Every finding on record at Arden Park Post Acute

Based on observation, interview, and record review, the facility failed to ensure two of eleven sampled residents (Resident 3, Resident 6) were free from physical abuse when:Resident 4 struck Resident 3 in the mouth, andResident 5 struck Resident 6 on the face and hand with a grabber reacher tool (device used to pick up objects out of reach).These failures resulted in Resident 3 experiencing facial pain and emotional distress, and Resident 6 sustaining a skin tear on left eyebrow and left hand. 1.A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in September 2021 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- disrupted blood flow to the brain causing brain cell death), heart failure (heart does not pump blood as efficiently as it should), epilepsy (seizure disorder), traumatic brain injury (an external force damages the brain), and chronic kidney disease (kidneys are damaged and lose ability to filter waste and extra fluid from the body). A review of Resident 3's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/13/26, indicated Resident 3 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated Resident 3 was cognitively intact. A review of Resident 3's INTERACT Change in Condition Evaluation, dated 8/12/26, indicated .@ 1645 [4:45 p.m.] received report from SSA (Social Services Assistant) that res. [resident] had verbal altercation without injury with other resident while attending activity . A review of Resident 3's Progress Note, dated 8/12/26 at 5:25 p.m., indicated .Resident had an altercation with another resident in the solarium. Both residents were separated immediately by staff. Resident was assessed by nursing .He was initially upset with the situation and was pacing his power wheelchair in the hallway. He came and stayed in the SS [Social Services] office for a while, calmed down and then went to the solarium for dinner . A review of Resident 3's Care Plan [Resident 3] is at risk for injury and recurrent aggression related to resident-to-resident conflict, date initiated 8/12/26, indicated Goal .Resident will have no delayed trauma from resident-to-resident conflict . A review of Resident 4's admission Record, indicated Resident 4 was admitted to the facility in June 2026 with multiple diagnoses including surgical aftercare following surgery on teeth or oral cavity, maxillary (upper jawbone) fracture, protein calorie malnutrition (body does not receive enough protein or calories), intermittent explosive disorder (mental health condition marked by frequent, sudden episodes of extreme anger or aggressive behavior that is out of proportion to the situation), and history of traumatic brain injury. A review of Resident 4's MDS, Cognitive Patterns, dated 6/23/26, indicated Resident 4 had a BIMS score of 8 out of 15 that indicated Resident 4 was moderately cognitively impaired. A review of Resident 4's INTERACT Change in Condition Evaluation, dated 8/12/26, indicated .Resident to resident altercation during activities . A review of Resident 4's Progress Note, dated 8/12/26 at 5:39 p.m., indicated .Resident had an altercation with another resident in the solarium. Both residents were separated immediately by staff .He was encouraged to maintain distance from the concerned resident to avoid any further arguments/unwanted occurrence . A review of Resident 4's Progress Note, dated 8/13/26 at 3:44 a.m., indicated .Monitoring pt [patient] for behaviors of agitation and or pain r/t [related to] altercation with another resident 8/12/26 AM shift during group activities . A review of Resident 4's Progress Note, dated 8/13/26 at 5:14 p.m., indicated .SS visited resident in his room .He remembers what happened yesterday and verbalized he does not mean to do it. He feels sorry for the other resident . A review of Resident 4's Care Plan [Resident 4] is at risk for injury and/or recurrent aggression d/t [due to] resident to resident altercation, date initiated 8/12/26, indicated Goal .Resident will remain free from injury and demonstrate safe behavior with no recurrent resident-to resident altercations . During a joint interview on 8/20/26 at 10:57 a.m. with the Director Nursing (DON) and the Assistant Director of Nursing (ADON), reviewed incident between Resident 3 and Resident 4 on 8/12/26. The DON stated the Activities Assistant (AA) reported a verbal exchange between the two residents. The DON stated the AA got up and put herself in the middle of the two residents. The DON stated Resident 4, who was ambulatory, got around the AA and got close to Resident 3. The DON stated there was physical contact between the residents. The ADON stated the verbal exchange got heated and Resident 4 touched Resident 3. The DON stated Resident 3 reported he was very upset and felt disrespected. The DON stated Resident 4 was discharged yesterday (8/19/26). During an interview on 8/20/26 at 11;30 a.m. with the AA, reviewed incident between Resident 3 and Resident 4 on 8/12/26. The AA stated while in the solarium waiting for piano player, Resident 3 was separated from Resident 4. Resident 3 left and then came back to solarium was instructed to stay in the front row away from Resident 4 but went around the table near Resident 4. The AA stated Resident 4 stood up, began yelling, went around her and hit Resident 3 in the mouth. The AA stated staff separated the residents. The AA stated Resident 3 was mad, really riled up, and shaken up. The AA stated Resident 4 was willful in his intent to hit Resident 3. During an interview of 8/20/26 at 11:45 a.m. with Resident 3, Resident 3 stated he recalled the incident with Resident 4. Resident 3 stated he was in the activities room and had a disagreement with a female resident. Resident 3 stated Resident 4 was walking and hit me in the face. Resident 3 stated he got mad but did not retaliate. Resident 3 stated his mouth hurt for two days. Resident 3 stated he does not feel safe in the facility because there is too much trouble. During an interview on 8/20/26 at 12:25 p.m. with the SSA, the SSA stated on 8/12/26 she heard noise in the solarium, but when she checked on it the incident was over. The SSA stated she checked on residents and Resident 3 stated he forgave the resident and Resident 4 stated he was sorry that he did that. The SSA stated Resident 4 had a history of aggression and needed to be observed and monitored. 2. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility in June 2025 with multiple diagnoses including dementia (loss of memory and thinking abilities that interferes with daily life), right foot amputation, heart failure, and peripheral vascular disease (circulation disorder caused by narrowing or blockage of blood vessels outside the heart). A review of Resident 5's MDS, Cognitive Patterns, dated 8/14/26, indicated Resident 5 had a BIMS score of 7 out of 15 that indicated Resident 5 had severe cognitive impairment. A review of Resident 5's INTERACT Change in Condition Evaluation, dated 7/19/26, indicated .Residential Dispute .Skin Status Evaluation .Not clinically applicable to the change in condition being reported . A review of Resident 5's Progress Note, dated 7/19/26 at 1:51 p.m., indicated .At approximately 1300 [1:00p.m.] hours the resident was alleged to have been involved in a dispute with roommate. It was stated that due to an attempted relocation of the bedside table located nearest the restroom, potential contact may have transpired. Residents were immediately separated . [Resident 5] was immediately moved to another room .Head to toe skin assessment revealed no major concerns (a scratch above the left eye and at the left wrist not clear as to whether a result of the situation) . A review of Resident 5's Progress Note, dated 7/19/26 at 4:50 p.m., indicated .During wound assessments, this writer heard a commotion and turned and witnessed two residents engaged in altercation. The initial of the altercation was not witnessed .Upon assessment, the alleged victim was noted to have a skin tear to left eyebrow and left hand. Bleeding is controlled and wound care was provided . A review of Resident 5's Progress Note, dated 7/20/26 at 4:38 p.m., indicated .Followed up with resident regarding incident with previous roommate .He could not recall what happened between them . A review of Resident 5's Care Plan Behavior: Monitor [Resident 5] for any aggressive epithets, outbursts, displays of outward disgruntlement r/t dispute with another resident, date initiated 7/19/26, indicated Interventions .Focused behaviors for aggression .Identify triggers such as noise, crowding, personal space invasion, or unmet needs .Monitor for injuries following altercation and provide appropriate treatment and monitoring .Monitor resident for feelings of safety and/or isolation as a result from alleged dispute with another resident . A review of Resident 6's admission Record indicated Resident 6 was admitted to the facility in July 2024 with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, end stage renal disease (kidneys no longer function to filter waste from the body), dependence on dialysis (medical treatment to filter waste and extra fluid from the body), and diabetes (too much sugar in the blood). A review of Resident 6's MDS, Cognitive Patterns, dated 6/25/26, indicated Resident 6 had a BIMS score of 15 out of 15 that indicated Resident 6 was cognitively intact. A review of Resident 6's INTERACT Change in Condition Evaluation, dated 7/19/26, indicated .Residential Dispute . A review of Resident 6's Progress Note, dated 7/19/26 at 1:38 p.m., indicated .At approximately 1300 [1:00 p.m.] hours the resident was alleged to have been involved in a dispute with roommate. It was stated that due to an attempted relocation of the bedside table located nearest the restroom, potential contact may have transpired . [Resident 6] was laying in bed when the nurse checked on him . During a joint interview on 8/20/26 at 12:56 p.m. with the DON and ADON, reviewed incident between Resident 5 and Resident 6 on 7/19/26. The DON stated she was not aware of the incident. The ADON reviewed Resident 5's progress note indicating skin tear to left eyebrow and left hand at the time of the incident. The DON stated the incident should have been reported as alleged abuse. During an interview on 8/20/26 at 1:11 p.m. with the Administrator (ADM), the ADM stated Resident 5 was going to the bathroom and Resident 6 pushed Resident 5's wheelchair away. The ADM stated Resident 6 made contact with Resident 5 and Resident 5 had skin tear on left eyebrow. During an interview on 8/20/26 at 1;24 p.m. with Resident 6, Resident 6 stated he recalled incident with former roommate. Resident 6 stated Resident 5 went to the bathroom and when he came out, he pushed the bedside table into him which pushed him into the bed. Resident 6 stated Resident 5 was standing over him, so he hit him with his reacher. Resident 6 stated he was defending himself. During an interview on 8/20/26 at 1:31 p.m. with Licensed Nurse (LN) 3, LN 3 stated on 7/19/26 the Certified Nursing Assistant (CNA) came to him and told him that two guys were fighting in Resident 5 and Resident 6's room. LN 3 stated when he went in Resident 6 was lying in bed and Resident 5 was in the hallway in wheelchair. LN 3 stated there had been a dispute over the bathroom. LN 3 stated Resident 6's bedside table was blocking the bathroom door. Resident 6 reported to LN 3 that Resident 5 had pushed him and he was upset. LN 3 stated Resident 6 told him that Resident 5 had come on to him, and he couldn't sit there and let him come at him. LN 3 stated Resident 5 had scratch on his eyebrow and hand. LN 3 stated he notified the abuse coordinator (ADM) and the DON. During an interview on 8/20/26 at 3:18 p.m. with Resident 5, Resident 5 stated did not remember any incident with former roommate. Resident 5 stated, I don't know about that. A review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Program, revised 8/2006, indicated .Our residents have the right to be free from abuse . Our facility is committed to protecting our residents from abuse by anyone including .other residents .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse .Our abuse prevention program provides policies and procedures that govern .Identification of occurrences and patterns of potential mistreatment/abuse .The implementation of changes to prevent future occurrences of abuse . A review of the facility's P&P titled Preventing Resident Abuse, revised 1/2011, indicated .Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc, to assist in preventing abuse .The facility's goal is to achieve and maintain an abuse free environment .Our abuse prevention/intervention program includes .Training all staff and practitioners to resolve conflicts appropriately .Training staff to understand and manage a resident's verbal or physical aggression .Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues . A review of the facility's P&P titled Resident-to-Resident Altercations, revised 12/2016, indicated .All altercations, including those that may represent resident-to-resident abuse, shall be investigated .Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents .If two residents are involved in an altercation, staff will . Separate the residents .Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation .

