Every finding on record at Arbor Glen Care Center

Based on interview and record review, the facility failed to administer medications within one hour after the prescribed time for three of three sampled residents (Residents 1, 8, and 9) in accordance with the facility's Policy and Procedure (P&P) titled, Pharmaceutical Services.The deficient practice had the potential to result in the loss of therapeutic drug effects and increased the risk of adverse drug reactions (undesired harmful effect resulting from a medication) to Residents 1, 8, and 9.Findings:a. During a review of Resident 1's Face Sheet (FS, admission record), the FS indicated the facility admitted Resident 1 on 5/29/2026 with diagnoses including Hemiplegia (muscle weakness or partial paralysis [complete or partial loss of muscle function in a part of the body] on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), chronic (long standing) obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). The FS indicated Resident 1's son (RR 1) was Resident 1's emergency contact.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/4/2026, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing and toileting hygiene. The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) from staff for dressing, eating, personal hygiene, and oral hygiene.During a review of Resident 1's Order Summary Report (OSR), active as of 7/27/2026, the OSR indicated Resident 1 had the following physician orders:1. Metoprolol Tartrate (medication used to treat high blood pressure) oral (relating to the mouth) tablet 25 milligram (MG, a unit of measurement), give 1 tablet by mouth (PO) two times a day (BID) for hypertension (high blood pressure).2. Eliquis (Apixaban, medication used to prevent dangerous blood clots from forming in the body) oral tablet 5 MG, give 1 tablet PO every 12 hours for Atrial fibrillation (A- FIB, an irregular and often very rapid heart rhythm).3. Metformin hydrochloride (HCl, unit of measurement) (medication used to treat DM) oral tablet 850 MG Give 1 tablet PO BID for DM.4. Amlodipine Besylate (medication used to treat hypertension) oral tablet 5 MG, give 2 tablets PO one time a day for hypertension.5. Atorvastatin Calcium (medication used to treat hyperlipidemia [a condition in which there are high levels of fat particles in the blood]) oral tablet 40 MG, give 1 tablet PO one time a day for hyperlipidemia.6. Sodium Chloride inhalation nebulization solution 3 % (inhaled solution used to loosen thick mucus and ease breathing) 3 milliliters (ML, metric unit used to measure volume) inhale orally every 8 hours for COPD.7. Baclofen (medication used to treat muscle stiffness, tightness, and spasms) oral tablet 5 MG, give 1 tablet PO at bedtime for muscle spasms.During a review of Resident 1's Medication Admin (administration) Audit Report (MAAR), dated July 2026, the MAAR indicated the following:Resident 1's medication Metoprolol Tartrate was scheduled to be administered at 8 AM and at 6 PM. Metoprolol Tartrate was administered one hour past the scheduled times on 7/4/2026, 7/9/2026, 7/10/2026, 7/13/2026, 7/14/2026, 7/20/2026, 7/24/2026, and 7/26/2026.Resident 1's medication Atorvastatin Calcium was scheduled to be administered at 9 AM. Atorvastatin Calcium was administered one hour past the scheduled time on 7/5/2026, 7/8/2026, 7/9/2026, 7/14/2026, 7/15/2026, and 7/20/2026.Resident 1's medication Metformin HCl was scheduled to be administered at 9 AM and 5 PM. Metformin HCl was administered one hour past the scheduled times on 7/5/2026, 7/8/2026, 7/9/2026, 7/10/2026, 7/13/2026, 7/14/2026, 7/15/2026, and 7/20/2026.Resident 1's medication Apixaban was scheduled to be administered at 9 AM and 9 PM. Apixaban was administered one hour past the scheduled time on 7/5/2026, 7/6/2026, 7/8/2026, 7/9/2026, 7/14/2026, 7/15/2026, 7/20/2026, and 7/26/2026.Resident 1's medication Amlodipine Besylate was scheduled to be administered at 9 AM. Amlodipine Besylate was administered one hour past the scheduled time on 7/5/2026, 7/8/2026, 7/15/2026, and 7/20/2026.Resident 1's medication Sodium Chloride Inhalation nebulization solution was scheduled to be administered at 9 AM. Sodium Chloride was administered one hour past the scheduled time on 7/6/2026, 7/10/2026, 7/18/2026, 7/20/2026, and 7/26/2026.Resident 1's medication Baclofen was scheduled to be administered at 9 PM. Baclofen was administered one hour past the scheduled time on 7/6/2026, 7/20/2026, and 7/26/2026.During a telephone interview on 7/27/2026 at 10:30 AM with RR 1, RR 1 stated the facility nurses (in general) administered medications late to Resident 1 on multiple occasions. During a concurrent interview and record review on 7/29/2026 at 2:34 PM with Licensed Vocational Nurse (LVN) 1, Resident 1's MAAR dated July 2026, was reviewed. The MAAR indicated LVN 1 administered Resident 1's medications late to Resident 1 on 7/6/2026. LVN 1 confirmed LVN 1 administered Resident 1's medications late to Resident 1 on 7/6/2026. LVN 1 stated that ordered medications should be given within one hour of the medication's scheduled time. LVN 1 stated part of the medication administration process included the nurse (in general) was supposed to record the administration of medication in the resident's (in general) medical record immediately after administering the medication to the resident (in general).During a concurrent interview and record review on 7/29/2026 at 3:02 PM with LVN 2, Resident 1's MAAR dated July 2026, was reviewed. The MAAR indicated LVN 2 administered Resident 1's medications late to Resident 1 on 7/10/2026 and 7/13/2026. LVN 2 stated sometimes LVN 2 gave medications late to the residents for reasons such as not being able to locate the ordered medication or if LVN 2 was busy with another resident (in general) due to a medical emergency.During a concurrent interview and record review on 7/29/2026 at 3:32 PM with LVN 3, Resident 1's MAAR dated July 2026, was reviewed. The MAAR indicated LVN 3 administered Resident 1's medications late on multiple days. LVN 3 confirmed LVN 3 administered Resident 1's medications late on multiple days for July 2026.b. During a review of Resident 8's FS, the FS indicated the facility admitted Resident 8 on 2/27/2020 and readmitted Resident 8 on 2/8/2026 with diagnoses including Hemiplegia and hemiparesis following cerebral infarction, hyperlipidemia, and DM.During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had no impairments in cognitive skills. The MDS indicated Resident 8 was dependent (helper does all the effort) on staff for bathing and lower body dressing. The MDS indicated Resident 8 required substantial/maximal assistance from staff for upper body dressing, toileting hygiene, personal hygiene, and oral hygiene. The MDS indicated Resident 8 required supervision (oversight, encouragement or cuing) or touching assistance from staff for eating.During a review of Resident 8's OSR, active as of 7/29/2026, the OSR indicated Resident 8 had physician orders that included:1. Senna (medication used to prevent constipation) tablet 8.6 MG, give 2 tablets by mouth at bedtime for bowel care.2. Atorvastatin Calcium oral tablet 80 MG, give 1 tablet PO at bedtime for Hyperlipidemia.3. Aspirin EC (medication used to treat minor aches, pains, and fevers, reduce inflammation, and prevent blood clots to lower the risk of heart attacks and strokes) oral tablet delayed release 81 MG, give 1 tablet PO in the evening for CVA (cerebrovascular accident, stroke).4. Docusate Sodium (medication used to prevent constipation) capsule 100 MG, give 1 capsule PO BID for bowel management.5. Amlodipine Besylate (medication used to treat hypertension) oral tablet 10 MG, give 1 tablet by mouth one time a day for HTN.During a review of Resident 8's MAAR, dated July 2026, the MAAR indicated the following:Resident 8's medications Docusate Sodium and Amlodipine Besylate were scheduled to be administered at 9 AM. The MAAR indicated Docusate Sodium was administered past 10 AM on 7/1/2026, 7/7/2026, 7/15/2026, 7/16/2026, 7/19/2026, and 7/28/2026. The MAAR indicated Amlodipine Besylate was administered past 10 AM on 7/1/2026, 7/7/2026, 7/16/2026, 7/19/2026, and 7/28/2026. The MAAR indicated Senna and Atorvastatin Calcium were scheduled to be administered to Resident 8 at 9 PM. The MAAR indicated Senna and Atorvastatin Calcium were administered past 10 PM on 7/6/2026, 7/13/2026, and on 7/20/2026. The MAAR indicated Aspirin was scheduled to be administered at 5 PM. The MAAR indicated Aspirin was administered past 6 PM on 7/18/2026.During a concurrent interview and record review on 7/29/2026 at 2:34 PM with LVN 1, Resident 8's MAAR, dated July 2026, 7/6/2026 was reviewed. LVN 1 stated LVN 1 administered Resident 8's medications late on 7/6/2026.c. During a review of Resident 9's FS, the FS indicated the facility admitted Resident 9 on 9/25/2024 with diagnoses including hyperlipidemia, muscle weakness, and hypertension.During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had no impairments in cognitive skills. The MDS indicated Resident 9 required supervision (oversight, encouragement or cuing) or touching assistance from staff for bathing, dressing, toileting hygiene and personal hygiene. The MDS indicated Resident 9 required set up or clean-up assistance from staff for eating and oral hygiene.During a review of Resident 9's MAAR, dated July 2026, the MAAR indicated Resident 9's medications were administered one hour past the scheduled administration time on 7/1/2026, 7/7/2026, 7/16/2026, and on 7/19/2026.During a concurrent interview and record review on 7/30/2026 at 12:28 PM with the Director of Nursing (DON), the DON stated nurses (in general) should administer medications to residents (in general) within one hour of the medication's scheduled time. The DON stated if medications were given late, the resident's medical record should indicate the reason why the medication was administered late.During a review of the facility's undated P&P titled, Pharmaceutical Services, the P&P indicated, Medications are to be administered within one (1) hour before or one (1) hour after the prescribed time. The P&P indicated, Documentation on the medication sheet is done immediately following administration.

Based on interview and record review, the facility failed to ensure two (2) of 17 sampled residents' (Resident 1's and Resident 10's) medical records were complete and accurate when Resident 1's and Resident 10's medical records did not contain documentation that the residents were turned and repositioned every two hours in accordance with the residents' care plans.This failure resulted in Resident 1's and Resident 10's medical records containing inaccurate information and had the potential for Resident 1and Resident 10 to receive inappropriate care and treatment.1. During a review of Resident 1's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility originally admitted Resident 1 on [DATE] and readmitted Resident 1 on [DATE] with diagnoses which included metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should), acute kidney failure (when kidneys suddenly stopped working), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to turn and reposition in bed. During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated Resident 1 had a pressure ulcer on the coccyx (tailbone) with potential for further impairment related to disease process, history of ulcers, and immobility. The CPR interventions included encouraging and assisting Resident 1 to turn and reposition and turning and repositioning Resident 1 every two hours and as needed. During a review of Resident 1's Task Chart for Activities of Daily Living (TCADL) for [DATE], there was no entry under Turning and Repositioning Q 2 hours (every 2 hours) and PRN (as needed). During a review of Resident 1's medical record, certified nursing assistant (CNA) documentation regarding turning and repositioning the resident every 2 hours was not found. 2. During a review of Resident 10's FS, the FS indicated the facility originally admitted Resident 10 on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and muscle weakness. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 10 was dependent on staff for bathing, toileting hygiene, and lower body dressing. The MDS indicated Resident 10 required partial/moderate assistance (helper does less than half the effort to complete the activity) from staff for oral, personal hygiene, and to turn and reposition in bed. During a review of Resident 10's CPR, dated [DATE], the CP indicated Resident 10 had potential for skin impairment due to a history of pressure ulcers. The CPR interventions included encouraging and assisting Resident 10 to turn and reposition and turning and repositioning Resident 10 every two hours. During a review of Resident 10's TCADL for [DATE], there were no entries for Turning and Repositioning Q2 hours until [DATE]. During a review of Resident 10's medical record, CNA documentation regarding turning and repositioning the resident every 2 hours was not found from [DATE] - [DATE]. During an interview on [DATE] at 2:35 PM with CNA 1, CNA 1 stated Resident 1 needed turning and repositioning every 2 hours and as needed for wound prevention. CNA 1 stated the nursing staff (in general) who turned and repositioned the resident should document turning and repositioning Q2 hours in the chart (medical record) for ADL charting every shift. During an interview on [DATE] at 9:45 AM with Registered Nurse (RN) 1, RN 1 stated that the CNA (in general) who turned and repositioned the resident (in general) should document in the chart (medical record). During a concurrent interview and record review on [DATE] at 4:30 PM with the Director of Nursing (DON), Resident 1's CPR, dated [DATE], and TCADL for [DATE] were reviewed. The DON stated there was no documentation regarding turning and repositioning the resident every 2 hours found in Resident 1's medical record. The DON stated it was important to complete the documentation to verify the resident's health condition and to document the care provided and following the resident's care plan. During a concurrent interview and record review on [DATE] at 2:10 PM with the DON, Resident 10's TCADL for [DATE] was reviewed. The DON stated the TCADL was the facility's proof that Resident 10 was provided turning and repositioning every 2 hours. The DON confirmed, from the resident's admission until [DATE], Resident 10's medical record did not contain documentation that Resident 10 was turned and repositioned every 2 hours. During a review of the facility's policy and procedure (P&P) titled, Turning and Repositioning, undated, the P&P indicated that the facility needs to provide a systematic method for turning and repositioning At Risk residents utilizing the turning and repositioning program. The P&P indicated, All designated staff will be monitoring the turning and repositioning program for resident in each shift. During a review of the facility's P&P titled, Charting and Documentation, dated 3/2026, the P&P indicated documentation needs to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care. The P&P indicated, Documentation pertaining to special observations and monitoring should include: a. Date and time observations made.f. All pertinent observations.

Based on interview and record review, the facility failed to promptly notify one (1) of 17 sampled residents' (Resident 2's) primary physician and Resident Representative (RR 1) regarding Resident 2's fall on [DATE].This failure had the potential for Resident 2 not to receive timely care and treatment for Resident 2's changes in condition and had the potential for Resident 2's representative of not being informed of Resident 2's change in condition and not making an informed decision (decision based on facts, relevant information, and clear understanding of potential risks, benefits, and alternatives) regarding Resident 2's fall.(Cross Reference F684)During a review of Resident 2's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including abnormalities of gait and mobility, muscle weakness, hypertension (high blood pressure), and acute respiratory failure with hypoxia (when the lungs suddenly fail to supply enough oxygen to the body).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 2 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's Care Plan Report (CPR), created on [DATE], the CPR indicated Resident 2 was at risk for falls related to weakness, impaired mobility, pain, and risk for episodes of shortness of breath (SOB). The CPR indicated Resident 2 had an assisted fall during transfer from bed to shower chair on [DATE].During a review of Resident 2's SBAR Communication Form (Situation, Background, Assessment, Recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated [DATE], the SBAR indicated Resident 2 had an assisted fall on [DATE] when a certified nursing assistant (CNA) transferred Resident 2 from the bed to the shower chair and Resident 2 lost balance. The SBAR indicated Registered Nurse (RN) 1 was waiting for Resident 2's primary physician to respond and was unable to reach and inform RR 1 regarding Resident 2's fall.During a phone interview on [DATE] at 2:50 PM with CNA 6, CNA 6 stated Resident 2 had an assisted fall when CNA 6 transferred Resident 2 from bed to shower chair on [DATE].During a concurrent interview and record review on [DATE] at 8:45 AM with Licensed Vocational Nurse (LVN) 1, Resident 2's SBAR, dated [DATE] was reviewed. LVN 1 stated a licensed nurse should notify the resident's (in general) physician and the resident's representative right away after a fall.During an interview on [DATE] at 9:45 AM with RN 1, RN 1 stated Resident 2 had an assisted fall on [DATE] at 8 PM and RN 1 was unable to reach Resident 2's primary physician and RR 1 on [DATE] to inform them of Resident 2's fall. RN 1 stated a licensed nurse must have notified Resident 2's physician and representative right away after the resident's fall on [DATE].During an interview on [DATE] at 12:50 PM with RR 1, RR 1 stated RR 1 did not receive any notification on [DATE] regarding Resident 2's fall on [DATE]. RR 1 stated the facility should have informed RR 1 about Resident 2's fall on the day Resident 2 had a fall.During a concurrent interview and record review on [DATE] at 4:30 PM with the Director of Nursing (DON), Resident 2's SBAR, dated [DATE], was reviewed. The DON stated RN 1 was unable to reach RR 1 after Resident 2 had a fall on [DATE]. The DON stated RN 1 should have followed up with informing RR 1 on [DATE] after RN 1 was unable to reach RR 1 on the first attempt.During a review of the facility's policy and procedure (P&P) titled, Change in Condition, revised 4/2025, the P&P indicated that at any time, the licensed nurse or nurse supervisor should be made aware if any team members recognize the condition or care needs of the resident (including fall or other related incident) have changed. The P&P indicated, The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. The resident/resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care.During a review of the facility's Policy and Procedure (P&P) titled, Fall Prevention, undated, the P&P indicated, Physician and responsible party/ resident representative will be notified. Notification will be documented in the resident's medical record.

