26 were reviewed. The Inservice indicated, . Dispose of PPE appropriately after use. The IP stated it was her expectation for all CNAs to follow proper disposal of PPE after use. The IP stated CNAs should not leave the used PPE on resident's bed. The IP stated the used PPE was dirty and contaminated (soiled, stained, or infected by contact) and should be bagged using a clear plastic bag and disposed of in the soiled linen immediately to prevent the spread of infection.During an interview on 6/19/2026 at 11:01 a.m. with the DON, the DON stated it was her expectation for all staff to follow and implement the facility's P&P for EBP to prevent cross contamination and the risk of spreading an infection. The DON stated CNAs should not leave used PPE on resident's bed. The DON stated the used PPE were dirty and contaminated and should be disposed immediately after use to prevent cross contamination and spread of infection. During a review of Resident 8's AR, dated 6/19/26, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnosis of Fusion of Spine.During a review of Resident 8's Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15) dated 6/15/26. Resident 8 had a BIMS score of 15 (a score of 13-15 cognitively intact, 8-12 moderately impaired, 0-7 severe impairment), which indicated Resident 8 was cognitively intact.During a review of Resident 8's care plan for EBP with revision date of 6/8/26, indicated, Patient meets criteria for enhanced barrier precautions Goal Patient will allow enhanced barrier precautions for duration of meeting criteria and will have no [NAME] avoidable complications related to infection.During a review of facility's P&P titled, Enhanced Barrier Precaution, dated 8/2022, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 3. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, 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 a dressing.During a review of the professional reference (PR), found on https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html an article titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, the PR indicated, . [Multi Drug Resistant organisms] (MDROs - germs which have become resistant to medications) may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds . are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs).Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, 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 a dressing.

Based on interview and record review, the facility failed to educate and offer Covid-19 vaccinations for three of three sampled employees (Certified Nurse Assistant [CNA] 5, CNA 7, and Licensed Vocational Nurse [LVN] 5) when CNA 5, 7, and LVN 5's employee files were reviewed and did not contain documentation that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccinations or if they were offered the COVID-19 vaccination.This failure had the potential to increase the risk to vulnerable nursing home residents by potentially exposing them to outbreaks and raising the likelihood of severe illness or death.During an interview on 6/19/26 at 9:50 a.m. with the Infection Preventionist (IP), the IP stated the facility did not offer Covid 19 vaccinations for staff because it was no longer mandated for staff to be vaccinated.During a concurrent interview and record review on 6/19/26 at 11:11 a.m. with the Director of Staff Development (DSD), three employee files (CNA 5, CNA 7, and LVN 5) were reviewed. The employee files reviewed did not contain documentation that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccination or if the COVID-19 vaccination was offered. DSD stated she confirmed with the Administrator (ADM) and stated the facility had not offered the Covid-19 vaccination to staff since 2023 because Covid-19 vaccinations were no longer required.During an interview on 6/19/26 at 2:16 p.m. with CNA 8, CNA 8 stated she had worked at the facility for seven years and could not remember the last time she received information or was offered a COVID-19 vaccination at the facility. CNA 8 stated Covid -19 had not been brought up at the facility in recent years. During a concurrent interview and record review on 6/19/26 at 1:27 p.m. with the Director of Nursing Services (DNS), the policy and procedure (P&P) titled, Coronavirus Disease (COVID-19)-Vaccination of Staff, dated May 2024 was reviewed. The DNS stated COVID- 19 education and vaccination was offered to staff at orientation upon hire and stated facility did not continue to offer the vaccine or provide continuing ongoing education regarding COVID-19 to staff after the initial orientation period. The DNS reviewed the P&P and stated the facility's P&P was not being followed. The DNS stated it was important to provide Covid-19 information and vaccinations to staff so that staff could be informed of the option to get the vaccine and for the protection of residents and other staff members.During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19)-Vaccination of Staff, dated May 2024, the P&P indicated, Staff are educated about benefits, risks, and potential side effects of the COVID-19 vaccine. Staff are required to adhere to state and local laws and facility practices pertaining to staff COVID-19 vaccination.Staff are offered vaccination against COVID-19.The facility maintains documentation related to staff COVID-19 vaccination that includes, at a minimum.That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine.Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine.

Number of residents sampled: 5Number of residents cited: 2Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality for two of five sampled residents (Resident 9 and Resident 25) when Licensed Vocational Nurse (LVN) 1 and LVN 3 did not follow physician order to administer Apixaban (medication used to prevent and treat blood clots) medication with food to Resident 9 and Resident 25 during medication pass on 6/18/26.These failures to follow proper medication administration had the potential to result in reduced effectiveness of treatment or harm to Resident 9 and Resident 25.During a concurrent observation and interview on 6/18/26 at 7:53 a.m. with LVN 1 outside of Resident 25's room, LVN 1 observed preparing Resident 25's medications including Apixaban. LVN 1 entered Resident 25's room and administered medications without food. Resident 12 was lying in bed watching TV and breakfast tray was on top of the over the bed table untouched. Resident 25 took her medications without food.During a review of Resident 12's AR dated 6/18/26, the AR indicated Resident 25 was admitted to the facility on [DATE] with diagnoses which included surgical after care following surgery on the digestive system, fracture (broken) of left femur (thigh bone) and muscle weakness.Review of Resident 25's Order Summary Report, dated 6/18/26 indicated, .Apixaban Oral Tablet five [5] milligram [MG-unit of measurement] (Apixaban) Give one [1] tablet by mouth two times a day.take with food. Order Date: 11/26/25. Start Date: 11/27/26.During an interview on 6/18/26 at 3:35 p.m. with LVN 2 and LVN 4 in the nursing station 300, LVN 2 and LVN 4 stated during medication administration, the practice was to compare medication order with the medication bubble pack direction to ensure direction was followed. LVN 2 and LVN 4 stated medication with instructions to administer with food had to be followed because it could lead to an upset stomach and affects medication absorption in the stomach.During a concurrent interview and record review on 6/18/26 at 4:04 p.m. with LVN 1, LVN 1 reviewed Resident 25's clinical record titled, Order Summary Report, dated 6/18/26 and stated Resident 25's apixaban order was to administer with food. LVN 1 stated she did not administer Resident 25's apixaban medication with food and she should have. LVN 1 stated she did not follow the physician order to administer medication with food which could cause an upset stomach, diarrhea, or constipation.During a concurrent observation and interview on 6/18/26 at 4:26 p.m. with LVN 3, LVN 3 prepared Resident 9's medications including apixaban. LVN 3 administered Resident 9's medications through Resident 9's gastrostomy tube (G- tube, soft, flexible tube placed directly into the stomach through a small, permanent opening in the belly). LVN 3 flushed Resident 9's G-tube with water and did not connect the feeding formula.During a concurrent interview and record review on 6/18/26 at 4:45 p.m. with LVN 3, LVN 3 reviewed Resident 9's EMAR dated 6/1/26-6/30/26 for apixaban medication order and stated the medication indicated to administer medication with food. LVN 3 stated she administered Resident 9's apixaban without food and she should have. LVN 3 stated she did not compare the medication directions from the bubble pack (blister pack-specialized packaging method that organizes patient medications by day). LVN 3 stated administering medication without food could cause an upset stomach and irritation of the stomach linings. During an interview on 6/19/26 at 1:40pm. with the Director of Nursing Services (DNS), the DNS stated licensed nurses were expected to follow medication administration rights (medication administration steps healthcare professionals follow to ensure patient safety when giving medication), to check the medication label, MAR and physician orders prior to administering medications.During a review of facility's policy and procedure (P&P) titled, Administering Medications, revised date 4/19, the P&P indicated, .Medications are administered in accordance with prescriber orders. The individual administering medication checks the label THREE [3] times to verify the right of the resident, right medication, right dosage, right time and right method [route] of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure necessary respiratory care consistent with professional standards of practice was provided for one of seven sampled residents (Resident 92) when there was no physician's order for Resident 92's use of continuous positive airway pressure (CPAP -a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure), a comprehensive person-centered care plan was not developed and implemented and the CPAP was not being routinely cleaned by the facility staff. Resident 92 had a diagnosis of Sleep Apnea (a condition that makes you stop breathing while you're sleeping).These failures resulted in Resident 92 not being assessed and monitored by qualified staff for the effectiveness of the CPAP, possible complications or side effects (unwanted undesirable effects) related to CPAP use and had the potential for Resident 92 to experience unrecognized negative outcomes including respiratory infection which could compromise Resident 92's overall health.Findings:During a concurrent observation and interview on 6/16/26 at 10:25 a.m. with Resident 92, in Resident 92's room, Resident 92 was lying in bed, awake, alert and oriented to person, time, place and situation. Resident 92 had difficulty hearing and was wearing a hearing aid. Resident 92 was asking for water and pointing to a machine at bedside table, and stated, for my CPAP. Resident 92's CPAP mask and tubing were laying on the head part of the bed. Resident 92 stated he applied his own CPAP but was not able to clean it. Resident 92 stated that his CPAP machine, mask, and tubing were not cleaned for two weeks, and stated, should be cleaned once a week. Resident 92 stated his wife is coming tomorrow (6/17/26) to clean his CPAP machine (a device that pumps mild air pressure through a hose and mask to keep airway open while sleeping, primarily treating obstructive sleep apnea).During a concurrent interview and record review on 6/17/26 at 11:35 a.m. with the Unit Nurse Manager (UNM), Resident 92's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), undated, Order Summary Report, dated 6/2026, care plan report, undated, consultation/clinic referral, dated 6/3/26 were reviewed. The admission Record indicated Resident 92 was admitted to the facility on [DATE] with diagnosis of sleep apnea. The Order Summary Report did not include an order for CPAP. The care plan report does not contain a care plan for CPAP use. The consultation/clinic referral indicated, . doing well with CPAP. Continue use.signed FNP (Family Nurse Practitioner). The UNM stated Resident 92 went to an appointment for a pulmonologist (a medical specialist who diagnoses and treats diseases of the respiratory system, including the lungs, airways, and breathing muscles) consult on 6/3/26 and had an order to continue use of the CPAP. The UNM stated the pulmonologist order was not carried out by the licensed nurses and a care plan for use of CPAP was not developed and implemented. The UNM stated the pulmonologist order for Resident 92 to continue CPAP use should be carried out due to Resident 92 having sleep apnea. The UNM stated the care plan for Resident 92's CPAP use should be developed and implemented to properly assess and monitor Resident 92's CPAP use and to provide necessary respiratory care and treatments. The UNM stated night shift nursing staff were responsible in cleaning Resident 92's CPAP machine and the machine should be cleaned to prevent infection.During an interview on 6/18/26 at 3:13 p.m. with the family member (FM), in Resident 92's room, the FM stated she is Resident 92's wife. The FM stated she cleaned the CPAP mask and tubing with the use of vinegar yesterday (6/17/26). The FM stated she brought Resident 92's personal CPAP machine from home when he was admitted to the facility.During an interview on 6/18/26 at 3:26 p.m. with the Director of Nursing (DON), the DON stated Resident 92's physician's order to continue use of CPAP should be carried out by the licensed nurses for continued care. The DON stated Resident 92's use of CPAP should be care planned to ensure monitoring of side effects and proper care is being implemented when applying the CPAP and cleaning of CPAP equipment and supplies. The DON stated the CPAP mask, and tubing should be cleaned weekly to prevent the risk of respiratory infection. The DON stated Resident 92 was referred to facility's Respiratory Therapist yesterday (6/17/26).During a review of Resident 92's AR, dated 6/19/26, the AR indicated that Resident 92 have a diagnosis of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic atrial fibrillation (an irregular heartbeat), hyperlipidemia (a condition where fats build up in the arteries, increasing the risk of a stroke [a condition when a blood vessel that carries oxygen and nutrients to the brain is either blocked or ruptures]or heart attack [a condition with the blood flow that brings oxygen to the heart is severely reduced or blocked]), morbid (severe) obesity (a serious health condition that results from an abnormally high body mass due to excess calories).During a review of facility's policy and procedures (P&P) titled, CPAP/BIPAP Support, dated 3/2025, the P&P indicated, Purpose. 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. Preparation. 2. Review the resident's medical record to determine his/her baseline oxygen saturation. respiratory, circulatory and gastrointestinal status. 3. Review the physician's order to determine the oxygen concentration and flow. 4. Review and follow manufacturer's instructions for CPAP machine setup. General Guidelines. 4. CPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/ obstructive lung disease. 6. Side effects associated with CPAP may include: a. Claustrophobia; b. Sleep disturbances; c. Discomfort upon exhaling; d. Headaches; e. Dry mouth; f. Sore throat; g. Nosebleeds; and/or h. gastrointestinal distension. 7. Complications associated with CPAP may include: a. Tension pneumothorax; b. Skin breakdown around the mask; c. Aspiration; and/or d. Diminished cardiac output. Steps in the Procedure. 1. Explain the procedure to the resident. 3. Explain possible side effects of CPAP and instruct to report any discomfort to the nurse. 5. Connect filter to air flow outlet. 7. Position the exhalation port of the mask away from the resident's face and free from obstruction. 8. Set mode, CPAP. 13. Monitor the oxygen saturation of the resident. General Guidelines for Cleaning 2. These guidelines are for single-resident use cleaning. 4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5 Humidifier (if used); a. Use clean, distilled water only in the humidifier chamber. B. Clean humidifier weekly and air dry. C. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. 6. Filter cleaning: a. Rinse washable filter under running water once a week to remove dust and debris. Replace filter at least once a year. b. Replace disposable filters monthly. 7. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. 8. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to air dry. Documentation. Document the following in the resident's medical record: 1. General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; 2. Time CPAP was started and duration of the therapy; 3. Mode and settings; 5. How the resident tolerated the procedure; and 6. Oxygen saturation during therapy. Reporting. 2. Notify the physician if the resident experiences any adverse consequences, including (but not limited to) respiratory distress and marked change in vital signs.During a review of facility's P&P titled, Care Plans, Comprehensive Person- Centered, dated 3/2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons;.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when:1. A box of zucchini was not labelled and dated in the walk-in refrigerator.2. Station 200's nourishment unit refrigerator was observed with a box of pizza brought into the facility that was not properly labeled with the resident's name, room number, date the food was brought in, opened or the use-by date.These failures had the potential for staff to have access to expired foods for residents.1. During concurrent observation and interview on 6/16/26 at 9:31 a.m. with the Kitchen [NAME] (KC) inside the walk-in refrigerator, an unlabeled and undated plastic bin containing zucchini was observed on a metal rack. KC stated all food items inside should be labeled. KC stated, once food or produce is put into another container for use, it should be labeled with received date and use by date. KC stated the kitchen staff missed the labelling of food and produce.During an interview on 6/17/26 at 9:50 a.m. with the Certified Dietary Manager (CDM), CDM stated the plastic bin containing zucchini was unlabeled and undated inside the walk-in refrigerator. CDM stated her expectation was that all food should have a received date and use by date. CDM stated all food such as produce should be labeled and dated. CDM stated it was important to label and put the use by date on food items for quality and to ensure food does not sit in the refrigerator for a long time.During an interview on 6/17/26 at 3:00 p.m. with the Registered Dietician (RD), the RD stated all foods such as produce received in the kitchen should be properly labeled with received date and used by date. RD stated food without labels and dates were thrown away. RD stated food should have been labeled and dated to determine when it needed to be discarded and to prevent unnecessary food waste. RD stated unlabeled and undated food posed a food safety risk because it could spoil and cause foodborne illness.During a review of the facility's policy and procedure (P&P) titled, Food receiving and Storage, dated 11/2022, the P&P indicated, .All foods stored in the refrigerator. labeled and dated ( use by date) .2. During an observation on 6/16/26 at 10:21 a.m. in Station 200 Nourishment Unit refrigerator, a box of pizza was observed with a date of 6/6/26.During an interview on 6/17/26 at 10:00 a.m. with the CDM, the CDM stated the kitchen staff were responsible for checking all food items in the nourishment unit refrigerator. The CDM stated kitchen staff should ensure foods are labeled and dated with the received date and the use-by date. The CDM stated the facility staff were also aware that any food brought in by residents and their families from outside sources was required to be labeled and dated with the received date and the use-by date. The CDM stated the facility staff were allowed to accept food brought in by residents or their family members and store it in the nourishment unit refrigerator. The CDM stated food inside the nourishment unit refrigerator without labels and dates, was thrown away. The CDM stated the untouched food, or unconsumed meals could be stored in the nourishment unit refrigerator for up to three days. The CDM stated leftover food is not allowed to prevent cross contamination.During an interview on 6/17/26 at 3:10 p.m. with the RD, the RD stated any outside food stored in the refrigerator on the nourishment unit should have been clearly labeled with the residents' name, room number, the date the food was brought in or opened and the use-by date. The RD stated the facility did not allow any leftover food to be kept or stored in the nourishment unit refrigerator. The RD stated leftovers were not stored in the nourishment unit refrigerator to prevent foodborne illnesses and for resident safety.During a review of the facility's policy and procedure (P&P) titled, Food from Outside Source, dated 12/1/26, the P&P indicated, . Food that does not have a manufacturer's printed date must be thrown out 72 hours from the time it was brought into the facility. The food must be dated by nursing staff with an open date and use by date .