Based on interview and record review, the facility failed to ensure an allegation of abuse for one of eleven sampled residents (Resident 5) was reported to The Department within the regulatory time frame when the report was faxed to the wrong number. This failure resulted in a delay of investigation by The Department with the potential for further abuse to occur. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility in June 2025 with multiple diagnoses including dementia (loss of memory and thinking abilities that interferes with daily life), right foot amputation, heart failure, and peripheral vascular disease (circulation disorder caused by narrowing or blockage of blood vessels outside the heart). A review of Resident 5's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/14/26, indicated Resident 5 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 7 out of 15 that indicated Resident 5 had severe cognitive impairment. A review of Resident 5's Progress Note, dated 7/19/26 at 1:51 p.m., indicated .At approximately 1300 [1:00p.m.] hours the resident was alleged to have been involved in a dispute with roommate. It was stated that due to an attempted relocation of the bedside table located nearest the restroom, potential contact may have transpired. Residents were immediately separated . [Resident 5] was immediately moved to another room .RP [Responsible Party] notified, NP [Nurse Practitioner] made aware. Head to toe skin assessment revealed no major concerns (a scratch above the left eye and at the left wrist not clear as to whether a result of the situation) . A review of Resident 5's Progress Note, dated 7/19/26 at 4:50 p.m., indicated .During wound assessments, this writer heard a commotion and turned and witnessed two residents engaged in altercation. The initial of the altercation was not witnessed .Upon assessment, the alleged victim was noted to have a skin tear to left eyebrow and left hand. Bleeding is controlled and wound care was provided .Charge nurse was made aware and followed facility protocol with notifying RPs and abuse coordinator . A review of Resident 6's admission Record indicated Resident 6 was admitted to the facility in July 2024 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain causing brain cell death) end stage renal disease (kidneys no longer function to filter waste from the body), dependence on dialysis (medical treatment to filter waste and extra fluid from the body), and diabetes (too much sugar in the blood). A review of Resident 6's MDS, Cognitive Patterns, dated 6/25/26, indicated Resident 6 had a BIMS score of 15 out of 15 that indicated Resident 6 was cognitively intact. A review of Resident 6's Progress Note, dated 7/19/26 at 1:38 p.m., indicated .At approximately 1300 [1:00 p.m.] hours the resident was alleged to have been involved in a dispute with roommate. It was stated that due to an attempted relocation of the bedside table located nearest the restroom, potential contact may have transpired . [Resident 6] was laying in bed when the nurse checked on him. NP made aware . During a joint interview on 8/20/26 at 12:56 p.m. with the DON and ADON, reviewed incident between Resident 5 and Resident 6 on 7/19/26 and that The Department had not received notification of the allegation of abuse. The DON stated she was not aware of the incident. The ADON reviewed Resident 5's progress note indicating skin tear to left eyebrow and left hand at the time of the incident. The DON stated the expectation is that the incident should have been reported within two hours as alleged abuse to The Department. During an interview on 8/20/26 at 1:11 p.m. with the Administrator (ADM), the ADM stated on 7/19/26 an incident occurred between Resident 5 and Resident 6. The ADM stated Resident 6 made contact with Resident 5 and Resident 5 had skin tear on left eyebrow. The ADM stated the incident was reported to The Department. The ADM stated The Department did not come to the facility to investigate, and he was aware that was unusual but did not follow up. The ADM provided the form SOC 341 Report of Suspected Dependent/Elder Abuse, dated 7/19/26. The report indicated it had been faxed to the Ombudsman's office. The report did not indicate it had been faxed to The Department. The ADM acknowledged that the number the report was faxed to was not The Department's fax number. The ADM stated he faxed the 5 day follow up report on 7/23/26 to the same number. The ADM stated he assumed the number the report had been faxed to be the correct number for The Department. The ADM stated his expectation if there is an allegation of abuse that is potentially willful, causing bodily harm or mental anguish it needs to be reported and sent to The Department, the ombudsman, and law enforcement. The ADM acknowledged that the incident was not reported to The Department within the regulatory time frame. During an interview on 8/20/26 at 1;24 p.m. with Resident 6, Resident 6 stated he recalled incident with former roommate. Resident 6 stated Resident 5 went to the bathroom and when he came out, Resident 5 pushed the bedside table into him which pushed him into the bed. Resident 6 stated Resident 5 was standing over him, so he hit him with his reacher tool. Resident 6 stated he was defending himself. During an interview on 8/20/26 at 1:31 p.m. with Licensed Nurse (LN) 3, LN 3 stated on 7/19/26 the Certified Nursing Assistant (CNA) came to him and told him that two guys were fighting in Resident 5 and Resident 6's room. LN 3 stated there had been a dispute over the bathroom. LN 3 stated Resident 6's bedside table was blocking the bathroom door. Resident 6 reported to LN 3 that Resident 5 had pushed him and he was upset. LN 3 stated Resident 6 told him that Resident 5 had come on to him, and he couldn't sit there and let him come at him. LN 3 stated Resident 5 had scratch on his eyebrow and hand. LN 3 stated he notified the abuse coordinator (ADM) and the DON. LN 3 stated he thought he had faxed the report to The Department and the Ombudsman. LN 3 acknowledged it was a mistake the report was not faxed to The Department. LN 3 stated the expectation is that the report will be faxed to The Department within two hours. A review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Program, revised 8/2006, indicated .Our abuse prevention program provides policies and procedures that govern .The reporting and filing of accurate documents relative to incidents of abuse . A review of the facility's P&P titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, revised 9/2022, indicated .All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports his or her suspicions to the following persons or agencies .The state licensing/certification agency responsible for surveying/licensing the facility .The local/state ombudsman .Law enforcement officials .Immediately is defined as .within two hours of an allegation involving abuse or result in serious bodily injury .within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .Verbal /written notices to agencies are submitted via special carrier, fax, email, or by telephone .Within five (5) business days of the incident, the administrator will provide a follow -up investigation report . A review of the facility's P&P titled Resident-to-Resident Altercations, revised 12/2016, indicated .Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy .

Based on observation, interview and record review, the facility failed to provide needed care or services to one of three sampled residents (Resident 1) when:Licensed Nurse (LN) 1 failed to assess Resident 1 per family requests when Resident 1 was unresponsive for approximately 5 hours,Facility failed to ensure Resident 1 was assessed for medications side effects,LN 1 failed to notify Resident 1's physician immediately when her condition changed and LN 1 administered blood pressure medication to Resident 1 outside physician's ordered parameters.These failures resulted in Resident 1's emergent transfer to the hospital after being found unresponsive with low blood pressure and required stabilization in the intensive care unit (ICU).1. A review of Resident 1's facesheet, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), diabetes (a chronic health condition where blood sugar levels are too high), malaise (a general feeling of being unwell), and dementia (a condition that affects memory and ability to care for self).A review of Resident 1's progress note dated [DATE] indicated LN 1 saw Resident 1 in bed with family at bedside at 8:30 a.m. There was no other documented progress note indicating LN 1 monitored or assessed Resident 1 from 8:30 a.m. to 1:30 p.m.A review of Resident 1's nursing assessments, indicated on [DATE], Resident 1 did not have a skilled nursing assessment completed.During an interview with Family Member (FM 1) on [DATE], at 10:50 a.m., FM 1 stated another family member left Resident 1's room on [DATE], at 8:55 a.m. and Resident 1 was alert and awake. FM 1 stated a different family member arrived at 9:30 a.m. and Resident 1 appeared to be asleep. FM 1 stated another group of family members arrived and stayed from 10:30 a.m. to 11:30 a.m. and Resident 1 continued to be asleep. FM 1 stated she called the facility at 11:36 a.m. and spoke with LN 1 and requested LN 1 to assess Resident 1 because she could not be woken up by the family who were there. FM 1 stated LN 1 responded to the request by saying Resident 1 is okay and is just sleeping. FM 1 stated a family member returned to the facility at 12:30 p.m. and noticed Resident 1 did not eat her lunch and was still not responsive with attempts to be woken up by family. FM 1 stated the family member at bedside requested LN 1 to check on Resident 1 for the second time around 12:30 p.m. because she could not be woken up. FM 1 stated LN 1 did not assess Resident 1 and dismissed the family member's concern. FM 1 stated she arrived at the facility at 1:30 p.m., and Resident 1's lunch was served to her and was still uneaten. FM 1 stated she asked LN 1 when the last time Resident 1's vital signs were checked and LN 1 responded by saying her vital sign machine was broken. FM 1 stated she began yelling at LN 1 to wake up Resident 1 and do something, then LN 1 called 911 (emergency services). FM 1 stated she believed if she did not arrive in person to the facility and demanded Resident 1 be assessed, Resident 1 would have died.During an interview on [DATE], at 12:22 p.m., with LN 1, LN 1 stated she saw Resident 1 in her room around 8 a.m. to 9 a.m. on [DATE], then the next time she saw Resident 1 was around 1:30 p.m., when a Certified Nursing Assistant (CNA) notified her that Resident 1 could not be woken up. LN 1 stated she did not see Resident 1 during the time period between 8:30 a.m. to 1:30 p.m.A review of Resident 1's progress note dated [DATE] indicated LN 1 was called to Resident 1's room around 1:30 p.m., by a staff member, who reported Resident 1 was very sleepy and not eating lunch. LN 1 found Resident 1 unable to wake up.unconscious and unable to wake up. Note indicated LN 1 checked Resident 1's vital signs and her blood pressure read 71/45 (the first number is the systolic blood pressure which is the measure of blood pressure while the heart beats: normal is around 120, and the second number is the diastolic blood pressure which is the measure of blood pressure when the heart is at rest, normal: is around 80), LN 1 then called 911.During an interview on [DATE], at 1:32 p.m., with Assistant Director of Nursing (ADON), ADON stated LN 1 received a write-up for not assessing Resident 1 on [DATE] timely after requests from family members, who notified LN 1 about Resident 1's sleepiness, and she did not assess the Resident right away.A review of the facility's policy and procedure titled, Acute Condition Changes-Clinical Protocol dated 2001 indicated, The physician will help identify individuals with a significant risk for having acute changes of condition during their stay .the nurse shall assess and document/report the following baseline information vital signs.level of consciousness.current level of pain .2. A review of Resident 1's Order summary report dated [DATE] indicated orders to administer Carbidopa-Levodopa (prescription medication primarily used to treat symptoms of Parkinson's disease (brain disorder causing slow movement and tremors), with side effects of dizziness, sudden daytime sleepiness and low blood pressure) at 7:30 a.m., Nortriptyline (anti-depressant used to treat nerve pain, with side effect of drowsiness and fatigue), and Pregabalin (medication used for nerve pain, with side effect of dizziness and somnolence (extreme sleepiness) to be administered at 8 a.m. Order summary report indicated no orders to monitor side effects of Carbidopa-Levodopa, Nortriptyline, or Pregabalin.A review of Resident 1's Medication Administration Record (MAR) dated [DATE], indicated Resident 1 was given Carbidopa-Levodopa, Nortriptyline, and Pregabalin at 8 a.m. by LN 1.During an interview on [DATE], at 11:22 a.m., with LN 1, LN 1 stated she gave Carbidopa-Levodopa, Nortriptyline, and Pregabalin to Resident 1 on [DATE] between 8 a.m. to 9 a.m. LN 1 stated she should not have given these medications because they all cause sleepiness and should have held the medications because she was already sleepy. LN 1 stated she did not chart an assessment for Resident 1 on [DATE].A review of Nurse Practitioner (NP) Note dated [DATE], indicated, Parkinson's disease: Continue Carbidopa-Levodopa, monitor.Neuropathic (nerve) pain: Continue Pregabalin and Nortriptyline, monitor.During an interview on [DATE] at 10:17 a.m., with NP, NP stated she did the initial provider visit for Resident 1 on [DATE]. NP stated she completed the medication review and recommended to continue giving Resident 1 Carbidopa-Levodopa and to monitor. NP further clarified she wrote monitor next to the medication to instruct nursing staff to monitor for side effects of the medication such as dizziness or drowsiness. NP further stated the same recommendation for Nortriptyline she instructed to monitor in her note to instruct staff to monitor for side effects such as dizziness and sleepiness. NP further stated she also instructed nursing staff to monitor the medication Pregabalin because the medication can cause dizziness and drowsiness. NP stated after she completes her visit note, the charge nurse, ADON or any nurse will create a monitoring order so the nurses can watch for these side effects. NP stated, as the provider it was her expectation the nurses monitor for all side effects of medications they are giving. A review of Resident 1's ED [Emergency Department] Provider note dated [DATE] indicated, Patient being admitted for metabolic encephalopathy [a brain malfunction caused by a chemical imbalance, organ failure, or a lack of key nutrients in the body]. Most likely etiology [cause] patient's decline is polypharmacy [when you regularly take multiple medications, especially with similar mechanism of actions] with medications that she was not prior on being given the last few days such as Sinemet [carbidopa levodopa] and nortriptyline. This likely caused profound fatigue [an overwhelming, all-consuming exhaustion that is not relieved by rest and significantly limits daily functioning] with low oral intake, leading to hypovolemia [low blood volume] as well as vasodilation [widening of blood vessels] with nortriptyline and hypotension [low blood pressure].A review of the facility P&P titled, Administering medications, dated 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having a potential adverse consequence for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the residents attending physician or the facility's medical director to discuss the concerns.3. During an interview on [DATE], at 11:22 a.m., with LN 1, LN 1 stated she was assigned to care for Resident 1 on [DATE] in the morning. LN 1 stated Resident 1 was Alert but weak when she first saw her around 8 a.m. LN 1 stated one of the Certified Nursing Assistants (CNA) checked Resident 1's blood pressure at 7:02 a.m., and it read 67/45 (normal is around 120/80), but the CNA used the automatic blood pressure machine, so LN 1 rechecked Resident 1's blood pressure manually and it read 90/62 sometime between 8-9 a.m. LN 1 stated she did not notify the physician or provider regarding the low blood pressure reading, or a concern with administering three medications that cause sleepiness to Resident 1 who was already sleepy because those meds can cause sleepiness and low blood pressure. LN 1 stated she learned from her mistake and needs to act early if something is wrong, stating I didn't have any help that day, and I was busy with another resident. During an interview on [DATE], at 12:56 p.m., with Director of Nursing (DON), DON stated, if a resident's vital signs are outside the normal parameters the doctor or provider needs to be notified. DON stated Resident 1's blood pressure was low on [DATE], at 8 a.m. according to the MAR the blood pressure was 90/62 and blood pressure medication (Lisinopril) was originally charted as given, then changed to state it was not given. DON stated that regardless, the doctor should have been notified. DON further stated it is important to notify the doctor early on, rather than wait before a condition gets worse.During an interview on [DATE], at 10:17 a.m., with NP, NP stated as a provider it is her expectation that nursing staff notify one of the providers if a resident had a low blood pressure of around 90 (systolic, top number: normal is around 120), so the provider can give feedback on what interventions to implement. NP stated, I don't want to delay if the BP [blood pressure] is low. If the patient is drowsy the nurse should recheck the BP and call the provider and say the situation and the provider will review and give instructions to the nurse. NP stated there is always a provider on call and available even on the weekends.A review of Resident 1's progress notes dated [DATE] indicated, no change in condition notification to provider after identifying low blood pressure at 8 a.m. on [DATE], until around 1:30 p.m.A review of Resident 1's Discharge Summary from the Hospital stay dated [DATE] through [DATE] indicated Resident 1 required to be admitted to the ICU for stabilization.4. A review of Resident 1's Order Summary Report dated [DATE] indicated medication order for Lisinopril (medication used to lower blood pressure) that directed to not give the medication if the blood pressure is below 110 (systolic-top number).A review of Resident 1's vital signs report dated [DATE] indicated Blood pressure was charted as 67/45 (indicating extremely low blood pressure: normal is around 120/80) at 7:02 a.m. and later crossed out by a staff member at 2:45 p.m. Vital signs report indicated the next blood pressure charted was 71/45 Warning Diastolic [bottom number of blood pressure, normal is around 80] Low. Systolic [top number of blood pressure, normal is around 120] low at 1:30 p.m. Vital signs report indicated no blood pressure was charted between 7:02 a.m. to 1:30 p.m. on [DATE]. During a concurrent observation and interview on [DATE], at 11:43 a.m., with LN 2 at the nursing cart for Resident 1, Resident 1's Lisinopril medication blister pack (pre-formed plastic and foil packages that organize and protect pills by dose, day, or time) was observed to have two pills left. Instructions indicated once per day with a starting quantity of 14. LN 2 stated this is the only blister pack Resident 1 has had since being admitted on [DATE] and the other ones were not open yet. LN 2 stated there were two pills left.During a concurrent record review and interview on [DATE], at 11:45 a.m., with LN 2, Resident 1's MAR was reviewed. Resident 1's MAR indicated 11 doses of Lisinopril were administered from [DATE]-[DATE], indicating three pills should be available in the blister pack. LN 2 stated there is one pill not accounted for because there were two pills left.A review of Resident 1's MAR dated [DATE], at 8 a.m., indicated LN 1 charted Resident 1's blood pressure as 90/62. MAR indicated, for the medication Lisinopril 4 medication held outside of parameters.A review of Resident 1's MAR Audit dated [DATE], indicated LN 1 administered Lisinopril to Resident 1 at 8:11 a.m., despite documented low blood pressure (90/62) below the ordered parameter of 110. The MAR Audit indicated LN 1 altered the MAR at 2:45 p.m. and was changed from lisinopril as 0 (administered) to 4 (not given outside parameters). A progress note was automatically generated which confirmed the MAR was altered at 1445 or 2:45 p.m.A review of Resident 1's progress note dated [DATE] indicated LN 1 was called to Resident 1's room around 1:30 p.m., by a staff member, who reported Resident 1 was very sleepy and not eating lunch, LN 1 found Resident 1 unable to wake up.unconscious and unable to wake up. Note indicated LN 1 checked Resident 1's vital signs and her blood pressure read 71/45, LN 1 then called 911.During an interview on [DATE], at 10:50 a.m., with FM 1, FM1 stated she was present when the emergency medical services (EMS) staff arrived, and she observed LN 1 tell the EMS staff she gave Resident 1 her blood pressure medication even though her blood pressure was low.During a follow up interview on [DATE], at 3:06 p.m., with DON, DON stated the MAR audit for Resident 1's lisinopril administration on [DATE] indicated, LN 1 gave the Lisinopril medication at 8:11 a.m., and later changed the record at 2:45 p.m., to state the medication was not given. DON stated the 0 means the medication was given, and the 4 means the medication was held.During an interview on [DATE], at 1:35 p.m., with Administrator (ADM), ADM stated LN 1 got a write up for improper documentation on [DATE].A review of Resident 1's progress notes, and nursing assessments dated [DATE] indicated no evidence LN 1 monitored Resident 1 between 8:30 a.m. and 1:30 p.m. after identifying her blood pressure was 90/62 at 8:30 a.m. There was no evidence in the progress notes, nursing assessments or MAR that any interventions were implemented to correct the low blood pressure from 8:30 a.m. to 1:30 p.m. on [DATE].A review of Resident 1's Hospital Emergency Department (ED) Provider note dated [DATE], indicated Resident 1 arrived at the ED with increased confusion and hypotension (low blood pressure). Blood pressure readings 80/52. ED provider note indicated, family notified ED provider staff at the skilled nursing facility stated the blood pressure machine was not working, and Resident 1 was given her Lisinopril despite having low blood pressure. ED note further indicated, Patient being admitted for metabolic encephalopathy. Most likely etiology [cause] patient's decline is polypharmacy.This likely caused profound fatigue with low oral intake, leading to hypovolemia [low blood volume] as well as vasodilation [opening of blood vessels: which lowers blood pressure] with nortriptyline and hypotension. She also continued to receive her diabetes and blood pressure medicines despite hypoglycemia (low blood sugar) and hypotension. Provider note further indicated, Labs here showed a hypoglycemia at 64 [average blood sugar is 70 to 99].A review of the facility policy & procedure (P&P) titled, Acute Condition Changes-Clinical Protocol dated 2001, indicated, The nursing staff will contact the physician based on the urgency of the situation.the nurse and physician will discuss and evaluate the situation.the physician will help identify and authorize appropriate treatments.the staff will monitor and document the resident's/patient's progress and responses to treatment.A review of the facility's Job Description for Licensed Nurses indicated, The primary purpose of your job is to provide direct nursing care to residents.to ensure that the highest degree of quality care is maintained at all times.Drug Administration Functions prepare and administer medications as ordered by the physician.