Based on interview and record review, the facility failed to ensure one (1) of 17 sampled residents (Resident 2) received the necessary care and services when Resident 2's vital signs (measurements of the body's basic functions, such as heart rate, breathing rate, oxygen saturation, blood pressure, and temperature) and neuro-check (neurological exam, a check of how well the brain, nerves, and muscles work often performed after a suspected head injury) were monitored every shift for 72 hours after the resident had a fall on [DATE].This failure had the potential for Resident 2 not to receive appropriate and necessary care timely.(Cross Reference F580)During a review of Resident 2's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including abnormalities of gait and mobility, muscle weakness, hypertension (high blood pressure), and acute respiratory failure with hypoxia (when the lungs suddenly fail to supply enough oxygen to the body).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 2 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's Care Plan Report (CPR), created on [DATE], the CPR indicated Resident 2 was at risk for falls related to weakness, impaired mobility, pain, and risk for episodes of shortness of breath (SOB). The CPR indicated Resident 2 had an assisted fall during transfer from bed to shower chair on [DATE].During a review of Resident 2's SBAR Communication Form (Situation, Background, Assessment, Recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated [DATE], the SBAR indicated Resident 2 had an assisted fall on [DATE] when a certified nursing assistant (CNA) transferred Resident 2 from the bed to the shower chair and Resident 2 lost balance. The SBAR indicated Resident 2's vital signs and neuro-check were not monitored.During a review of Resident 2's Medication Administration Record (MAR) for 5/2026, the MAR indicated Resident 2's vital signs should be documented every shift. The MAR indicated that there were no vital signs documented on [DATE] NOC shift (from 11 PM on [DATE] to 7 AM on [DATE]).During a review of Resident 2's Medical Record (MR), the MR indicated there was no document regarding Resident 2's 72 hours neuro-check after Resident 2's fall on [DATE].During a phone interview on [DATE] at 2:50 PM with Certified Nursing Assistant (CNA) 6, CNA 6 stated that Resident 2 had an assisted fall when CNA 6 transferred Resident 2 from bed to shower chair on [DATE].During a concurrent interview and record review on [DATE] at 8:45 AM with Licensed Vocational Nurse (LVN) 1, Resident 2's SBAR, dated [DATE] was reviewed. LVN 1 stated a care plan should have been developed and implemented right after the fall on [DATE] and the interventions should include 72 hours of neuro-check.During an interview on [DATE] at 9:45 AM with Registered Nurse (RN) 1, RN 1 stated that RN 1 did not start 72 hours neuro-check for Resident 2 after Resident 2 had a fall on [DATE].During a concurrent interview and record review on [DATE] at 4:30 PM with the Director of Nursing (DON), Resident 2's SBAR, dated [DATE], Resident 2's MAR, dated 5/2026, and Resident 2's MR were reviewed. The DON stated that there were no documented vital signs on [DATE] night shift and no 72 hours neuro-check after Resident 2 had a fall on [DATE]. The DON stated Resident 2's vital signs and neuro-check should have been monitored every shift for 72 hours after Resident 2 had a fall on [DATE]. The DON stated it was important to check and document the vital signs every shift post fall to monitor the resident's health condition.During a review of the facility's policy and procedure (P&P) titled, Change in Condition, revised 4/2025, the P&P indicated that at any time, the licensed nurse or nurse supervisor should be made aware if any team members recognize the condition or care needs of the resident (including fall or other related incident) have changed. The P&P indicated examples of changes in condition include, Change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation.Change in mental status. The P&P indicated, The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions.

Based on observation, interview, and record review, the facility failed to ensure one of one kitchen (Kitchen 1) had safe and proper storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to:1. Discard a gallon of expired ClassicGourmet [brand name] classic Caesar dressing on or before the expiration date that was stored inside Refrigerator # 3.2. Label and date a large clear plastic storage bin that had ready to eat corn flakes with raisins inside and supplied from the manufacturer's original bulk container.3. Properly store two (2) rectangular pans of facility baked yellow cake left out for cooling.These deficient practices could result in food borne illness (illness caused by the ingestion of contaminated food or beverage) and serious health complications to the residents consuming the foods and/or affect the quality and palatability of the food items. Findings:During a concurrent observation and interview on 3/24/2026 at 8:25 AM with the Dietary Supervisor (DS) during the initial tour of Kitchen 1, a gallon of expired ClassicGourmet classic Caesar dressing with half contents with a manufacturer's date of Best By: 01 02 26 was inside Refrigerator # 3. The DS stated the facility should have checked (date) and should not have accepted the dressing from the vendor. The DS stated, checking the expiration date of the dressing was important since an expired dressing, will not be good to the residents, who could maybe get stomachache, diarrhea, cramps, throw-up.During a concurrent observation and interview on 3/24/2026 at 8:49 AM with the DS inside the dry goods storage room of Kitchen 1, there was an unlabeled, undated 16-gallon (a unit of volume) clear plastic storage bin with one fourth (1/4) contents of ready to eat corn flakes with raisins on the multiple open shelving racks for dry goods. Additionally, there were 2 uncovered half sheet (18 inches x 13 inches) rectangular pans of facility baked yellow cake stored on top of a clear plastic storage bin of beans. The DS stated, the cornflakes were from the original container (manufacturer's bulk bag) and should have been labeled with open date and a use by date immediately so the facility knew when to use the corn flakes because we could be using expired, old products. The DS stated the baked yellow cakes were not covered because the yellow cakes were being cooled off.During an interview on 3/27/2026 at 1 PM with the DS, the DS stated, [the facility] did not have a designated area in Kitchen 1 for cooling facility baked goods and it was important to properly store and cool baked goods to prevent burns to staff.During an interview on 3/27/2026 at 3:18 PM with the Registered Dietician (RD), the RD stated the facility baked yellow cakes could have been stored inside the dry goods storage room but had to be stored in a cart and not on top of the plastic bin of beans in the open shelving rack. The DS stated, storing the baked yellow cakes properly was important so the cakes would not be exposed to physical contamination like dust, droppings.During a review of the facility's undated P&P titled, Labeling and Dating of Foods, the P&P indicated, all food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation (FIFO - First In - First Out). The P&P indicated, the individual opening or preparing a food should be responsible for date marking at the time of processing and/or storage.During a review of the facility's undated P&P titled, Dry Goods Storage Guidelines, the P&P indicated, the storage length was to be followed unless you [facility] had manufacturer's recommendations indicating otherwise. The P&P indicated, opened, refrigerated salad dressing had one (1) month of storage and opened cereals, ready to eat had two (2) months of storage.During a review of the facility's P&P titled, Foods Brought by Family or Visitor, reviewed date 3/2026, the P&P indicated, foods to be served via the kitchen would be handled according to food and nutrition professional food safety standards.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for three of three sampled residents (Residents 7, 56, and 98) when the facility:1. Failed to follow a physician's (health professional who is licensed and trained to practice medicine) order indicating to ear lavage (a medical procedure used to remove excess ear wax [cerumen] or foreign materials from the ear canal with a gentle stream of warm water) for Resident 7 who was hard of hearing.2. Did not complete a fall risk evaluation following Resident 56's third fall on [DATE].3. Failed to follow a physician's order and performed cardiopulmonary resuscitation (CPR -an emergency lifesaving procedure performed when a person's breathing or heartbeat has stopped) to Resident 98 when the order for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), indicated Do Not Attempt Resuscitation/DNR [Allow Natural Death].These failures resulted in: The potential to result in worsened hearing and further impairing Resident 7's ability to communicate Resident 7's needs leading to negatively affecting Resident 7's his quality of life, the potential to result in Resident 56's safety needs not being addressed and the potential for further falls and serious injury to Resident 56, and a violation of Resident 98's rights and wishes regarding life-sustaining treatment.Findings 1. During a review of Resident 7's Face Sheet (admission record, FS), the FS indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heartbeats), dysphagia (difficulty swallowing), and generalized muscle weakness. During a review of Resident 7's History and Physical (H&P), dated [DATE], the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the Minimum Data Set (MDS - a resident assessment tool), indicated Resident 7's cognitive (the ability to think and process information) was intact and required moderate assistance (helper does less than half the effort) with toilet hygiene, upper body dressing, chair to bed and toilet transfers. The MDS's section B: Hearing, Speech and Vision indicated Resident 7 had the ability to hear with minimal difficulty (difficulty in some environments e.g., when people speak softly or setting is noisy). During a review of Resident 7's physician orders (PO), dated [DATE], the PO indicated ear lavage, one time only on [DATE]. During a review of Resident 7's Medication Administration Record (MAR), dated [DATE], the MAR indicated ear lavage one time only, ordered on [DATE]. The MAR indicated the ear lavage on [DATE] was left blank (not signed by a licensed nurse, a signature indicates the treatment was completed) and the lavage was not completed. During an observation and concurrent bedside interview with Resident 7 on [DATE] at 10:30 AM, with the MDS Coordinator (MDS) 1, Resident 7 gestured for the surveyor to come closer to Resident 7's bedside, and stated, Speak louder and put your mask down so I can hear you. I have had trouble hearing from before I got here [the facility]. They [facility] were putting drops in my ear for five days and were supposed to flush [to clean the ear canal by removing excess wax with a gentle stream of warm water] my ear out of wax, but that never happened. During an interview and concurrent record review on [DATE] at 10:52 AM with MDS 1. Resident 7's MAR, dated [DATE], was reviewed. MDS 1 stated Resident 7's physician order for ear lavage was not done on [DATE]. MDS 1 stated it was important for us [the facility] to carry out [implement, to perform] physician orders to provide appropriate care and treatment to Resident 7. MDS 1 state Resident 7 already had difficulty hearing and [not following the order for ear lavage could] effect Resident 7's quality of life. MDS 1 stated [a resident's] hearing was important and MDS 1 would like to have [Resident 7's hearing] last as long as possible. During an interview on [DATE] at 3:07 PM with the Director of Nursing (DON), the DON stated Resident 7's physician's order for ear lavage was not carried out. The DON stated following physician orders was important to ensure resident's (in general) well-being. The DON also stated the facility did not have a policy specifically addressing following physician orders. During a review of the facility's policy and procedure (P&P) titled Physician Orders, reviewed 3/2026, the P&P's policy indicated drugs and treatments shall be administered only upon the written order by a person duly licensed and authorized to prescribe such drugs and treatments. During a review of the facility's P&P titled Hearing-Impaired Resident, revised 3/2026, the P&P's policy indicated to improve communication with hearing impaired individuals. 2. During a review of Resident 56's FS, the FS indicated the facility admitted Resident 56 on [DATE] with diagnoses including malignant neoplasm of unspecified site of unspecified female breast (breast cancer) and secondary malignant neoplasm of brain (brain cancer). During a review of Resident 56's H&P, dated [DATE], the H&P indicated Resident 56 could make needs known but could not make medical decisions. During a review of Resident 56's Care Plan (CP), initiated [DATE], the CP indicated Resident 59 was at risk for falls related to weakness, impaired mobility, impaired gait (manner of walking), and confusion. The CP indicated Resident 56 had three falls on [DATE]. During a review of Resident 56's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated [DATE], timed at 7:09 PM, the SBAR indicated Resident 56 had an unwitnessed fall. During a concurrent interview and record review on [DATE] at 10:57 AM with the DON, Resident 56's Fall Risk Evaluations dated [DATE], timed at 6:39 AM and timed at 10 AM were reviewed. The DON stated the facility did not complete a fall risk evaluation for Resident 56's unwitnessed fall that occurred in the evening (7:09 PM) of [DATE]. The DON stated it was the policy of the facility to complete a fall risk evaluation after each fall. The DON stated it was important to complete a fall risk evaluation to ensure Resident 56's needs were met and proper interventions were initiated. During a review of the facility's P&P titled, Fall Management System, revised [DATE], the P&P's policy indicated, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The P&P's procedure indicated, A fall risk evaluation will be completed post fall incident. 3. During a review of Resident 98's admission Record (AR), the AR indicated Resident 98 was admitted to the facility on [DATE] with diagnoses including hemiplegia (form of paralysis that causes total or partial loss of movement on one side of the body affecting the arm, leg, and sometimes the face) and hemiparesis (weakness, reduced muscle strength, or numbness on one side of the body) following cerebral infarction (CVA – stroke, loss of blood flow to a part of the brain) affecting right non-dominant side, dementia (a progressive state of decline in mental abilities) in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic (a mental disorder characterized by a disconnection from reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 98's MDS, dated [DATE], the MDS indicated Resident 98's cognitive skills (ability to think and process information) for daily decision making were severely impaired. The MDS indicated, Resident 98 was dependent (helper does all of the effort) for activities of daily living (ADLs - activities such as bathing, dressing, toileting and feeding a person performs daily). The MDS indicated Resident 98 had a POLST indicating Do not attempt resuscitation/DNR, that was signed by the physician and resident or legally recognized decisionmaker. During a review of Resident 98's Order Summary Report (OSR), active orders as of [DATE], the OSR indicated, an order, dated [DATE], for DNR/Do Not Attempt Resuscitation. During a review of Resident 98's POLST, dated [DATE], signed by Resident Representative (Resident 98's representative, RR) 3, the POLST indicated a copy of a signed POLST form is a legally valid physician order. The POLST indicated if patient [Resident 98] had no pulse and was not breathing, Do Not Attempt Resuscitation/DNR (Allow Natural Death). During a review of Resident 98's Social Services Assessment/Evaluation (SSA), dated [DATE], timed at 12:17 PM, the SSA indicated Resident 98 and RR 3 chose to convey wishes for advanced care planning using a POLST paradigm document. The SSA indicated a POLST was completed indicating, DNR/Do Not Attempt Resuscitation. During a review of Resident 98's H&P, dated [DATE], the H&P indicated Resident 98 did not have the capacity to understand and make decisions. During a review of Resident 98's CP, initiated [DATE], the CP indicated Resident/resident representative requested a physician order for life sustaining treatment (POLST). The CP indicated request (DNR/Do Not Attempt Resuscitation) would be honored until the next review x (for) ninety (90) days. During a review of Resident 98's Progress Notes (PN), dated [DATE], the PN indicated, at 12:30 AM, Resident 98 was noted pale, staff (unnamed) assessed vitals (measure the basic functions of your body that include your body temperature, blood pressure, pulse and respiratory (breathing) rate), no pulse, no respirations, CPR was initiated, 911 (emergency response system) was called, and RR 3 was notified. The PN indicated, paramedics (highly trained emergency medical professionals who provide advanced life-saving care on the scene and during ambulance transport) were called and Resident 98's time of death at 1:10 AM. During a review of Resident 98's MAR, dated 1/2026, the MAR indicated DNR/Do Not Attempt Resuscitation. During a concurrent interview and record review on [DATE] at 10:22 AM with Licensed Vocational Nurse (LVN) 6, Resident 98's POLST, dated [DATE], and the PN, dated [DATE], were reviewed. LVN 6 stated a POLST was how the resident [in general] wants their care, and Resident 98's POLST indicated DNR. LVN 6 stated, DNR meant staff [in general] do not perform CPR when a resident went into cardiac arrest (heart stops beating suddenly). LVN 6 stated, staff should check the POLST, should be doing it as soon as you see, a resident becomes nonresponsive. LVN 6 stated CPR should not have been initiated on Resident 98 and staff (unidentified) violated Resident 98's wishes and rights and did not follow the physician's order (for life-sustaining treatment) and possibly caused trauma to Resident 98 when staff provided CPR to Resident 98. During a concurrent interview and record review on [DATE] at 10:40 AM with the DON, Resident 98's POLST, dated [DATE], and PN, dated [DATE], were reviewed. The DON stated Resident 98's POLST indicated DNR and a POLST was a resident or family's wishes and a physician's order for life sustaining treatment. The DON stated, DNR meant when staff found a resident with no pulse, staff were not to provide CPR. The DON stated staff did not follow the physician's order for life-sustaining treatment for Resident 98 when staff performed CPR to Resident 98 on [DATE]. During a review of the facility's P&P titled, Physician Orders, reviewed 3/2026, the P&P indicated, drugs and treatments should be administered only upon written order of a person duly licensed and authorized.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices by failing to ensure four of four sampled residents' (Resident 72, 80, 16 and 70) personal care item was labeled and stored properly.This deficient practice had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections for Resident 72, 80, 16 and 70).Findings:During a review of Resident 72's Face Sheet (FS - admission record), the FS indicated Resident 72 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cerebral infarction (CVA - stroke, loss of blood flow to a part of the brain), unspecified, and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction.During a review of Resident 72's History and Physical Examination (H&P), dated 7/26/2025, the H&P indicated Resident 72 could make needs known but could not make medical decisions.During a review of Resident 72's Minimum Data Set (MDS - a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 72's cognitive skills (ability to think and process information) for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 72 required substantial/maximal assistance (helper does more than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, shower/bathe, and personal hygiene.During a review of Resident 80's FS, the FS indicated Resident 80 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cerebral infarction, unspecified, and hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side.During a review of Resident 80's H&P, dated 2/11/2026, the H&P indicated Resident 80 had the capacity to understand and make decisions.During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80's cognitive skills for daily decision making were moderately impaired.During a review of Resident 16's FS, the FS indicated Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and cerebral infarction, unspecified.During a review of Resident 16's H&P, dated 10/23/2025, the H&P indicated Resident 16 did not have the capacity to understand and make decisions.During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16's cognitive skills for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 16 was dependent (helper does all of the effort) and required substantial/maximal activity with toileting hygiene, shower/bathe, and personal hygiene.During a review of Resident 70's FS, the FS indicated Resident 70 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), unspecified, and anemia (a condition where the body does not have enough healthy red blood cells), unspecified.During a review of Resident 70's H&P, dated 7/12/2025, the H&P indicated Resident 70 had the capacity to understand and make decisions.During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 70's cognitive skills were intact. During an observation on 3/24/2026 at 9:42 AM, Resident 72, 80, 16 and 70's shared room had an Enhanced Barrier Precaution (EBP - an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in nursing homes) signage posted by the room door and there was a black colored trimmed 3-drawer personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart outside of the room.During a concurrent observation and interview on 3/24/2026 at 9:58 AM with Certified Nursing Assistant (CNA) 3 inside Resident 72, 80, 16, and 70's shared restroom there was an unlabeled eight (8) fluid oz (ounce - a unit of weight and volume) Essentials Cleanse Shampoo & Body Wash stored on the sink. CNA 3 stated, the shampoo & body wash was a cleanser and should have been labeled with a resident's (in general) name and kept at the resident's bedside so staff (in general) knew, who it belongs to and any patient could just use it, to prevent cross contamination, and for infection control.During an interview on 3/26/2026 at 7:40 AM with Infection Preventionist (IP) 1, IP 1 stated, Resident 72, 80, 16, and 70's shared room was on EBP, and the room had one (1) restroom. IP 1 stated, leaving the unlabeled body wash and shampoo in the restroom could result in cross contamination, we have 4 residents sharing the restroom. The IP stated, resident's personal care items should be labeled with the resident's name and left at the resident's drawer or closet to prevent other residents from using the item, for protection, and infection control.During a review of the facility's policy and procedure (P&P) titled, Personal Care Items, reviewed 3/2026, the P&P indicated, it was the facility's policy to ensure proper hygiene, safety, and accountability regarding personal care items provided to or brought in by individuals. The P&P indicated, items must be stored in designated personal storage areas and must be labeled with residents' name.During a review of the facility's P&P titled, IPCP Standard and Transmission-Based Precautions, revision/review date 3/2026, the P&P indicated, it was the facility's policy to implement infection control measures to prevent the spread of communicable diseases and conditions.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 104 and Resident 6), were treated with dignity when:a. On 3/24/2026, Certified Nursing Assistant (CNA) 5 did not close Resident 104's drapes (privacy curtain) all around Resident 104's bed while getting ready to clean up Resident 104 and CNA 5 removed Resident 104's bed sheet exposing Resident 104 from the waist down.b. On 3/27/2026, CNA 7 and CNA 8 did not close Resident 6's drapes all around Resident 6's bed while providing peri care (cleaning and caring of the genital and anal areas) to Resident 6 and exposing Resident 6's back, buttocks, and scrotal (dual-chambered sac of skin and muscle that protects the testes and regulates their temperature for optimal sperm production) area.This deficient practice had the potential to cause Resident 104 and Resident 6 to feel humiliated and could negatively impact Resident 104 and Resident 6's psychosocial well-being.Findings:a.During a review of Resident 104's Face Sheet (FS - admission record), the FS indicated Resident 104 was newly admitted to the facility on [DATE] with multiple diagnoses including muscle weakness (generalized) and essential (primary) hypertension (HTN - high blood pressure).During a concurrent observation and interview on 3/24/2026 at 10:38 AM with CNA 5, Resident 104's bed was in between two (2) roommates (unnamed). Resident 104 was lying in bed and CNA 5 was preparing to clean up Resident 104. Resident 104's drapes were partially drawn on both sides of Resident 104's bed. CNA 5 removed Resident 104's bed sheet and Resident 104's diaper was exposed from the waist down and making it visible to others (potential passers-by). CNA 5 stated, CNA 5 should have closed Resident 104's drapes all the way, (around the bed), for privacy before CNA 5 started cleaning up Resident 104.During an interview on 3/27/2026 at 7:45 AM with the Director of Nursing (DON), the DON stated, [when cleaning up a resident] the drapes should be closed all the way around resident's (in general) beds for privacy.b. During a review of Resident 6's admission Record (AR), the AR indicated, Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM II - an adult onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, and obesity (too much body fat), unspecified.During a review of Resident 6's Care Plan (CP), initiated 12/26/2025, the CP indicated Resident 6 had ADL self-care performance deficit r/t (related to) weakness, impaired mobility (bed bound), pain, and incontinence. The CP's interventions indicated to promote dignity by ensuring privacy.During a review of Resident 6's History and Physical Examination (H&P), dated 12/27/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 12/29/2025, the MDS indicated Resident 6's cognitive skills (ability to think and process information) for daily decision making were intact. The MDS indicated Resident 6 was frequently (7 or more episodes) incontinent (loss of bladder control) of urine and frequently (2 or more episodes) incontinent of bowel movement. The MDS indicated Resident 6 was dependent (helper does all of the effort) and required setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADLs - activities such as bathing, dressing, toileting and feeding a person performs daily).During an observation on 3/27/2026 at 9:35 AM, Resident 6 was lying in bed, awake, and alert, in a double occupancy room, and waiting for wound care. Resident 6 was positioned on Resident 6's left side while CNA 7 and CNA 8 were cleaning up Resident 6 of bowel incontinence. Resident 6's drapes were partially drawn on both sides of Resident 6's bed and Resident 6's back, buttocks, and scrotal area with external hemorrhoids (swollen, inflamed veins around your anus) were exposed. During an interview on 3/27/2026 at 10:14 AM with CNA 7, CNA 7 stated, Resident 6's drapes should have been drawn, all the way, completely closed for Resident 6's dignity and privacy and to prevent Resident 6 from being exposed if Resident 6's roommate (unnamed) walked in.During a review of the facility's policy and procedure (P&P), titled, Dignity and Privacy, reviewed date 3/2026, the P&P indicated, all residents be treated with kindness, dignity, and respect. The P&P indicated residents should be examined and treated in a manner that maintains the privacy of their bodies. The P&P indicated a closed door or drawn curtain shielded the resident from passers-by. The P&P indicated, privacy of a resident's body should be maintained during toileting, bathing, and other activities of personal hygiene.