Based on observation, interview, and record review, the facility failed to ensure a safe, functional, and sanitary condition was maintained when four containers (five gallon each) containing chemicals in the dirty area of the laundry room were found covered with thick white foamy substance and the floor directly below the containers also contained the thick white foamy substance. This failure had the potential to affect the health condition of the 105 residents, staff and visitors of the facility, like severe skin burns, eye damage and toxic (poisonous or harmful) respiratory irritation. Findings: During a concurrent observation and interview on [DATE] at 8:22 a.m. with the Laundry Person (LP) in the dirty room area of the laundry room, nine containers were stacked in the corner of the room and four of the containers were covered with a white foamy substance. The LP stated she did not notice the thick white foamy substance covering the containers and was not sure what the white foamy substance was. The LP stated she had never used the chemicals before. The LP stated it was not normal and she was not sure if the white foamy substance was safe. During a concurrent observation and interview on [DATE] at 8:30a.m. with the Housekeeping Director (HD), the HD stated the containers contained liquid sanitizer and were used in the kitchen. The HD stated four of nine containers were covered with a white foamy substance. The HD stated he was made aware of the white foamy substance a few weeks ago by the dietary supervisor. The HD stated the Administrator (ADM) and the Director of Maintenance (DM) were also made aware and had checked on the containers. The HD stated, I thought it was taken care of. The HD stated the white foamy substance was a chemical. The HD stated it should have been taken care of because the chemical could cause chemical reactions and may affect residents and staff members' health if mishandled. During an interview on [DATE] at 9:05 a.m. with the Dietary Services Manager (DSM), the DSM stated she noticed the containers containing chemicals stored in the dirty room of the laundry department about four weeks ago were covered with white foamy substances. The DSM stated she notified the ADM and DM. The DSM stated the chemicals belonged in the kitchen but were no longer used because it was past its expiration date. During an interview on [DATE] at 9:42 a.m. with the DM, the DM stated his main responsibility was to ensure a safe environment for residents and staff and to make sure everything was working properly. The DM stated he remembered the DSM reporting to him about the containers of chemicals stored in the dirty room of the laundry room. The DM stated some of the containers were covered with thick white foamy substances. The DM stated he called the county regional waste and was told they did not take chemicals and was provided with a number to call and might be able to help. The DM stated he called the number provided to him and left message but did not remember receiving any call back. The DM stated he should have followed up more often until the chemicals were picked up. The DM stated it was not safe to store the chemicals for a long time because it could cause chemical reactions creating dangerous vapors (invisible gases) which could affect the health of residents and staff.During an interview on [DATE] at 2:20 p.m. with the ADM, the ADM stated he was made aware of the containers of chemicals stored in the dirty area of the laundry room a month or two months ago and thought the DM took care of it. The ADM stated the chemicals had expired because the company delivered too much. The ADM stated the chemicals were dangerous, could spill and could cause health issues to residents, staff and visitors when not handled properly. The ADM stated the issue of the chemicals should have been safely disposed of when it was first reported to him and the DM. During a review of facility's document titled, Job Description; Maintenance Director, revised date [DATE], the Job Description, indicated, The Maintenance Director is responsible to maintain the facility in good repair at all times, and oversee the Maintenance, Housekeeping and Laundry departments. The interior and the exterior surfaces, fixtures, and mechanical systems are the responsibility of the Maintenance Director. Ensure that all interior fixtures in good repair. Ensure that plumbing, electrical, heating, ventilation and air conditioning are maintained. Respond promptly and provide direction for emergency repair requests. Maintain required Material Safety data Sheet [MDSD-chemical cheat sheet. It details exactly how dangerous a material is and how to handle it safely. Oversee the maintenance, housekeeping and laundry departments.During a review of facility's policy and procedure (P&P) titled, Maintenance Service, revised date 12/09, the P&P indicated, .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Maintaining the building in good repair and free from hazards. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Maintenance personnel shall follow the established safety regulations to ensure the safety and well-being of all concerned.

Based on observation, interview, and record review, the facility failed to maintain medical records of residents that are complete and accurately documented in accordance with accepted professional standards and practice for two of 10 sampled residents (Resident 11 and Resident 9) when:1.Resident 11's electronic health record (EHR) contained no documentation of completed ileostomy (a specific type of surgery where the lower part of the small intestine is brought through an opening in the belly to form a stoma [an artificial opening made by a surgeon on the abdomen-belly]) bag changes since 7/3/25.This failure had the potential to disrupt continuity of care, create gaps in the services provided, and lead to miscommunication among staff regarding Resident 11's status.2. Licensed Vocational Nurse (LVN) 1 did not document Resident 9's medications administered in his electronic Medication Administration Record (eMAR-digital medication chart or a smart medicine checklist used by nurse and caregivers) after she administered medications during medication pass on 6/18/26.This failure had the potential for Resident 9 to miss doses of medication, receive double-dosing of medication, delayed medication interventions, and increased risk of life-threatening adverse drug events. 1. During a review of Resident 11's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/18/26, the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses of spondylosis with myelopathy-cervical region (when age-related wear-and-tear in the neck causes the spinal canal to narrow, resulting in dangerous pressure and injury to the spinal cord), anxiety disorder, muscle spasm, morbid (severe) obesity due to excess calories, chronic pain syndrome (when persistent pain-lasting longer than 3-6 months- causes other widespread problems), ileostomy status (when a person has undergone a surgical procedure where the lowest part of the small intestine is brought through the abdominal wall to create a stoma), and muscle weakness-generalized. The AR indicated under the contacts section of the document that Resident 11 was her own responsible party (RP-indicates that the resident holds the legal, medical, and financial authority over their own care). During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/13/26, the MDS section C indicated Resident 11 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 11 was cognitively intact. During a review of Resident 11's facility document titled, Order Summary Report (OSR), dated 6/18/26, the OSR indicated, .Ostomy: Change Ileostomy bag PRN [as needed] if soiled or dislodgement as needed.Ostomy: Ileostomy care as needed. During a review of Resident 11's facility document titled, Treatment Administration Record (TAR), dated 4/1/26-4/30/26, the TAR indicated the following orders, .Ostomy: Change Ileostomy bag PRN if soiled or dislodgement as needed.Ostomy: Ileostomy care as needed. TAR contained no documentation of completed ileostomy bag dressing changes. During a review of Resident 11's facility document titled, TAR, dated 5/1/26-5/31/26, the TAR indicated the following orders, .Ostomy: Change Ileostomy bag PRN if soiled or dislodgement as needed.Ostomy: Ileostomy care as needed. TAR contained no documentation of completed ileostomy bag dressing changes. During a review of Resident 11's facility document titled, TAR, dated 6/1/26-6/30/26, the TAR indicated the following orders, .Ostomy: Change Ileostomy bag PRN if soiled or dislodgement as needed.Ostomy: Ileostomy care as needed. TAR contained no documentation of completed ileostomy bag dressing changes. During a concurrent interview and record review on 6/18/26 at 4:13 p.m. with Licensed Vocational Nurse (LVN) 7, Resident 11's TAR was reviewed. LVN 7 stated Resident 11's ostomy bag was changed as needed when it was full and changed according to doctors' orders. LVN 7 stated ostomy bag changes should be documented on the TAR. LVN 7 reviewed Resident 11's TAR's in the EHR and stated the last documented ostomy bag change was on 7/3/25. LVN 7 stated it was important to document the ostomy care and bag changes to keep track of skin changes or irritation that could occur due to frequent dressing changes and to document the care that was being provided. During a concurrent interview and record review on 6/18/26 at 3:45 p.m. with the Director of Nursing Services (DNS), Resident 11's TAR was reviewed. The DNS reviewed Resident 11's EHR and stated there were current doctor orders for ostomy care PRN. The DNS stated staff should document ileostomy bag changes in the TAR and should be done according to physicians' orders. The DNS stated the floor nurses changed the ostomy bag about every other day or when it was needed and was half full and stated she was unable to locate any staff signatures indicating ileostomy care had been provided. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, .All services provided to the resident.shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.Treatments or services performed.Documentation of procedures and treatments will include care-specific details, including.The date and time the procedure/treatment was provided.The name and title of the individual(s) who provided the care.The signature and title of the individual documenting. 2.During observation on 6/16/26 at 11:14 a.m. during the initial tour in Resident 9's room, Resident 9 was lying in bed with eyes closed. Resident 9 was observed with head of bed slightly elevated and feeding tube machine (enteral feeding pump-device that pushes liquid food through tubing at a slow, controlled rate) at bedside. Resident 9 did not answer questions asked. During a review of Resident 9's AR, undated, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one entire side of the body) hemiparesis (one-sided muscle weakness), dysphagia (difficulty or discomfort in swallowing), and dementia (a progressive state of decline in mental abilities). During a concurrent interview and record review on 6/18/26 at 8:12 a.m. with LVN 1 during medication administration observation, LVN 1 stated Resident 9 has a gastrostomy tube (G-tube-small feeding tube that goes through the skin of the belly directly into the stomach), and administered his medications at 7 a.m. LVN 1 reviewed Resident 9's eMAR and stated, I forgot to sign the eMAR after I administered his [Resident 9] medications. LVN 1 stated she should have signed the eMAR immediately after administering medications. LVN 1 stated the practice was to sign the eMAR immediately, but she did not. During an interview on 6/18/26 at 4:45 p.m. with LVN 3, LVN 3 stated the practice during medication administration was to document after medication was administered to residents and not prior to administering medication or an hour after. LVN 3 stated it could lead to over medication or under medicating resident and could lead to serious health conditions. During an interview on 6/18/26 at 3:40 p.m. with LVN 2 and LVN 4, they stated medication administration practice was to prepare medication, administer medication then document in the eMAR to avoid medication error. During an interview on 6/19/26 at 1:31 p.m. with the Director of Nursing Services (DNS), the DNS stated she expected licensed nurses to document right away after medication was administered. The DNS stated not documenting immediately could lead to a medication error, duplication of medication or non-administration of medication which could lead to serious health problems for residents. During a review of facility's policy and procedure (P&P) titled, Administering Medications, revised date 4/19, the P&P indicated, .Only person licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Medications are administered in accordance with prescribed orders, including any required time frame. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview, and record review, the facility failed to ensure resident's entire medication regimen was monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for three of ten sampled residents (Resident 8, Resident 2 and Resident 24) when:1.Resident 8 was not being monitored for anticoagulant (medication that prevents blood clots from forming) side effects as indicated on Resident 8's care plan. Resident 8 was receiving Rivaroxaban (a blood thinner that treats or prevents blood clots) for Deep Vein Thrombosis (DVT) prophylaxis preventive measures used to stop the formation of dangerous blood clots in deep veins, primarily in the legs) and Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). This failure resulted in Resident 8 not being monitored for possible complications or side effects (unwanted undesirable effects that are possibly related to a drug) of anticoagulant by qualified staff and had the potential for Resident 8 to experience unrecognized negative outcomes including bleeding, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, and sudden changes in mental status.2. Resident 2's ticagrelor ( antiplatelet medicine that acts like a slippery shield for the blood, keeping platelets from sticking together to form dangerous clots) did not have adequate indication for use.This failure had the potential for Resident 2 to go unmonitored for serious side effects of the medication prescribed. 3. No non-pharmacological (non-medications strategies) interventions were started for Resident 2 and Resident 24's before the use of psychotropic medications (prescription drugs that alter brain chemicals to influence mood, behavior, thoughts, or perception) were ordered and administered. These failures had the potential for Resident 2 and Resident 24 to result in higher doses of psychotropic medications which could lead to more side effects (unintended reactions) of medications. Findings: 1. During a concurrent observation and interview on 6/17/26 at 9:42 a.m. with Resident 8, in Resident 8's room, Resident 8 was lying in bed, alert and orientated to names, time, places, and situation, pleasant, clean, and well groomed. Resident 8 stated he had spinal surgery and came to the facility for therapy. Resident 8 had multiple circular brownish discoloration in right arm. During a concurrent interview and record review on 6/17/26 at 3:00 p.m. with the Unit Nurse Manager (UNM), Resident 8's Order Summary Report and Electronic Medication Administration Record (EMAR - a daily electronic documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2026 were reviewed. The Order Summary Report indicated, Brand Name (Rivaroxaban) 10 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) Give 1 tablet by mouth in the evening for DV prophylaxis Order date 6/8/26. The EMAR indicated, Brand Name (Rivaroxaban) 10 mg Give 1 tablet by mouth in the evening for DVT prophylaxis Order date 6/8/26. The UNM stated licensed nurses were administering Rivaroxaban to Resident 8 per physician's order and were not monitoring for possible side effects of anticoagulant usage. The UNM stated she cannot locate the monitoring of side effects in Resident 8's EMAR. The UNM stated monitoring for side effects should be completed by licensed nurses every shift and should be documented in Resident 8's EMAR. The UNM stated it was important for licensed nurses to assess and monitor Resident 8 for side effects related to anticoagulant use. The side effects licensed nurse should be monitoring for are bleeding and bruising and should notify the physician for further evaluation and treatment. During a concurrent interview and record review on 6/17/26 at 3:15 p.m. with the UNM, Resident 8's care plan for anticoagulant dated 6/8/26 was reviewed. The care plan indicated, .is on anticoagulant therapy related to Atrial Fibrillation Goal: will be free from discomfort or adverse reaction related to anticoagulant use.Interventions: Monitor for side effects and effectiveness every shift. Monitor/document/report PRN adverse reactions of ANTICOAGULANT therapy; blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant of sudden changes or v/s (vital signs). The UNM stated Resident 8's care plan should be implemented to ensure Resident 8 is monitored by licensed nurses every shift for possible side effects related to anticoagulant use. During a review of Resident 8's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/19/26, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnosis of Fusion of Spine, Chronic Atrial Fibrillation, Long term (current) Use of Anticoagulants, and Essential Hypertension (HTN-high blood pressure). During a review of Resident 8's Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15) dated 6/15/26. Resident 8 had a BIMS score of 15 (a score of 13-15 cognitively intact, 8-12 moderately impaired, 0-7 severe impairment), which indicated Resident 8 was cognitively intact. During an interview on 6/19/26 at 8:42 a.m. with the Director of Nursing (DON), the DON stated it was her expectation for all Licensed Nurses to monitor residents for side effects of anticoagulant use every shift to identify signs and symptoms of bleeding such as bruising, blood in the urine and stool to notify the physician immediately for further treatment and interventions. The DON stated the monitoring of side effects of anticoagulant use should have a physician's order and licensed nurses should be documented in residents' EMAR. The DON stated Resident 8's care plan for anticoagulant use should be followed and implemented by nursing staff to ensure necessary care and treatment is provided. During a review of facility's policy and procedures (P&P) titled, Anticoagulation -Clinical Protocol, dated 11/2018, the P&P indicated, Assessment and Recognition. 