Based on interview and record review the facility failed to ensure Licensed Nurses (LNs) had the knowledge, competencies and skill sets to provide care to residents prior to caring for residents on their own for nine of 13 sampled staff members when: 9 LNs did not have a completed competency checklist on hire.This failure resulted in the facility being unable to confirm LNs were competent prior to caring for residents and had the potential for residents in the facility to receive substandard care.During a concurrent interview and record review on 6/12/26, at 10:37 a.m. with Director of Staff Development (DSD), LN 1's employee file was reviewed. LN 1's employee file indicated, LN 1 did not have a complete competency checklist on hire signed by a Registered Nurse (RN). DSD stated, there was a competency checklist partially filled out by a Licensed Vocational Nurse, but it needs to be signed by an RN.During a concurrent interview and record review on 6/12/26, at 10:37 a.m with DSD, LN 2's employee file was reviewed. LN 2's employee file indicated, LN 2 did not have a complete competency checklist on hire. DSD stated, she did not see a completed competency checklist in the employee file.During a concurrent interview and record review on 6/12/26, at 12:20 p.m. with Assistant Director of Nursing (ADON), LN 3's employee file was reviewed. LN 3's employee file indicated, LN 3 did not have a complete competency checklist on hire. ADON stated LN 3 did not have a complete competency checklist form on hire.During a concurrent interview and record review on 6/12/26, at 12:22 p.m. with ADON, LN 4's employee file was reviewed. LN 4's employee file indicated, LN 4 did not have a complete competency checklist on hire. ADON stated LN 4 did not have a complete competency checklist form on hire.During a concurrent interview and record review on 6/12/26, at 12:24 p.m. with ADON, LN 5's employee file was reviewed. LN 5's employee file indicated, LN 5 did not have a complete competency checklist on hire. ADON stated LN 5 did not have a complete competency checklist form on hire.During a concurrent interview and record review on 6/12/26, at 12:26 p.m. with ADON, LN 6's employee file was reviewed. LN 6's employee file indicated, LN 6 did not have a complete competency checklist on hire. ADON stated LN 6 did not have a complete competency checklist form on hire.During a concurrent interview and record review on 6/12/26, at 12:28 p.m. with ADON, LN 7's employee file was reviewed. LN 7's employee file indicated, LN 7 did not have a complete competency checklist on hire. ADON stated LN 7 did not have a complete competency checklist form on hire.During a concurrent interview and record review on 6/12/26, at 12:30 p.m. with ADON, LN 8's employee file was reviewed. LN 8's employee file indicated, LN 8 did not have a complete competency checklist on hire. ADON stated LN 8 did not have a complete competency checklist form on hire.During a concurrent interview and record review on 6/12/26, at 12:32 p.m. with ADON, LN 9's employee file was reviewed. LN 9's employee file indicated, LN 9 did not have a complete competency checklist on hire. ADON stated LN 9 did not have a complete competency checklist form on hire.During an interview with the Director of Nursing (DON) on 6/12/26 at 12:43 p.m., the DON stated she had worked for the facility for nearly 3 years. The DON stated the facility determined nurses were competent by putting the nurses on orientation with other already competent nurses on the floor when they are hired. The DON stated the floor nurses will complete the competency checklist for the new nurse and then it is sent to her for review prior to the new nurse working on their own, then the checklist is sent to Human Resources (HR) to be placed in the employee's file. The DON stated all the licensed nurses should have a completed competency checklist in their employee file. The DON further stated, LN 6 was recently hired and she did not remember seeing her competency checklist completed prior to working on her own. The DON stated, I can't say when asked who cleared LN 6 as competent to provide care to residents in the facility as a new employee.A review of the facility's Daily Staffing Schedule dated 6/12/26, indicated, LN 6 was on the schedule to work on her own with a Resident assignment on the medication cart during AM [morning] shift.During an interview on 6/12/26, at 1:02 p.m., with LN 10, LN 10 stated new nurses are usually trained by following three different nurses and then they take an assignment on their own.A review of the facility's Job Description: Director of Nursing indicated, Essential Duties .Responsible for the recruiting, hiring and training of nursing staff. Job description was singed by DON in 2023.A review of the facility's Policy and Procedure (P&P) titled, Orientation Program for Newly Hired Employees, Transfers, Volunteers dated 2019 indicated, An orientation program shall be conducted for all newly hired employees.a written record is maintained of each participant's orientation program.A review of the facility's P&P titled, Staffiing, Sufficient and Competent Nursing dated 2026 indicated, The facility provides sufficient nursing staff with the appropriate skills and competencies necessary to provide nursing and related care and services for all residents.1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.

Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 6) received care in accordance with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 6's foley catheter (a tube inserted through the urethra into the bladder to drain urine) care, management, and monitoring were not consistently done.These failures had the potential for Resident 6 to develop foley catheter complications such as blockage or infection, and for Resident 6 to not achieve his highest practicable well-being.Findings:A review of Resident 6's clinical record indicated Resident 6 was admitted in January of 2026 and had diagnoses that included hepatic encephalopathy (decline in brain function caused by severe liver disease), benign prostatic hyperplasia (BPH- the prostate gland grows larger than normal potentially causing urinary problems), obstructive and reflux uropathy (occurs when the urine cannot drain through the urinary tract), and muscle weakness.A review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/24/26, indicated Resident 6 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 6 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 6's Bladder and Bowel Status, dated 2/24/26, indicated Resident 6 uses an indwelling urinary catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time).A review of Resident 6's care plan, revised 1/28/26, indicated, Bladder: [Resident 6] is @ [at] risk for complications with urinary system related to Benign Prostatic Hyperplasia (BPH), Obstructive Reflux Uropathy, indwelling catheter, noted pain level of 10 no relief with prn [as needed] pain medication.Indwelling Catheter: provide catheter care and empty catheter every shift and as needed.A review of Resident 6's physician order, dated 1/27/26, indicated, Indwelling Urinary Catheter: Cleanse Site With Warm Soap & Water & Rinse Then Pat Dry every shift.A review of Resident 6's treatment administration records (TAR- a daily documentation record used by a licensed nurse to document treatments given to a resident) for February 2026 indicated the care order for Resident 6's indwelling urinary catheter was not done on the following shifts:-Day shift on 2/2/26-Evening shift on 2/12/26-Day shift on 2/19/26A review of Resident 6's physician order, dated 1/28/26, indicated, Indwelling Urinary Catheter .For URINARY RETENTION). Check Every Shift Intact/Functioning every shift for for [sic] Obstructive & Reflux Uropathy 2/2 [secondary to] BPH.A review of Resident 6's TAR for February 2026 indicated the monitoring order for Resident 6's indwelling urinary catheter was not done on the following shifts:-Day shift on 2/2/26-Evening shift on 2/12/26-Day shift on 2/19/26A review of Resident 6's physician order, dated 2/4/26, indicated, FLUSH Foley every night 60cc [cubic centimeter- unit of measurement] NS [Normal saline solution- a mixture of sodium chloride and water] PLEASE gently irrigate to encourage UA [urine] to flow freely. at bedtime for prevention of clogging.A review of Resident 6's TAR for February 2026 indicated the flush order for Resident 6's indwelling urinary catheter was not done on bedtime of 2/12/26.A review of Resident 6's physician order, dated 2/7/26, indicated, TX [treatment]: FLush foley cath [catheter] with 60cc gentely [sic] to prevent clogging every morning in the morning.A review of Resident 6's TAR for February 2026 indicated the flush order for Resident 6's indwelling urinary catheter was not done in the morning of 2/19/26.During a concurrent interview and record review on 6/8/26 at 5:05 p.m. with the Director of Nursing (DON), Resident 6's medical records were reviewed. The DON confirmed that Resident 6's foley catheter care, management, and monitoring orders were not consistently done. The DON stated Resident 6 would be at risk for indwelling urinary catheter complications such as infection or clogging if the indwelling catheter care orders were not followed. During an interview on 6/8/26 at 5:35 p.m. with the DON, the DON stated that she would expect staff to consistently follow the indwelling urinary catheter care orders for residents.A review of the facility's P&P titled, Catheter Care, Urinary, revised 8/2022, indicated, 1. Review the resident's care plan to assess for any special needs of the resident .Perineal Care .1. Use soap and water or bathing wipes for routine daily hygiene. Antiseptic wipes for daily cleansing are not recommended. 2. Clean the area under the foreskin in uncircumcised males daily .Maintaining Unobstructed Urine Flow .5. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction .Complications .1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately .Reporting .1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 6) received treatment and care in accordance with professional standards of practice, the facility's policy and procedure (P&P), and physician's orders when the facility did not consistently complete Resident 6's ordered skin care and wound management treatments. These failures had the potential to cause Resident 6's skin and wound conditions to worsen and for Resident 6 to not achieve the highest practicable well being.Findings:A review of Resident 6's clinical record indicated Resident 6 was admitted in January of 2026 and had diagnoses that included hepatic encephalopathy (decline in brain function caused by severe liver disease), congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body), malnutrition (state of poor nutrition that occurs when the body does not receive enough or the right nutrients to function properly), and muscle weakness.A review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/24/26, indicated Resident 6 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 6 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 6's Skin Conditions, dated 2/24/26, indicated Resident 6 was at risk for developing pressure ulcers/injuries.A review of Resident 6's care plan, revised 1/28/26, indicated, Skin: [Resident 6] has impaired skin integrity present on admission as evidenced by scattered bruising to BUE [bilateral upper extremities- Both arms], surgical incision [cut] to genitals covered with dry dressing. Open areas to sacrum [area on base of the spine, between hip bones], left glute [buttocks] and right glute, Gray scaly skin covering lower BLE [bilateral lower extremities- both legs] with scattered boils [pus-filled bump] .Abdomen is distended, firm, and shiny in appearance .Administer treatments as ordered and monitor for effectiveness .Apply barrier cream as indicated .A review of Resident 6's physician order, dated 1/27/26, indicated, Monitor scattered bruising to B/L [bilateral] upper extremities every shift.A review of Resident 6's treatment administration records (TAR- a daily documentation record used by a licensed nurse to document treatments given to a resident) for February 2026 indicated the care order for Resident 6's bilateral extremity bruises were not done on the following shifts:-Day shift on 2/2/26-Day shift on 2/10/26-Evening shift on 2/12/26-Day shift on 2/19/26A review of Resident 6's physician order, dated 1/29/26, indicated, TX [treatment]: fragile skin to bilateral [both sides] buttock- cleanse with soap and water Pat dry apply house barrier cream daily to prevent skin breakdown every day shift.A review of Resident 6's TAR for February 2026 indicated the treatment order for Resident 6's bilateral buttocks were not done on 2/2/26 and 2/19/26.A review of Resident 6's physician order, dated 1/29/26, indicated, TX: monitor discoloration to abdomen up date np [nurse practitioner] if s/s [signs and symptoms] worsen every day shift.A review of Resident 6's TAR for February 2026 indicated the monitoring order for Resident 6's abdomen discoloration was not done on 2/2/26 and 2/19/26.A review of Resident 6's physician order, dated 1/29/26, indicated, TX: scaly skin to BLE apply house OTC [over-the-counter] ammonium lactate 12% [a medicated lotion] daily to help soften and restore skin every day shift.A review of Resident 6's TAR for February 2026 indicated the treatment order for Resident 6's BLE skin were not done on 2/2/26 and 2/19/26.A review of Resident 6's physician order, dated 1/29/26, indicated, TX: surgical site to left scrotum - cleanse with NS [Normal saline solution- a mixture of sodium chloride and water commonly used in cleaning wounds] Pat dry pack with plain packing strip moistened with vasche wash pack [a solution used to safely cleanse, irrigate, and debride wounds] apply ABd [abdominal]pad underneath scrotum daily and as needed if dislodged every day shift for surgical.A review of Resident 6's TAR for February 2026 indicated the treatment order for Resident 6's surgical site to left scrotum was not done on 2/2/26.A review of Resident 6's physician order, dated 2/17/26, indicated, TX: surgical site to left scrotum - cleanse with NS Pat dry pack with collagen place ABD pad under scrotum daily every day shift for surgical.A review of Resident 6's TAR for February 2026 indicated the treatment order for Resident 6's surgical site to left scrotum was not done on 2/19/26.During a concurrent interview and record review on 6/8/26 at 5:05 p.m. with the Director of Nursing (DON), Resident 6's medical records were reviewed. The DON confirmed that Resident 6's physician orders for skin care and wound management were not consistently done. The DON stated Resident 6's skin conditions would be at risk for developing complications or getting worse if the treatment and care orders were not followed. During an interview on 6/8/26 at 5:35 p.m. with the DON, the DON stated that she would expect staff to consistently follow skin care and wound treatment frequency for residents as ordered.A review of the facility's P&P titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised 4/2026, indicated, 1. The provider will order pertinent wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings .and application of topical agents .2. The provider will help identify medical interventions related to wound management .A review of the facility's P&P titled, Dressings, Dry/Clean, dated 2001, indicated, 1. Verify that there is a physician's order for this procedure .2. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs .Documentation .The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: .8. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal .Reporting .1. Notify the supervisor if the resident refuses the dressing change .2. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for four of 35 sampled residents (Resident 164, Resident 6, Resident 36, and Resident114) when:1. Staff did not notify the physician of abnormal high lab values for Resident 164;2. Staff did not notify the physician of abnormal low lab values for Resident 6;3. Resident 36 was administered 3LPM (liters per minute, flow rate of the oxygen) of oxygen instead of the ordered 2LPM; and 4. Resident 114 was given 2.5 LPM of oxygen instead of the ordered 3 LPM.These failures placed Resident 164 and Resident 6 at risk for unmet care needs and delayed treatment, and placed Resident 36 and Resident 114 at risk for not receiving appropriate oxygenation.Findings: 1.Resident 164 was admitted to the facility in early 2026 with diagnoses which included kidney disease. During a review of Resident 164's Order Summary Report [OSR], order date 2/20/26, the OSR indicated an order for a complete metabolic panel (CMP, a lab that provides information on the body's chemistry, metabolism and electrolytes, including potassium: essential for nerve function, muscle contraction and maintaining a healthy heartbeat) to be completed on 2/23/26. During a review of Resident 164's Lab Results Report, reported 2/24/26, the report showed an H [high] potassium level of 5.6 mEq/l (unit of measurement normal range 3.5 -5.1). During a review of the facility provided document, All Inclusive Medical Services, Inc. [AIMS], undated, the AIMS indicted, REPORT ALL CRITICAL/PANIC VALUES.These parameters must be called to the on-call provider.No faxes or voice mail.Lab results for K+ [potassium].if greater than 5.5. During a review of Resident 164's electronic health record (EHR) no documentation was found indicating the physician was notified of the high potassium level. During a concurrent interview and record review on 3/17/26 at 3:26 p.m. with Licensed Nurse (LN 8), LN 8 confirmed Resident 164's potassium level on 2/23/26 was high and stated the physician should have been notified. LN 8 confirmed the lab was not marked reviewed in the EHR and stated she was unable to find any documentation the physician had been notified. During an interview on 3/17/26 at 3:34 p.m. with the Director of Nursing (DON), the DON confirmed there was no documentation of the physician being notified of Resident 164's elevated potassium. The DON stated it was important to notify the physician of elevated potassium, because potassium was an electrolyte that affects the heart. During an interview on 3/19/26 at 11:34 with the Medical Director (MD 2), the MD 2 confirmed a potassium level of 5.6 mEq/l met the AIMS criteria for provider notification and confirmed the facility did not call the physician. 2.Resident 6 was admitted to the facility in early 2026 with diagnoses that included anemia (a blood condition that did not have enough healthy red blood cells to carry sufficient oxygen to the body's tissues). During a review of Resident 6's Lab Result Report, report date 2/28/26, the report showed an L [low] hemoglobin level of 7.6 g/Dl (unit of measurement, normal range 11.2-15.7). During a review of Resident 6's EHR, no documentation was found indicating the physician was notified of the low hemoglobin level. During a concurrent interview and record review on 3/19/26 at 8:25 a.m. with LN 10, of Resident 6's EHR, LN 10 confirmed Resident 6's hemoglobin value of 7.6 g/dL was low. LN 10 confirmed the lab was not marked reviewed in the EHR and stated she was unable to find any documentation the physician had been notified. LN 10 stated if there was no documentation that it had been sent to the physician, staff would not know if any of the labs had been addressed or if anything had been done to help the resident, no continuity of care. During a review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results- Clinical Protocol, dated 11/18, the P&P indicated, The physician will identify and order diagnostic and lab testing based on the resident's diagnosis and monitoring needs.When test results are reported to the facility, an nurse will first review the labs.A physician can be notified by phone, fax, voicemail.Facility staff would document information about when, how and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record. 3. A review of an admission record indicated Resident 36 was admitted to the facility in May 2023 with diagnoses that included congestive heart failure and respiratory failure. During a concurrent observation and interview on 3/16/26 at 8:52 a.m. with Resident 36, the resident's oxygen concentrator was observed to be set at 3 LPM. Resident 36 stated, My oxygen should be at 2. A review of Resident 36's Order Summary Report (OSR), dated 11/20/22, the OSR indicated an order for continuous oxygen at 2 LPM via nasal cannula (a thin tube connecting the oxygen source to the resident's nose for administration). During an interview on 3/16/26 at 8:55 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated the oxygen was set at 3 LPM. During an interview on 3/16/26 at 9:05 a.m. with LN 8, LN 8 stated that the oxygen should be at 2LPM. LN 8 further stated that staff must follow the doctor's orders. A review of Resident 36's care plan, dated 1/18/24, indicated the resident required the use of continuous oxygen at 2 LPM via nasal cannula related to congestive heart failure and shortness of breath. 4. A review of an admission record indicated Resident 114 was readmitted to the facility in January 2025 with diagnoses that included congestive heart failure and respiratory disorder. During an observation on 3/16/26 at 10:23 a.m. in Resident 114's room, the resident's oxygen concentrator was observed to be set at 2.5 LPM. During an interview on 3/16/26 at 10:26 a.m. with CNA 8, CNA 8 stated the oxygen was set at 2.5 LPM. During an interview on 3/16/26 at 10:32 a.m. with LN 1, LN 1 stated the oxygen was on 2.5LPM and should have been at 3 LPM. LN 1 further explained that staff must follow the doctor's order, otherwise it could affect Resident 114's oxygen saturation. A review of Resident 114's OSR, dated 1/28/25, the OSR indicated an order for continuous oxygen at 3LPM via nasal cannula for respiratory failure and shortness of breath. A review of Resident 114's care plan, dated 3/14/25, indicated the resident required continuous oxygen at 3 LPM via nasal cannula related to congestive heart failure and respiratory illness with chronic respiratory failure. During an interview on 3/19/26 at 10:53 a.m. with the DON, the DON stated that staff were expected to adhere to physicians' orders to ensure residents received appropriate oxygenation.