Based on interview and record review, the facility failed to provide specialized rehabilitative services (therapy services that help a resident improve or regain physical, mental, or functional abilities) for one of one sampled resident (Resident 56) when:1. Resident 56's physical therapy (PT-a treatment focused on improving or restoring physical movement and function) evaluation was not completed.2. Resident 56's occupational therapy (OT-a treatment focused on improving the performance of activities required in daily life) evaluation was not completed.This failure had the potential to result in Resident 56's rehabilitative needs not being addressed, leading to a significant physical decline posing a serious risk to the resident's overall health and safety.Findings:During a review of Resident 56's Face Sheet (admission record, FS), the FS indicated the facility admitted Resident 56 on 3/12/2026 with diagnoses including malignant neoplasm of unspecified site of unspecified female breast (breast cancer) and secondary malignant neoplasm of brain (brain cancer).During a review of Resident 56's History and Physical (H&P), dated 3/15/2026, the H&P indicated Resident 56 could make needs known but could not make medical decisions.During a review of Resident 56's Order Summary Report (OSR), dated 3/12/2026, the OSR indicated Resident 56 had the following physician orders:OT to evaluate and treatment as indicated, ordered 3/12/2026.PT to evaluate and treatment as indicated, ordered 3/12/2026.During an interview on 3/27/2026 at 10:34 AM with Resident Representative (RR) 1, RR 1 stated RR 1 was concerned because Resident 56 did not receive PT while at the facility.During a concurrent record review and interview on 3/27/2026 at 2:18 PM with the Director of Rehabilitation (DOR) services, Resident 56's Net Health electronic medical record (a healthcare software technology specializing in rehabilitation therapy) was reviewed. The DOR stated Resident 56 had an order for PT and OT evaluation but there was no documentation in Resident 56's Net Health record indicating the evaluations were completed. The DOR stated if PT and OT evaluations were not documented it meant they were not done. The DOR emphasized that completing PT and OT evaluations for Resident 56 was essential to support Resident 56's return to prior functional capacity.During a review of the facility's Policy and Procedure (P&P) titled, Rehabilitation Policy & Procedures - Evaluation & Plan of Care, revised 8/1/2019, the P&P's purpose indicated, Therapy services must be directly and specifically related to an active written treatment plan that is based upon an initial evaluation performed by a clinician. The P&P's policy indicated, for each new patient admitted to therapy services, the evaluating clinician will establish a Plan of Care (POC) upon completion of the evaluation process. The evaluation process should be initiated within 72 hours of the date of the physician's order.

Based on observation, interview, and record review, the facility failed to ensure a licensed nursing staff informed one of four sampled residents (Resident 79) of the type of medication being administered during medication administration on 3/26/2026 and as indicated in the facility's Policy and Procedure (P&P), titled Med Pass. This deficient practice had the potential to result in medication errors due to Resident 79 not being encouraged to participate during Resident 79's medication administration. Findings:During a review of Resident 79's Face Sheet (admission record, FS), the FS indicated the facility admitted Resident 79 on 3/20/2024 with diagnoses that included type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine), parkinsonism (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait).During a review of Resident 79's History and Physical (H&P), the H&P indicated Resident 79 had the capacity to understand and make decisions.During an observation on 3/26/2026 at 8:29 AM, Licensed Vocational Nurse (LVN) 1 prepared Resident 79's 9 AM scheduled oral (by mouth) medications. LVN 1 placed seven (7) oral medications into a small clear cup and brought the cup with medications to Resident 79's room. LVN 1 informed Resident 79 LVN 1 would administer 9 AM medications, LVN 1 did not inform Resident 79 the types of medications being administered.During an interview on 3/26/2026 at 2:50 PM, LVN 1 stated residents (in general) needed to be informed of the types of medications residents were administered.During an interview on 3/27/2026 at 3:09 PM with the Director of Nursing (DON), the DON stated it was standard nursing practice to inform residents what [type of] medications were administered because it was a patient's right to know. The DON stated if a resident was alert, awake, and oriented, the resident could notify the nurse if there was an error with the medications being administered.During a review of the facility's undated P&P, titled Med Pass, the P&P's policy indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The P&P's procedure indicated to explain to the residents the type of medication being administered.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 42), who was unable to carry out activities of daily living (ADL - routine tasks activities such as bathing, dressing, and toileting, a person performs daily to care for themselves) was properly groomed.This deficient practice had the potential to impact Resident 42's overall health and could affect Resident 42's psychosocial well-being.Findings:During a review of Resident 42's Face Sheet (admission record, FS), the FS indicated Resident 42 was admitted to the facility on [DATE] with diagnoses that included heart failure, essential hypertension (high blood pressure), and abnormalities of gait (manner of walking).During a review of Resident 42's Care Plan (CP), initiated 3/8/2026, the CP's focus indicated Resident 42 had an ADL self-care performance deficit. The CP's interventions indicated Resident 42's personal hygiene routine included: preferred to being shaved, and getting hands washed.During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 3/13/2026, the MDS indicated Resident 42's cognitive skills (ability to think and process information) for daily decision making were moderately impaired. The MDS indicated Resident 42 needed moderate (helper does less than half the effort) to maximal assistance (helper does more than half the effort) with ADLs.During a review of Resident 42's History and Physical Examination (H&P), dated 3/17/2026, the H&P indicated Resident 42 could make needs know but could not make medical decisions.During an observation and concurrent interview on 3/24/2026 at 10:05 AM with Resident 42, at Resident 42's bedside, Resident 42 had unshaven facial hair, all fingernails were long and had dark brown blacking paste under them.During an observation and concurrent interview, at Resident 42's bedside on 3/24/2026 at 10:12 AM with Licensed Vocational Nurse (LVN) 6 and Resident 42. Resident 42 stated, I often ask to be shaved, but it is not always done. I don't like having a beard. Resident 42 stated look at my nails, they are so long. no one cuts them. Look at my arms and forehead, there are scratch marks from my nails. LVN 6 stated [Resident 42's fingernails] are not clean. LVN 6 stated Resident 42's hair and beard needed to be shaved. LVN 6 stated the resident's fingernails were long and had dirt underneath them. LVN 6 stated having long fingernails was not acceptable because [long nails] could result in scratches to Resident 42 and could lead to cuts and an infection.During an interview with the Director of Nursing (DON) on 3/27/2026 at 3:07 PM, the DON stated ADL's were important to ensure residents (in general) remained clean and with good hygiene. The DON stated long fingernails were not acceptable because it was a sign of poor hygiene and could lead to infections.During a review of the facility's policy and procedure (P&P) titled ADL, reviewed 3/2026, the P&P indicated it was the policy of the facility that residents were given the appropriate treatment and services to maintain or improve his/her abilities. The P&P's procedures indicated residents who are unable to carry out ADLs will receive necessary services to maintain: grooming, personal hygiene, and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure a low air loss (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) mattress was set at intermittent pressure mode (alternating pressure, continuous, automatic inflation and deflation of air cells in a cyclical pattern) for one of four sampled residents (Resident 43).This deficient practice had the potential for Resident 43 to develop new pressure injuries (PI, lesion/wound caused by unrelieved pressure usually over a bony prominence that results in damage of underlying tissue) or delayed healing to Resident 43's existing PI.Findings:During a review of Resident 43's Face Sheet (admission record, FS), the FS indicated the facility admitted Resident 43 on 3/2/2026 with diagnoses that included unstageable PI (pressure ulcer with slough [yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture] or eschar [dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like] on the wound bed) of the sacral region (bone at the base of the spine) and generalized muscle weakness.During a review of Resident 43's Braden Scale (a tool for predicting PI risk evaluation), dated 3/2/2026, the BS indicated a score of 15 indicating a mild risk for the development of PIs.During a review of Resident 43's History and Physical (H&P), dated 3/3/2026, the H&P indicated Resident 43 had unstageable PI on the right sacrum measuring 4.5 centimeters (cm unit of measurement) in length by 5 cm in width.During a review of Resident 43's Minimum Data Set (MDS - a standardized resident assessment tool), dated 3/6/2026, the MDS indicated Resident 43 had intact cognitive (the ability to think and process information) and required maximal assistance with all bed mobility. During a review of Resident 43's Order Recap Report (ORR), dated 3/1/2026 to 3/31/2026, the ORR included a physician's order, dated 3/9/2026, indicating a LAL mattress for wound healing every shift, setting by weight or comfort for unstageable PI for Resident 43.During an interview on 3/24/2026 at 10:47 AM, Resident 43 stated Resident 43 had a PI.During an observation on 3/26/2026 at 3:40 PM, Resident 43's LAL mattress was set on static mode (holds all air cells at the same inflation level, providing a stable, firm, and evenly distributed support surface for the resident).During a concurrent record review and interview on 3/27/2026 at 10:37 AM, with Registered Nurse (RN) 2, Resident 43's ORR, dated 3/1/2026 to 3/31/2026, was reviewed. The OSR indicated a LAL mattress was ordered for Resident 43 based on weight or comfort. RN 2 stated the mattress setting was set based on Resident 43's weight or based on Resident 43's comfort.During a concurrent observation and interview on 3/27/2026 at 10:40 AM, Resident 43's LAL was set on static mode. RN 2 stated LAL mattresses were ordered for residents (in general) who had PIs. RN 2 stated Resident 43's LAL mattress setting needed to be set to intermittent pressure and not set on static mode to promote healing of Resident 43's PI. RN 2 stated static mode on the LAL mattress was only used during position changes or when providing care such as diaper changes or baths because static mode kept the pressure on the mattress firm.During an interview on 3/27/2026 at 3:17 PM with the Director of Nursing (DON), the DON stated Resident 43's LAL mattress needed to be set on alternating pressure and not on static mode to promote healing of Resident 43's PI.During a review of the undated Alternating Pressure with LAL Manufacturer's Manual (MM), the MM indicated there were 4 therapy settings for the LAL mattress: autofirm, alternating, static, and seat function. The MM indicated alternating function was for normal alternating function and static function does not alternate and keeps the mattress firm and always inflated.During a review of the facility's Policy and Procedure (P&P) titled Skin and Wound Monitoring Management revised 3/2026, the P&P's policy indicated a resident having PIs receives necessary treatment and services to promote healing. The P&P's purpose indicated for the facility to provide care and services to promote the healing of PIs that are present (including prevention of infection to the extent possible); and to prevent the development of additional, avoidable PI. The P&P indicated to use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc).