1. As part of the initial assessment, the physician and staff will identify individuals who are currently anti-coagulated; for example, those with recent history of deep vein thrombosis (DVT), or heart valve re-placement, atrial fibrillation or those who have had recent joint replacement surgery. a. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Monitoring and Follow-Up. 5. The staff and physicians will monitor for possible complications individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in the urine), hemoptysis (coughing or spitting up blood, or other evidence of bleeding, the nurse will discuss the situation with physician before giving next scheduled dose of anticoagulant. b. The physician will order measures to address any complications, including holding or discontinuing the anticoagulant as indicated. 2. During a concurrent observation and interview on 6/16/26 at 9:58 a.m. during the initial tour in Resident 2's room, Resident 2 was lying in bed watching TV. Resident 2 stated she was in the facility working with therapy. Resident 2 stated she had no concerns; staff are providing her assistance with her activities of daily living (ADL-routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During a review of Resident 2's admission Record (AR- document containing resident personal information), dated 6/19/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain disease, damage, or malfunction), atherosclerosis (hardening of the arteries) of native arteries of extremities (limbs parts of the body that stick out from the main trunk) and depression (serious mood disorder that causes persistent sadness and a loss of interest in life). During a review of Resident 2's Order Summary Report (OSR), dated 6/19/26, the OSR indicated, Resident 2 had an active order for . Sertraline (medication used to treat depression) HCL [hydrochloride] 100 MG [milligram-unit of measurement] Give 1 tablet by mouth one time a day for depression.Ticagrelor Oral Tablet 90 MG (Ticagrelor) Give 1 [one] tablet by mouth two times a day for intermittent [stopping and starting] claudication [muscle pain, cramping, or weakness]. During a concurrent interview and record review on 6/18/26 at 3:24 p.m. with LVN 2 and LVN 4, Resident 2's Order Summary Report, for the month of June 2026 was reviewed. LVN 2 and LVN 4 stated Resident 2 was receiving the medication Ticagrelor with the indication of intermittent claudication. LVN 2 and LVN 4 stated the indication for the medication was not appropriate indication and was not sure what it was. LVN 2 and LVN 4 reviewed Resident 2's discharged summary from acute hospital and stated Resident 2 was admitted to the facility with the medication but had no diagnosis or indication. LVN 2 and LVN 4 stated they did not find documentation the medical doctor gave the diagnosis or indication. 3. During a concurrent observation and interview on 6/16/26 at 10:16 a.m. during initial tour in Resident 24's room, Resident 24 was seated in her wheelchair propelling self out of the bathroom. Resident 24 stated she had surgery on her left knee and now receiving antibiotic (medication to fight bacterial infection) for the bone infection (tiny, harmful germs like bacteria enter the body and begin to multiply). During a review of Resident 24's AR dated 6/18/26, the OSR indicated Resident 24 was re-admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery infection and inflammatory reaction (body's built-in alarm and defense system) due to internal left knee prosthesis (artificial replacement for a missing or non-functioning body part) and major depressive disorder. During a review of Resident 24's OR dated 6/18/26, the Resident 24 had an active order for . Sertraline HCL Oral Tablet 50 MG . Give one [1] tablet by mouth one time a day for Depression. During an interview on 6/18/26 at 1:38 p.m. with LVN 1, LVN 1 stated non-pharmacological interventions should be initiated for residents receiving psychotropic medications. LVN 1 stated it was important to ensure residents were provided with alternatives to medications like relaxation techniques and participation in activities. LVN 1 stated she was not sure who was responsible in ensuring an order was placed in resident's record. During a concurrent interview and record review on 6/18/26 at 3:44 p.m. with LVN 2 and LVN 4, Resident 2 and Resident 24's Order Summary Report, for the month of June 2026 were reviewed. LVN 2 and LVN 4 stated Resident 2 and Resident 24 had orders for antidepressant medications. LVN 2 and LVN 4 stated there were non-pharmacological interventions and was not sure if it was needed. After consulting with DNS, LVN2 and LVN 4 stated all psychotropic medications should have non-pharmacological interventions. LVN 2 and LVN 4 stated it was important to offer non-pharmacological interventions to help re-direct, distract residents or just someone to talk to. LVN 2 and LVN 4 stated it was the responsibility of licensed nurses to ensure non-pharmacological interventions were initiated. During an interview on 3/19/26 at 1:45 p.m. with the Director of Nursing Services (DNS), the DNS stated Resident 2's ticagrelor medication did not have appropriate diagnosis or indication. The DNS stated she was not sure where the nurse obtained the indication. The DNS stated she did not find documentation the primary doctor gave the diagnosis or indication. The DNS stated her expectation was for licensed nurses to start non-pharmacological interventions as soon as they received order for psychotropic medications. The DNS stated non-pharmacological interventions was to assist with de-escalation techniques to calm residents. The DNS stated non-pharmacological interventions are approaches to deal with residents without using medications. During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 7/22, the P&P indicated, .Residents, families, and and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indication for use. d. adequate monitoring for efficacy and adverse consequences. 10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medication when possible. 11. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue medications.

Based on observation, interview and record review the facility failed to develop a baseline care plan for one of seven residents (Resident 97) when Resident 97 did not have a baseline care plan initiated within 48 hours of admission on [DATE] for end stage renal disease (ESRD -a condition where the kidneys can no longer function and hemodialysis treatment (a medical treatment that uses a machine to clean a person's blood by removing waste products and excess water). This failure had the potential to result in Resident 97's hemodialysis needs to go unmet, which placed Resident 97 at risk for complications associated with ESRD which could compromise Resident 97's overall health. Findings:During a concurrent observation and interview on 6/17/2026 9:51 a.m. with Resident 97, in Resident 97's room, Resident 97 was lying on bed, awake, alert and oriented to person, places, and situation. Resident 97 stated she is receiving dialysis treatment.During a concurrent interview and record review on 6/17/26 at 11:35 a.m. with the Unit Nurse Manager (UNM), Resident 97's Clinical admission dated 6/12/26, and current care plan report were reviewed. The Clinical admission indicated, .Diagnosis: End Stage Renal Disease (ESRD).A. Hemodialysis: Yes. The care plan report did not include a care plan for diagnosis of ESRD and hemodialysis. The UNM stated there was no care plan for diagnosis of ESRD and hemodialysis. The UNM stated Resident 97's care plan for diagnosis of ESRD and hemodialysis should be developed within 72 hours from readmission date of 6/12/26. The UNM stated Resident 97's care plan should reflect the necessary care and treatment which include hemodialysis. The UNM stated licensed nurses and Minimum Date Set Nurse (MDSN) were responsible in developing and reviewing residents' care plan. During a concurrent interview and record review on 6/19/26 at 9:31 a.m. with the MDSN, Resident 97's care plan report dated 6/12/26 to 6/18/26 were reviewed. The care plan report indicated, .The resident needs dialysis renal (kidney) failure Date initiated: 6/17/26 Created date 6/17/26. Goal The resident will have no signs and symptoms (s/sx) of complications from dialysis. at risk for fluid overload or potential for fluid overload related to CKD (Chronic Kidney Disease) hemodialysis.Fluid Restriction. Date initiated: 6/19/26 Created date 6/19/26.Goal: will remain free of signs and symptoms of fluid overload. Interventions: Monitor/document/report to MD PRN s/sx of fluid overload: Anorexia, Anxiety, Mood/behavior changes, Confusion, Edema (swelling), Nausea/vomiting, Shortness of breath, difficulty breathing (Dyspnea), Increased respirations (Tachypnea), Difficulty breathing when lying flat (Orthopnea), Congestion, Cough, Fatigue, Jugular Venous Distention (JVD), Sudden weight gain. The MDSN stated baseline care plan should be developed within 72 hours from admission or readmission of residents to the facility. The MDSN stated care plan for hemodialysis related to renal failure and risk for fluid overload was developed beyond 72 hours. The MDSN stated residents' care plan should reflect current plan of care based on assessment and physician's orders. During an interview on 6/19/2026 at 2:10 p.m. with the Director of Nursing (DON), the DON stated it was her expectation for all licensed nurses and Interdisciplinary Team (IDT) to follow the facility's policy and procedures (P&P) for baseline care plans to ensure necessary care and treatment were being implemented to the residents. The DON stated baseline care plans should be developed within 48 hours from residents' admission or readmission to the facility. The DON stated baseline care plan should be individualized or person-centered based on residents' assessment and needs. The DON stated Resident 97's care plan for diagnosis of ESRD and hemodialysis should be developed when Resident 97 was re-admitted to the facility on [DATE] to prevent unrecognized complications related to diagnosis of ESRD and hemodialysis treatment. During a review of Resident 75's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/19/26, the AR indicated Resident 75 was admitted to the facility on [DATE] with diagnosis of encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg above the knee, and ESRD.During a review of Resident 97's Order Summary Report dated 6/19/26, indicated a diagnosis of ESRD.During a review of facility's P&P titled, Care Plans - Baseline,' dated 3/2022, the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders. 3. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP) for one of seven sampled residents (Resident 3) when Resident 3 did not have a comprehensive CP implemented for Resident 3's depression medication. This failure had the potential for Resident 3's medication side effects and adverse reactions to go unnoticed and undetected by nursing staff.During a review of Resident 3's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/18/26, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnosis of displaced intertrochanteric fracture of right femur-subsequent encounter for closed fracture with routine healing (a broken right thigh bone), unspecified fracture of the lower end of left radius (a broken left wrist) subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus (when the body cannot use insulin properly and/or does not make enough insulin) without complications, depression unspecified ( a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), post-traumatic stress disorder unspecified (PTSD-when a person is suffering from trauma-related symptoms), anxiety disorder unspecified (when a person experiences fear that disrupts their daily life).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/15/26, the MDS section C indicated Resident 3 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 3 was cognitively intact.During a review of Resident 3's facility document titled, Order Summary Report (OSR), dated 6/18/26, the OSR indicated, .PARoxetine HCL Tablet 20 mg Give 1 tablet by mouth one time a day for depression.Administer with 40 mg dose to equal 60 mg total dose.PARoxetine HCL Tablet 40mg Give 1 tablet by mouth one time a day for depression.Administer with 20 mg dose to equal 60 mg total dose.During an interview on 6/18/26 at 1:54 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated there was always an admission nurse when residents got admitted who input medications, CP, and all orders into the electronic health record (EHR). LVN 6 stated the admission nurse then provided hand off report to the nurse on the floor that would be caring for the newly admitted resident. LVN 6 stated all new admits got a CP including a CP for medications. LVN 6 stated she saw an anti-anxiety CP, sedative (a substance or medicine that calms the brain and body) CP, hypnotic (a prescription or over-the-counter sleep aid) CP, anticoagulant (a medication that stops or slows down the body's process of making blood clots) CP, and was looking in the EHR but could not find a CP relating to Resident 3's antidepressant medication. LVN 6 stated there was not a CP and there should be a CP to monitor side effects. LVN 6 stated a CP was important so staff knew that Resident 3 was on that medication, for resident safety, and because CP's helped to guide the care provided.During an interview on 6/18/26 at 3:24 p.m. with the Director of Nursing Services (DNS), The DNS stated her expectation was that CP's for medications such as antianxiety, psychotropic (any prescription drug or chemical substance that alters how the brain works and changes your mood, thoughts, feelings, or behavior) medications, and antidepressant medications should have a CP indicating monitoring for side effects and adverse reactions of those medications for which the resident is currently on. The DNS stated it was important to have an individualized CP to ensure residents' health and safety were being met and stated it was also important for CP's to be implemented to guide the care that was being provided. The DNS stated her expectation was for comprehensive CP's to be created and implemented within 21 days after admission.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.the comprehensive, person-centered care plan is developed no more than 21 days after admission.The comprehensive, person-centered care plan. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review the facility failed to ensure that the administration of enteral nutrition (delivers specialized liquid formulas directly to the stomach) was consistent with physician's orders for one of seven sampled residents (Resident 21) when Resident 21's enteral nutrition was administered by Licensed Vocational Nurse (LVN) 5 for almost three hours past the prescribed time of administration on 6/16/26. Resident 21 was NPO (nothing by mouth).This failure resulted in Resident 21 receiving her enteral feeding (also referred to as tube feeding is the delivery of nutrients through a feeding tube directly into the stomach) late and had the potential risk of receiving inadequate nutrition and experience unrecognized decline in health conditions which could compromise Resident 21's overall health.Findings:During a concurrent observation and interview on 6/16/26 at 10:09 a.m. with Resident 21, in Resident 21's room, Resident 21 was self-propelling her wheelchair from bathroom to her bed. Resident 21 was pleasant, clean, and well groomed. Resident 21 was alert and oriented to person, time, place and situation or event. Resident 21 stated her stomach was growling and was showing her gastrostomy tube (GT, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) Resident 21 stated she did not receive her morning enteral feeding and had been waiting for her formula. Resident 21 stated she should receive her formula feeding for breakfast.During a concurrent observation and interview on 6/16/26 at 10:09 a.m. with Resident 21, in Resident 21's room, Resident 21 was lying in her bed, awake. Resident 21 stated she was still waiting for the nurse to give her formula feeding in her tube. Resident 21 stated she cannot have oral food and only gets her food through her GT.During a concurrent observation and interview on 6/16/2026 at 10:31 a.m. with LVN 5, in front of Resident 21's room, LVN 5 was at her medication cart. LVN 5 stated Resident 21's GT feeding was scheduled at 8:00 a.m. LVN 5 stated Resident 21's GT feeding was late, . started on the other side.I am behind. During an observation on 6/16/26 at 10:37 a.m. with LVN 5, outside Resident 21's room, LVN 5 was preparing the GT formula on top of the medication cart. LVN 5 went inside Resident 21's room with the GT formula, and the privacy curtains were pulled around the bed.During a concurrent observation and interview on 6/16/26 at 10:50 a.m. with LVN 5, in Resident 21's room, LVN 5 came out of the room and opened the computer on top of the medication cart. LVN 5 stated she administered Resident 21's enteral feeding.During a concurrent interview and record review on 6/17/26 at 11:35 a.m. with the Unit Nurse Manager (UNM), Resident 21's Electronic Medication Administration Record (EMAR - a daily electronic documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2026 was reviewed. The EMAR indicated, Enteral Feed Order every 4 hours related to GASTROSTOMY STATUS. Brand Name 1.2 (237 ml [Milliliters-used to measure units of liquid volume) 6 cartons/day to provide 1710 kcal (kilocalories - a unit of energy), 79 g (grams- unit of mass) protein, 1146 ml free water -Order Date- 06/07/2026.Hours 0000 0400 0800 1200 1600 2000. The UNM stated licensed nurses should follow the prescribed GT feeding administration of every four hours at 12 midnight, 4:00 a.m., 8:00 a.m., 12:00 noon, 4:00 p.m. and 8:00 p.m. to ensure Resident 21 was receiving the required calories and proteins as indicated in the EMAR. The UNM stated a.m. shift nurse should administer the enteral feeding at 8:00 a.m. and when administered beyond the prescribed time was considered late administration and will be close to the next enteral feeding time. The UNM stated there is potential risk of weight loss and feeding intolerance when Resident 21's enteral feeding was not followed according to the physician's order.During an interview on 6/17/26 at 3:10 p.m. with the Director of Nursing (DON) and LVN 5, the DON validated with LVN 5 about the time Resident 21 was administered the GT feeding on 6/16/26. LVN 5 stated she completed administering Resident 21's GT feeding almost 11:00 a.m. on 6/16/26, which was due at 8:00 a.m. LVN 5 stated trial oral intake was started at 12:00 p.m. on 6/16/26 with the speech therapist (ST). The DON stated Resident 21's GT feeding administration was late and will closely monitor Resident 21 for weight loss. The DON stated it was her expectation for all licensed nurses to follow the physician's orders to ensure residents are receiving necessary care and treatment. During a concurrent interview and record review on 6/18/26 at 11:00 a.m. with the Registered Nurse (RN), Resident 21's EMAR dated 6/16/26 was reviewed. The EMAR indicated, Enteral Feed Order Administration Details Scheduled for 0800 Effective date 6/16/26 10:36 a.m. Administered by Name of LVN 5 Documented 6/16/26 at 10:51 a.m. The RN stated Resident 21's enteral feeding was administered late. The RN stated licensed nurses should follow the scheduled time of feeding administration based on physician's order to ensure Resident 21 receives adequate nutrients and to prevent weight loss. During a concurrent interview and record review on 6/18/26 at 12:05 p.m. with the RN, Resident 21's and Order Summary Report dated 5/18/26 was reviewed. The Order Summary Report indicated, Enteral Diet, NPO texture, NPO consistency.Start Date 5/15/26. The RN stated Resident 21 was NPO since 5/15/26 and receiving enteral feeding as the primary source of nutrition. During a review of Resident 21's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/19/26, the AR indicated Resident 21 was admitted to the facility on [DATE] with diagnosis encounter for surgical aftercare following surgery of digestive system, gastrostomy status (refers to the presence of a surgically created artificial opening in the stomach), dysphagia (difficulty swallowing) chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid), and essential (primary) hypertension (abnormally high blood pressure [the amount of force the heart uses to pump blood through the arteries] that is not the result of a medical condition), and severe protein calorie malnutrition (inadequate intake of food).During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/18/26, the MDS section C indicated Resident 23 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 10 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 21 was moderately impaired.During a review of Resident 21's care plan dated 5/18/26, indicated, The resident has a nutritional problem or potential nutritional problem related to diagnosis of gastrostomy status, dysphagia, pneumonia, severe protein calorie malnutrition.underweight.Goal Resident will tolerate tube feeding (TF) with no gastrointestinal (GI) issues; and requires tube feeding related to dysphagia. Goal The resident will maintain adequate nutritional and hydration status.During a review of facility's policy and procedures (P&) titled, Enteral Nutrition, dated 11/2018, the P&P indicated, . Adequate nutritional support through enteral nutrition is provided to residents as ordered. 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. 5. Some examples of potential benefits of using a feeding tube include: a. Addressing malnutrition and dehydration; c. Allowing a resident to gain strength that may allow him or her to return to oral nutrition.

Based on interview, and record review, the facility failed to meet professional standards of quality for one of three residents (Resident 1) when Resident 1 was admitted with a pressure ulcer (a localized area of skin damage and underlying tissue that develops when prolonged pressure is applied to the body) of the sacral region (the area of the lower back and pelvis) and Resident 1 required to be turned and repositioned every two hours. Resident 1's care plans did not indicate Resident 1 be turned and repositioned every two hours and Resident 1's medical records did not indicate Resident 1 was turned and repositioned every two hours. This failure resulted in incomplete and inaccurate documentation of when Resident 1 was turned and repositioned and had the potential to result in the worsening of Resident 1's pressure ulcer and the potential of developing new pressure ulcers resulting in the death of Resident 1 on [DATE] with a diagnosis of septic shock (a life-threatening condition that occurs when an infection triggers a widespread inflammatory response that leads to dangerously low blood pressure and organ damage). Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE] and with a history of Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infarction (loss of blood flow to part of the brain) affecting left non-dominant side and Pressure Ulcer of sacral region unspecified stage. During a review of Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life), dated [DATE], Resident 1's BIMS score was 12 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long-term care nursing facilities), dated [DATE], the MDS indicated, Resident 1's functional abilities was dependent (Helper does all the effort. Resident does none of the effort to complete the activity) on toileting hygiene (the ability to maintain cleanliness after voiding or bowel elimination) and rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). During a review of Resident 1's Clinical Admission (CA), (undated), the CA indicated, . 72. Skin Issue. 73. Location . h. Coccyx (a small triangular-shaped bone located at the bottom of the spine) . Open wound . 77. Length (cm; centimeter; unit of measurement) 4 . 78. Width (cm) 0.5 . During a review of Resident 1's Wound Consultation (WC), dated [DATE], the WC indicated, . Wound Location: Coccyx a Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia; a thin, fibrous connective tissue that surrounds and supports all the structures in the body, muscle, tendon, ligament, cartilage, or bone) Type: Pressure. L (length in cm) 6 x (by) W (width in cm) 7 x D (depth in cm) UTD (unable to determine) . Plan: Implement pressure relieving measures and offloading as tolerated. - offload/reposition . Specialty Devices: Bed - Group 2: Low Air loss Mattress (a medical-grade mattress designed to prevent and treat pressure injuries by distributing weight, minimizing heat and moisture buildup, and promoting airflow through tiny air holes in the mattress surface) . During a review of Resident 1's WC, dated [DATE], the WC indicated, . Wound Location: . coccyx. L 9.5 x W 6.5 x D 3.4. R (right) heel L 4.4 x W 4.9 x D 0.1. L (left) trochanter (a bony prominence located at the upper end of the femur; thigh bone) L 1.5 x W 2.3 x D 0.4. L elbow L 0.3 x W 0.3 x D 0.1 . Plan: Offload/Reposition . Devices: Low Air loss Mattress . During a review of Resident 1's Progress Notes (PN), dated [DATE], the PN indicated, . Upon assessment patient was . nonresponsive to physical stimuli or verbal communication . Patient's BP (blood pressure) was noted to be dropping while oxygen was increasing . 1st (first) EMT (emergency medical technician) arrived at 0655 (6:55 a.m.) . and 3 EMT's departed facility in 1 (one) truck with patient at 0715 (7:15 a.m.) . During a review of Resident 1's hospital Final Report (FR), dated [DATE], the FR indicated, . Admission Information: admitted : [DATE] 10:35 (p.m.) . Hospital Course: . In the ED (Emergency Department) here patient was noticed to be hypotensive (low blood pressure) with blood pressure of 57 x 48, hypoxic (low oxygen level) with O2 (oxygen) sats (saturation) in 60s and GCS (Glasgow Coma Scale; a neurological assessment tool used to evaluate a person's level of consciousness) 4 (a score of 1 indicating no response up to a score of 15 indicating fully responsive). Patient was intubated (a tube inserted into the lungs to assist with breathing) . Patient was then treated aggressively in the ICU (Intensive Care Unit) with a working diagnosis of septic shock likely from his urinary/infected decubitus ulcer (a skin lesion that develops when prolonged pressure on an area of the body restricts blood flow, leading to tissue damage) . Despite aggressive measures patient went into multiorgan failure became anuric (absence or significantly low production of urine) needing emergent Quinton catheter (a tunneled, double-lumen, flexible silastic catheter used for long-term central vascular access) and starting of dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys have failed) . But despite all the efforts patient's condition continued to deteriorate and later at night patient coded (when a person experience a cardiac or respiratory arrest and require immediate, life-saving resuscitation efforts) . Patient was pronounced dead on ,d+[DATE] ([DATE]) at 01:12 am (1:12 a.m.) . During a review of Resident 1's Interdisciplinary Team (IDT; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Review, dated [DATE], the IDT Review indicated, . IDT Recommendations. 1. Nursing to monitor and provided wound tx (treatment) as ordered . Reposition q (every) 2 hrs (hours) and prn (as needed) . During a review of Resident 1's IDT Review, dated [DATE], the IDT Review indicated, IDT Recommendations. 1. Turning and repositioning - care plan updated . During a review of Resident 1's IDT Review, dated [DATE], the IDT Review indicated, IDT Recommendations. 1. Turning and repositioning - care plan updated - wound vac (a device that applies gentle suction to a wound to promote healing) to be placed [DATE] to sacrum . During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, Wound Management. admitted with bruising. admitted with open area to coccyx . Interventions: Monitor ulcer for signs of infection. Notify provider if no signs of improvement on current wound regimen. Provide wound care per treatment order. During a review of Resident 1's CPR, dated [DATE], the CPR indicated, Documented Pressure on admission . Interventions: Encourage Resident to frequently shift weight. Evaluate skin for areas of blanching or redness. Notify family of new onset finding. Notify provider if no signs of improvement on current wound regimen. Provide skin care per facility's guidelines and PRN as needed. Provide wound care per treatment order. During a review of Resident 1's CPR, dated [DATE], the CPR indicated, Upon my admission, I have an ADL (Activities of Daily Living; dressing, toileting, washing, feeding, mobility, and transferring) self-care performance deficit r/t (related to) HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON-DOMINANT SIDE. Goal: I am dependent on help to perform all of my ADLs and require staff assistance to meet all of my ADL needs . Interventions: Assist and meet ADL needs. Encourage to assist with ADLs as able. Encourage to attend/participate in therapy. Observe for decline in ADL function. Observe for improvement in ADL function. During a review of Resident 1's Roll Left and Right (RLR), dated [DATE] through [DATE], the RLR indicated, Resident 1 required substantial to dependent assistance. The times Resident 1 was rolled left and right indicated Resident 1 was not rolled left and right every two hours. On [DATE], the record indicated Resident 1 was rolled left and right at 1:36 a.m., 9:35 a.m., 8:37 p.m., and 11:48 p.m. On [DATE], the record indicated Resident 1 was rolled left and right at 3:54 a.m., 1:59 p.m., and 7:41 p.m. During an interview on [DATE] at 12:59 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1 on [DATE]. LVN 1 stated Resident 1 was immobile (incapable of moving or being moved) and was turned and repositioned every 2 hours. LVN 1 stated lying in one position longer than two hours will cause skin injuries. During an interview on [DATE] at 1:11 p.m. with Certified Nursing Assistant (CNA), CNA stated she was assigned to Resident 1 on [DATE]. CNA stated Resident 1 was dependent on transfer and required the use of a hoyer lift (a mechanical device used to safely transfer individuals with limited mobility from one place to another) and was turned and repositioned every two hours. CNA stated Resident 1 was incontinent (unable to control bowel and bladder) and was toileted every two hours. CNA stated lying in one position longer than two hours will cause skin injuries. During an interview on [DATE] at 1:26 p.m. with LVN 2, LVN 2 stated she was the Treatment Nurse (a nurse assigned to provide wound care to residents with wounds). LVN 2 stated Resident 1 was incontinent and required the use of a hoyer lift. LVN 2 stated Resident 1 required wound care and turning and repositioning every two hours. LVN 2 stated turning and repositioning was required every two hours to alleviate pressure points on the body to prevent skin break down and to let wounds heal. During an interview on [DATE] at 1:40 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had impaired mobility, was incontinent of bowel and had an indwelling foley catheter (a tube inserted into the bladder to collect urine). The DON stated staff was required to check Resident 1's briefs (adult diaper) and turn and reposition Resident 1 every two hours. The DON stated it was the standard of practice to prevent skin break down and promote wound healing by turning and repositioning residents with wounds every two hours. The DON stated Resident 1's care plan did not specify how often Resident 1 should be turned and repositioned and should have. The DON stated there was no documentation that Resident 1 was turned and repositioned every two hours and should have. The DON stated the facility recently added turning and repositioning every two hours as a task for CNAs to complete for residents who required turning and repositioning every two hours to reflect that care was provided as indicated. The DON stated complete and accurate documentation was a requirement. During an interview on [DATE] at 1:45 p.m. with the Administrator (ADM), the ADM stated Resident 1 was unable to articulate (verbally express) his needs. The ADM stated Resident 1's spouse visited Resident 1 every day and she was his advocate (a person who supports and defends the interests of a patient). The ADM stated Resident 1 had skin breakdown and required two people to assist with transfer. The ADM stated it was standard of practice to turn and reposition immobile residents every two hours to avoid skin breakdown and promote wound healing. The ADM stated documentation of turning and repositioning every two hours should be complete and accurate to reflect the care provided. During an interview on [DATE] at 11:09 a.m. with the Medical Doctor (MD), the Medical Doctor stated he specialized in wound care. The MD stated the standard of practice to turn and reposition residents with pressure ulcers was every two hours to relieve pressure to the injured area, to promote wound healing and prevent the formation of pressure ulcers. The MD stated care plans should indicate offloading devices and repositioning every two hours. The MD stated documentation should be complete and accurate to reflect the required care ordered and provided. During a review of the facility's policy and procedure (P&P) titled, Wound and Skin Management, dated [DATE], the P&P indicated, Purpose: To maintain and/or improve tissue tolerance to pressure in order to prevent injury and/or infection and to assure that skin breakdown, and/or the potential for skin breakdown, is identified on admission and weekly thereafter as needed . Prevention: 1. The IDT, licensed nurses and CNAs are to ensure the following preventative measures are implemented for residents at risk for skin breakdown: . c. Ensure the resident is turned and repositioned as needed in bed and/or chair, if the resident can't do so independently . Intervention: 1. All staff are to take preventative measures for residents at risk for skin breakdown . During a review of the facility's P&P titled, Turning and Repositioning Patients, dated [DATE], the P&P indicated, Purpose: To prevent skin breakdown and contractures while providing the patients with appropriate circulation and comfort. Policy: It is the policy of this facility that patients will be repositioned throughout the day as needed for their physical and medical wellbeing. Procedure: . 2. Patients are to be repositioned routinely based on their needs . During a professional reference review retrieved from https://medlineplus.gov/ency/patientinstructions/000147.htm titled, Preventing pressure ulcers, dated [DATE], the professional reference indicated, Pressure ulcers are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This pressure reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. When this happens, a pressure ulcer may form . Change your position every 1 to 2 hours to keep the pressure off any one spot .