Based on observation, interview, and record review, the facility failed to implement its Emergency Medications policy and procedure for a census of 152 residents when the Emergency Kit (E Kit), a storage box containing emergency medications, was not replaced upon the next routine medication delivery after being used.This failure increased the potential risk of not having essential emergency medications available when needed and increased the risk of drug diversion.During a medication storage inspection in the facility's east station medication room on 3/16/26 at 9:20 a.m. with Licensed Nurse 1 (LN 1), E Kit #082 was observed secured with a red plastic zip tie, indicating that the E Kit had been previously opened by the facility. In a concurrent interview and record review, LN 1 confirmed that the E Kit contained documentation showing it was used on nine occasions, with 3/8/25 noted as the first documented use by licensed nursing staff.During an interview on 3/18/26 at 3:20 p.m. with the Director of Nursing (DON), the DON stated the used E Kit should have been replaced with a new E Kit. The DON further stated emergency medications should be available for resident use and that having a used E Kit with many medications removed places resident safety at risk.A review of the facility's policy titled Emergency Medications, dated 4/2021, indicated: Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order.

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly according to the facility's Policy and Procedure (P&P), when:1. An opened inhaler (used to administer medication by breathing in) in the medication cart was not correctly dated with an expiration date, and2. A labeled pharmaceutical bag was found behind the drawers in the back of a medication cart These failures placed the residents at risk for receiving expired or outdated medication and had the potential for medication error and drug diversion for the census of 152. Findings:1. During an inspection of medication cart 2 east station on [DATE] at 9:08 a.m., an open budesonide and formoterol inhaler (used to control and prevent symptoms of asthma and improve lung functions) had an open date (date the medication was removed from the protective foil pouch) of [DATE]. The instructions on the inhaler carton indicated, Discard within three months after removing from the foil pouch.During an interview on [DATE] at 9:09 a.m. with Licensed Nurse (LN) 1. LN 1 verified the inhaler had an incorrect expiration date of [DATE] on the label instead of [DATE].During an interview on [DATE] at 3:11 p.m. with the Director of Nursing (DON), the DON stated the multidose inhaler's efficacy could be compromised when the inhaler did not have a correct expiration date. A review of the facility P&P titled, Medication Labeling and Storage, dated 2/2023, indicated, labeling of medication and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: d. expiration date.if medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.2. During an inspection of the west station Medication Cart 2 on [DATE] at 9:42 a.m., a bag of pharmaceutical product was found behind the drawers at the back of the medication cart.During an interview on [DATE] at 9:45 a.m. with LN 2, LN 2 confirmed that a medication bag was found at the back of the medication cart behind the drawers. LN 2 stated the medication bag belonged to a resident who had been discharged three weeks ago, and that the cart should have been checked daily to ensure medications did not fall behind the drawers.During an interview on [DATE] at 3:15 p.m. with the DON, the DON stated all medications should be stored inside the medication cart and the staff should have noticed and retrieved the medication bag that had fallen behind the drawers.A review of the facility's policy and procedure titled Medication Labeling and Storage, dated 2/2023, indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview and record review, the facility failed to ensure food was prepared and served under sanitary conditions for 149 residents who received meals from the kitchen in a census of 152 when:1. Multiple dishes were stored upright, exposed to dust and splatter, and 2. Two of five roasts were thawed improperly.These findings increased the potential for food born illness.Findings:1.During an initial tour observation and concurrent interview on 3/16/26 at 8:08 a.m. with the Dietary Director (DD), eight stacks of multiple bowls, 11 decanter lids, 10 thermal lids available for food service were stored upright on the kitchen counter. The DD verified the observation and said, They should be stored face down to be protected from dust.A review of the FDA Food Code 2022, Section 4-903, indicated, Cleaned Equipment and Utensils . shall be stored . where they are not exposed to splash, dust, or other contamination; The guidance further indicated, (1) In a self-draining position that allows air drying; and (2) covered or inverted.2.During a subsequent observation and interview on 3/16/26 at 8:10 a.m., two of five ten-pound frozen turkey breasts were piled up in a container but not completely submerged in water with a low volume stream of water running over the roast to thaw them. The DD verified the observation and said, They should be submerged with water running over them.During a review of the facility P&P titled Food Preparation and Service, dated 2001, the P&P indicated Thawing Frozen Food.Foods are not thawed at room temperature. Appropriate thawing procedures include.completely submerging in cold running water.that is running fast enough to agitate and remove loose ice particles.

Based on observation, interview, and record review, the facility failed to ensure 33 of 60 resident' rooms (Rooms 100, 102, 103, 104, 105, 106, 107, 108, 111, 204, 205, 206, 207, 208, 209, 210, 212, 300, 301, 302, 303, 304, 305, 306, 307, 310, 311, 408, 410, 411, 503, 505, and 517) met the minimum requirement of 80 square feet (sq. ft.) per resident.This failure had the potential to result in inadequate space for the provision of care for 100 residents.Findings:During a review of facility letter, dated 3/17/26, the letter indicated 33 rooms measure less than 80 sq. ft. per resident. The letter further indicated, Residents occupying these rooms have a reasonable amount of privacy, closet, and storage space. All rooms have a bedside table and bedside nightstand for their use. The residents are not restricted in their mobility with a wheelchair or with ambulation and have access to the use of their toilet. During an observation on 3/16/26 at 9:15 a.m. in room [ROOM NUMBER], staff was observed assisting a resident using a wheelchair in the room. Both the staff and resident had adequate space to maneuver without complaints.During an observation on 3/16/26 at 11:11 a.m. in room [ROOM NUMBER], staff was observed assisting a resident to stand from the bed using a walker. Both the staff and resident had adequate space to maneuver, despite the presence of a bedside table. During a concurrent observation and interview on 3/18/26 at 9:24 a.m. with Resident 120 in room [ROOM NUMBER], Resident 120 was observed lying in bed with a nightstand and bedside table next to the head of the bed. A wheelchair was observed at the end of the bed nearly touching the curtain separating the space from the adjacent bed. This writer had no space to maneuver into the room to speak privately with Resident 120 without moving the table. Resident 120 stated the space was too small; staff always had to move things around when they came in to assist her. Resident 120 further stated her visitors had no where to sit when they came to visit and would frequently hover at the end of her bed spilling into her roommate's space. During a concurrent observation and interview on 3/18/26 at 9:38 a.m. with Resident 106 in room [ROOM NUMBER], Resident 106 was observed sitting in his bed with a wheelchair next to the bed. This writer had no space to maneuver into the room to speak privately with Resident 106 without moving the wheelchair out of the space entirely. Resident 106 stated the space was too cramped and didn't provide enough privacy. Resident 106 further stated, If I was sitting in my wheelchair, I would have to speak with my back to you.During a concurrent observation and interview on 3/18/26 at 9:42 a.m. with Resident 66, Resident 66 was observed lying in bed. Resident 66 stated she had sufficient space to maneuver and had no issues transferring in and out of her wheelchair and had enough space for her personal belongings.During a concurrent observation and interview on 3/18/26 at 9:48 a.m. with Certified Nursing Assistant (CNA) 5 in Resident 120's room, CNA 5 was observed moving a bedside table. CNA 5 stated the table needed to be moved to maneuver around the room.The Department recommends granting a room waiver per the facility request for rooms 100, 102, 103, 104, 105, 106, 107, 108, 111, 204, 205, 206, 207, 208, 209, 210, 212, 300, 301, 302, 303, 304, 305, 306, 307, 310, 311, 408, 410, 411, 503, 505, and 517.

Based on observation, interview and record review, the facility failed to ensure the rights for privacy and a dignified existence were respected for seven residents (Residents 31, 39, 66, 76, 130, 141, and 143) in a census of 152 when their curtains did not enclose their cubicles for privacy.This failure increased the potential for embarrassment during personal care and private visits for the residents.Findings: During multiple observations on 3/16/26 through 3/19/26, seven residents were observed with curtains which did not surround their beds for privacy. During a concurrent observation and interview on 3/16/26 at 9:21 a.m. with Certified Nurse's Assistant (CNA) 3, CNA 3 verified the curtains did not reach around the beds of Resident 66 and Resident 130's beds for privacy and said, They should be longer. During a concurrent observation and interview on 3/16/26 at 10:54 a.m. with CNA 4, CNA 4 verified Residents 76 and Resident 141's privacy curtains did not reach around their beds. During an interview on 3/16/26 at 11:08 a.m., the Director of Nursing (DON) was asked her expectations for the privacy curtains and said, The curtains should reach around the bed for privacy. During a concurrent observation and interview on 3/17/26 at 8:42 a.m., Resident 39 verified her privacy curtain did not surround her bed completely and said, There's no privacy if I have to use the bathroom [in bed]. When I'm going to the bathroom [in bed] or taking a bed bath, staff can come in and pass my bed when I need privacy. During a concurrent observation and interview on 3/18/26 at 9:24 a.m. with Resident 31, Resident 31 confirmed her privacy curtain did not extend around her bed. Resident 31 stated staff and visitors passed by her bed to get to her roommate's bed and she was exposed without a privacy curtain. Resident 31 further stated she would like a privacy curtain to maintain her dignity. During a concurrent observation and interview on 3/18/26 at 9:48 a.m. with Resident 143, Resident 143 confirmed her privacy curtain did not extend around her bed. Resident 143 further stated staff and visitors frequently passed by her to get to her roommate's bed. Resident 143 stated she would like the curtain to extend all the way around her bed. During an interview on 3/18/26 at 10:05 a.m. with CNA 6, CNA 6 stated Resident 31 and Resident 143's privacy curtains did not extend all the way around their beds. CNA 6 further stated Residents 31 and Resident 143 had no privacy when staff or visitors wanted to pass through to the adjacent beds. During an interview on 3/19/26 at 7:59 a.m. with the Housekeeping (HS), the HS said, Curtains are replaced between each resident and as needed by Housekeeping. Sometimes Maintenance needs to replace hooks or add hooks. We've had a very limited supply recently.The curtains should surround each bedspace for privacy. During a review of the Maintenance Log for all five halls, dated 1/14/26 through 3/18/26, no request for curtain replacement or lengthening was found. During a review of the facility policy and procedure (P&P) titled Bedrooms, dated 2001, the P&P indicated Bedrooms are designed to provide full visual privacy for each resident (in the form of ceiling-suspended curtains that extend around the bed) and equipped for adequate nursing care.

Based on interview and record review, the facility failed to report an allegation of abuse, for two of 35 sampled residents (Resident 77 and Resident 79), when an incident on 2/26/26 involving Resident 77 and Resident 79 was not reported to the Department.This failure had the potential to place Resident 77 at risk for continued abuse.Findings:A review of Resident 77's Progress Note (PN), dated 2/26/26, the PN indicated, Resident [Resident 77] had a verbal altercation with his roommate [Resident 79]. Per resident, his roommate threw water at him. Close contact of aggressive nature was alleged to have happened.During an interview on 3/17/26 at 8:31 a.m. with Resident 77, Resident 77 indicated that on 2/26/26, he was positioned in his wheelchair between his and Resident 79's bed. Resident 77 indicated he had asked Certified Nursing Assistant 7 (CNA 7) to open the curtains to the outside window and that is when Resident 79 became frustrated. Resident 77 then stated, He [Resident 79] threw a full water pitcher at me and yelled, 'Fxxx you. Goddamnit'.the water pitcher hit me on the right side. Resident 77 confirmed that the impact of the water pitcher caused him pain to the right side of his head.During an interview on 3/17/26 at 8:46 a.m. with CNA 7, CNA 7 confirmed that, during the incident on 2/26/26, he had witnessed Resident 79 throw a water pitcher at Resident 77 and heard Resident 79 curse at Resident 77. CNA 7 further confirmed that he had reported the incident to Licensed Nurse 6 (LN 6).During an interview on 3/18/26 at 11 a.m. with the Administrator (ADM), the ADM confirmed that he was made aware of the incident between Resident 77 and Resident 79 but did not report it to the Department.During an interview on 3/19/26 at 8:18 a.m. with Licensed Nurse 6 (LN 6), LN 6 confirmed that the incident on 2/26/26 between Resident 77 and Resident 79 would be considered abuse and would require reporting to facility management. LN 6 indicated that a SOC341(abuse reporting form used by facilities) form would have to be filled out. LN 6 further indicated she had reported the incident to the ADM.During an interview on 3/19/26 at 9:03 a.m. with the ADM, the ADM indicated that he had investigated the incident between Resident 77 and Resident 79 and, after the investigation was completed, the ADM decided the incident would not be considered abuse. The ADM further explained that because he felt the incident didn't rise to the level of abuse, he did not report the incident to the Department.During a review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/22, the P&P indicated, All reports of resident abuse (including injuries of known origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.The administrator or the individual making the allegation immediately reports his or her suspicion to the following person or agencies.The state licensing/certification agency responsible for surveying/licensing the facility.