Based on observation, interview, and record review, the facility failed to supervise two of two sampled residents (Resident 82 and Resident 106) while smoking in the patio's designated smoking area.This failure had the potential to result in injury, accidental burns, and fire hazards to the resident.Findings:During a review of Resident 82's Face Sheet (FS), the FS indicated Resident 82 was admitted to the facility on [DATE] with diagnoses including but not limited to effusion of right knee (abnormal fluid in the knee), muscle weakness, and schizoaffective bipolar disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 82's History and Physical (H&P), dated 3/14/2026, the H&P indicated Resident 82 had the capacity to understand and make decisions.During a review of Resident 82's Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2026, the MDS indicated Resident 82 smoked one to two times a day.During a review of Resident 82's Care Plan (CP), dated 3/12/2026, the CP indicated Resident 82 had potential risk of injury related to smoking. The CP did not indicate whether or not Resident 82 required supervision while smoking.During a review of Resident 106's Face Sheet (FS), the FS indicated Resident 106 was admitted to the facility on [DATE] with diagnoses including but not limited to acute pancreatitis (an inflammation of the pancreas), muscle weakness, difficulty walking, and nicotine dependence (a chronic need to use tobacco).During a review of Resident 106's History and Physical (H&P), dated 3/22/2026, the H&P indicated Resident 106 had the capacity to understand and make decisions.During a review of Resident 106's MDS dated [DATE], the MDS indicated Resident 106 smoked four to six times a day.During a review of Resident 106's Care Plan (CP), dated 3/21/2026 and 3/27/2026, the CP indicated Resident 106 had potential risk of injury related to smoking, risk for impaired cognitive function or impaired thought processes, required assistance with ambulation and mobility, and potential for behavioral problems related to psychosis. The CP did not indicate whether or not Resident 106 require supervision while smoking.During an observation on 3/27/2026 at 8:39 AM in the facility's patio smoking area, Resident 82 was smoking unsupervised.During an interview on 3/27/2026 at 9:03 AM with Human Resources Manager (HRM), HRM stated the smoking supplies are held in the HR office during day shift and then handed over to the evening and night shift Charge Nurse. HRM stated HRM supervises residents who smoke, but if MDS smoking assessment indicates a resident is awake, alert, and oriented to smoke independently, sometimes, the resident is left unsupervised to finish smoking. HRM stated the Activities Director (AD) has an open view of the patio from the activity room and the AD can also supervise residents who are in the patio's smoking area.During an observation on 3/27/2026 at 1:16 PM in the facility's patio smoking area, Resident 82 and Resident 106 were smoking unsupervised.During a concurrent interview and record review on 3/27/2026 at 1:18 PM with Infection Preventionist Nurse (IPN), the facility's policy and procedure (P&P) titled, Smoking Policy, revised July 2025 was reviewed. The P&P indicated the facility has designated smoking areas and a smoking schedule with assigned staff to supervise. The IPN nurse stated the residents should not be left unsupervised while they are smoking because it could be dangerous.During a concurrent observation and interview on 3/27/2026 at 1:20 PM with Director of Nursing (DON) in the facility's patio smoking area, Resident 82 and Resident 106 were smoking unsupervised. DON stated the P&P indicated smoking should be supervised with a staff member present in the smoking area. DON stated the residents should not have been left unsupervised because the residents could burn or hurt themselves.

Based on observation, interview, and record review, the facility failed to ensure call lights (a device used by a resident to signal the need for assistance) were within reach for two of two sampled residents (Resident 10 and Resident 41).This deficient practice had the potential to result in unmet needs for Resident 10 and Resident 41 due to the residents being unable to call for assistance from staff or alert staff during an emergency.Findings: a. During a review of Resident 10's Face Sheet (admission record, FS), the FS indicated the facility admitted Resident 10 on 9/10/2024 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and metabolic encephalopathy (disease that affects the function or structure of the brain). During a review of Resident 10's Minimum Data Set (MDS – a standardized resident assessment tool), dated 3/3/2026, the MDS indicated Resident10's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated Resident 10 had impairment on one upper extremity (arm). During a concurrent observation and interview on 3/24/2026 at 9:55 AM with Registered Nurse (RN) 2, Resident 10 was lying in bed and facing the left side. There was a touchpad call light located on Resident 10's right side near the resident's right ear. Resident 10's right hand was contracted (a permanent tightening and shortening of muscles, tendons, skin, or nearby soft tissues that causes joints to become rigid and stiff, severely restricting normal movement) and turned inward toward the wrist. Resident 10 was saying oh my God, the bottom of my feet hurt. RN 2 stated it would be hard for Resident 10 to find the call light since it was placed behind Resident 10. RN 2 stated the call light needed to be placed close to Resident 10's left hand because Resident 10 was able to use the left hand and able to ask for assistance [from staff]. b. During a review of an admission Record (AR), the AR indicated Resident 41 was re-admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis (complete loss of muscle function on one side of the body) following cerebral infraction (a condition that cuts of oxygen to the brain) affecting the right side, and need for assistance with personal care. During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 1/22/2026, indicated Resident 41 was cognitively intact and was dependent (helper does all effort) with bed mobility (moves to and from lying position, turns side-to-side and body position). The MDS indicated Resident 41 was fully dependent (full staff performance) with transfers (how resident moves to and from bed, chair, wheelchair) and toilet use. During a concurrent observation and interview on 3/24/2026 at 11:12 AM with Resident 41, at Resident 41's bedside, Resident 41 was lying in bed, a touch-pad call light (a specialized, highly sensitive patient safety device designed to help, individuals with limited mobility, call for assistance) was observed close to Resident 41's right shoulder. Resident 41 stated can you please call the nurse; I cannot reach the call light. I can't use my right arm. I can't even go across my body with my left arm. How am I supposed to reach that [call light]? During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1), on 3/24/2026 at 11:22 AM, at Resident 41's bedside, LVN 1 stated Resident 41 can minimally move his left arm but cannot grab a call light. LVN 1 stated the resident's touch pad call light was located on the right side of Resident 41's body and Resident 41 could not reach it. LVN 1 stated it was important for the call light to be within reach so the residents could ask for assistance [from staff]. During an interview with the Director of Nursing (DON) on 3/27/2026 at 3:04 PM, the DON stated call lights should be within reach for the residents (in general) to communicate their needs to staff. During a review of the facility's policy and procedure (P&P) titled Call Light, reviewed 3/2026, the P&P's policy indicated to provide the resident a means of communication with nursing staff. The P&P's procedure indicated to listen to the resident's request/need, leave the resident comfortable and place the call device within the resident's reach before leaving the room. The P&P indicated to provide a touchpad call light for residents with limited mobility of fingers but functional upper extremities.

Based on interview and record review, the facility failed to develop an individualized person-centered care plan (CP) for one of one sampled resident (Resident 7) that addressed Resident 7's moderate difficulty (speaker has to increase volume and speak distinctly) hearing.This failure had the potential to result in unmet individual needs for Resident 7 and the potential to affect Resident 7's physical and psychosocial well-being.Cross reference with F636Findings:During a review of Resident 7's Face Sheet (admission record, FS), the FS indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heartbeats), dysphagia (difficulty swallowing), and generalized muscle weakness.During a review of Resident 7's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 7 had the capacity to understand and make decisions.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive (the ability to think and process information) was intact and required moderate assistance (helper does less than half the effort) with toilet hygiene, upper body dressing, chair to bed and toilet transfers. The MDS's section B: Hearing, Speech and Vision indicated Resident 7 had the ability to hear with minimal difficulty (difficulty in some environments e.g., when people speak softly or setting is noisy).During an observation and concurrent bedside interview, at Resident 7's bedside, on 3/26/2026 at 10:30 AM, with MDS Coordinator (MDS) 1, Resident 7 gestured for the surveyor to come closer and stated, Speak louder and put your mask down so I can hear you. I have had trouble hearing from before I got here [to the facility].During an interview and concurrent record review on 3/26/2026 at 10:52 AM, with MDS 1, MDS 1 stated Resident 7 did not have a CP that addressed Resident 7's hearing [difficulty]. MDS 1 stated [creating] CPs was important to provide appropriate care to the residents (in general).During an interview on 3/27/2026 at 3:11 PM with the Director of Nursing (DON), the DON stated CPs were important because they provided plan of care direction and helped ensuring resident (in general) care was appropriate.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 3/2026, the P&P indicated it is the policy of the facility that the interdisciplinary team (IDT) develops a comprehensive person-centered CP for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated the facility IDT will develop and implement a comprehensive person-centered, culturally competent CP for each resident within 7 days of completion of the resident MDS and will include resident's needs identified in the comprehensive assessment, the resident's goals and desired outcomes.

Based on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 7's) hearing. Resident 7's Minimum Data Sheet (MDS, a resident assessment and care-screening tool) indicated minimal difficulty, when it was observed Resident 7 had moderate difficulty in hearing.This deficient practice had the potential to result in Resident 7 not receiving appropriate care or treatment services to effectively communicate with others.Cross reference with F656Findings:During a review of Resident 7's Face Sheet (admission record, FS), the FS indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heartbeats), dysphagia (difficulty swallowing), and generalized muscle weakness.During a review of Resident 7's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 7 had the capacity to understand and make decisions.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive (the ability to think and process information) was intact and required moderate assistance (helper does less than half the effort) with toilet hygiene, upper body dressing, chair to bed and toilet transfers. The MDS's section B: Hearing, Speech and Vision indicated Resident 7 had the ability to hear with minimal difficulty (difficulty in some environments e.g., when people speak softly or setting is noisy).During an observation and concurrent bedside interview with Resident 7 on 3/26/2026 at 10:30 AM, with the MDS Coordinator (MDS) 1, Resident 7 gestured for the surveyor to come closer to Resident 7's bedside, and stated, Speak louder and put your mask down so I can hear you. I have had trouble hearing from before I got here [the facility]. They [facility] were putting drops in my ear for five days and were supposed to flush [to clean the ear canal by removing excess wax with a gentle stream of warm water] my ear out, but that never happened.During an interview on 3/27/2026 at 3:09 PM with the Director of Nursing (DON), the DON stated accuracy of resident assessment was important to make sure we [the facility] took care of residents appropriately.During an interview and concurrent record review on 3/26/2026 at 10:52 AM, with MDS 1, Resident 7's MDS dated [DATE] was reviewed with MDS 1, MDS 1 stated Resident 7's ability to hear should reflect Resident 7's moderate difficulty (speaker has to increase volume and speak distinctly) in hearing. MDS 1 stated Resident 7's MDS assessment should be accurate. MDS 1 stated Resident 7 could not hear us and the facility risked missing important information provided to the resident or missing information provided from the resident to us (the facility).During a review of the facility's policy and procedure (P&P) titled, Resident Assessment and Associated Processes, revised 3/2026, the P&P indicated it is the policy of the facility that residents will be assessed. The P&P indicated the assessment will be comprehensive, accurate and will be conducted initially and periodically as [NAME] of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.

Based on interview and record review, the facility failed to notify the ombudsman (an advocate for residents of nursing home, board and care centers, and assisted living facilities) of one of one sampled resident's (Resident 9) transfer to an acute hospital (GACH).This deficient practice had the potential to result in the ombudsman not being able to advocate for Resident 9 and could potentially lead to illegal or inappropriate discharge (resident dumping) or loss of bed-hold (keeping a resident's bed available while the resident is temporarily absent/hospitalized ) rights for Resident 9. Findings:During a review of Resident 9's Face Sheet (admission record, FS), the FS indicated the facility admitted Resident 9 on 8/20/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD - type of obstructive lung disease characterized by long-term poor airflow) and generalized weakness.During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 2/23/2026, the MDS indicated Resident 9 had intact cognition (ability to think and make decisions) and Resident 9 was independent with bed mobility (rolling left and right, sit to lying, lying to sitting, sit to stand).During a review of Resident 9's Physician's Order (PO), dated 3/11/2026, the PO indicated Resident 9 was transferred to the GACH due to possible stroke (medical emergency occurring when blood flow to part of the brain is interrupted or a blood vessel burst causing brain cells to die from lack of oxygen) or sepsis (a life-threatening blood infection).During an interview on 3/27/2026 at 10:33 AM with the Social Services Director (SSD), the SSD stated Resident 9 was transferred from the physician's office to the GACH, the SSD stated the facility needed to notify the Ombudsman of the transfer because Resident 9 was a resident at the facility. The SSD stated the importance of notifying the Ombudsman of [resident] transfers was for the safety of the resident.During a review of the facility's policy and procedure(P&P) titled Discharge Planning Process dated 3/2026, the P&P did not indicate the process for ombudsman notification for resident transfer to the GACH.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 95), who spoke a dialect from China, was provided a communication tool or resources to effectively ensure Resident 95 communicated Resident 95's needs.This deficient practice had the potential to result in Resident 95's care needs not effectively conveyed to the facility staff, which could lead to a decline in the resident's physical and psychosocial well-being.Findings:During a review of a Face Sheet (admission record, FS), the FS indicated Resident 95 was re-admitted to the facility on [DATE] with diagnosis that included traumatic subdural hemorrhage (dangerous collection of blood between the brain surface and its outer covering, caused when tiny bridging veins tear, usually due to head trauma), and abnormalities of gait (manner of walking) and mobility (ability to actively move joints through their full range of motion).During a review of Resident 95's history and physical (H&P), dated 2/20/2026, the H&P indicated Resident 95 was alert and oriented to person only.During a review of Resident 95's Social Services Assessment (SSA), dated 3/5/2026, the SSA indicated Resident 95's primary language was Mandarin and Resident 95 was a Mandarin speaker.During a review of Resident 95's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 3/7/2026, the MDS indicated the resident's preferred and primary language was Mandarin (a Chinese dialect) and Resident 95 had adequate (no difficulty) hearing. The MDS indicated Resident 95 needed maximal assistance (helper does more than half the effort) with oral and toilet hygiene, sit to stand and chair to bed transfers.During an observation and an attempted interview with Resident 9, in Resident 9's room, on 3/24/2026 at 12:19 AM, Resident 95 smiled, nodded head, and did not respond to questions when asked in English.During a telephone interview with Resident 95's Family Member (FM) 1 and FM 2 on 3/24/2026 at 12:19 PM, FM 1 stated Resident 95 communicated in Mandarin. FM 2 stated Resident 95 did not speak English.During an observation with Licensed Vocational Nurse (LVN) 5 on 3/24/2026 at 12:29 PM, LVN 5 performed blood sugar checking for Resident 95 and administered insulin (a medication used to control sugar in the blood). LVN 5 did not speak Mandarin and communicated with Resident 95 through gestures. LVN 5 did not attempt to use a communication tool.During an interview with LVN 5 on 3/24/2026 at 12:29 PM, LVN 5 stated Resident 95 only spoke Chinese (Mandarin). LVN 5 stated a communication board should have been used to communicate thoroughly with Resident 95. LVN 5 stated communication boards were important so we can all be on the same page and [be able to] inform Resident 95 of the treatments we are giving the resident.During an interview with the Director of Nursing (DON) on 3/27/2026 at 3:06 PM, the DON stated communication tools were important to properly communicate with the residents (in general) and ensure their needs were met.During a review of the facility's policy and procedure (P&P) titled Quality of Life-Non-English & Aphasic Residents, Communication for, dated 3/2026, the P&P indicated it is the policy of this facility that all residents who are cognitively intact will be able to communicate their needs to facility staff, other residents, and other persons as desired by the resident. The P&P indicated the facility will also provide interpreter services for non-English speaking residents. The P&P indicated social services determines the language or tool needed for interpreter services and will supply residents and/or family members with the use of a communication board that has universally known drawings, whenever desired. The P&P indicated all attempts will be made to write in the resident's native tongue, the name of each pictured item, using available staff, family members, and community resources as appropriate.During a review of the facility's policy P&P titled Accommodation of Needs, reviewed 3/2026, the P&P indicated it was the policy of the facility to provide accommodation of reasonable needs to the resident while in the facility.

Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 2 (CNA 2) turned and repositioned one of two sampled residents (Resident 2) with pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) in accordance with the resident's plan of care.This deficient practice had the potential for worsening or delaying healing of Resident 2's Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on [DATE] with diagnoses that included muscle weakness and displaced subtrochanteric fracture of the left femur (broken bone of the left leg).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 2 had moderately impaired cognitive skills (ability to make daily decisions) and required substantial/maximal assistance (helper does more than half the effort to complete the activity) with toileting and personal hygiene, and with upper and lower body dressing. The MDS indicated Resident 2 required partial/moderate assistance (helper lifts, holds or supports trunk or limbs, but provides less than half the effort) in rolling left and right. The MDS indicated Resident 2 had a Stage 4 pressure ulcer.During a review of Resident 2's Care Plan Report (CPR), initiated on [DATE], the CPR indicated Resident 2 has a pressure ulcer or potential for pressure ulcer development related to weakness, pain, impaired mobility, episodes of incontinence, and risk for impaired circulation. The CPR interventions indicated Resident 2 needed monitoring, reminding, and assistance to turn and reposition. The CPR also indicated to turn and reposition Resident 2 every two hours and as needed.During a review of Resident 2's CPR, initiated on [DATE], the CPR indicated Resident 2 was resistive to care related to non-compliance with turning and repositioning. The CPR interventions indicated educating Resident 2 of the possible outcomes of not complying with treatment or care.During an observation on [DATE] at 10:11 AM, Resident 2 was lying in bed, on his back. During an observation on [DATE] from 9:06 AM to 9:36 AM, the Treatment Nurse (TN) provided wound care treatment to Resident 2's pressure ulcer.During an observation on [DATE] from 9:52 AM to 10:03 AM, CNA 1 and CNA 2 provided a bed bath and perineal care to Resident 2. CNA 1 and CNA 2 then turned and positioned Resident 2 to face slightly towards the right side and placed a pillow on Resident 2's left side. The pillow was positioned lengthwise from Resident 2's left side of the neck, under the left shoulder down to the waistline.During an observation on [DATE] at 12:55 PM, Resident 2 was sitting up in bed eating lunch, there was a pillow under the left shoulder down to the waistline.During an observation on [DATE] at 2:55 PM, Resident 2 was lying in bed slightly turned to the right, with a pillow on the left side positioned from the shoulder down to the waistline.During an interview with CNA 2 on [DATE] at 3 PM, CNA 2 stated CNA 2 changed Resident 2's diaper but did not reposition Resident 2 because Resident 2 refused to turn. CNA 2 stated CNA 2 did not inform the charge nurse or any licensed nurse that Resident 2 refused to turn.During an interview with the Treatment Nurse (TN) on [DATE] at 3:12 PM, the TN stated the facility follows a turning schedule to remind staff to position residents (in general) at a certain position at certain times. The TN stated CNA 2 needed to inform the charge nurse of Resident 2's non-compliance with turning and repositioning so that the charge nurse could provide education, encouragement and explain the risk and benefits of turning and repositioning. Once the nurse becomes aware of Resident 2's continued non-compliance to turning and repositioning, we could notify the physician. The TN stated Resident 2 already had impaired skin integrity and the parts of the wound that had healed can easily reopen.During an interview on [DATE] at 4:26 PM, the Director of Nursing (DON) stated CNAs (in general) needed to follow the repositioning schedule and report to the charge nurse for refusal to turn so the licensed nurse could do a proper follow up.During a review of the facility's policy and procedure (P&P) titled Prevention and Management of Pressure Injuries, undated, the P&P indicated, Encourage to reposition; consider the resident's condition, the support surface in use, tolerance, and the resident's stated preferences. The facility will promote turning schedule. Reposition frequently as needed.