Based on observation, interview and record review, the facility failed to provide palatable and flavorful food when: 1. Broccoli was bland and without flavor for the regular diet. 79 Residents received broccoli at the facility. 2. Puree salad did not taste good. Five residents (Residents 2, 9, 63, 481, 482) were on the puree diet. These failures resulted in lack of flavor and palatability in vegetables and puree salad which can lead to residents having a decreased food intake and could result in weight loss and further compromise nutritional and medical status. There were 84 residents eating at the facility. Findings: During an interview on 12/9/24 at 1:10 p.m. with Resident 60 (R 60), R 60 stated the food was bland. During an interview on 12/10/24 at 12:32 p.m. with Resident 20 (R 20), R 20 stated the food did not taste good and he will not eat the food item if he does not like it. During a review of the facility menu titled, Winter Menus, the lunch menu on 12/10/24 indicated residents on regular, mechanical soft, dysphagia mechanical, no added salt and controlled carbohydrate diets received Pork with Pear Sauce, Sweet Potatoes, Seasoned Broccoli, Fresh [NAME] Salad with Dressing, Cranberry Crunch Square and Milk. The lunch menu indicated residents on puree diets received, Grinded Pork with Puree Pear Sauce, Sweet Potatoes, Seasoned Broccoli, Fresh [NAME] Salad with Dressing, Cranberry Crunch Square and Milk. During a review of the facility document titled, Diet Type Report, dated 12/9/24, showed there were 84 residents eating at the facility. 1. During a concurrent observation and interview on 12/10/24 at 12:43 p.m. with the Director of Nutritional Services (DNS) during a test tray of the regular and puree diets. Surveyors and DNS tasted the food items on the test trays. The broccoli was soggy and mushy, watery, bland, and dull green in color. DNS stated, limited salt and seasoning was added to the broccoli, and she needed to add additional salt and pepper to eat the food item. DNS stated the recipes do not call for many seasonings. DNS acknowledged the broccoli was bland and stated she was not sure why it was watery as they only use the steamer to cook it. During an interview on 12/12/24 at 12:31 p.m. with DNS, DNS stated excess moisture from cooking the broccoli made the food item soggy and additional salt seasoning would have made the food item taste better. DNS acknowledged that cooking with seasonings and salt helped improve flavor in the food. DNS stated, the goal should be to liberalize regular and therapeutic diets so residents will eat and enjoy their food. DNS stated she will have the RD discuss with the menu company. During a review of the facility's broccoli recipe titled, Healthcare Menus Direct, LLC Recipe: Seasoned Broccoli, dated 2024, the recipe indicated, 96 servings required only 1 tablespoon of salt seasoning. 2. During a concurrent observation of food preparation and interview on 12/10/24 at 10:48 a.m., with (DA 2) Dietary Aid 2, while making the puree salad, DA 2 put the salad in the robot coupe (food processor) then put the food in the blender. DA 2 stated she had to put the food in the robot coupe first to get enough liquid for the blender since the recipe does not call for any liquid when pureeing the salad. DA 2 stated they put salad dressing packets on the trays for the residents to use for the puree salad. During a review of the facility document titled Diet Type Report, showed there were five residents (Residents 2, 9, 63, 481, 482) on the puree diet. During a concurrent observation and interview on 12/10/24 at 12:43 p.m. with the Director of Nutritional Services (DNS) during a test tray of the regular and puree diets. Surveyors and DNS tasted the food items on the test trays. The puree salad tasted sharp and earthy and not very good. The salad dressing packet was very difficult for the DNS and surveyors to open. The puree salad tasted better with the Italian salad dressing however still not very palatable. DNS stated the recipe is without adding any liquid and the salad dressing is to be added at bedside. During an interview with CNA 1 on 12/11/24, CNA 1 stated she helps residents that are on puree diet with meals and trays. CNA 1 stated she will usually put salad dressing on the puree salads when the residents ask for it. CNA 1 stated if the trays do not have salad dressing, then she will go get some. CNA 1 stated the residents do not like the puree salads and will not eat it. During a review of the facility's document, Resident Council minutes (RCM), dated 10/28/24, the RCM's indicated, a dietary concern of, food not being good. During an interview on 12/12/24 at 10:06 a.m. with the Administrator (ADM), ADM stated he was unable to locate response forms for the last three months of resident council. ADM stated the activities director has been out on leave and resident council response forms were never completed. During an interview on 12/12/24 at 10:20 a.m. with the Registered Dietitian (RD), RD stated she is not involved in resident council and no changes in the menus or recipes have been made based on recent RCM's. RD stated, she would expect to be notified of any issues residents may have with food so menus and diets can be reviewed to determine changes. RD stated most food items in the kitchen use less salt seasoning since that is what is recommended by The American Heart Association (a nonprofit organization that aims to reduce the number of deaths and disabilities caused by cardiovascular disease). RD stated regular and therapeutic diets should be liberalized so residents can enjoy their food. RD stated she does do test trays and she relies on others to let her know if the residents do not like food items. RD does not ask kitchen staff or observe plate waste of puree salads and was not aware residents do not really eat that food item. RD stated she would discuss with the menu company about the lower sodium menu. During a review of document titled, Nutritional Breakdown of the Winter 2024-25 menus, showed for the regular diet there was 2,785 milligrams (mg) of sodium. During a review of the Academy of Nutrition and Dietetics Nutrition Care Manual, dated 2024, showed that a reduction in sodium intake to 2000 mg to 3000 mg sodium per day has been effective in patients with heart failure. It showed a more liberalized approach to sodium intake may benefit older adults. It indicated that many institutions offer diet orders with varying degrees of sodium restriction and the most liberal sodium diet is the no-salt-packet diet and the no-added-salt (NAS) (3000 mg to 4000 mg sodium) diet limits high-sodium foods and eliminates the salt packet. It showed the low-sodium diet (1500 mg to 2300 mg sodium) restricts some high-sodium foods and replaces other higher-sodium foods with lower-sodium items. The facility regular diet provides 485 mg more than the upper range of what is considered a low sodium diet. During a review of the Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings, dated 2018, indicated the Pioneer Network's New Dining Practice Standards are supported by multiple health care organizations, including the Academy. It indicated the standards encourage liberalizing dietary restrictions that are not essential to a resident's well-being. It indicated food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. It indicated older adults may find restrictive diets unpalatable, resulting in reduced pleasure in eating, decreased food intake, unintentional weight loss, and malnutrition. 28773 51134

Based on interview and record review the facility failed to inform and provide written information on how to formulate an advance directive (a legal document that outlines a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness or injury) for 87 of 87 residents when staff did not document information on how to obtain an advance directive in resident charts. This failure violated the rights of 87 residents to be informed on how to formulate and obtain an advance directive. Findings: During an interview on 12/11/24 at 10:28 a.m. with the Medical Records Director (MRD), the MRD stated the facility did not help residents obtain an advance directive, they refer the resident to someone else such as their primary physician to get an advance directive completed. The MRD stated the facility will only keep a resident's advance directive on file in their chart if a resident came in with one. The MRD stated if a resident did not have an existing advance directive when they came into the facility no education or information on how to obtain an advance directive will be documented in the resident's chart. During an interview on 12/11/24 at 10:34 a.m. with Social Services Director Assistant (SSDA) 1, SSDA 1 stated if a resident or their family wanted an advance directive the resident or their family would get directed to follow up with the Long Term Care Ombudsman (LTCO) in order to have the LTCO help them obtain an advance directive. SSDA 1 stated no documentation was put in resident's charts regarding advance directives. SSDA 1 stated it was important to ensure proper documentation was present regarding how to obtain an advance directive because an advance directive ensured a resident's wishes for end of life were followed. During an interview on 12/11/23 at 10:47 a.m. with the Intake Coordinator (IC), the IC stated if a resident came into the facility and did not have an advance directive but would like one, the facility staff would direct the resident to go to their primary physician for assistance in obtaining one. The IC stated staff did not keep documentation in resident charts regarding communication to the resident or their family on how to obtain an advance directive. The IC stated documentation on how to obtain an advance directive was important because an advance directive would allow a resident's last wishes to be honored if they became too ill to make their own decisions. During an interview on 12/13/24 at 4:31 p.m. with the Assistant Director of Nursing (ADON) the ADON stated it was not a practice of the facility to document on any resident's chart whether or not they provided education and information to residents on how to obtain an advance directive. During a review of the facility's policy and procedure titled, Advance Health Care Directive (AHCD), dated 4/30/22, indicated, . 6. If the resident is not able to discuss an advance health care directive due to his/her condition, the social service designee is to review when the resident and/or representative is ready to discuss his/her wishes .7. Social Services designee is to document discussions with the resident and/or representative in the resident's medical record . 49949

Based on interview and record review, the facility failed to revise and implement a person-centered comprehensive care plan (CP- road map for the care of a resident and a necessary tool in following the nursing process) for one of eight sampled residents (Resident 45) when the care plan was not updated to reflect discharge from hospice (end of life) service. This failure had the potential for Resident 45's needs to not be meet. Findings: During an interview on 12/10/24 at 9:38 p.m. in Resident 45's room with Family Member (FM) 1, FM 1 stated her mother was no longer on hospice services. During a concurrent interview and record review on 12/11/24 at 11:23 a.m. with License Vocation Nurse (LVN) 5, LVN 5 stated Resident 45 had been on hospice but was discharged from hospice on 11/16/24. LVN 5 stated the care plan for hospice should have been updated on the same day Resident 45 was discharged from hospice. LVN 5 stated the business office and primary physician were notified when Resident 45 was discharged from hospice. LVN 5 stated she received a verbal order from the hospice agency to discharge Resident 45 on 11/16/24. LVN 5 stated she documented the conversation on Resident 45's chart. LVN 5 stated the care plan for hospice should have been discontinued. LVN 5 stated Resident 45's care plan should have been updated when there was a change in condition (CIC-refer to a resident's health or functioning that is either short term or significant) LVN 5 stated a discharge from hospice was considered a changed in condition. LVN 5 stated Resident 45's care plan tells the nurses how to care for her and it was something the nurses needed to follow. LVN 5 stated, It should be updated because it is the care plan we are following. LVN 5 stated an incorrect care plan could have led to lack of communication for staff. LVN 5 stated care plans were individualized and specific to each resident's needs. LVN 5 stated licensed nurses should have updated the care plan. LVN 5 stated it was not done for Resident 45. During an interview on 12/11/24 at 11:56 a.m. with Minimum Data Set Nurse (MDSN) 2, MDSN 2 stated Resident 45 had a significant change in condition and the care plan should have been updated when she was discharged from hospice. MDSN 2 stated it was important for care plan to be updated when Resident 45 was no longer receiving hospice services. MDSN 2 stated Resident 45's care plan was used for communication with other healthcare team members, and it should have been done. During an interview on 12/13/24 at 3:26 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the MDSN should have updated and reviewed the care plan when there was a change in condition. The ADON stated updating care plan was part of the job description for licensed nurses. The ADON stated Resident 46's care plan was not patient specific and individualized when it was not updated. The ADON stated all care plans were specific to each resident's care. The ADON stated Resident 45's care plan should have been updated when she was discharged from hospice, and it was not done. During a review of Resident's Admission Record (AR-a document with personal identifiable and medical information), dated 12/12/24 the AR indicated, Resident 45 was admitted to the facility on [DATE] with diagnoses which included hemiplegia ( a neurological condition that causes paralysis or weakness on one side of the body/0 and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infraction (a serious condition that occurs when blood flow to the brain is blocked, leading to brain cell death), hypertension (high blood pressure- is when the pressure in your blood vessels is too high (140/90 mmHg or higher), anxiety (feeling of fear, dread, and uneasiness that can be a normal reaction to stress ), severe protein-caloric malnutrition (a condition that occurs when someone doesn't consume enough protein, calories, and other essential nutrients), muscle weakness and pain. During a review of Resident 45's Physician Order (PO), dated 11/16/24, the PO indicated, .Created Date 11/16/24 00:16 [line] Communication Method: Verbal .Order Summary: Admit to [Hospice Agency Name] hospice: Dx: Hemiplegia following cerebral infection [infraction] affecting left non-dominant side. [line]Discontinue: 11/16/24 .Discontinue Date/Reason: pt requesting bx (biopsy) from oncology, hospice dc [discharged ] . During a review of Resident 45's [Facility Name] Transitional Care- Progress Note (PN), dated 11/15/24, the PN indicated, .Note Text: Per hospice RN [nurse name] patient came off hospice today d/t patient is pending a biopsy on 11/18/24 with an oncologist . During a review of Resident 45's Care plan (CP) dated 12/13/24, the CP indicated, .[box] Resolved:1 The resident was admitted to [hospice Agency Name] Hospice: Dx: Hemiplegia following cerebral infarction affecting left non-dominant side .Resolved date: 11/28/2024. During a review of the facility's policy and procedure titled, Care Plans dated revision date 7/1/2014, the Care Plans indicated, .2. The care plan will be reviewed and revised by the IDT [ Interdisciplinary Team (IDT) meeting is a collaborative meeting where professionals from different disciplines work together to plan and coordinate resident care] after each resident's assessment, quarterly and more often as warrant by the changes in the resident's condition .4. The resident's care plan will be updated as changes occur including, but not limited to .