Based on interviews, and record review, the facility failed to protect one of 35 sampled residents' (Resident 77) right to be free from physical and verbal abuse by another resident when Resident 79 cursed at Resident 77 and threw a water pitcher at Resident 77's head.This failure had the potential to cause physical and mental harm to Resident 77. Findings:Resident 77 was admitted to the facility in June of 2024 with diagnoses that included rectal cancer.A review of Resident 77's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 2/13/26, indicated Resident 77 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident 77 was cognitively intact.Resident 79 was admitted to the facility in September of 2025 with diagnoses that included type 2 diabetes (disease where the body has poor blood sugar control). A review of Resident 79's MDS, dated [DATE], indicated Resident 79 had a BIMS score of 6 indicating Resident 79 had significant cognitive impairments.A review of Resident 77's Progress Note (PN), dated 2/26/26, the PN indicated, Resident [Resident 77] had a verbal altercation with his roommate [Resident 79]. Per resident, his roommate threw water at him. Close contact of aggressive nature was alleged to have happened.During an interview on 3/16/26 at 4:22 p.m. with the Social Services Assistant (SSA), the SSA indicated that, besides physical abuse, abuse could be verbal and confirmed the incident that took place on 2/26/26 between Resident 77 and Resident 79 would be considered abuse.During an interview on 3/17/26 at 8:31 a.m. with Resident 77, Resident 77 indicated that on 2/26/26, he was positioned in his wheelchair between his and Resident 79's bed. Resident 77 indicated he had asked Certified Nursing Assistant 7 (CNA 7) to open the curtains to the outside window and that is when Resident 79 became frustrated. Resident 77 then stated, He [Resident 79] threw a full water pitcher at me and yelled, 'Fxxx you. Goddamnit'.the water pitcher hit me on the right side. Resident 77 confirmed that the impact of the water pitcher caused him pain to the right side of his head.During an interview on 3/17/26 at 8:46 a.m. with CNA 7, CNA 7 confirmed that, during the incident on 2/26/26, he had witnessed Resident 79 throw a water pitcher at Resident 77 and heard Resident 79 curse at Resident 77.During an interview on 3/19/26 at 8:18 a.m. with Licensed Nurse 6 (LN 6), LN 6 confirmed that the incident on 2/26/26 between Resident 77 and Resident 79 would be considered abuse.During a review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on observation, interview and record review the facility failed to maintain an accurate medical record for one of 35 sampled residents (Resident 157) when PICC (peripherally inserted central catheter, a long thin flexible tube inserted through a vein in the upper arm and into a large vein just above the heart used to deliver medications directly into the bloodstream) dressing changes and an administration of IV (intravenous) medication were not recorded in the resident's medical record.These failures resulted in an inaccurate medical record and had the potential for miscommunication among healthcare professional which could lead to inadequate care for Resident 157.Findings:Resident 157 was admitted to the facility in early 2026 with diagnoses which included a serious lung infection caused by a specific type of staph bacteria that is resistant to many common antibiotics.During a review of Resident 157's Order Summary Report [OSR], dated 3/2/26, the OSR indicated an order for PICC dressing changes every seven days and as needed.During an observation on 3/16/26 at 10:26 a.m. of Resident 157 in her room, Resident 157 had a PICC line inserted into her left upper arm. The bandage covering the PICC line showed the date 3/15. There were no staff initials or time on the dressing.During a review of Resident 157's IV Administration Record [IVAR], dated 3/26, the IVAR indicated PICC dressing changes were completed on 3/3/26, 3/8/26, and 3/10/26. There was no documentation that the PICC dressing was changed on 3/15/26.During a concurrent interview and record review on 3/18/26 at 8:39 a.m. with Licensed Nurse (LN 8), of Resident 157's medical record, LN 8 confirmed the PICC line on Resident 157 was dated 3/15. LN 8 stated she did not see any initials on the PICC dressing which would indicate who changed the dressing. LN 8 confirmed there was no documentation in the IVAR or in the progress notes regarding a PICC line dressing change on 3/15/26. LN 8 stated the documentation should have been completed according to the physician orders, and it was important to have accurate records to provide continuity of care for the residents and to ensure other nurses knew what had been completed.During a review of Resident 157's OSR dated 3/9/26, the OSR indicated an order for Vancomycin (an antibiotic) to be administered intravenously (IV, into a vein via PICC line) every 12 hours for a lung infection.During a review of Resident 157's Medication Administration Record [MAR], dated 3/26, the MAR indicated, Vancomycin HCI Intravenous Solution.every 12 hours [for lung infection]. The MAR was blank on 3/11/26 for the 9 p.m. dose of Vancomycin.During a concurrent interview and record review on 3/18/26 at 10:55 a.m. with LN 8 of Resident 157's MAR, LN 8 confirmed there was no documentation in the MAR or progress notes indicating Resident 157 received the medication on 3/11/26 at 9 p.m. LN 8 stated it was important for the resident to receive the antibiotic because it was a necessary medication.During a concurrent interview and record review on 3/19/26 at 2:37 p.m. with the Director of Nursing (DON), of Resident 157's medical record, the DON confirmed the lack of documentation for the 3/11/26 Vancomycin dose and stated she would expect to see documentation of the administered dose in the MAR or in a progress note.During an interview on 3/19/26 at 2:42 p.m. with LN 9 with the DON present, LN 9 stated he administered Resident 157's dose of Vancomycin on 3/11/26 at 9 p.m. but stated he forget to document the administration in the medical record.During a review of the facility's policy and procedures (P&P) titled, Administering Medications, dated 4/19, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered.During a review of the facility's P&P titled, Peripheral and Midline IV Dressing Changes, dated 5/25, the P&P indicated, This (sic) purpose of this procedure is to prevent complications associated with the intravenous therapy.The following should be documented in the resident's medical record: Date, time, type of dressing, and reason for change.

Based on observation, interview and record review, the facility failed to maintain three resident wheelchairs (Resident 80, Resident 130 and Resident 143) in a census of 152 in safe operating order when the armrests were damaged and unable to be sanitized.This failure placed the residents at risk for discomfort, skin tears, abrasions and infection.Findings: During observations on 3/16/26, three resident wheelchairs were found in disrepair when both armrests were found cracked, missing pieces of upholstery for Resident 80, Resident 130and Resident 143.During a concurrent observation and interview on 3/16/26 at 9:21 a.m. with Certified Nurses Assistant (CNA) 3, CNA 3 verified the wheelchair armrests used by Resident 130 was cracked and missing pieces of the upholstery and unable to be sanitized.During an observation and interview on 3/16/26 at 12:17 p.m. with the Director of Nurses (DON), the DON verified the wheelchair armrests of Residents 80 and Resident 143 were in disrepair, unable to be sanitized and said, Skin could get caught on the armrests when the cover is worn and the fabric is showing through.During an interview on 3/18/26 at 6:54 a.m. with the Maintenance Supervisor (MS), the MS was asked about the procedure for repairs and said, We check the maintenance log every morning and if some repairs needs to be done, we do it right away and sign that it's done.During an interview on 3/18/26 at 9:13 a.m. with Licensed Nurse (LN) 5, LN 5 was asked about damage to the wheelchair armrests and said, If the wheelchair armrest cover is ripped .It could contribute to skin breakdown and infection.During an interview on 3/19/26 at 7:59 a.m. with the Housekeeping Supervisor (HS), the HS said, We sanitize the wheelchairs but Maintenance repairs them .I've never used the Maintenance log.During a review of the facility document titled, WORK ORDER / REPAIR REQUEST, dated 1/14/26 through 3/18/26, no request for wheelchair repair was documented.During a review of the facility policy and procedure (P&P) titled Assistive Devices and Equipment, dated 2001, the P&P indicated Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include.wheelchairs.Defective or worn devices are discarded or repaired .

Based on observation, interview, and record review, the facility failed to ensure services were provided to meet professional standards of quality for one of three sampled residents (Resident 3) when Resident 3 had ongoing oxygen therapy without a physician's order. This failure had the potential to put Resident 1's health and safety at risk. Findings: A review of the Admission Record indicated Resident 3 was admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). A review of Resident 3's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 1/16/25 indicated Resident 3 was cognitively intact with a score of 13 out of 15. A concurrent observation and interview was conducted on 3/28/25 at 10:40 a.m. inside Resident 3's room. Resident 3 was lying in bed with ongoing oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) attached to a concentrator (a device that takes air from the surroundings, filters it and provides extra oxygen) at 2 liters per minute. Resident 3 was able to state her full name and spell out her last name. Resident stated she has the oxygen all the time. Further review of Resident 3's clinical records indicated the following: -there was no physician order for the oxygen use; -the Weekly Summary Notes dated 3/11/25 indicated Resident 3's oxygen use was PRN or as needed; and, -the Weekly Summary Notes dated 3/21/25 indicated Resident 3 was on continuous oxygen. A concurrent observation and interview was conducted on 3/28/25 at 12:10 p.m. inside Resident 3's room with Licensed Nurse 1 (LN 1). The LN 1 stated LN 2 was responsible for Resident 3's care today. The LN 1 confirmed Resident 3 had ongoing oxygen via nasal cannula at 2 liters per minute. Resident 3 was asked how long she had the oxygen and Resident 3 stated she had the oxygen for weeks. A subsequent interview and record review was conducted on 3/28/25 at 12:12 p.m. with the LN 1 in the nurses' station. The LN 1 checked Resident 3's physician orders and LN 1 confirmed Resident 3 had no physician order for oxygen use. The LN 1 stated Resident 3 should have an order for oxygen. A concurrent interview and record review was conducted on 3/28/25 at 12:35 p.m. with the LN 2 in front of the nurses' station. The LN 2 stated Resident 3 was moved in the 500 hall 2 weeks ago. The LN 2 further stated when she came in this morning, Resident 3 had oxygen on and it was reported to her Resident 3 was stable. The LN 2 was unable to state who initiated the oxygen for Resident 3. The LN 2 explained the process of initiating oxygen and LN 2 stated there should be an order for oxygen. The LN 2 further explained if there was a change in condition, administration of oxygen can be a nursing measure and for them to notify the physician about the change. The LN 2 confirmed Resident 3's weekly summary dated 3/21/25 indicated Resident 3 was on continuous oxygen. A review of the facility's policy and procedure revised October 2010 and titled, Oxygen Administration indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure .After completing the oxygen setup .the following information should be recorded in the resident's medical record .The date and time that the procedure was performed .the name and title of the individual who performed the procedure .the rate of oxygen flow, route, and rationale .the reason for p.r.n. [as needed] administration.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse, when Certified Nursing Assistant 1 (CNA 1) hit Resident 1 in the face. This failure resulted in Resident 1 sustaining a cut on his nose bridge about half an inch in length, a bruise under his left eye, and expressing feeling like a piece of crap. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting left non-dominant side and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 2/5/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 12 out of 15 with mild memory impairment. During an observation on 3/4/25 at 10:37 a.m. Resident 1 had a cut on his nose bridge, about half an inch in length, and a bruise under his left eye, green and purple in color. During an interview on 3/4/25 at 10:37 a.m. with Resident 1, Resident 1 stated on 3/3/25 between 1 a.m. to 3 a.m., he pressed the call light button because he needed to be changed. Resident 1 did not want help from CNA 1 because CNA 1 was rough. CNA 1 was mad and angry and yanked the call button out of Resident 1's hand. Resident 1 added CNA 1 hit himself with the call button and blamed Resident 1, then punched Resident 1 in the face and it wasn't a light hit . Resident 1 further stated CNA 1 then mocked him, told him you're a big baby. Resident 1 felt like a piece of crap and stated CNA 1 probably did not care at all. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in November 2024. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 15 out of 15 with good memory. During an interview on 3/4/25 at 11:28 a.m. with Resident 2 (Resident 1's roommate), Resident 2 confirmed he was awake when CNA 1 was arguing with Resident 1 and stated Resident 1 yelled and asked CNA 1 why he hit him. Resident 2 further stated CNA 1 told Resident 1 you're just a baby, you can't do anything for yourself. A review of Resident 1's progress note, dated 3/3/25 at 8:38 a.m., indicated Resident 1 was noted with left lower eye swelling and discoloration and an abrasion to the bridge of nose. The note further indicated Resident 1 stated he had an argument and physical contact with staff that resulted in the discoloration and abrasion to his nose. A review of Resident 1's progress note, dated 3/3/25 at 10:37 a.m., indicated Resident 1 reported a bruise that was not there and stated overnight staff hit him with his hand. During an interview on 3/4/25 at 11:48 a.m. with CNA 2, CNA 2 stated Resident 1 told him he did not like CNA 1 because he was rough. During an interview on 3/4/25 at 12 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated Resident 1 usually advocated for himself, but today he was acting more timid. A review of Resident 1's Nursing- Weekly Summary, dated 3/2/25, indicated Resident 1's skin was intact with no issues. During an interview on 3/4/25 at 2:10 p.m. with CNA 3, CNA 3 stated she assisted Resident 1 during her morning shift on 3/2/25 and Resident 1 did not have any bruises or cuts on his face. CNA 3 further stated on 3/3/25 at around 7:05 a.m. she was surprised when she saw Resident 1's face with a cut on the nose bridge and a bruise on his left eye. During an interview on 3/4/25 at 3:08 p.m. with LN 2, LN 2 confirmed she did not see a cut on Resident 1's nose bridge or a bruise on his left eye on 3/2/25 during the p.m. shift. During an interview on 3/4/25 at 3:06 p.m. with the Administrator (ADM), ADM stated he interviewed nursing staff and confirmed that Resident 1 did not have a cut on his nose bridge and a bruise under his left eye on 3/2/25. A review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised in April 2021, indicated, Residents have the right to be free from abuse . This includes but not limited to freedom from .verbal, mental . or physical abuse .