Based on observation, interview and record review, the facility failed to provide pain medication to one of two sampled residents (Resident 2) and let the pain medication take effect prior to continuing with Resident 2's wound care to Resident 2's Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and prior to providing a bed bath to Resident 2.This deficient practice resulted in Resident 2 experiencing unrelieved pain for 40 minutes on 2/20/2026.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 7/7/2025 with diagnoses that included muscle weakness and displaced subtrochanteric fracture of the left femur (broken bone of the left leg).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/28/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills (ability to make daily decisions) and required substantial/maximal assistance (helper does more than half the effort to complete the activity) with toileting and personal hygiene, and with upper and lower body dressing. The MDS indicated Resident 2 required partial/moderate assistance (helper lifts, holds or supports trunk or limbs, but provides less than half the effort) in rolling left and right. The MDS indicated Resident 2 had a Stage 4 pressure ulcer.During a review of Resident 2's Order Summary Report (OSR), dated 1/31/2026, the OSR indicated there was a physician's order, dated 10/8/2025, for Resident 2 to consult with a Pain Management physician. The OSR also indicated there was a physician's order to give Resident 2 hydrocodone-acetaminophen (medication used to treat sever pain) 5-325 milligrams (mg- unit of measure) tablet every six hours as needed for severe pain of 7-10 on the pain scale (tool used to measure pain intensity).During an observation on 2/20/2025 from 9:17 AM to 9:57 AM at Resident 2's bedside, the Treatment Nurse (TN) asked Resident 2 what Resident 2's pain level was, prior to starting the wound care on Resident 2's pressure ulcer. Resident 2 stated Resident 2's pain level was 7. Certified Nursing Assistant 1 (CNA 1) removed the pillow under Resident 2's heels and Resident 2 moaned when CNA 1 lifted both of Resident 2's feet. CNA 1 and CNA 2 turned Resident 2 to the right side and Resident 2 stated Resident 2's groin and back hurt. Resident 2 stated, You're doing everything else to hurt me. The TN proceeded with wound care to Resident 2's pressure ulcer. At 9:36 AM, while providing wound care to Resident 2, the TN asked Resident 2 what Resident 2's pain level was and Resident 2 stated Resident 2's pain level was 7. The TN asked Resident 2 if Resident 2 wanted the TN and CNA 1 and 2 to stop and come back after Resident 2 has had pain medication. Resident 2 stated, Let's get this done. After Resident 2's wound care, CNA 1 and Lead CNA provided Resident 2 with a bed bath. During the bed bath, Resident 2 cried out in pain three times. At 9:57 AM, Resident 2 stated, I've had 45 minutes of pain, Oh my God.During an interview on 2/20/26 at 3:12 PM, the TN stated pain management is important prior to treatment to promote resident's comfort. During an interview on 2/20/2026 at 4:26 PM, the Director of Nursing (DON) stated pain management was important prior to wound care treatment to ensure the resident would not be in pain and suffer during the procedure. The DON stated the treatment nurse and the charge nurse need to communicate with each other to premedicate residents prior to wound care treatment.During a review of the facility's Policy and Procedure (P&P) titled Pain Management 5/2007, the P&P indicated, The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: Screening to determine if the resident has been or is experiencing pain. Comprehensively assessing the pain. Identifying circumstances when pain can be anticipated. Developing and implementing a plan, using pharmacologic and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals.

Based on interview and record review, the facility failed to provide the care and services for one of six sampled residents (Resident 2) according to the facility's policies and procedures (P&P) titled, Resident Care, Monitoring of, Change of Condition Reporting, and Significant Change of Condition, Response, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 notified Resident 2's Primary Care Provider/Medical Doctor (MD) 1 promptly (quickly/with little or no delay) when LVN 1 noted a lump (growth, swelling, or mass that can appear anywhere on the body) in Resident 2's left breast on 4/17/2024 at 12:15 pm. 2. Ensure LVN 1 and/or assigned licensed nurses (LVNs or Registered Nurses [RNs]) developed a plan of care and implemented interventions to address Resident 2's left breast lump. 3. Ensure LVNs 1, 4, 5, 6, 8, 9, 10, and 11 communicated with MD 1 and clarified MD 1's recommendation to order a mammogram (X-ray [pictures of the inside of the body] examination of the breast to help detect breast cancer [a disease caused by an uncontrolled division of abnormal cells in a part of the body]) to Resident 2's both breast as documented on Resident 2's eINTERACT Change in Condition Evaluation (CIC [a change in the resident's health or functioning that requires further assessment and intervention] Evaluation) dated 4/17/2024, timed at 12:15 pm. 4. Ensure the assigned licensed nurses reassessed the condition of Resident 2's left breast lump after 72 hours (on 4/21/2024) and followed-up with MD 1 to obtain the necessary orders to care and/or treat Resident 2's unresolved left breast lump. 5. Ensure MD 1's order for mammogram to Resident 2's both breasts dated 4/25/2024 was carried out (to do or complete) as MD 1 ordered on 4/25/2024. As a result, Resident 2 did not receive the care and services for Resident 2's left breast lump from 4/17/2024 to 7/1/2024. On 7/1/2024 at 3:15 am, Resident 2 complained of severe and uncontrolled pain under Resident 2's left breast and left rib cage (bones in the chest that protect the lungs and heart). On 7/1/2024 at 8:50 am, Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for further evaluation of the left breast lump. Resident 2 was found with a 1.8 centimeter (cm, unit of measurement) by 2.4 cm by 1.3 cm mass suspicious for malignancy (cancer) on Resident 2's left breast at GACH 1. On 7/31/2024, Resident 2 had an ultrasound guided biopsy (procedure that involves removing cells or tissue from the body for examination and testing by a physician and laboratory) at GACH 1 which showed infiltrating ductal carcinoma (a type of breast cancer that originates in the milk ducts of the breast and then spreads into surrounding tissue) of the left breast. Cross Reference F580 and F656 Findings: During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included multiple sclerosis (long standing disease that affects the brain, spinal cord, optic nerves, and blocks messages between the brain and body), hydronephrosis (condition where one or both kidneys become stretched and swollen as a result of build-up of urine), and cerebral palsy (disorder of movement, muscle tone, or posture). During a review of Resident 2's eINTERACT CIC Evaluation dated 4/17/2024, timed at 12:50 pm, the CIC Evaluation indicated Resident 2 was noted with a lump on the left breast after showering. The CIC Evaluation indicated LVN 1 notified MD 1 on 4/17/2024 at 12:15 pm and MD 1 recommended to order a mammogram to both breasts for Resident 2. During a review of Resident 2's physician order (PO) dated 4/25/2024, transcribed by LVN 6, the PO indicated an order for a mammogram to both breasts for Resident 2. During a review of Resident 2's CIC Evaluation dated 7/1/2024, timed at 3:05 am, the CIC Evaluation indicated Resident 2 complained of uncontrolled and severe pain under Resident 2's left breast, and left rib cage. The CIC Evaluation indicated Resident 2 requested to be transferred to GACH 1. During a review of Resident 2's Progress Notes (PN) dated 7/1/2024, timed at 3:15 am, the PN indicated MD 1 was notified regarding Resident 2's complaint of severe pain under Resident 2's left breast and left rib cage not relieved with pain medication (name of pain medication was not listed). The PN indicated MD 1 ordered to transfer Resident 2 to GACH 1 Emergency Department (GACH 1 ED) for further evaluation. The PN indicated the facility transferred Resident 2 to GACH 1 ED on 7/1/2024 at 8:50 am. During a review of Resident 2's GACH 1 ED General Note, dated 7/1/2024, timed at 9:05 am, the GACH 1 ED General Note indicated Resident 2 was brought to GACH 1 for severe pain on the left ribs unrelieved by pain medication. The GACH 1 ED General Note indicated Resident 2 had a mass on the left breast that was noted three months ago (4/17/2024) and Resident 2 had not had a mammogram. During a review of Resident 2's GACH 1 Ultrasound (US- imaging that uses soundwaves to make pictures of organs, tissue, and other structures inside the body) Report of Resident 2's left breast dated 7/1/2024, timed at 12:48 pm, the US Report indicated Resident 2 had a 1.8 cm by 2.4 cm by 1.3 cm mass in the left breast, highly suspicious for malignancy (cancer). The US Report indicated a recommendation for a mammogram and US-guided biopsy of Resident 2's left breast to ensure appropriate care. During a review of Resident 2's GACH 1 ED Assuming Care Note (EDACN), dated 7/1/2024, timed at 2:03 pm, the EDACN indicated (on 7/1/2024) at 3:36 pm, Resident 2 was unable to get into position to perform a mammogram and the mammogram was canceled. The EDACN indicated (on 7/1/2024) at 3:42 pm, Resident 2's breast US showed a category four (indicates likelihood for malignancy) suspicious breast lesion (mass), and a US-guided biopsy was recommended. The EDACN indicated (on 7/1/2024) at 3:47 pm, Resident 2's breast US showed concerning malignancy and required further workup from a specialist. The EDACN indicated Resident 2 would follow-up with MD 1 with a referral for breast cancer specialist. During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/3/2024, the MDS indicated Resident 2 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 2 was dependent (helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity) on staff for showering/bathing self, putting on/taking off footwear, sitting to lying (in bed), sitting to standing, chair/bed-to-chair transfers, and toilet transfers. The MDS indicated Resident 2 required substantial/maximal assistance (helper did more than half the effort; helper lifted or held the trunk or limbs and provided more than half effort) with oral hygiene, toileting, personal hygiene, upper and lower body dressing, and rolling left and right (in bed). During a review of Resident 2's GACH 1 Hematology (study of blood and blood disorders) Oncology (branch of medicine that specializes in the diagnosis and treatment of cancer) Progress Note (HOPN) dated 10/25/2024, the HOPN indicated Resident 2's US-guided biopsy dated 7/31/2024 showed Resident 2 had infiltrating ductal carcinoma (breast cancer). During a telephone interview on 11/4/2024 at 12:07 pm with Resident 2, Resident 2 stated in later part of April 2024 (unable to specify date), the facility nurses (unable to identify) found a lump in Resident 2's left breast. Resident 2 stated the facility was not doing anything. Resident 2 stated Resident 2 expressed to the facility that Resident 2 was stressed and concerned about the lump, but Resident 2 was dismissed by facility staff (unidentified). Resident 2 stated Resident 2 had asked facility staff (unidentified) more than three times to call MD 1 to inform MD 1 regarding Resident 2's left breast lump and pain in Resident 2's left breast but was dismissed by facility staff. Resident 2 stated Resident 2 was not seen by MD 1 or taken to the hospital until 7/1/2024, when Resident 2 had a lot of pain in her chest and ribs. Resident 2 stated the only reason Resident 2's left breast lump was assessed at GACH 1 on 7/1/2024 was because Resident 2 advocated for herself and told the ED physician Resident 2 had a lump. Resident 2 stated MD 1 did not assess Resident 2 for a left breast lump until 7/2/2024, when GACH 1 informed MD 1 Resident 2 needed to be referred to a specialist for breast cancer. Resident 2 stated Resident 2 cried every day and tried to keep a positive attitude about the diagnosis, but it was hard because Resident 2 was struggling to not give up. Resident 2 stated Resident 2 felt like a death sentence had been given to her (Resident 2). Resident 2 stated Resident 2 felt so unseen and dismissed because facility staff did not listen to her. During a telephone interview on 11/5/2024 at 1:38 pm, with the hematologist/oncologist (physician who specializes in blood disorders and cancer)/MD 2, MD 2 stated MD 2 was Resident 2's primary oncologist. MD 2 stated Resident 2 was diagnosed with infiltrating ductal carcinoma with metastasis (process by which cancer cells spread from their original location to other parts of the body) to the bone. MD 2 stated it was important for Resident's 2 left breast lump to be assessed as soon as it was found and get a biopsy to investigate if the lump was cancerous. MD 2 stated a biopsy was needed to be done as soon as possible to determine the best course of treatment for Resident 2. MD 2 stated a delay in assessment and treatment could affect Resident 2's cancer prognosis. MD 2 stated with cancer, the faster the diagnosis was made, the faster [the oncologist] can treat cancer symptoms and hope to reduce the size of the tumor. MD 2 stated at this time, Resident 2's cancer was not curable. During an interview on 11/5/2024 at 3:08 pm with the Director of Nursing (DON), the DON stated LVN 1 was on maternity leave and could not be reached for an interview. During a telephone interview on 11/6/2024 at 8:12 am with LVN 5, LVN 5 stated (in general) when a resident had a change in condition, LVN 5 needed to notify the resident's physician (MD 1) to see if any orders were needed. LVN 5 stated if LVN 5 was unable to speak to the physician (MD 1), LVN 5 needed to follow-up and speak with the physician to obtain orders. LVN 5 stated when there was a change in resident's (Resident 2's) condition licensed staff (in general) needed to monitor a resident for at least 72 hours. LVN 5 stated when the condition was still present after 72 hours, the licensed nurses needed to inform the resident's physician to see if new orders such as a referral or hospital transfer for further evaluation was needed. LVN 5 stated when a resident's physician could not be reached, it could be fatal and could endanger the resident's health in a negative way. LVN 5 stated Resident 2's left breast lump needed to be followed-up on in April 2024 because the lump turned out to be cancerous and could metastasize. LVN 5 stated when Resident 2's cancer metastasized, the cancer could spread to other organs, be harder to treat, and could be fatal. LVN 5 stated Resident 2's left breast lump required reassessment by the licensed nurses. LVN 5 stated the assigned licensed nurses (all the assigned licensed nurses) to Resident 2 needed to call MD 1 to report Resident 2's left breast lump and obtain the necessary orders to care and/or treat Resident 2's left breast lump. During a telephone interview on 11/6/2024 at 9:08 am with LVN 6, LVN 6 stated (in general) when completing change in resident condition monitoring, when LVN 6 did not see any new orders or progress notes indicating new orders from the resident's physician, LVN 6 would need to follow-up and call the physician (in general) immediately to see if orders were needed to ensure appropriate care and treatment were provided and the best possible prognosis of the change in condition was possible. LVN 6 stated Resident 2 complained that the Resident 2's left breast lump hurt (unable to specify date and time). LVN 6 stated it was important for staff to communicate and follow-up with MD 1 regarding Resident 2's left breast lump so orders and referrals could have been made for Resident 2. LVN 6 stated Resident 2 could have been assessed by MD 1 in April 2024 and there would have been no delay in care. During a concurrent telephone interview and record review on 11/6/2024 at 12:03 pm with LVN 6, Resident 2's PO dated 4/17/2024 to 4/20/2024 and 4/25/2024 were reviewed. Resident 2's PO dated 4/17/2024 to 4/20/2024, indicated no transcribed (put into written or printed form) telephone order from MD 1 for Resident 2's mammogram to both breasts as indicated on Resident 2's CIC Evaluation dated 4/17/2024. LVN 6 stated LVN 6 documented a telephone order from MD 1 on 4/25/2024 at 12:31 pm, for Resident 2 to have a mammogram to both breasts. LVN 6 stated LVN 1 instructed LVN 6 to transcribe the mammogram order because MD 1 requested the mammogram, so LVN 6 made the physician order. LVN 6 stated LVN 6 could not remember if LVN 6 notified the Social Services Director (SSD) to arrange and schedule Resident 2's mammogram appointment. LVN 6 stated notifying the SSD regarding Resident 2's mammogram order was important so the SSD could arrange and schedule an appointment for Resident 2. LVN 6 stated he did not notify MD 1 regarding Resident 2's left breast lump and did not obtain the mammogram order directly from MD 1 on 4/25/2024. During a concurrent interview and record review on 11/6/2024 at 12:55 pm with MD 1, Resident 2's Physician Progress Notes (PPN) dated 4/27/2024, 5/20/2024, 6/26/2024, and 7/2/2024 were reviewed. MD 1 stated there was no documentation in Resident 2's PPN dated 4/27/2024, regarding Resident 2's left breast lump because facility staff did not notify MD 1 of Resident 2's left breast lump on 4/17/2024. MD 1 stated when facility staff notified MD 1 regarding any change in resident's condition, MD 1 would see the resident as soon as possible. MD 1 stated MD 1 would have assessed and documented Resident 2's left breast lump in Resident 2's PPN dated 4/27/2024 and recommended a mammogram if MD 1 knew about Resident 2's breast lump when MD 1 examined Resident 2 on 4/27/2024. MD 1 stated MD 1 did not give an order for a mammogram on 4/25/2024. MD 1 stated GACH 1 ED staff notified MD 1 on 7/1/2024 regarding Resident 2's breast cancer while Resident 2 was at GACH 1. MD 1 stated MD 1 visited Resident 2 at the facility on 7/2/2024, examined and assessed Resident 2's left breast lump, and placed an order for mammogram on 7/2/2024. MD 1 stated Resident 2 could not have a mammogram due to Resident 2's medical condition so Resident 2 had an US-guided biopsy of the left breast lump instead. MD 1 stated Resident 2 had the US-guided biopsy of the left breast lump on 7/31/2024 which showed infiltrating ductal carcinoma. MD 1 stated Resident 2 was referred to a surgeon for evaluation. MD 1 stated when a lump was found in a resident's breast, the lump needed to be investigated immediately to rule out cancer. MD 2 stated cancer needed to be diagnosed quickly so the resident could get the appropriate treatment. MD 1 stated it was possible the delay in assessment and diagnosis could have negatively impacted Resident 2's cancer prognosis. During a concurrent interview and record review on 11/6/2024 at 1:06 pm with the SSD, Resident 2's PN dated 4/17/2024 to 7/31/2024 were reviewed. The PN indicated no documented evidence that the physician order dated 4/25/2024 for Resident 2's mammogram to both breasts was carried out. The SSD stated when SSD received a physician order or referral to schedule an appointment from licensed nurses, the SSD would arrange and schedule the appointment for the resident. The SSD stated the SSD could not schedule any resident appointments until the SSD received the order or referral from the licensed nurses (any licensed nurses). The SSD stated the SSD did not receive any orders to schedule a mammogram for Resident 2 on 4/25/2024. The SSD stated it was important for licensed nurses to inform the SSD about any ordered appointments/referrals so the SSD could arrange and scheduled the appropriate care/services. During an interview on 11/6/2024 at 4:29 pm with the DON, the DON stated (in general) when a resident had a change in condition, licensed staff needed to assess the resident, inform the resident's physician of the change in condition and assessment, and await orders, and inform the resident and/or the resident's family. The DON stated licensed nurses needed to carry out the orders provided and monitor the resident for 72 hours. The DON stated monitoring the resident for 72 hours after a change in condition helped determine if a physician order was carried out. The DON stated licensed nurses needed to communicate with each other and document in the PN to ensure orders were carried out after a change in the resident's condition. The DON stated the licensed nurse who obtained the phone order from the physician should transcribe/input the order in the electronic health record (EHR) to ensure there was no lapse in care or confusion. The DON stated when new orders due to a change in the resident's condition were not carried out, it was not safe for the resident because it could cause further complications and/or negative outcomes for the resident. The DON stated if the SSD did not schedule a mammogram for Resident 2 on 4/25/2024, it was most likely because the SSD was not informed by the nursing staff to schedule the appointment for Resident 2. The DON stated if Resident 2's left breast lump had been addressed earlier than 7/2/2024, then facility staff and MD 1 could have provided earlier interventions to see what could have been done. The DON stated not doing this for Resident 2 was considered a delay in care could cause further complications for Resident 2 and affect Resident 2's cancer prognosis. During a concurrent interview and record review on 11/6/2024 at 4:29 pm with the DON, Resident 2's Progress Notes (PN) dated 4/17/2024 to 4/20/2024 were reviewed. The PN indicated no documented evidence that LVNs 1, 4, 5, 6, 8, 9, 10, and 11 communicated with MD 1, clarified MD 1's recommendation for a mammogram as indicated in Resident 2's CIC Evaluation dated 4/17/24, and obtained/transcribed the mammogram order in Resident 2's medical record. The DON stated if MD 1 recommended for Resident 2 to have a mammogram on 4/17/2024 when Resident 2's lump was first assessed, then the order for mammogram should have been transcribed on 4/17/2024 by the licensed nurse who wrote it on the CIC Evaluation (LVN 1). During the same concurrent interview and record review on 11/6/2024 at 4:29 pm with the DON, Resident 2's untitled care plans and medical record were reviewed. Resident 2's untitled care plans and medical record indicated no care plan was developed for Resident 2's left breast lump. The DON stated Resident 2 did not have a care plan developed and interventions implemented to address Resident 2's left breast lump. During a review of the facility's P&P titled, Resident Care, Monitoring of, reviewed 1/2024, the P&P indicated, Nursing service Staff cares for its residents in manner and in an environment that promotes maintenance or enhancement of each resident's quality of life and promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The P&P indicated, Each resident receives or is provided the necessary care and services enabling him/her to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. During a review of the facility's P&P titled, Change of Condition Reporting, undated, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in resident's medical/mental condition and/or status . The P&P indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a (an) . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly . The P&P indicated, A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or implementing standard disease-related clinical interventions (is not self-limiting) . c. Requires interdisciplinary review and/or revision to the care plan . During a review of the facility's P&P titled, Significant Change of Condition, Response, reviewed 12/2023, the P&P indicated, If, at any time, it is recognized by any one of the team members that the condition of care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware . The P&P indicated, The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider . to obtain new orders or interventions. The P&P indicated, The resident will be placed on the 24-Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions . The P&P indicated, The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation . The P&P indicated, Each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly. The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident Electronic Medical Record (EMR). The P&P indicated, the facility shall collaborate with the attending physician, resident, and/or resident representative to review risk indicators and the plan of care .