Based on observation, interview and record review, the facility failed to meet professional standards of practice for four of 16 sampled residents (Resident 46, Resident 231, Resident 233, and Resident 235) when: 1. Resident 46, Resident 231 and Resident 235's oxygen tubing were not labled with the date the tubing was changed. This failure put Residents 46, 231 and 235 at risk of infection. 2. The Attending Physician (AP) was not notified when Resident 233's medication for hypertension (high blood pressure) was not given due to low blood pressure levels. This failure put resident 233 at risk of harm due to low blood pressure levels. 3. Resident 235's physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident) for oxygen flow rate was for 2 L/min (liters per minute - a unit of measurement) and it was set at 4.5 L/min. This failure resulted in Resident 235 receiving too much oxygen and had the potential to result shortness of breath and respiratory distress (difficulty breathing) for Resident 235. Findings: 1. During a concurrent observation and interview on 12/09/24 at 11:50 a.m. in Resident 46's room, Resident 46 had no date on his nasal cannula tubing (a device that gives you additional oxygen through your nose). During a concurrent observation and interview on 12/10/24 at 4:41 p.m. in Resident 46's room, LVN 6 confirmed no date was on the nasal cannula tubing. LVN 6 stated the nasal cannula tubing should have been labeled with a date. LVN 6 stated, it was important to date the nasal cannula tubing to ensure when it was last changed. LVN 6 stated, night nurses were responsible for changing the nasal cannula tubing weekly. LVN 6 stated, Resident 46 was at risk for an infection when the nasal cannula was not changed weekly. During a review of Resident 46's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/13/24, the AR indicated Resident 46 was admitted on [DATE], with diagnoses of transient ischemic attack (TIA - a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), candidiasis (a type of fungal infection) of skin and nails, type 2 diabetes mellitus, resistance to multiple antibiotics, dependent on oxygen, muscle weakness, anxiety (feeling of fear, dread, and uneasiness that can be a normal reaction to stress), sleep apnea ( a sleep disorder characterized by repeated episodes of pauses in breathing during sleep). During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 10/23/24 the MDS section C indicated Resident 46 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 12 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 46 was moderated impaired in cognition. During a concurrent observation and interview on 12/09/24 at 11:56 a.m. with Resident 231 in Resident 231's room, Resident 231 was observed in a gown sitting in a wheelchair with oxygen (O2) infusing via a nasal cannula (a tube that delivers oxygen through the nose to people who have low oxygen levels). Resident 231's O2 nasal cannula was observed to not have the date the oxygen tubing was changed. Resident 231 stated she had been in the facility for two days. During a review of Resident 231's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/13/24, the AR indicated Resident 231 was admitted to the facility from the acute care hospital on 12/6/24 with diagnoses of chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 231's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/11/24, the MDS section C indicated Resident 231 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 11 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 231 was moderately impaired. During a concurrent observation and interview on 12/10/24 at 8:55 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 231's room, Resident 231's oxygen tubing was observed to be not labled with a date. LVN 2 verified Resident 231's oxygen tubing was not dated. LVN 2 stated Resident 231's oxygen tubing should have been dated so staff would know when it was changed. LVN 2 stated if Resident 231's oxygen tubing was not changed weekly, Resident 231 could get an infection. During a concurrent observation and interview on 12/10/24 at 11:20 a.m. in Resident 235's room, Resident 235 was observed dressed in bed, wearing oxygen tubing with a nasal cannula Resident 235's oxygen tubing did not have a date label. During a review of Resident 235's AR dated 12/12/24, the AR indicated Resident 235 was admitted to the facility from the acute care hospital on 11/21/24 with diagnoses of emphysema (a chronic lung disease in which the air sacs may be destroyed, making it difficult to breath. Also referred to as chronic obstructive pulmonary disease - COPD), pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest, dysphagia (difficulty swallowing), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), atrial fibrillation (an irregular and often very rapid heart rhythm), intestinal obstruction (a blockage that keeps food or liquid from passing through the small intestine or large intestine), and surgical aftercare following surgery on the digestive system. During a review of Resident 235's MDS dated [DATE], the MDS section C indicated Resident 235 had a BIMS score of 15 which suggested Resident 235 was cognitively intact. During a concurrent observation and interview on 12/10/24 at 11:52 a.m. with LVN 5 in Resident 235's room. Resident 235's oxygen tubing was not labeled with a date. LVN 5 stated Resident 235's oxygen tubing should have been labeled with the date it was changed. LVN 5 stated Resident 235's oxygen tubing should have been dated so staff would know when the tubing was changed. LVN 5 stated the oxygen tubing should have been changed weekly so no dirt or particulates were in the tubing. LVN 5 stated residents could aspirate the dirt or particles in the tubing which would be a risk of infection to residents. During an interview on 12/13/24 at 12:21 p.m. with the Infection Prevention Nurse (IP), the IP stated a date on the oxygen tubing would let other staff know when the tubing was last changed. The IP stated if there was no date on the tubing, staff could not assume when the tubing was changed. The IP stated Resident 46, Resident 231and Resident 235's oxygen tubing should have been dated due to a risk of infection for Residents 46, Resident 231and Resident 235. During a review of the facility's job description document titled, Charge Nurse, undated, the document indicated, . implement plan of care consistently, effectively . with focus on resident centered outcomes . follow facility policies and procedures to ensure a safe, caring, comfortable and clean environment . During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 1/3122, indicated, . humidifiers and oxygen devices (cannulas or mask) are to be marked with black sharpie the date and nurse's initial . nasal cannulas are to be changed weekly or as needed if soiled. The date and initials of the nurse who changed these items is to be marked with a black sharpie . 2. During an observation on 12/11/24 at 12:20 p.m. in Resident 233's room, Resident 233 was observed wearing a gown, sitting in his wheelchair. LVN 4 was observed taking Resident 233's blood pressure, with a reading of 96/59. LVN 4 was observed to not give Resident 233's high blood pressure medication. During a review of Resident 233's AR, dated 12/13/24, the AR indicated, Resident 233 was admitted on [DATE] from the acute care hospital with diagnoses of heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid), hypertension (high blood pressure), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 233's MDS, dated [DATE], the MDS section C indicated Resident 233 had a BIMS score of three, which indicated Resident 233 had severe impairment. During a concurrent interview and record review on 12/12/24 at 3:38 p.m. with LVN 2, Resident 233's physician Order Summary Report, undated was reviewed. The Order Summary Report indicated, . hydralazine hcl oral tablet 25 mg (milligram - a unit of measurement) . give one tablet by mouth two times a day for HTN (hypertension) hold if SBP (systolic blood pressure [when the heart muscle contracts] < (less than) 100 and notify MD (physician) . Resident 233's Medication Administration Record (MAR), dated 12/1/24 to 12/31/23 was reviewed. The MAR indicated Resident 233's medication for hypertension was held on 12/11/24 and 12/12/24. LVN 2 stated there was no documentation from the nurse that Resident 233's physician was notified when Resident 233's medication was not given. LVN 2 stated if the physician was not notified, the nurse was not following physician orders. LVN 2 stated a negative outcome could occur with Resident 233 if his medication was not given due to low blood pressure and the physician was not notified. During an interview on 12/13/24 at 12:21 p.m. with the IP, the IP stated nurses should have followed physician orders. The IP stated if staff did not follow physician orders, they could have caused harm to Resident 233. The IP stated an adverse (harmful) reaction could have occurred with Resident 233 if staff did not follow physician orders. During a review of the facility's job description document titled, Charge Nurse, undated, the document indicated, . implement plan of care consistently, effectively . with focus on resident centered outcomes . carries out physician orders as prescribed . follow facility policies and procedures to ensure a safe, caring, comfortable and clean environment . keep physician and/or other health care professionals (Nurse Practitioner, Physician Assistant, podiatrist, dentist, etc.) informed of resident's condition; and notify physician and/or other healthcare professions immediately of significant changes of condition . administers medications as ordered and monitors for signs and symptoms of adverse effects . follows up on resident change of conditions. Documents all findings and communicates with the physician . notify physician and/or other health care professionals if orders are not carried out and document event appropriately . During a review of the facility's P&P titled, Documentation, Nursing, dated 1/31/22, indicated, . licensed nurses are to document throughout their shift, capturing all changes in condition, treatments, responses to treatment and overall observation of the resident . nurses notes are written for any episodic issue, physician communication or other nursing measure that requires documentation in the medical record . During a review of the facility's P&P titled Physician Orders, dated 12/01/15, indicated, . the facility may also fax to the physician a blank (except when sending statistical information) facsimile order form on which the physician may write an order or instructions and return to the facility via facsimile . the facility may fax a MD Notification form to physician with information regarding resident condition on which the physician may write an order/response and return to the facility . 3. During a concurrent observation and interview on 12/10/24 at 11:20 a.m. in Resident 235's room, Resident 235 was observed dressed in bed, wearing oxygen tubing with a nasal cannula. Resident 235 stated she is receiving oxygen at a rate of 2 L/min. Oxygen was being administered at 4.5L/min. Resident 235 stated the oxygen rate seemed high. During a review of Resident 235's AR dated 12/12/24, the AR indicated Resident 235 was admitted to the facility from the acute care hospital on 11/21/24 with diagnoses of emphysema (a chronic lung disease in which the air sacs may be destroyed, making it difficult to breath. Also referred to as chronic obstructive pulmonary disease - COPD), pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest, dysphagia (difficulty swallowing), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), atrial fibrillation (an irregular and often very rapid heart rhythm), intestinal obstruction (a blockage that keeps food or liquid from passing through the small intestine or large intestine), and surgical aftercare following surgery on the digestive system. During a review of Resident 235's MDS dated [DATE], the MDS section C indicated Resident 235 had a BIMS score of 15 which suggested Resident 235 was cognitively intact. During a concurrent observation and interview on 12/10/24 at 11:52 a.m. with LVN 5 in Resident 235's room, Resident 235's oxygen rate was observed to be set at 4.5L/min. LVN 5 stated Resident 235's oxygen rate should have been set to 3L/min. During a concurrent interview and record review on 12/10/24 at 11:54 a.m. with LVN 5, Resident 235's Order Summary Report, undated was reviewed. The Order Summary Report indicated, . oxygen @ (at) 2L/min via n/c (nasal cannula), prn (as needed), to keep sats (oxygen saturation - the amount of oxygen circulating in the blood) at or above 90% as needed . LVN 5 stated during report she received information that Resident 235's oxygen rate was to be set at 3L/min. LVN 5 stated she was not sure why Resident 235's rate was changed. LVN 5 stated Resident 235's oxygen rate should have been set to 2L/min. LVN 5 stated Resident 235's oxygen rate should have been checked every day during shift change after nurses received report, and during each medication pass to the Resident 235. LVN 5 stated it was important to follow physician orders to prevent adverse events occurring with residents. During an interview with LVN 2 on 12/12/24 at 3:38 p.m., LVN 2 stated she expected nurses to follow physician's orders. LVN 2 stated if staff did not follow physician orders, residents could have a negative outcome. During an interview on 12/13/24 at 12:21 p.m. with the IP, the IP stated nurses should have been following orders for Resident 235's oxygen rate. The IP stated staff could cause more harm to residents if oxygen was not given as ordered by the physician especially for residents with certain diagnoses such as COPD. The IP stated an adverse reaction could occur to residents if staff did not follow physician orders. During a review of the facility's job description document titled, Charge Nurse, undated, the document indicated, . implement plan of care consistently, effectively . with focus on resident centered outcomes . carries out physician orders as prescribed . follow facility policies and procedures to ensure a safe, caring, comfortable and clean environment . administers medications as ordered and monitors for signs and symptoms of adverse effects . performs prescribed treatments and documents all findings in the resident's medical record . notify physician and/or other health care professionals if orders are not carried out and document event appropriately . During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 1/31/22, indicated, . oxygen will only be administered by physician's order . oxygen shall be administered to residents only by a licensed nurse . licensed nurses are to document on the MAR (Medication Administration Record) each shift that oxygen is used at the ordered flow rate . check the operation of the oxygen delivery system when monitoring the flow rate . 49949

Based on observation, interview, and record review the facility failed to ensure nursing staff information data posting contained or demonstrated the total numbers and actual hours worked by Registered nurses (RN), license vocational nurses (LVN) and Certified nurse aides, were posted daily. This failure resulted in 87 out of 87 residents and their family members not being able to identify who was responsible for their care, how many licensed and unlicensed staff were on shift, and the total number of hours staff were working. Findings: During an observation on 12/13/24 at 2:35 p.m. in the hallway, the Census and Direct Care Services Hours Per Patient Day (DHPPD) did not contain the total number of actual hours worked for RNs, LVNs and CNAs. During an interview on 12/13/24 at 3:04 p.m. with the Administrator (ADM) the ADM stated, We have only CNA hours posted and no nursing hours posted. The ADM stated, the posting sign had CNA actual hours and no licensed nurse actual hours posted. The ADM stated he was not aware the hours needed to be posted. The ADM stated there were no posted numbers of RNs, LVNs and CNAs working. During an interview on 12/13/24 at 3:56 p.m. with the Staff Coordinator (SC), the SC stated, The hours for everyone is on there, but it is not specific. The SC stated she and ADM were responsible for inputting the posting hours. The SC stated, You can't tell how many hours were worked by the RN, LVN and CNA. The SC stated the hours on the DHPPD were for the total hours worked by the combined staff. The SC stated she was not aware she needed to post the RN, LVN and CNA hours separately. During a review of the facility's policy and procedure (P&P) titled, Nursing Staffing Ratio Posting, dated review date 1/31/22, the P&P indicated, It is the policy of this facility to post the daily nurse staffing ratios in a clear and readable format that is readily available to the staff, residents and interested members of the public .The Staff Coordinator, designated by the facility administrator, is responsible for the following on a daily basis: 1. Collect and document the required staffing information on the facility staff posting form: a. Facility name b. The current date c. The total number of staff bodies and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. i. Registered nurse ii. Licensed vocational nurses iii. Certified nurse aides .

Based on interview and record review, the facility failed to implement an effective process to ensure the maintenance of acceptable parameters of nutritional status and hydration for one of three sampled residents (Residents 1) when staff did not weigh Resident 1 weekly in accordance with facility policy and procedure, the recommendations and instructions provided by the Registered Dietician (RD) after identifying a risk for weight loss during the admission assessment, and again after weight loss had occurred, were not implemented by nursing staff. Staff did not notify the physician of Resident 1's decreased intake of food and fluids and weight loss until Resident 1 had experienced severe weight loss and was dehydrated. Staff did not consistently provide Resident 1 with assistance with eating and drinking. Resident 1 was on a Controlled Carbohydrate diet (CCHO- a diet ordered for diabetics) from [DATE] to [DATE] and did not have a diagnosis of diabetes. These failures resulted in Resident 1 experiencing an avoidable severe weight loss of 24% from an admission weight of 146.7 pounds (lbs.) on [DATE] to 111.2 lbs. on [DATE], contributed to dehydration and the development of two pressure-induced Deep Tissue Injuries (DTI) and a decline in health. Resident 1 was transferred to the hospital Emergency Department (ED) on [DATE] when Resident 1 became difficult to arouse and again on [DATE] due respiratory distress and was admitted to the hospital. Resident 1 was discharged from the hospital to hospice on [DATE] where he expired on [DATE]. Findings: During a review Resident 1 ' s medical record, the document titled, Admission Record (AR) dated [DATE], indicated, Resident 1 was admitted on [DATE] from an acute care hospital (Hospital A) following hip replacement surgery. The AR indicated Resident 1 was a [AGE] year old male with diagnoses of muscle weakness, difficulty walking, retention of urine after surgery, placement of a indwelling urinary catheter, facial weakness, and a history of chronic kidney disease, hearing loss, unspecified dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) without behavioral disturbance, enlargement of prostate without urinary tract symptoms, presence of a cardiac pacemaker (a small electronic device, implanted in the chest to help the heart beat at a normal rate and rhythm), and prior cardiac surgery. The AR indicated Resident 1 had been discharged from the facility to an acute care hospital (Hospital B) on [DATE]. During an interview on [DATE] at 10:10 a.m., with a close friend (CF) of Resident 1, CF stated she had been close friends with Resident 1 for [AGE] years, saw him frequently before his fall and surgery, and visited him several times while he was at the facility. CF stated Resident 1 had stooped posture and had difficulty sitting up enough to be able to feed or hydrate himself. CF stated Resident 1 was weak and unable to reach and pick up a glass of water and bring it to his mouth to drink. CF stated when she visited Resident 1 on more than one occasion there was a cup of water with a straw, a carton of milk or juice with a straw in it on the bedside table but Resident 1 could not drink from them unless someone was there to pick up the drink and put the straw up to his mouth. CF stated she was very concerned Resident 1 would become dehydrated. CF stated Resident 1 lost so much weight while at the facility he was just skin and bones. During a review of Resident 1 ' s admission orders, dated [DATE], the orders indicated Resident 1 had the ability to make his own decisions and wanted Cardiopulmonary Resuscitation (CPR- a lifesaving procedure performed when the heart stops beating) performed if needed. The record included orders for physical therapy and an order for a CCHO mechanical soft diet with thin liquids. During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool used to identify resident cognitive and physical function), dated [DATE], the MDS assessment indicated Resident 1 ' s Brief Interview for Mental Status (BIMS, an assessment used to identify a resident ' s current cognition) score was 7 out of 15, which indicated at the time of the assessment Resident 1 had severe cognitive impairment. The MDS also indicated Resident 1 required one-person physical assist with Eating/Drinking, and two or more-person physical assist with Bed Mobility (how resident moves to and from lying position, or turns side to side, and positions self in bed). During an interview on [DATE] at 3 p.m. with the Director of Nurses (DON), the DON stated Resident 1 was no longer a resident at the facility. The DON stated Resident 1 was sent from the facility to the hospital (Hospital B) on [DATE] and did not return to the facility. The DON stated she was aware that Resident 1 had passed away several days after he was sent to Hospital B. During an interview on [DATE] at 3:15 p.m. with the Social Services Assistant (SSA), the SSA stated she met with Resident 1 shortly after he was admitted , and Resident 1 was alert, aware of his name and where he was, and did not seem confused. The SSA stated Resident 1 was independent prior to having hip surgery and lived at home with his girlfriend and her caregiver. The SSA stated Resident 1 ' s goal was to be discharged back to his home. During a review of Resident 1 ' s Admission Nutrition Assessment, dated [DATE] at 4:43 p.m., the assessment completed by RD 2 indicated Resident 1 was 5 feet 10 inches tall and weighed 146.7 pounds on admission to the facility with a Body Mass Index (BMI - measure of body fat based on height and weight. A normal BMI is 18.5 to 24.9) of 21. RD 2 indicated Resident 1 ' s usual weight was unknown, and his ideal body weight was 166 lbs. RD 2 ' s assessment indicated Resident 1 was alert and was not confused. RD 2 indicated Resident 1's estimated daily calorie requirements were between 1340 and 1675 kilocalories (kcals- a unit of measurement, used interchangeably with calories) estimated daily protein requirements were between 54 and 67 grams (gms- a unit of measurement), and estimated daily fluid requirements were between 1340 and 1675 milliliters (mls- a unit of measurement). RD 2 indicated Resident 1's current CCHO diet provided 1961 calories and 93 gms of protein per day. RD 2 reviewed the three days of oral intake since admission and noted Resident 1 consumed approximately 36% of his meals (706 calories and 33 gms of protein per day) which met 53% of Resident 1 ' s estimated nutritional needs. RD 2's assessment indicated Resident 1 was at risk for weight loss and required a therapeutic diet. RD 2 ' s recommendations included a fortified diet (addition of protein, fat, and/or carbohydrate to foods), nutritional supplement shakes twice a day, weekly weights, monitor oral intake and skin. During a review of Resident 1's report of meal percentage (%) consumed, the report showed the % eaten by Resident 1 for each meal (breakfast, lunch, and dinner) during his stay at the facility from [DATE] through [DATE]. Of the 65 meals scheduled, three meals were not served due to Resident 1 being away from the facility or fasting for lab work. The report showed for 45 of the 62 meals (72.5%) served, Resident 1 ate 50% or less of the meal. The report showed Resident 1 ate 75% or more for eight of the meals served (13%) and refused six meals (9.6%). The report indicated there was no documentation of how much Resident 1 ate for three of the meals (4.8%). During a review of the Interdisciplinary Care Conference (meeting with staff from different disciplines involved in the resident's care) Summary dated [DATE], the Dietary section completed on [DATE] by the Dietary Manager indicated, .Percentage of Meal Consumption 38% and fluid intake of 631 mls per day [estimated daily fluid requirement- ,d+[DATE] mls]. Last recorded weight of 111.2 lbs. on [DATE]. Weight loss of 35.5 lbs./24.2% since admission weight on [DATE]. Admission weight suspected to be inaccurate. Dietary Goal: Continue to tolerate current diet per MD [medical doctor] orders with increased PO (oral) meal and fluid intake and no significant weight changes . During a review of Resident 1 ' s Dietician Note, dated [DATE] at 10:52 a.m., the note written by RD 2 indicated Resident 1 had significant weight loss of 35.5 lbs. in two weeks. RD 2 ' s note indicated Resident 1's current daily diet provided 2214 kcal (calories) with 97 gms protein, and Resident 1 consumed approximately 37% of meals (819 calories, 36 gms protein) and approximately 689 ml of fluid per day for the past seven days [approximately 51% of estimated daily fluid need of ,d+[DATE]mls per day]. The note indicated, .RD [RD 2] recommended to fortify diet and provide [nutritional supplement shakes] twice a day upon admission assessment, recommendations not yet carried out. Weight loss r/t [related to] inadequate intake of nutrient needs, 54% of estimated kcal needs met via diet .Malnutrition r/t inadequate intake of meals AEB [as evidenced by] underweight BMI 16, significant weight loss 24.4%/35 lbs. x 2 weeks. Fortify diet, shakes with lunch and dinner, MD- add malnutrition as diagnosis. During a concurrent interview and record review on [DATE] at 9:35 a.m. with the Registered Dietician (RD 1), RD 1 stated she did not take care of Resident 1, but she had reviewed the record. RD 1 stated weights are supposed to be done on admission and once a week for the first four weeks and then at least once a month unless they need to be done more frequently. Review of Resident 1 ' s Weight and Vitals Summary indicated: [DATE] 146.7 lbs. (pounds) [DATE] 106.9 lbs. [DATE] 111.2 lbs. RD 1 stated she did not know why Resident 1 was not weighed again after [DATE] given there was such a significant change. RD 1 stated it may be that the nursing staff thought things were improving when the weight was 111.2 lbs. on [DATE]. RD 1 stated 106.9 lbs. is quite a drop. RD 1 stated if someone gets a weight which seems wrong, they should re-weigh the resident to make sure they are getting an accurate weight. RD 1 stated the staff can contact the RD if they have a concern about weight loss and should also notify the physician. During a concurrent interview and record review on [DATE] at 12:30 p.m. with the Director of Nurses (DON), Resident 1's weight summary record was reviewed. The DON confirmed the weight summary indicated Resident 1 had experienced a weight loss of 35.5 lbs. from admission on [DATE] to [DATE] and that no more weights were obtained after [DATE]. The DON stated she does not know why Resident 1 was not weighed again after [DATE] since weights were supposed to be done weekly The DON stated she thought the resident had refused to be weighed but could not remember specifically when Resident 1 refused. The DON stated the record indicated staff did not document any unsuccessful attempts to weigh Resident 1 or any occasions when Resident 1 refused to be weighed. The DON also stated there was no documentation in Resident 1 ' s medical record indicating the physician was notified about a refusal, if it had occurred. The DON stated if there is a question about a weight being correct, it should be rechecked. During a review of Resident 1's record, the intake record from [DATE] through [DATE] was reviewed. The record indicated the date, time, and amount of oral fluid intake, and the total amount for each day which included the amount of fluid served with the meal trays. The record indicated Resident 1's daily oral fluid intake between [DATE] and [DATE] ranged from 240 ml (one cup) to 1090 ml per day. The record indicated the majority of the time (13 of 20 days [[DATE] and [DATE] excluded]), Resident 1's fluid intake was 720 ml or less per day. The record indicated there were no days that Resident 1's fluid intake met the estimated daily fluid requirement of between 1340 ml and 1675 ml per day. During a concurrent interview and record review on [DATE] at 12:40 p.m. with the Director of Nurses (DON), Resident 1 ' s fluid intake records were reviewed. The DON stated Resident 1 refused fluids frequently. Review of the record of fluid intake from admission on [DATE] until [DATE], indicated out of the 119 times Resident 1 was offered fluids, the record indicated he refused six times. The DON stated the staff need to document any time the resident refuses. A review of the care plan dated [DATE] through [DATE] did not indicate refusal of food and fluids had been identified as a problem. During an interview on [DATE] at 1 pm with the Director of Staff Development (DSD), the DSD stated in order to ensure weights are accurate and not missed, there needs to be a consistent process. The weights need to be done in the same way, on the same day of the week, and by the same core group of certified nursing assistant (CNA) staff. The DSD stated they used to do it this way but that stopped this last year when they did not have enough staff to dedicate to that task which meant each CNA was responsible for doing the weights of the residents on their assigned team. The DSD stated this method of taking weights led to missed weights, inaccurate weights, and the need to reweigh residents. The DSD stated all of the staff were trained before, it is just that some staff are better than others at weighing residents. The DSD stated the facility just restarted the process that week (the last week of [DATE]) of having a core group of CNAs doing the weights on a designated day of the week. The DSD stated this process was not in place when Resident 1 was at the facility ([DATE]- [DATE]). During a concurrent interview and record review on [DATE] at 2 p.m. with the DON, a report of the documented level of eating/drinking support provided by staff for breakfast, lunch, and dinner was reviewed. The DON stated staff assisted Resident 1 with eating and drinking. The report indicated from [DATE] to [DATE] set up help only was provided with eating and drinking for 31 of 62 meals served (50%) meals, one-person physical assist was provided for 24 meals (38.7%), and the level of assistance provided was not documented for seven meals (11.3%) Review of the Care Plan dated [DATE], indicated a Focus of Risk for Weight Fluctuations however, the only interventions were to provide supplements as ordered and to weigh resident weekly and did not include providing staff assistance with eating and drinking. During a review of Resident 1 ' s Skin/Wound Note, dated [DATE] at 8:33 p.m., the note indicated Resident 1 had developed deep tissue injuries (DTI) on both of his heels, the left one measuring four centimeters by four centimeters in size, and the right one measuring six centimeters by six centimeters in size. During a review of Resident 1 ' s record, the Physical Therapy notes dated [DATE] at 9:48 a.m., indicated, Resident 1 experienced a syncopal episode (passed out) while sitting in his wheelchair and was unresponsive for ,d+[DATE] minutes. During a review of the Physician's Assistant's (PA - a licensed health care professional trained to provide medical care under physician supervision) progress note dated [DATE], untimed, the progress note indicated, . Staff reporting decreased oral intake. BMI 16, weight 111.2 lbs. [[DATE]], height 70 inches .oral mucosa dry .Foley [urinary catheter] cloudy .discussed with Dr. [name of MD] .Plan: Lab- Complete Blood Count [CBC- test to evaluate the different types of blood cells and can be used to help diagnose health conditions such as anemia and infection], basic metabolic panel [BMP s a blood test that includes eight different measurements and may be used to evaluate kidney function, fluid and electrolyte balance, blood sugar, and acid-base balance], clamp foley for urinalysis [UA] and urine culture and sensitivity [C&S- a test to