Based on observation, interview, and record review, the facility failed to manage pain for one of three sampled residents (Resident 3) by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) assessed Resident 3 ' s leg pain (pain on both legs) and re-evaluated the effectiveness of the Tylenol (pain relief medication) administration on 3/16/23, at 2 p.m. as indicated in Resident 3 ' s care plan for pain. 2. Ensure LVN 1 implemented the facility ' s policy and procedure titled, Nursing Administration, when LVN 1 did not notify Medical Doctor 1 (MD 1) regarding Resident 3 ' s uncontrolled/unrelieved leg pain (unrated). As a result, on 3/16/23 and on 3/17/23, Resident 3 experienced physical and emotional distress due to unrelieved/uncontrolled pain on both legs. Cross reference: F580 Findings: A review of Resident 3 ' s Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection) and contractures (shortening and hardening of muscles, tendons, or tissues leading to deformity and joint stiffness) on both knees. A review of Resident 3 ' s Care Plan for Pain, initiated on 10/18/22, revised on 1/1/23, indicated Resident 3 was at risk for alteration in comfort related to pain manifested by complaints of pain, facial grimace (facial expression of disgust or pain), guarded movements (stiff or rigid movements). The goal was for Resident 3 not to have interruptions in normal activities due to pain. The nursing interventions included for nursing staff (in general) to anticipate the need for pain relief, respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions. A review of Resident 3 ' s History and Physical (H&P), dated 10/28/22, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3 ' s Minimum Data Set (MDS, a comprehensive assessment and a care planning tool), dated 1/22/23, indicated Resident 3 had severe cognitive (processes of thinking and reasoning) impairment and had unclear speech. The MDS indicated Resident 3 required extensive assistance (resident involved in activities, staff provide weight bearing support) with bed mobility, dressing, and toilet use. The MDS indicated Resident 3 received a scheduled pain medication regimen. A review of Resident 3 ' s Order Summary Report, active orders as of 3/1/23, indicated Resident 3 had the following physician orders: 1. Order dated 10/18/22, indicated pain assessment according to scale: 0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 to 10 = severe pain. 2. Order dated 10/18/22, indicated Tylenol, tablet, 500 milligrams (mg, unit of measurement), one tablet given via feeding tube [a tube that is inserted through the nose, down the throat and esophagus (canal that connects the throat to the stomach), and into the stomach] every four hours as needed for mild pain rated 1 to 3. 3. Order dated 10/18/22, indicated Tylenol tablet 325 mg, two tablets given via feeding tube every four hours as needed for moderate pain rated 4 to 6. 4. Order dated 10/18/22, indicated Tylenol tablet 500 mg, two tablets given via feeding tube every four hours as needed for severe pain rated 7 to 10. 5. Order dated 10/18/22, indicated Meloxicam (medication to treat swelling, stiffness, and joint pain) tablet 7.5 mg, one tablet given via feeding tube, one time a day for pain management. 6. Order dated 10/19/22, indicated pain assessment and management completed every shift. 7. Order dated 11/21/22, indicated Tylenol 325 mg tablet, two tablets given through the feeding tube, every six hours for management of leg pain. 8. Order dated, 2/7/23, indicated Restorative Nursing Assistant (RNA, staff that provides exercises designed to help with joint movement) to apply extension splints (a firm material used for supporting and immobilizing a bone) on both knees for up to 2.5 hours (2 hours and 30 minutes) once a day, seven times per week. A review of Resident 3 ' s Physician ' s Order, dated 3/9/23, indicated Tramadol Hydrochloric Acid (HCL, medication that treats moderate to severe pain) 50 mg tablet, one tablet given via feeding tube, two times a day for management of leg pain. During a concurrent observation of Resident 3 ' s room and interview with Resident 3 on 3/16/23, at 2:28 p.m., Resident 3 ' s head of the bed was raised and Resident 3 ' s legs were bent toward the resident ' s abdomen. Resident 3 was lying in bed with flushed face (reddening of the face) and sweat drops on the resident ' s forehead. Resident 3 was crying, screaming, tossing (move from side to side) on the bed. Resident 3 was turning his head from left to right with facial grimacing and was restless (inability to rest or relax). Resident 3 had tears coming down his face and the resident ' s hair was wet. Resident 3 bit his fist and continued to cry and scream. Resident 3 did not respond when the surveyor asked if the resident was in pain. During an observation and concurrent interview on 3/16/23, at 2:30 p.m., Resident 3 had splints on both legs. Restorative Nursing Assistant 1 (RNA 1) stated Resident 3 was grimacing, crying, screaming, biting his fist, moving his upper body on the bed and was restless. RNA 1 stated Resident 3 ' s face looked red, and the resident ' s head was sweaty. RNA 1 stated Resident 3 had the splints on, and the splints were too painful for Resident 3. RNA 1 stated, See how he tries to bite his hand from the pain he has. RNA 1 stated she applied the splint on Resident 3 today at 2 p.m. and Resident 3 had to keep the splints on for four hours. RNA 1 stated Resident 3 could not tolerate wearing the splints. During an interview on 3/16/23, at 2:32 p.m., Resident 4 (Resident 3 ' s roommate) stated Resident 3 cried in pain even at nighttime. Resident 4 stated I feel so bad for him. During an observation on 3/16/23, at 2:37 p.m., Resident 3 remained restless in bed. Resident 3 was screaming and hitting his face with his left hand. Resident 3 continued to cry and yell. During an observation and concurrent interview on 3/16/23, at 2:38 p.m., LVN 1 and Certified Nurse Assistant 1 (CNA 1) walked in Resident 3 ' s room. CNA 1 repositioned Resident 3 and Resident 3 screamed. LVN 1 stated Resident 3 ' s adult brief (disposable underwear) was dry and clean, and she (LVN 1) administered the pain relief medication (Tylenol) at 2 p.m. LVN 1 stated she would let MD 1 know that Resident 3 ' s pain was not controlled due to Resident 3 ' s grimacing, crying, screaming, sweating, and restlessness. A review of Resident 3 ' s Restorative Nursing Weekly Summary Range of Motion/Exercises, dated 3/16/23, indicated to apply splints on both knees up to 2.5 hours, seven times per week. The summary indicated Resident 3 was cooperative, had pain, and nursing was notified. A review of Resident 3 ' s Medication Administration Record (MAR), dated 3/16/23, under Pain Assessment, indicated Resident 3 did not have pain the whole day, during the morning, evening, and night shifts. The MAR indicated Resident 3 did not have any episodes of yelling out, moaning, and groaning during any of the shifts on 3/16/23. The MAR indicated Resident 3 received Tylenol 500 mg, two tablets (1000 mg) on 3/16/23, at 2 p.m. A review of Resident 3 ' s Nurses Note, dated 3/16/23, indicated there was no documentation regarding Resident 3 ' s screening, crying, and yelling due to pain. The note indicated there was no documented evidence LVN 1 notified MD 1 about Resident 3 ' s unrelieved pain after the Tylenol administration on 3/16/23 at 2 p.m. During an interview on 3/17/23, at 5 p.m., the Assistant Director of Nursing (ADON) stated the ways to determine pain for Resident 3 were assessing for grimacing, moaning, crying, and guarding. The ADON stated other signs and symptoms of severe pain included being physically uncomfortable, tensed, yelling, sweating/flushing, and restlessness. The ADON stated the purpose of administering breakthrough pain (a sudden flare up of pain from long standing medical conditions and additional pain medication is needed) medication was to prevent severe pain. The ADON stated staff (in general) needed to administer pain relief medication for breakthrough pain when routine pain medication did not work, or when the next routine pain medication was not due to be given. The ADON stated it was important to accurately assess Resident 3 ' s pain to prevent the resident from feeling uncomfortable. The ADON stated pain reassessment could be done to determine if pain medication was ineffective (not working). During a concurrent interview on 3/17/23, at 5:15 p.m. and a review of Resident 3 ' s Nurse Notes, dated 3/16/23, the ADON stated Resident 3 received Meloxicam and Tramadol for pain management due to contractures. The ADON stated Resident 3 received pain relief medication (Tylenol 1000 mg) on 3/16/23 at 2 p.m. The ADON stated nurses (in general) needed to assess Resident 3 for pain during splint application on Resident 3 ' s contracted legs. The ADON stated the application of the splints could be painful for Resident 3. The ADON stated on 3/16/23, at 2:38 p.m., after LVN 1 witnessed Resident 3 crying and yelling in pain, LVN 1 did not notify MD 1 regarding Resident 3 ' s pain. The ADON reviewed Resident 3 ' s Nurse Notes, dated 3/16/23 and stated there was no documented evidence to indicate LVN 1 notified MD 1 regarding Resident 3 ' s uncontrolled pain during the splint application despite of Tylenol administration on 3/16/23, at 2 p.m. During a concurrent review of Resident 3 ' s Care Plan for Pain, initiated on 10/18/22, and an interview on 3/17/23, at 5:51 p.m., the ADON stated LVN 1 did not implement nursing interventions to respond to Resident 3 ' s complaint of pain or re-evaluate the effectiveness of Resident 3 ' s pain relief medication. A review of the facility ' s Daily Staffing Sheet, dated 3/17/23, indicated LVN 1 was not scheduled to work on 3/17/23 (LVN 1 was not available to be interviewed). During an interview on 3/17/23, at 6:23 p.m., LVN 2 who was assigned to care for Resident 3, stated signs and symptoms of pain for Resident 3 included facial grimacing, clenched hands, and moaning. LVN 2 stated when Resident 3 was in pain, the pain had to be treated before it reached moderate or severe pain level (rated at 7-10). LVN 2 stated pain could cause mental anguish (mental suffering). During an interview on 3/17/23, at 6:40 p.m., CNA 3 who was assigned to care for Resident 3, stated when Resident 3 yelled he could be frustrated or in pain. CNA 3 stated when Resident 3 was in pain, the resident bit his fist. CNA 3 stated when Resident 3 bit his fist it was to communicate to staff (in general) that he was in pain. During an observation and concurrent interview on 3/17/23, at 6:50 p.m., Resident 3 was screaming, and moaning help me. LVN 2 asked Resident 3, Are you in pain? Resident 3 yelled, yes, yes, help me. A review of Resident 3's Progress Notes, dated 3/17/2023, indicated Resident 3 had a change of condition (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) due to increased pain (no specific location and the pain was not rated). The notes indicated LVN 2 notified MD 1 at 8 p.m. regarding Resident 3 ' s COC. A review of Resident 3 ' s Physician ' s Order, dated 3/17/28, timed at 8:18 p.m., indicated MD 1 ordered to increase Tramadol HCL, 50 mg, one tablet given via feeding tube, three times a day, for management of leg pain. A review of the facility ' s undated policy & procedure, titled, Nursing Administration, indicated the policy ' s subject was pain management. The policy indicated the facility was to provide an environment that assisted each resident who had pain to attain or maintain resident ' s highest practicable physical, mental, and psychosocial well-being by comprehensively assessing the pain, developing, and implementing a plan. The policy indicated to document residents ' response to pain treatment and assess significant change to ensure pain remains controlled. The policy indicated to monitor pain status, treatment effects and consult the physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. The policy indicated if the resident is unable to communicate pain using the rating scale, the clinician will assess behavioral factors that signal pain or discomfort.

Based on observation, interview, and record review the facility failed to ensure three of eight sampled residents (Residents 1, 4 and 6) receiving enteral feedings (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) received appropriate care and services. These deficient practices included: 1. A licensed nurse used a declogger (a mechanical device used to remove an accumulation of matter in the [DEVICE]) on Resident 4's gastrostomy ([DEVICE]), a tube surgically placed into the stomach, which allows for nutrition and medications). The licensed nurse had never used the declogger device before and had not received training on how to use a declogger. 2. Resident 1 went to the hospital 11 times, within 16 months, for a clogged and leaking gastrostomy tube ([DEVICE]). There was no indication of the cause for Resident 1's [DEVICE] issues and hospitalization s. 3. During a medication observation, a licensed nurse administering nine medications through Resident 6's [DEVICE] without administering water between each medication. During the same medication observation, the licensed nurse administered [MEDICATION NAME] without stopping the enteral feeding one hour before and after the administration for absorption purposes. The licensed nurse stated water flushes are not necessary and only done prior to medication administration and after the last medication is administered through the [DEVICE]. On 2/7/2020 at 2:40 p.m., the Department of Public Health called an Immediate Jeopardy situation (IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the administrator. These failures include: 1. Licensed nurses' use of a declogging device on Resident 4's [DEVICE], twice, without knowledge or training on how to use the declogging device, without following the manufacturer's instructions or manual, and without a physician's orders [REDACTED].>2. A licensed nurse lacking knowledge about water flushes between medications administration through Resident 6's [DEVICE]s. Additionally, the licensed nurse did not stop Resident 6's continuous tube feeding one hour prior to and after administering the [MEDICATION NAME] medication. These practices did not ensure Resident 1 absorbed the correct dose of [MEDICATION NAME]. On 2/8/2020 at 1:16 p.m., the administrator provided an acceptable written plan of action (POA) that included the following summarized actions: In-services given by a clinical consultant and pharmacy staff, to the licensed nursing staff regarding: 1. Gastrostomy tube placement, management, care, emphasizing declogging and the facility's policy revision on steps to take to declog a [DEVICE] and inclusion of a performance skills checklist for each licensed nurse. 2. Removal of all declogging devices from the facility's supply room and will no longer be available. 3. Medication administration, which included medication rights, [MEDICATION NAME]es, liquid medications, and an emphasis on enteral medication administration, which also included placement verification. On 2/08/20 at 1:16 p.m., while onsite and after verifying and confirming the facility's implementation of the immediate corrective actions (POA), the Department removed the Immediate Jeopardy, in the presence of the administrator. Findings: On 2/6/20 at 5:08 a.m., the Department made an onsite visit to the facility. During an observation and tour of the facility on 2/6/20 at 5:16 a.m., residents of the facility were in their rooms. Two licensed nurses were in the hallways in Stations 2 and 3, at the medication carts, preparing to administer medications to the residents. 1. During an observation on 2/6/20 at 5:26 a.m., Resident 4 was lying in bed asleep with the head of the bed elevated to approximately 20 degrees. There was a continuous formula feeding of Glucerna (a calorically dense formula used to minimize elevated blood sugar levels) connected to the resident's [DEVICE] port infusing at 50 milliliters ((mL) a unit of measure) per hour (mL/hr, the amount of formula over an hour). A review of Resident 4's Face Sheet indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's History and Physical (H&P) dated 1/09/20, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 1/15/20, indicated Resident 4 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. During an observation of a [DEVICE] feeding change on 2/6/20 at 5:26 a.m., Licensed Vocational Nurse 4 (LVN 4) stated and confirmed the formula feeding was infusing at 50 mL/hr. LVN 4 stated, I saw the MD (medical doctor) order and it was different. It should have been set at 70 mL/hr. LVN 4 proceeded to change infusion rate on Resident 4's feeding pump. LVN 4 then disconnected the feeding from the resident's [DEVICE] and injected 10 mL of air into [DEVICE] port, but the air would not go into the tube. LVN 4 stated he needed to flush [DEVICE] first. LVN 4 did not check the [DEVICE] for any residual. LVN 4 placed 30 mL into a large syringe (a 60 mL syringe that enables tube feeding and water flushes) and attached the syringe to Resident 4's [DEVICE] port. LVN 4 raised the [DEVICE] and syringe to allow water to flow in by gravity, but the water did not enter the [DEVICE]. LVN 4 then began squeezing the entire [DEVICE] connected to the resident. LVN 4 stated, The tubing felt squishy and was milking it (squeezing the tubing) to unclog it. LVN 4 continued to squeeze the entire tubing and pull at tubing while doing so. An abdominal binder (an elastic abdominal support band) was over the entry point of [DEVICE]. LVN 4 pulled and squeezed the [DEVICE] with enough force to cause the binder to lift away from Resident 4's abdomen. On 2/6/20 at 5:55 a.m., during an observation and interview, LVN 4 stated he needed to grab a declogger located in the facility's supply room. LVN 4 went to the facility's supply room, where he grabbed two long declogger packages. At 6 a.m., LVN 4 entered Resident's 4 room and applied gloves without performing hand hygiene. LVN 4 opened the declogger package, removed the declogger device, and discarded the packaging in the trash can. LVN 4 did not read the packaging instructions and began inserting the declogger, a long light blue flexible plastic stick, approximately 16 inches long, into Resident 4's [DEVICE]. After fully inserting the declogger into the [DEVICE], LVN 4 began twisting the declogging device in a right and left twisting motion while squeezing and milking the [DEVICE]. During an observation and interview, on 2/6/20 at 6:09 a.m., LVN 4 stated he needed to use another declogger and tried again. LVN 4 again opened the declogger packaging, removed the declogger and discarded the packaging, with the instructions into the trash can. LVN 4 then reinserted the declogger into Resident 4's [DEVICE] using the same twisting motion while squeezing and milking the [DEVICE]. At 6:20 a.m. LVN 4 removed the declogger, threw it away in the trash can. LVN 4 proceeded to the restroom and obtained warm water from the sink. LVN 4 then placed 30 mL of water into a syringe and attached it to Resident 4's [DEVICE]. LVN 4 began forcefully pushing on the plunger trying to inject water into [DEVICE] multiple times. At 6:25 a.m., after two unsuccessful attempts with the decloggers and three unsuccessful attempts with the warm water, LVN 4 stated he would go to doctor's room and ask the physician's assistant (PA) what he should do. LVN 4 returned and stated the PA told him to get another nurse to try. During an observation on 2/6/20 at 6:40 a.m., LVN 5 entered Resident 4's room without knocking or performing hand hygiene. LVN 5 put on gloves and began to release Resident 4's abdominal binder. LVN 5 instructed LVN 4 to push the water in Resident 4's [DEVICE] as LVN 5 squeezed the entire length of the G-tubing. After a few attempts, LVN 4 was able to inject 30 mL of water throughout Resident 4's [DEVICE]. During an interview, on 2/6/20 at 7 a.m., LVN 4 stated he had pre documented Resident 4's [DEVICE] feeding change at 4 a.m. instead of the actual time of 6:44 a.m. LVN 4 stated documentation should be done in real time in case something happens. LVN 4 also stated the feeding was infusing at a lower rate than ordered by the physician. Resident 4 did not receive feeding for 1.5 hours while he tried to unclog the [DEVICE]. LVN 4 stated this could lead to Resident 4 being malnourished. LVN 4 added he did not document declogging the [DEVICE] because there was no place to do so. LVN 4 stated he never received any training on declogging the [DEVICE] and this was his first time using the declogger. LVN 4 stated he saw the declogging device in the supply room, so he thought he would use it. LVN 4 stated he did not know the policy on declogging and did not know where any of the facility's policies were located. LVN 4 stated it was important to have access to policies so he would know how to do his job and provide the best care. LVN 4 stated the facility never trained him to check for residual in the [DEVICE] and he just thought he needed to inject air to check for [DEVICE] placement. LVN 4 continued that he was not sure how to unclog a [DEVICE] so he guessed he could squeeze and pull on the [DEVICE] in an up and down motion. LVN 4 stated pulling on the [DEVICE] could cause displacement or dislodgement (removal). LVN 4 stated by forcing water into the [DEVICE] with the syringe could have burst or rip the [DEVICE]. A review of Resident 4's Progress Notes dated 2/6/20 indicated LVN 4 did not document trying to unclog the [DEVICE] with the declogging device or consultation with the physician's assistant During an interview on 2/06/20 at 12:48 p.m., the Director of Nursing (DON) stated she could not locate a policy for the declogging device. The DON stated and confirmed LVN 4 did not document the attempts at declogging the [DEVICE] or consultation with the physician assistant (PA) in Resident 4's medical record. The DON stated it is a standard of practice to document as documentation is used as a communication tool between the staff members and the physician. During a concurrent interview and observation, on 2/6/20 at 1:11 p.m., LVN 6 entered the supply room, a box of 10 decloggers were packaged in a box on the shelf. There were six decloggers remaining in the box. LVN 6 stated she was never trained on how to use the declogger devices. LVN 6 stated she observed the declogger being used once during her orientation by another nurse. LVN 6 stated she did not know if there was a policy for the decloggers and did not know how to use the declogging device. A review of Resident 4's progress notes, dated 2/6/20 at 4:08 p.m., indicated LVN 4 used a declogger on Resident 4's [DEVICE] at approximately 6 a.m. The progress notes indicated the licensed nurse did not obtain a physician's orders [REDACTED]. The progress notes also indicated the licensed nurses are not professionally trained in the use of the declogging device. The American Society for [MEDICATION NAME] and Enteral Nutrition (ASPEN) recommends warm water as the best initial choice for trying to unclog a feeding tube. Additional second-line interventions include using a commercially available enzyme declogging kit or mechanical declogging device. These also must be used in accordance with facility policy and procedure and only by experienced clinicians . Nursing2019: June 2018 - Volume 48 - Issue 6 - p 66 doi: 10.1097/01.NURSEXXX XXX .5e 2. A review of Resident 1's Face Sheet in the closed record indicated an initial admission to the facility on [DATE] and a re-admission on 11/27/19. Resident 1's [DIAGNOSES REDACTED]. A closed record review of Resident 1's Minimum (MDS) data set [DATE] indicated Resident 1 was dependent on others for eating and personal hygiene. A closed record review of Resident 1's History and Physical (H&P) dated 11/30/19, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's closed record indicated 17 transfers from the skilled nursing facility to the general acute care hospital (GACH) from 1/08/18 to 12/20/19. Eleven of the 17 hospitalization s were for Gastro-Jejunal (GJ) Tube (a tube, surgically placed, into the stomach (G-port) and the small intestine (J-port), which allows for nutrition and medications) blockage, leakage, rips, or tears on 6/26/28, 7/19/18, 12/30/18, 12/31/18, 1/03/19, 1/18/19, 1/24/19, 3/30/19, 4/5/19, 6/6/19, and 10/13/19. A closed record review of Resident 1's care plan for alteration in gastrointestinal (stomach and small and large intestines) status dated 12/30/18 and revised on 1/15/19 indicated Resident 1 had a dislodged GJ-tube. The interventions indicated to transfer the resident to a general acute care hospital. There were no other revisions indicated. A review of Resident 1's care plan, in the closed record, for tube feeding dated 1/7/19 indicated Per the physician, expected leakage due to stoma being bigger than GJ-tube outlet. There were no care plan interventions created. Another review of Resident 1's care plan, in the closed record, for potential for fluid deficit/dehydration related to nausea and GJ-tube feeding revised on 12/24/18 indicated to monitor and document the intake and output as per facility policy. Another intervention indicated to report any signs or symptoms of dehydration (a harmful reduction in the amount of water in the body) to the physician. A review of Resident 1's skilled nursing facility progress notes, in the closed record, dated 12/30/18 at 4:09 p.m., documented Resident 1 had returned from the hospital to the facility with GJ-tube intact, no residual (the amount of formula left in the stomach), or redness noted. Another progress note dated 12/30/18 at 8:30 p.m., indicated leakage from Resident 1's GJ-tube and soiling on the gauze dressing, surrounding the GJ-tube. The progress note indicated to transfer Resident 1 to GACH. A review of Resident 1's skilled nursing facility progress notes, in the closed record, dated 3/30/19 at 10 p.m., indicated Resident 1 received medication via the GJ-tube at 5 p.m. The progress note indicated at 8 p.m. a licensed nurse found the GJ-tube port open with fluid back flowing. The progress note indicated three nurses attempted to flush the clogged line unsuccessfully. Resident 1 required a transfer to GACH for a clogged GJ-tube. 3. During an observation on 2/6/20 at 8:17 a.m., Resident 6 was lying in bed, with the head of bed elevated, and a continuous feeding of Glucerna 1.2 calories (cal) infusing at 70 milliliter per hour (mL/hr.) via the [DEVICE]. A review of Resident 6's Face Sheet indicated an admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 6's history and physical examination [REDACTED]. A review of Resident 6's Minimum Data Set, dated dated [DATE], indicated Resident 6 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. During a medication administration observation on 2/6/20 at 9 a.m., LVN)1 paused Resident 6's continuous feeding immediately prior to checking the placement of the [DEVICE]. LVN 1 injected 30 mL of air with a 60 mL syringe into Resident 6's [DEVICE] while auscultating (listening) with a stethoscope. After validating hearing the placement of Resident 6's [DEVICE], LVN 1 aspirated 30 mL of gastric residual. LVN 1 initiated the medication administration to Resident 6 by pouring 40 mL of water into a syringe attached to the [DEVICE]. The licensed nurse administered nine medications including [MEDICATION NAME] (a medication used to prevent [MEDICAL CONDITION]) 15 mL through Resident 6's [DEVICE]. LVN 1 did not flush water between each of the nine medication administered. After administering all of Resident 6's medications, LVN 1 flushed the [DEVICE] with 40 mL of water and immediately resumed Resident 6's continuous feeding of Glucerna. During an interview, on 2/6/20, at 9:30a.m., LVN 1 stated she did not perform a flush of water between each of Resident 6's medications. LVN 1 stated a water flush is not necessary and only done prior to medication administration and after the last medication is administered. LVN 1 stated she monitors the [DEVICE], the gastric residual, drainage from the [DEVICE] site and the resident's discomfort. During a concurrent interview and record review on 2/6/20, at 2:07 p.m., of Resident 6's February 2020 Medication Administration Record [REDACTED]. LVN 1 stated she did not receive any training on flushing water in between each medication via the [DEVICE]. LVN 1 stated she follows the physician orders [REDACTED]. LVN 1 added when giving Resident 6's [MEDICATION NAME] suspension there were no special instructions prior to administering [MEDICATION NAME]. LVN 1 stated Resident 6 receiving continuous feeding that ends at 10 a.m. and resumes at 2 p.m., for a total of 20 hours. LVN 1 could not state the importance of not administering [MEDICATION NAME] while infusing the continuous feeding. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. LVN 1 stated, I messed up. During an interview on 2/6/20, at 2:20 p.m., the DON stated when administering medications to a resident with a [DEVICE], 5-10 mL of water should be flushed between each medication. The DON stated if the licensed nurse did not flush between medications, the medication would not completely dissolve and this could increase the risk for clogging the [DEVICE]. The DON stated [MEDICATION NAME] is a medication for [MEDICAL CONDITION] and if a resident was on a continuous feeding pump, then the licensed nurse should stop the feeding for one hour prior to and after administering the medication for absorption purposes. The DON stated if the licensed nurse did not stop the tube, feeding this could increase the chance the resident would experience of [MEDICAL CONDITION]. During a concurrent interview and closed record review on 2/11/20 at 11:47 a.m., the director of nurses' designee (DOND) stated to hospitalize a resident so many times for GJ-tube issues is inappropriate. The DOND also stated and confirmed there was no documentation in the medical record indicating Resident 1 pulled on the GJ-tube therefore it was the director of nurses (DON's) responsibility to find the root cause for all the [DEVICE] issues, such as being pulled out while turning or providing care for the resident. The DOND also stated and confirmed the nursing staff left Resident 1's GJ-tube port open on 3/30/19, causing the tube to clog and requiring the resident to go to the GACH. During a concurrent interview and closed record review on 2/11/20 at 11:47 a.m., the DOND stated a lack of nurses' competency could be a cause requiring all of Resident 1's transfers to GACH for GJ-tube issues, especially when there were rips and tears. The DOND stated the rips/tears could have only been caused by an external factor such as the tube not being flushed or handled correctly. The DOND stated documentation throughout Resident 1's medical record did not detail the condition of the GT-tube and should have prompted further investigation. The DOND stated prolonged issues with a GJ-tube could lead to malnourishment, infections, and dehydration, which could lead to [MEDICAL CONDITION] and be fatal. During an interview, on 2/6/20, at 9:58 a.m., the assistant director of nurses (ADON) stated the declogging devices were in central supply and any licensed nurse could use the declogger. The ADON initially stated uncertainty about needing a physician's orders [REDACTED]. The ADON stated before using a declogger, the licensed nurse notifies the physician followed by a physician's orders [REDACTED]. The ADON further stated the declogger was the last option to unclogging a [DEVICE], the first intervention is warm water. During an interview on 2/6/20, at 1:18 p.m., the Director of Nurses (DON) stated the licensed nurses could use a declogger to unclog a [DEVICE]. The DON stated the declogger was part of central supply and was unsure if the use requires a physician's orders [REDACTED]. The DON was unable to provide the manufactures instructions or manual for the use of the declogger. During an interview on 2/6/20, at 1:38 p.m., the Director of Staff Development (DSD), stated, when checking for placement of a [DEVICE], an air-filled syringe attaches to the [DEVICE] and the licensed nurse slowly injects air into the [DEVICE]. Then the licensed nurse aspirates (withdraws) gastric (stomach) residual. The DSD stated when a [DEVICE] becomes clogged, warm water flowed by gravity is placed into the [DEVICE], if the [DEVICE] was still clogged the licensed nurse notifies the physician and the resident goes to the hospital. The DSD stated occasionally a declogger is used but should have a physician's orders [REDACTED]. The DSD stated there is potential the declogger could perforate the [DEVICE], cause a tear, or could become stuck inside the [DEVICE]. The DSD stated she had never received any training on how to use the declogger and provided inservices based on the packaging instructions. During an interview on 2/7/20 at 1:15 p.m., the DON stated the use of a declogger could cause nausea and vomiting, cramping, pain, trauma to the lining in the stomach, and could potentially poke a hole in something. The DON stated she was sure what part of the anatomy could be poked. The DON stated the facility used the decloggers before she was employed (April 2018) and she had never received any training on the decloggers. The DON confirmed the facility did not request physician's orders [REDACTED]. We identified the deficient practice yesterday. A review of the facility's policy, titled, Gastrostomy Tube, revised on 5/2019, indicated to Flush the [DEVICE] with 5-10 mL of water after administering each medication. If a [DEVICE] clogs, Never insert a device into a gastrostomy tube. A review of the facility's policy titled, Gastrostomy tube revised on 5/2019 indicated it was the policy of the facility to provide proper care and maintenance of a [DEVICE]. The policy indicated there was a daily checklist for [DEVICE]s, which included checking for pain, checking the tube exit site, rotating the tube and external bolster ¼ turn, daily cleaning of stoma sites, verifying position before every feeding, and flushing the feeding tube and adapter every four hours per physician's orders [REDACTED]. A review of the facility's policy titled, Gastrostomy-Site Care revised on 5/2007, indicated to document the date and time of care, condition of stoma site and surrounding skin, centimeters marking of skin disc French size of tube, and the resident's tolerance of procedure. A review of the facility's policy titled Licensed Nurse Procedures: Enteral Tube - Patency Check with a revised date of 5/2007, indicated it was the policy of the facility to ascertain the feeding tube was in the proper place and patent (open). The policy indicated patency checks needed to be done and documented every eight hours in the progress notes.