identify what bacteria is present in the urine and which antibiotics will be most effective in treating the infection] . Start Intravenous line [IV-into a vein)] D5NS [IV fluid containing dextrose and sodium chloride] infuse at 100 ml/hour .Intake and Output [I&O]- Record hourly urine output . During a review of Resident 1 ' s record, the SBAR (Situation, Background, Assessment, and Recommendation-a communication tool used by staff for assessing and recording change in resident status) note dated [DATE] at 4:42 p.m., indicated, .At 3:40 p.m . noticed a change in condition in pt [patient] from prior days. Pt had been sleeping throughout the day and hard to arouse awake and was drinking and eating very little .This is new as previous days pt would be awake and able to answer questions .PA to send pt to ER . The record indicated Resident 1 was sent to the Emergency Department (ED) at Hospital B at 4:02 p.m. During of review Hospital B ' s ED physician ' s note dated [DATE] at 4:27 p.m., the note indicated Resident 1 was brought to ED by ambulance due to staff concern that Resident 1 has not been eating and does not want to get out of bed and is not at his baseline mentation. The note indicated Resident 1 was at baseline with no neuro deficits (abnormal function caused by injury to the brain, spinal cord, nerves), was alert and oriented and had no complaints except being tired. Lab work including blood cultures, imaging, and an electrocardiogram were done. A urinalysis was ordered but not done. ED MD indicated Resident 1 was dehydrated and IV fluids were given. The note indicated at 7:07 p.m. Resident 1 was feeling better and the ED MD gave a discharge order and diagnoses of dehydration, acute renal failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), and generalized weakness. Resident 1 was transferred back to the facility at approximately 10:30 p.m. During a interview on [DATE] at 2:10 p.m. with the DON, the DON was asked if a urinalysis (UA) was obtained by the facility per the PA ' s note on [DATE]. The DON stated no UA was done at the facility; once the resident goes to the ED, that negates any orders given by the PA. The DON stated she was not sure if the hospital did a UA. During a review of the Nursing Progress Note, dated [DATE] at 9:52 a.m., the progress note indicated Resident 1 tested positive for COVID-19. During a review of Resident 1 ' s Dietician Note, dated [DATE] at 6 p.m., the note written by RD 3 indicated Resident 1 was on a CCHO diet. The note indicated Resident 1 had developed pressure induced DTI and had a recent ED visit because of a change in condition. Average intake for the last six days of approximately 31% of meals (686 calories, 30 gms protein per day) with a fluid intake of 658 ml per day (approximately 44% of estimated daily fluid requirements of ,d+[DATE] mls). RD 3 noted Resident 1 did not have a diagnosis of diabetes and recommended liberalizing the diet, discontinuing the CCHO diet and starting him on a regular fortified diet, nutritional supplement shakes, and adding a concentrated form of liquid protein to promote wound healing and meet Resident 1 ' s estimated needs. During a review of the document Clinical Physician Orders, dated [DATE], the document indicated on [DATE] the CCHO mechanical soft diet was discontinued, and a Fortified Regular mechanical soft diet was ordered. During a review of Resident 1 ' s Dietician Note, dated [DATE] at 11:58 a.m., the note written by RD 2 indicated Resident 1 was being seen due to a change in condition and that Resident 1 had not been weighed since [DATE]. The note indicated Malnutrition r/t inadequate nutrient intake AEB [as evidenced by] significant weight loss, emergence of DTI to bilateral heels . The note indicated the recommendation to add malnutrition to diagnosis [BMI 16], provide assistance with oral intake as needed .monitor weight, skin, PO [oral] intake . During a concurrent interview and record review at [DATE] at 10:57 a.m. with the DON and the Administrator (ADM), Resident 1 ' s Nutrition Assessments were reviewed. The DON indicated when the RD has completed her note and recommendations, an email goes out to the DON, the ADON, the MDS Coordinator, and the dietary manager so everyone knows. The DON stated the MDS coordinator then faxes the recommendations to the physician who is supposed to review the recommendations and send back orders. The DON and ADM agree the orders and the Medication Administration Record (MAR) from [DATE] through [DATE] did not indicate Resident 1 was receiving nutritional supplement shakes, and the RD notes on [DATE] and [DATE] indicate Resident 1 was not receiving nutritional supplements. However, the ADM stated the dietary list of what is included on the meal tray indicated Resident 1 was receiving shakes twice a day beginning on [DATE]. The DON stated they have standing orders for supplements so as soon as the RD writes her notes the dietary manager gets alerted so the supplement can get added to the meal tray. Unfortunately, for some reason the supplements didn ' t get added to the orders, so they were not part of the medical record. The ADM stated they need to communicate better, and a consistent process has to be followed. The ADM stated the addition of supplements needs to get onto the orders, not just onto the meal tray list so that information is available for the dieticians and others to review. As far as the fortified diet, the DON stated she does not know why the RD ' s recommendation on [DATE] and [DATE] for a fortified diet was not implemented until [DATE] or why Malnutrition was never added as a diagnosis as the RD recommended on [DATE] and [DATE]. During a concurrent interview and record review on [DATE] at 11:55 a.m. with RD 2, the Dietician Note dated [DATE] and [DATE] were reviewed. RD 2 stated when she documents her nutrition assessment and recommendations, the recommendations are sent to nursing to carry out and to send to the doctor for orders. RD 2 stated it is her expectation that the nursing staff implement the recommendations of the RD. RD 2 stated if she sees that a recommendation was not implemented, she follows up by notifying the DON. RD 2 stated in this case, on [DATE] when she checked on Resident 1 for the second time, she noticed the recommendations from [DATE] were not carried out and notified the DON. As far as the weights, RD 2 stated she does not know why staff did not weigh Resident 1 again after [DATE]. RD 2 was asked why Resident 1 was on a CCHO diet from admission on [DATE] until the diet was changed by RD 3 on [DATE] since Resident 1 did not have a diagnosis of diabetes. RD 2 stated she was not sure but stated usually a resident will be put on whatever they were on at the hospital. RD 2 was asked what the benefit of continuing the CCHO diet was for Resident 1 who had poor intake and significant weight loss. RD 2 stated, Good question. During a concurrent interview and record review on [DATE] at 12:35 p.m. with the DON and the ADM, the DON was asked when the nursing staff first notified the MD or a PA about Resident 1's ongoing inadequate oral intake of food and fluid and severe weight loss. The DON stated she wasn't sure and needed to review the record. The DON reviewed the nurses ' notes for Resident 1 from [DATE] through [DATE] and stated the nursing staff notified the PA on [DATE], when Resident 1 was sent to the ED. The DON confirmed there were no nurses' notes other than on [DATE] indicating the MD or PA were notified about weight loss, or poor oral intake of food or fluids. The DON was asked under what circumstances would she notify the MD or PA about a resident's ongoing inadequate oral intake of fluids over a period of a week or more. The DON stated if a resident did not drink anything for a day, she would notify the physician. During an interview on [DATE] at 10:40 a.m. with CNA 1, CNA 1 stated she does not recall Resident 1 specifically but stated she had worked with residents who did not want to eat or drink much. CNA 1 stated she cannot recall ever being told a resident was dehydrated or that there was a certain amount of fluid the resident should be drinking. CNA 1 stated if a resident is not eating or drinking very much or is refusing to eat or drink, CNA 1 would always inform the nurse. During an interview on [DATE] at 11:25 a.m. with CNA 2, CNA 2 stated he recalled taking care of Resident 1 on several days during Resident 1 ' s stay. CNA 2 was asked what set up only and one-person physical assist meant in terms of CNA support provided to a resident for eating or drinking. CNA 2 stated set up only means the meal tray is placed on the table within reach of the resident and the lid removed. CNA 2 stated one-person physical assist means the resident needs staff to stay with him to assist him with eating and drinking. CNA 2 stated if a resident is unable to reach for a cup and lift it to his mouth the resident would need to be offered assistance with drinking fluids every two hours. CNA 2 stated Resident 1 required total assistance with eating and drinking. CNA 2 stated he was not told by anyone that Resident 1 required feeding but found out after taking care of him. CNA 2 stated on one of the first days he took care of Resident 1, he set the meal tray and drink on the bed table in front of him and left the room. Later when CNA 2 returned he saw the food and drink was still sitting there untouched. From then on when CNA 2 took care of Resident 1 he stayed with the resident and fed him and helped him to drink fluids. CNA 2 recalled Resident 1 did not want to eat or drink very much and required a lot of encouragement and assistance. CNA 2 stated Resident 1 did not communicate when he was hungry or thirsty and was quiet most of the time. CNA 2 stated he recalled there were times when Resident 1 ate less than 25% of his food. CNA 2 stated he always notifies the nurse if a resident is refusing to eat or drink or does not eat or drink very much. CNA 2 stated he was not told Resident 1 had lost weight or was getting dehydrated and had not been told Resident 1 should try to drink a certain volume of fluid. During an interview on [DATE] at 11:50 a.m. with Restorative Nursing Assistant (RNA 1), RNA 1 stated she was recently assigned along with a CNA to do all the residents' weights. RNA 1 stated this process started at the beginning of the year. RNA 1 stated all residents on the short-term unit of the facility get weighed every Sunday. Residents on the long-term unit are weighed at least once a month, on Sunday during the first week of the month. Weights are done either with a Hoyer lift or a chair scale depending on the ability of the resident. Standing weights are not done. RNA 1 stated she has a list of all the residents and what each resident's weight was the last time they were weighed. After she weighs a resident, she compares that weight to what they weighed the last time and if the weight is five pounds or more over or five pounds or more under what their last weight was then she does not record the weight. RNA 1 stated she notes this on the list and those residents will be reweighed the next day. RNA 1 stated she gives the list with all the residents' weights and the residents that need to be reweighed to the DSD. During a review of Resident 1 ' s record, the SBAR note, dated [DATE] at 10:25 a.m., the note indicated Resident 1 ' s oxygen saturation (the amount of oxygen carried by the red blood cells- Normal values are ,d+[DATE]%) dropped to 80% and he became difficult to arouse. The physician was notified, and Resident 1 was transferred to Hospital B. During a review of Hospital B ' s ED record dated [DATE] at 11:15 a.m., the record indicated Resident 1 was brought by ambulance to Hospital B with shortness of breath due to possible aspiration (the accidental breathing in of food or fluid into the lungs) arriving to ED with altered mental status and was hypoxic. COVID+ since [DATE]. Oxygen saturation of 88% on 15 liters of oxygen. Temperature 38.5 degrees Celsius, respirations 34 breaths per minute, gurgling respirations. Diagnoses included aspiration syndrome, urinary tract infection, sepsis (the body's overwhelming and life-threatening response to infection), pneumonia, acute kidney injury. admitted to ICU. Review of the discharge summary dated [DATE], indicated Resident 1 was receiving end of life care and was discharged to hospice on [DATE]. During a review of the facility ' s policy and procedure (P&P) titled Weights, dated [DATE], the P&P indicated, .All residents are to be weighed upon admission to the facility. The resident is to be weighed by the CNAs and/or licensed nurse as soon as possible after arrival to the facility .New residents are to be weighed weekly for the first four weeks in the facility . Physician orders should be obtained for residents who require daily weights. Daily weights may be indicated for residents with specific medical conditions that require close monitoring of weight fluctuations. Gross weight gains or losses should trigger an immediate reweighing of the resident to be completed the day after the original weight. Reweighs are to be done on any resident who has a five (5) pound weight difference, whether it is a gain or loss .Weight Variance: Calculate weight loss or gain every time a resident is weighed . Significant weight variances [5% or more in 30 days; 10% or more in 180 days] are to be reported to the Registered Dietitian for review . Dietitian or designee is to review weight changes and discuss recommended interventions with the resident and/or their authorized representative. Recommendations and discussions are to be documented in the resident's medical record .The physician is to be notified of significant weight changes by the licensed nurse. All dietitian recommendations are to be communicated to the physician and orders carried out as indicated . The resident's care plan is to be updated with recommendations made by the dietitian and IDT [Interdisciplinary Team- a healthcare approach that integrates multiple disciplines through collaboration] upon review. Residents should be weighed by the same type of scales on a consistent basis, when possible. The type of scale used should be documented and considered when a significant weight variance is found . During a review of a professional reference, retrieved from https://www.aafp.org/dam/brand/aafp/pubs/afp/issues/,d+[DATE]/p640.pdf titled, Evaluating and treating unintentional weight loss in the elderly, dated [DATE], the reference indicated, . Elderly patients with unintentional weight loss are at higher risk for infection, depression and death .Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications . Various studies demonstrated a strong correlation between weight loss and morbidity and mortality .One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death . Another study showed institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within a year . During a review of a professional reference titled, Prognostic Significance of Monthly Weight Fluctuations Among Older Nursing Home Residents, dated [DATE], the reference indicated, .a weight loss of =10% in any 3-month interval was associated with an 8-fold increased risk for death after controlling for age and other health status variables .A 1-month weight loss of 5% or more was a powerful predictor of death . During a review of the professional reference Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines (,d+[DATE]), the reference indicated, The Registered Dietitian (RD) should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). During a review of a professional reference titled Dehydration in Geriatrics -Medscape, dated [DATE], the refe[TRUNCATED]