Based on interview, and record review the facility failed to notify the physician of a significant change in potassium and sodium levels (also known as electrolytes which are minerals that are involved in many essential processes in the body. Potassium affects the heart function and sodium affects the brain function) for one out of two sampled residents (Resident 1). The facility did not notify Resident 1's attending physician of the resident's high potassium level and low sodium level on the laboratory report. The facility could not produce documentation the licensed nurses informed Resident 1's attending physician of the potassium and sodium levels. The licensed nurses did not recognize that high levels of potassium and low levels of sodium were life threatening. These deficient practices resulted in delayed care for Resident 1. A certified nursing assistant (CNA) found Resident 1 unconscious inside her room on [DATE]. The facility staff (not able to identify) performed cardiopulmonary resuscitation (CPR, an emergency procedure that combines chest compressions often with ratification ventilation in an effort to manually preserve the brain function in a person with cardiac (heart) arrest (stop)) on the resident and called 911 (a telephone number for an emergency service). Resident 1 was transported to the general acute care hospital (GACH) and was admitted into intensive care unit (ICU). Resident 1 was found to have a high potassium level and low sodium level. Resident 1 died on [DATE]. Findings: A review of Resident 1's Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE], indicated the resident needed extensive assistance with bed mobility, dressing, and toilet use. The MDS indicated Resident 1 was totally dependent on others for eating and personal hygiene. A review of Resident 1's History and Physical (H&P) dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Comprehensive Metabolic Panel (CMP, a blood test that measures blood sugar levels, electrolyte and fluid balance, kidney and liver function) dated [DATE] at 4:50 am, indicated an elevated potassium blood level of 5.8 (normal range is 3.5 to 5.5) milliequivalents per liter (meg/L, a unit of measure). The CMP also indicated Resident 1's blood sodium level was low at 121 meq/L (normal range is ,[DATE]). A review of Resident 1's Progress Notes dated [DATE] at 2:31 pm, the progress note indicated the resident's attending physician (AP 1) was informed of lab results and an order was given to increase continuous flushing due to elevated blood urea nitrogen level (BUN, a test how well the kidneys are working). The note did not indicate if AP 1 was informed of potassium or sodium level. A review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions, who work together to establish plans of care for residents) meeting dated [DATE] at 9:34 am, indicated the IDT was held as a quarterly review. The IDT did not address any lab levels or recent [DIAGNOSES REDACTED]. A review of Resident 1's Comprehensive metabolic panel (CMP) dated [DATE] at 5:30 am (on [DATE] at 10:39 am, the Director of Nursing Designee stated, during an interview, the CMP report should have a date of [DATE]), indicated Resident 1 had an elevated potassium blood level of 6.9 meq/L . The CMP also indicated Resident 1's blood sodium level was 110 meq/L. A review of Resident 1's Progress Notes dated [DATE] at 4:49 pm, indicated AP 1 went to the facility to see the resident. The note indicated no new orders were given and to continue the plan of care. The note did not indicate if the licensed nurses addressed the potassium or sodium levels with AP 1. The potassium and sodium levels were not reported to the physician. A review of Resident 1's Progress Notes dated [DATE] at 12:30 am, indicated that on [DATE] at 8:45 pm, Resident 1 was found by a CNA breathing abnormally. The note indicated a charge nurse and nurse supervisor went to Resident 1's room where they found her unconscious. The note indicated Resident 1 was observed to gasp for air twice and then stopped breathing, then CPR was performed and 911 called. The note indicated Resident 1 was transported to the emergency room (ER) by paramedics. A review of the GACH ED General note dated [DATE], indicated Emergency Medical Services (EMS) staff reported they achieved the return of a cardiac rhythm (the heart beat again) which indicated the resident had suffered a [MEDICAL CONDITION] (occurs when the flow of blood to the heart is blocked). Resident 1 arrived at the ED at 9:44 pm, blood work indicated Resident 1's potassium level was 8.3 meq/L, sodium level 108.0 meq/L, and ionized calcium 0.8 mmol/L (1XXX,[DATE].32) (ionized calcium is a mineral and is tested if the person showed signs of kidney disease). The GACH impression indicated Resident 1 suffered a [MEDICAL CONDITION] which lead to cardiopulmonary (heart and lungs) arrest (to stop). At 9:47 pm Resident 1's heart stopped again; ED staff were unable to resuscitate Resident 1. Resident 1 was pronounced dead at 10:23 pm. A review of Resident 1's Certificate of Death, indicated Resident 1 died on [DATE] at 10:03 pm. The immediate causes of death indicated were cardiopulmonary arrest and [MEDICAL CONDITIONS] (narrowing of the arteries (blood vessels that carry oxygen and nutrients to the heart) caused by buildup of plaque). During an interview on [DATE] at 10:39 am, the Director of Nursing Designee (DOND) stated changes in condition (COC) included abnormal labs. The DOND stated when a COC happens, the Director of Nursing (DON) collaborates with the IDT and physician to update the plan of care as needed. It is then the DON's responsibility to follow up and make sure everything is implemented. The DOND stated if the physician does not act on any COC, it is the DON 's responsibility to double check the accuracy of assessments and document the findings in the medical record. During a concurrent interview and closed record review of the CMP report dated [DATE] with the DOND, on [DATE] at 1:15 pm, the DOND stated a high potassium level could cause arrythmias (irregular heart beat) and cardiac (heart) arrest. The DOND stated the progress notes on [DATE] indicated the physician was made aware of labs but the notes did not specify which labs were told to the physician. The DOND stated the physician wrote an order to address the elevated BUN, but the potassium was not addressed and should have been. The DOND stated the licensed nurses should know the significance of potassium and a 5.8 meq/L potassium level should have raised a flag (alert as a potential danger or trouble) and something should have been done. During the same concurrent interview and closed record review on [DATE] at 1:15 pm, the DOND stated on [DATE], the physician went to the facility to see Resident 1 and the resident's potassium level was not addressed. The DOND stated that was another opportunity to do so but it was not, and no documentation addressing potassium was entered in Resident 1's medical record. The DOND reviewed the resident's potassium level collected on [DATE] at 5:30 am, the DOND stated the level of 6.9 meq/L meant a [MEDICAL CONDITION] would happen. The DOND stated the date collected should have read [DATE] because the Resident expired on the 19th. The DOND stated lab results are usually received around 3 pm via fax but the nurses have access to them earlier via computer access. During the same concurrent interview and closed record review on [DATE] at 1:15 pm, the DOND stated and confirmed no action was taken by the facility, nor documentation was made regarding the resident's potassium level until 8:45 pm (on [DATE]) in which the resident was found needing CPR and a transfer to the hospital. The DOND stated if the labs were addressed on [DATE], Resident 1's death could have potentially been avoided by lowering the risks of [MEDICAL CONDITION]. The DOND stated the facility should have advocated for Resident 1 and confirmed no action was taken by the facility on [DATE] when Resident 1's potassium was noted to be high, and that the resident's potassium was not addressed at all after that. During a telephone interview on [DATE] at 9:18 am, Resident 1's attending physician (AP 1) stated he had cared for Resident 1 for many years and remembered her case in detail. AP 1 stated he went to the facility to examine Resident 1 once a month. AP 1 stated his exams of Resident 1 consisted of a physical exam, vital signs review, listening to the heart and lung sounds, and a chart review. AP 1 stated he relied on the facility to monitor the resident and inform him of any declines in condition. AP 1 stated if a lab is abnormal or if a resident is not doing well, it is the responsibility of the facility to report it immediately to the physician. AP 1 stated it was then the responsibility of the facility to call him and document conversation and new orders in detail in the resident's medical record. During the telephone interview on [DATE] at 9:18 am, AP 1 stated he did not remember the facility ever notifying him of Resident 1's critical potassium level of 5.8 meq/L on [DATE]. AP 1 stated that was a critical lab (laboratory result) requiring a redraw to confirm level, administration of [MEDICATION NAME] (a medication used to remove excess potassium from the body), and a transport to the emergency room . AP 1 stated he did not remember the facility ever notifying him of Resident 1's critical potassium level of 6.9 meq/L on [DATE] (per the DOND on [DATE] at 1:15 pm, the correct laboratory report date should have been [DATE]). AP 1 stated a level that high could cause cardiac arrhythmias (irregular heart rhythm) and [MEDICAL CONDITION] (the heart to stop beating). AP 1 state he was not notified of the sodium level of 121 meq/L on [DATE] or the sodium level of 110 meq/L on [DATE] (per the DOND on [DATE] at 1:15 pm, the correct laboratory report date should have been [DATE]). During the telephone interview on [DATE] at 9:18 am, AP 1 stated those levels required treatment at a higher level of care (ER), and a sodium imbalance could disrupt the entire body physiology. AP 1 stated if a lab is not available for the physician or overlooked by the physician when visiting the resident, it is the nurse's responsibility to inform the doctor ,it is by law. AP 1 stated it is their (facility licensed nurses) job; they must address the abnormal labs. AP 1 stated he expects the facility staff to advocate for residents and let him know, he only goes to the facility on ce a month and does not have access to labs from his office, the nurses are always there. AP 1 stated if the nurse's feel a lab or medication need to be ordered or adjusted the nurses are responsible to call the doctor. A review of the facility's policy titled care and treatment: Significant Change in Condition and Monitoring, communication, 24 hours chart check and endorsement between shift with a revised date of ,[DATE], indicated if at any time a facility staff member identify a change in the care needs of a resident the nurse supervisor was to be made aware. Reasons that changes in care may be needed included change in mental status, signs and symptoms of infection. The policy indicated that there would be ties where immediate attention would be warranted and nursing was responsible for notifying appropriated departments. The policy indicated the physician, resident, and responsible party would be notified of significant changes in condition. A review of the facility's policy titled Resident Rights: Notification, Physician or Responsible party with a revised date of ,[DATE], indicated nurse supervisors were to notify the attending physician when there was a significant change in condition or if it was deemed necessary or appropriate in the best interest of the resident.

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent the development of pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction) for one of three sampled residents (Resident 2) who was at risk for developing pressure ulcer. The facility failed to identify, assess and provide treatment to Resident 2's open wound on the right and left buttocks. This deficient practice resulted in the delay of treatment and healing of the wound. Findings: On 6/30/2016 at 1:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care/treatment. A review of Admission Record indicated Resident 2 was admitted to facility on 3/14/2016, readmitted to facility on 6/3/2016, with [DIAGNOSES REDACTED]. A review of document titled Initial Admission Record dated 6/3/2016 indicated Resident 2 had skin problems on admission, however, the resident refused body check and requested to have body check in AM (morning). A review of Resident 2's clinical record, no documentation was found that a body check was done the following day. A review of Resident 2's Braden Scale for Predicting Pressure ulcer Risk dated 6/4/2016 indicated Resident 2 had a score of 14 which categorizes Resident 2 as moderate risk. Resident 2 was assessed as being bedfast (confined to bed), very limited ability to change and control body position, unable to make frequent or significant changes independently, and had a problem with friction and shear, required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. A review of physician order [REDACTED]. A review of MDS (Minimum Data Set), a comprehensive assessment tool, dated 6/10/2016 indicated Resident 2 had a BIMS (brief interview for mental status) score of 15 (12-15 indicated cognitively intact), required extensive assistance with one-person assist for bed mobility, toilet use and personal hygiene, had an indwelling catheter (tube used to drain urine) and was frequently incontinent of bowel. The MDS indicated Resident 2 had one Stage IV pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle) measuring 7 cm (centimeters)(in length) x 13 cm (width) x 0.2 cm (depth) with granulation tissue (healing tissue). No other wounds were found on Resident 2. During an interview with Treatment Nurse (TN) 1 on 6/30/2016 at 3:30 pm, TN 1 stated she was not the nurse who admitted Resident 2 on 6/3/2016. TN 1 stated that she had performed Resident 2's wound treatment since it was ordered on [DATE]. TN 1 stated that Resident 2's pressure ulcer was not measured on admission. TN 1 Resident 2's pressure ulcer was not measured until she measured the wound on 6/14/2016. TN 1 further stated that she measured the sacrococcyx wound last 6/27/2016 but did not check the right and left buttocks for any skin breakdown. A review of facility's Pressure Ulcer Management Record indicated the following: 1. 6/14/2016, Resident 2 had a stage IV sacrococcyx pressure ulcer measuring 7 cm x 13 cm x 0.2 cm with wound vac treatment order. 2. 6/21/2016 and 6/27/2016 Resident 2's pressure ulcer measurements were: 7 cm x 12 cm x 0.2 cm. No documentation of any skin condition was noted for the right and left buttocks. A review of Resident 2's Nursing Summary-Weekly indicated the following: 1. 6/11/2016: No skin problems were noted, provide good skin care. 2. 6/18/2016: Sacrococcyx pressure ulcer with treatment. 3. 6/25/2016: Resident 2 was free of any open areas. A review of Resident 2's Skin Assessment indicated the following: 1. 6/28/2016: Redness (ulcer) on sacrococcyx with treatment. 2. 6/29/2016: With treatment on sacrococcyx area. No documentation indicated that there were any wounds or open areas to the right and left buttocks. During a treatment observation with TN 2 on 6/30/2016 at 2:00 pm, TN 2 changed dressing of Resident 2's sacrococcyx pressure ulcer. Resident 2 was observed to have a 2 x 3 x 0.2 cm wound on the left buttock. Wound bed was covered with 80% black material and the remaining 20% was pink in color. Resident 2 was also observed with excoriation (superficial peeled skin) on the right buttock. During an interview with TN 2 on 6/30/2016 at 2:30 pm, TN 2 stated that the wound on Resident 2's right and left buttocks were new and there were no treatment order for it. TN 2 also stated she will report it to the primary physician to get an order. TN 2 also stated that the left buttocks wound on Resident 2 looked like it had been there for a while because the black covering of the wound looks like an eschar (dead tissue) and it does not develop overnight. During an interview with LVN 1 on 6/30/2016 at 4:00 pm, LVN 1 stated the charge nurses perform weekly summary charting which includes skin assessments and perform body checks for the weekly summary. LVN 1 also stated the CNA's perform body checks daily and submit a body check form at the end of their shift. During an interview with Certified Nursing Assistant (CNA) 1 on 7/1/2016 at 8:20 am, CNA 1 stated he gave a shower to Resident 2 on 6/28/2016 and did not check the resident's buttocks. CNA 1 stated he did not see Resident 2's buttocks on 6/29/2016 because it was covered with a diaper. CNA 1 further stated he did not offer to reposition Resident 2 on 6/29/2016 because he always refuses. During an observation with Resident 2 on 7/1/2016 at 8:00 am and at 10:00 am, Resident 2 was lying on his back on an air mattress bed. Resident 2 was interviewed on 7/1/2016 at 10:05 am and stated that nobody has offered to reposition him yet since the morning shift. During an interview with CNA 2 on 7/1/2016 at 10:20 am, CNA 2 stated she did not offer to reposition Resident 2 that morning because Resident 2 always refuses. During an interview with the Director of Nursing (DON) on 7/1/2016 at 10:30 am, the DON stated Resident 2's admission skin assessment was not done until 6/14/2016. The DON also stated nobody from the facility had identified the wounds on Resident 2's right and left buttocks. A review of care plan for pressure ulcer dated 6/4/2016 indicated to assess/record/monitor wound healing, daily body checks. A review of document titled Skin Assessment dated 5/2007 indicated It is the policy of this facility to assess all residents upon admission, when a comprehensive assessment is required and quarterly thereafter to identify risk of skin breakdown. A review of document titled Skin inspection, Shower Day dated 9/2007 indicated It is the policy of this facility to identify any pertinent skin issues with residents during routine inspections of residents at shower/bath times. A review of document titled Skin Breakdown dated 10/2007 indicated the following: Policy: It is the policy of this facility to complete an initial assessment upon admission. Procedures included: 1. The skin integrity will be monitored on an ongoing basis and any reddened area noted will be reported to the licensed nurse. 2. If the resident is bedfast, then the resident should be repositioned at least every 2 hours, as appropriate.