Based on observation, interview, and record review, the facility failed to ensure proper infection control practice for two of seven sampled residents (Resident 1 and Resident 2), when Licensed Nurse 1 (LN 1) did not sanitize (to clean or disinfect) a shared glucometer (device used to measure blood sugar levels using a test strip and drop of blood) in between use. This failure had the potential to spread infection among residents. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in February 2025 with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1 ' s Order Summary Report, dated 3/3/25, indicated to check Resident 1 ' s blood sugar (BS) as needed for DM management. A review of an admission record indicated Resident 2 was admitted to the facility in January 2024 with a diagnosis of DM. A review of Resident 2 ' s Order Summary Report, dated 3/3/25, indicated to check Resident 2 ' s BS as needed for DM management. During an observation on 3/3/25 at 1:43 p.m. in Resident 1 ' s room, LN 1 was carrying a small tray containing lancets (a sharp piercing device), alcohol wipes, test strips, and a shared glucometer, to check Resident 1 ' s BS. After LN 1 checked Resident 1 ' s BS, LN 1 exited Resident 1 ' s room, discarded the used lancet and test strip, wrote the BS ' s result on a piece of paper, and then entered Resident 2 ' s room carrying the same glucometer, small tray, and supplies. During an observation on 3/3/25 at 1:45 p.m. in Resident 2 ' s room, LN 1 used the same glucometer to check Resident 2 ' s BS. LN 1 exited Resident 2 ' s room, discarded the used lancet and test strip, and wrote the BS ' s result on a piece of paper. During an interview on 3/3/25 at 1:48 p.m. with LN 1, LN 1 confirmed she did not disinfect the glucometer in between use and was unaware that it should have been disinfected. During an interview on 3/3/25 at 2:15 p.m. with the Director of Nursing (DON), DON stated she expected nurses to disinfect the glucometer with bleach in between use. DON further stated failing to disinfect the glucometer in between use had the potential for cross contamination (transfer of harmful bacteria from one person, object, or place to another). A review of the facility ' s policy and procedure, titled, Obtaining a Fingerstick Glucose Level, dated 2001, indicated, . Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice when the comprehensive centered care plan was not followed. This failure had the potential to result in Resident 1 ' s gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (G-tube) to be displaced during Activities of Daily Living ( (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). Findings: During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated, Resident 1 was admitted to the facility July 2023 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool), dated 1/8/25, the MDS indicated, Resident 1 was dependent with ADLs. During a review of Resident 1 ' s active orders in the Orders Summary Report, dated 7/6/23, the Orders Summary Report indicated, Resident 1 had a G-tube. During a review of Resident 1 ' s Change in Condition Evaluation, dated 1/27/25, the Change in Condition Evaluation indicated, .GT dislodged during ADL care . During a review of Resident 1 ' s Nurse ' s Note, dated 1/27/25, the Nurse ' s Noted indicated, .RP [Responsible Party] verbalized concern regarding resident ' s g-tub getting dislodged .explained to RP that licensed nurses will be instructed to be present at bedside during resident ADL care to monitor resident ' s g-tube and assist in preventing it from getting dislodged . During a review of Resident 1 ' s care plan, initiated 1/27/25, the care plan indicated, .[Resident 1] has a GT and is at risk for .complications .potential tubing displacement .interventions .Licensed Nurse to be present at bedside during reposition/ADL care . During a review of Resident 1 ' s Nurse ' s Note, dated 2/16/25, the Nurse ' s Note indicated, .At 1225, CNA [Certified Nursing Assistant] informed this writer that g tube was accidentally pulled out. They were changing diapers at that time . During a review of Resident 1 ' s Change in Condition Evaluation, dated 2/16/25, the Change in Condition Evaluation indicated, .G tube accidentally dislodged .found .by CNA while changing diaper .transfer resident to hosp [hospital] . During an interview on 2/21/25 at 3:20 p.m. with Licensed Nurse 1 (LN 1) stated she was the nurse on duty when Resident 1 ' s G-tube was displaced on 2/16/25. LN 1 further stated she was on lunch break when the CNA notified her that Resident 1 ' s G-tube was found dislodged during ADL care. During a follow up interview on 2/21/25 at 4:42 p.m. with LN 1, LN 1 confirmed a licensed nurse was not supervising CNA ' s, providing ADL care, when G-tube was found dislodged on 2/16/25. During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised December 2016, the P&P indicated, .comprehensive, person-centered care plan that includes measurable objectives .to [NAME] the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident .the Interdisciplinary Team (IDT) .implements a comprehensive, person-centered care plan . Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice when the comprehensive centered care plan was not followed. This failure had the potential to result in Resident 1's gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (G-tube) to be displaced during Activities of Daily Living ( (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). Findings: During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated, Resident 1 was admitted to the facility July 2023 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS- an assessment tool), dated 1/8/25, the MDS indicated, Resident 1 was dependent with ADLs. During a review of Resident 1's active orders in the Orders Summary Report, dated 7/6/23, the Orders Summary Report indicated, Resident 1 had a G-tube. During a review of Resident 1's Change in Condition Evaluation, dated 1/27/25, the Change in Condition Evaluation indicated, .GT dislodged during ADL care . During a review of Resident 1's Nurse's Note, dated 1/27/25, the Nurse's Noted indicated, . RP [Responsible Party] verbalized concern regarding resident's g-tub getting dislodged .explained to RP that licensed nurses will be instructed to be present at bedside during resident ADL care to monitor resident's g-tube and assist in preventing it from getting dislodged . During a review of Resident 1's care plan, initiated 1/27/25, the care plan indicated, .[Resident 1] has a GT and is at risk for .complications .potential tubing displacement .interventions .Licensed Nurse to be present at bedside during reposition/ADL care . During a review of Resident 1's Nurse's Note, dated 2/16/25, the Nurse's Note indicated, .At 1225, CNA [Certified Nursing Assistant] informed this writer that g tube was accidentally pulled out. They were changing diapers at that time . During a review of Resident 1's Change in Condition Evaluation , dated 2/16/25, the Change in Condition Evaluation indicated, . G tube accidentally dislodged .found .by CNA while changing diaper .transfer resident to hosp [hospital] . During an interview on 2/21/25 at 3:20 p.m. with Licensed Nurse 1 (LN 1) stated she was the nurse on duty when Resident 1's G-tube was displaced on 2/16/25. LN 1 further stated she was on lunch break when the CNA notified her that Resident 1's G-tube was found dislodged during ADL care. During a follow up interview on 2/21/25 at 4:42 p.m. with LN 1, LN 1 confirmed a licensed nurse was not supervising CNA's, providing ADL care, when G-tube was found dislodged on 2/16/25. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered , revised December 2016, the P&P indicated, .comprehensive, person-centered care plan that includes measurable objectives .to [NAME] the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .the Interdisciplinary Team (IDT) .implements a comprehensive, person-centered care plan .

Based on observation, interview, and record review, the facility failed to ensure one resident(Resident 8) was provided with adequate supervision and safe environment, for a census of 154. This failure resulted in Resident 8's fall and transfer to the acute care hospital due to a bump and cut to the right forehead. Findings: A review of the clinical record indicated Resident 8 was admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) and epileptic seizures (sudden, temporary disruption in brain activity that causes involuntary movements, sensations, or changes in awareness). The Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/4/24 indicated Resident 8 was cognitively intact, required setup to wheel 50 feet with two turns and required setup to wheel 150 feet in a corridor or similar space with the use of a motorized scooter. Further review of Resident 8's clinical records indicated the following: - Fall Risk assessment dated [DATE], indicated Resident 8 was high risk for falls with a score of 18; - Care Plan, dated 2/9/24, indicated Resident 8 was at risk for falls related to decreased muscular coordination, history of falls, visual impairment, uses scooter as primary mode of locomotion and poor safety awareness. The interventions included to keep within supervised view as much as possible and on 4/19/24, resident was assessed for powerchair use for safety and provided with regular wheelchair at this time; and, - Nurse's Note dated 4/19/24 at 15:34 (3:34 p.m.) indicated, Placed call and spoke to resident's RP [Responsible Party] regarding resident's unwitnessed fall on 4/18/24 from his power chair and report of resident leaving the facility to go out for a smoke in an undesignated area to smoke. Care conference held on 4/16/24 with RPvia [sic] phone with recommendation to remove resident's power chair as part of resident's safety intervention after resident's unwitnessed fall outside the parking lot .Explained to RP that resident will be providedwith [sic] regular wheelchair for mobility and will reassess resident for the use of power chair .RP agreed .Resident aware that he will be provided with regularwheelchair [sic] at this time for safety and agreed. This note was written by the Director of Nursing (DON). A review of Resident 8's 'Nurse's Note' dated 12/4/24 at 14:03 [2:03 p.m.] indicated, Writer returned from lunch and is notified by MDS coordinator that [Resident 8] fell @ 1205. Writer went to assess resident. Resident found on front entrance of building accompanied by DON and ADON [Assistant Director of Nursing]. Writer assessed resident and noted a bump to R [right] lateral forehead with [sic] appears to be laceration in mid section. Resident is alert, but with baseline confusion. Resident c/o [complained of] hitting his head .Notified [name] NP [Nurse Practitioner] .received from NP to send resident to ER [emergency room ] for eval [evaluation] and tx [treatment]. MDS coordinator called 911 [phone number to contact emergency services] @ 1210 and 911 arrived @ 1216 . A review of Resident 8's 'Nurse's Note' dated 12/4/24 at 15:18 [3:18 p.m.] indicated, This writer heard a loud noise like something had fallen outside the building. This writer looked outside the window and saw resident lying on his right side on the ground next to his powerchair which is standing upright. Resident assessed with no c/o pain and assisted back to his powerchair. Resident noted with bump and cut to his RT [right] forehead with bleeding. Resident alert, oriented and verbally responsive. Resident stated that he was returning to the facility and noted with a plastic bag on his powerchair .911 was called and arrived to pick up resident . This note was written by the DON. A review of Resident 8's 'Nurse's Note' dated 12/5/24 at 02:52 indicated, Received resident back from the ER [sic]. Received report from ER nurse .labs and ct scan [computed tomography, a medical imaging procedure showing detailed images of a body part] negative for injuries.Upon arrivel [sic] resident had dry blood from right side of the forehead . A review of Resident 8's 'REHAB - STATUS POST-FALL SCREEN' dated 12/5/24 indicated, .Comments .transferred to acute, power scooter removed and resident issued manual wheelchair . An observation of Resident 8 was conducted on 12/6/24 at 12:55 p.m. Resident 8 was up in his wheelchair, sleeping, in front of the smoking patio door. The surveyor alerted staff of resident sleeping upright in his wheelchair. The staff confirmed resident was sitting in the doorway and staff did not approach resident. In an interview on 12/6/24 at 12:57 p.m., Licensed Nurse 1 (LN 1) stated they were monitoring Resident 8 for his laceration from the fall. The LN further stated the hospital had no new orders post discharge. A concurrent observation and interview was conducted on 12/6/24 at 12:58 p.m. with the DON in the facility's driveway where Resident 8 had a fall on 12/4/24. There was a sewer cap in the driveway which was lower than the surrounding concrete surface. The DON stated she heard a bang like something fell , she and the MDS Coordinator looked at the window and when they went outside Resident 8 was lying on his right side. The DON further stated Resident 8 had bleeding on his right forehead and resident was facing towards the building. The DON stated she was able to talk to resident and resident told DON he was coming back from the convenience store. The DON further stated Resident 8 goes outside the building without supervision and resident should be signing himself out everytime he goes out since he's alert and oriented. A concurrent observation and interview was conducted on 12/6/24 at 2:31 p.m. with the Maintenance Supervisor (MS) infront of the facility's driveway. The MS stated the clean up sewer cover was part of the city. The MS further stated they [residents] are not allowed to go outside, if they go out it's dangerous. We should probably call them [city] to fix it. The MS confirmed the area was unsafe for everybody and the MS was aware of the fall that happened. The MS stated, We have to fix this, it cant be like this. It has to be done to fix the uneven area. A review of the facility's policy revised July 2017, and titled, Safety and Supervision of Residents indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident .

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 2) was provided with adequate supervision and safe environment, for a census of 145. This failure resulted in Resident 2's fall and transfer to the acute care hospital for further evaluation. Resident 2 sustained multiple fractures (break) of the bones of the neck requiring surgical intervention. Findings: A review of the clinical record indicated Resident 2 was admitted with diagnoses including hemiplegia and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (disruption of blood flow to the brain) affecting right dominant side, schizoaffective disorder, bipolar type (episode of mood swings ranging from depression [loss of interest in activities] to mania [extreme changes in mood or emotions]). The Minimum Data Set (MDS, an assessment tool) indicated Resident 2 was cognitively impaired and required moderate assistance once in a wheelchair to wheel at least 50 feet and make 2 turns. Further review of Resident 2's clinical records indicated the following: - Fall Risk Assessment, dated 2/27/24,, indicated Resident 2 was a high risk for falls with a score of 26; -Care plan, dated 5/6/23, indicated Resident 2 was at risk for alteration in Activities of Daily Living related to hemiplegia, history of CVA (stroke) and cognitive impairment. The interventions included staff supervision with mobility, self propels in wheelchair; -Care plan, dated 5/6/23, indicated Resident 2 was at risk for repeat falls related to history of falls, hemiplegia and cognitive impairment. The intervention included to provide resident with safe environment such as even floors; and -Care plan, dated 4/13/23, indicated Resident 2 was at risk for fall or injury due to poor fall safety awareness. The interventions included during activities keep close observation to minimize potential for falls and to keep environment free of hazards. A review of Resident 2's 'Nurse's Note,' dated 4/20/2024 at 14:30 [2:30 p.m.] indicated, I was told the [Resident 2] fell outside on the smoking area at 1345 p.m., she was in her wheelchair heading to the smoking area and she fell because the wheelchair was pulled to the edge of the slightly uneven surface. we [sic] assisted her back to the wheelchair. on [sic] assessment I noticed the bruise and minimal bleeding on her right side of the head. i [sic] asked her if she hit her head and she said yes. she [sic] said it hurts my head and my back .paramedics .picked her [up] . and left the facility . A review of Resident 2's physician note from the Emergency Department (ED) on 4/20/24 indicated, [brought in by ambulance] to the ED [status post] witnessed mechanical GLF [ground level fall] today at SNF [Skilled Nursing Facility]. A review of Resident 2's 'TRAUMA ADMISSION HISTORY AND PHYSICAL NOTE,' dated 4/20/24, indicated Resident 2 was admitted to Surgical ICU (Intensive Care Unit, provides critical care and life support for the acutely ill or injured). The assessment and plan included, NSG consulted due to multiple cervical fractures (break in the bones of the neck) including C6 (controls the muscles of the wrist and the large muscle on the front of the upper arm between the shoulder and elbow) left floating lateral (side) mass fracture and C5 to C7 (C5- controls the large muscles of the shoulders and front of the upper arm, C7- controls the large muscle on the back part of the upper arm and wrist muscles) left lateral mass fractures. A review of Resident 2's 'DEPARTMENT OF NEUROLOGICAL SURGERY SPINE CONSULTATION,' dated 4/20/24, indicated, .fell at SNF and was found to have multiple cervical injuries .consider trauma consultation for full trauma workup given significance of cervical injuries. A review of Resident 2' s 'INPATIENT OPERATION RECORD' indicated an operation date of 4/22/24. Resident 2 had pre and post operative diagnosis of closed fracture of cervical vertebra, unspecified cervical vertebral level (there are 7 bones of the neck, from C1 to C7). The procedure performed included: Anterior interbody fusion (a major surgery performed through the abdominal cavity to fuse 2 or more bones to restore stability), with discectomy (surgical removal of abnormal disc material that presses on a nerve root) and decompression (helps return bulging discs to their correct locations), of the C5 to C7. During an observation conducted on 4/24/24 at 8:05 a.m., there was an uneven curved pavement on the right side of the building leading to the smoking area. The dirt area had a yellow plastic caution sign around it supported by 5 sticks and 4 cones along the side. An interview was conducted on 4/24/24 at 8:09 a.m. with Resident 6 in the smoking area. Resident 6 stated he knew Resident 2 and she was in the hospital. Resident 6 stated, 5 to 6 days ago at the scheduled smoke break at 1:30 p.m., Resident 2 was impatient and she went out without assistance. Resident 2 pushed herself out and started rolling. Resident 2's wheelchair tipped sideways and she hit her head on the wall. The CNA told Resident 2 to stay there [inside], she let herself out and she fell . Resident 6 stated the caution sign was there at the time of fall and the cones were put up 2 days after Resident 2 fell . In a concurrent observation and interview on 4/24/24 at 8:23 a.m., Resident 6 pointed to the area where Resident 2 fell . Resident 6 stated Resident 2 fell in the middle of the dirt area. Upon further inspection of the location of the fall, the unpaved area on the side of the building had approximately 4-5 inches of elevation from the ground to the cemented area. A review of the clinical records indicated Resident 6 was admitted with diagnoses including acute and chronic respiratory failure (lungs have a hard time loading the blood with oxygen). Resident 6's MDS, dated [DATE], indicated he was cognitively intact. In an interview on 4/24/24 at 8:24 a.m., the Activities Director (AD) stated there was a big palm tree that was removed on the side of the building. The AD further stated she heard about Resident 2's fall. In an interview on 4/24/24 at 8:30 a.m., the Director of Nursing (DON) stated she received a text message from the Social Services Director (SSD) on 4/20/24 regarding Resident 2. The DON further stated Resident 2 had a fall, one wheel got caught on the uneven pavement. In an interview on 4/24/24 starting at 11:07 a.m., the SSD stated she was the Manager of the Day on 4/20/24, when Resident 2 fell . The SSD was in the hallway, CNA 2 was outside by the patio door, Resident 2 was going slowly, she used her hand to propel her wheelchair, the wheelchair got close to the cement and the front wheel on the right tipped over, The SSD saw Resident 2 lying on her side and her head was against the wall. The SSD stated the area was curved and Resident 2 went straight. The SSD further stated before the CNA 2 could turn around, Resident 2's wheelchair tipped off the ledge. The yellow tape was there with the sticks, no cones. Resident 2 was picked by nurses from the ground back to her wheelchair. The SSD stated the fall could have been prevented if CNA 2 pushed the residents in their wheelchairs one at a time. The SSD described there was approximately 5 inches difference from the cemented area to the ground. The SSD stated a tree was taken out and the elevation from the cemented area to the ground was something new. In a follow-up interview on 4/24/24 starting at 12:01 p.m., the DON stated she could not tell if Resident 2's fall was preventable or not. In an interview on 4/24/24 at 1:17 p.m., the Administrator (ADM) stated a huge palm tree was taken out since the roots were going underneath the foundation of the building. The ADM added the facility put the caution sign when the tree was taken out. The ADM was unable to state if Resident 2's fall was preventable or not. A telephone interview was conducted with the Licensed Nurse 2 (LN 2) on 4/24/24 starting at 2:51 p.m. The LN 2 stated the SSD was the one who informed him of Resident 2's fall. When LN 2 went to check on Resident 2, she was in the soil area, lying on her right side and her wheelchair was tipped. The LN 2 saw a little bruise on the right side of her head. The LN 2 stated they did a manual transfer because resident was in the soil and there was an uneven surface between the cement and the soil. The LN 2 stated the safest way should be to leave Resident 2 on the ground. The RN further stated Resident 2 was transferred manually with 3 people (including LN 2) from the ground back to her wheelchair because resident was screaming and she insisted on getting up. The LN 2 stated Resident 2 complained of pain on her head and on her back after she was transferred. LN 2 further stated, the fall was preventable, and the surface should be even. In a telephone interview on 4/25/24 at 12:15 p.m., the AD stated the safest way to assist Resident 2 while going outside to the the patio was for another staff to push her wheelchair when she was not agitated. If Resident 2 was agitated she will immediately notify the nurse or certified nursing assistant to assist her and make them aware on her behavior. The AD described there was a huge palm tree with the roots that had lifted up. The AD added there was no way a wheelchair would flip due to the area being pretty high. In a telephone interview on 4/25/24 at 12:38 p.m., the Maintenance Supervisor (MS) stated there was 4 inches of elevation between the concrete and the dirt. In a telephone interview on 4/25/24 starting at 3:12 p.m., CNA 2 stated she was assigned to supervise the residents for the smoking break on 4/20/24. The CNA 2 further stated Resident 2 was in the wheelchair and she was going out with other residents to the smoking area. CNA 2 was in the middle of helping a male resident when Resident 2 had a fall. CNA 2 further stated her back was facing Resident 2 and she was not able to see how she fell . CNA 2 saw Resident 2 on the ground lying on her right side in the wheelchair and her head was touching the wall. CNA 2 stated she could have prevented the fall if she had the chance but it was too late. CNA 2 further stated Resident 2 fell on the dirt and she could not have fallen if the area was all cemented. CNA 2 stated the yellow sign did not prevent Resident 2's wheelchair from tipping over the side. In a follow-up telephone interview on 4/26/24 at 10:06 a.m., the MS stated the 30 foot palm tree was taken out on 4/16/24. The MS further stated the contractor worked on the site for 2 days, they removed 150 foot of gravel and it was 4 inches deep. The MS agreed the area was unpaved when the tree and the stump was removed. A review of the facility's policy revised July 2017 and titled, Safety and Supervision of Residents indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment . The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) .

Based on observation, interview, and clinical record review, the facility failed to provide sufficient fluid intake to maintain electrolyte balance and nutritional status for 1 of 3 sampled residents (Resident 1). As a result of this failure, Resident 1 was transferred to the hospital twice for aggressive fluid resuscitation. Findings: According to the facility Record of Admission, Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. In a Dietary Progress Note, dated 7/13/17, the Registered Dietician (RD) documented that Resident 1's daily dietary needs included, .2100 mls (milliliters, a metric unit of volume) (of) fluids . Section K of Resident 1's MDS (Minimum Data Set, an assessment tool), dated 7/18/17, indicated no signs and symptoms of a swallowing disorder. A Dehydration Risk Assessment tool, dated 7/24/17, indicated Resident 1 was at moderate risk for dehydration with a score of 25 (greater than 50 indicated high risk). Instructions on Resident 1's Dehydration Risk Assessment tool, dated 7/24/17, indicated, Complete the following assessment for each resident within 72 hours of admission, significant change .individualized care plan should be developed to address resident's dehydration risk factor. A Fluids Offered section of a Certified Nursing Assistant (CNA) activities of daily living (ADL) Tracking Form, dated (MONTH) (YEAR), indicated Resident 1 was offered and consumed 200 mls of fluid on 9/1/17; 600 mls on 9/2/17; 600 mls on 9/3/17; and 600 mls on 9/4/17. 24 Hour Daily Staffing Sheets, dated 9/1/17, 9/2/17, 9/3/17, and 9/4/17, showed CNA 1 was working in the facility and caring for Resident 1 on each of those four evening shifts (2 p.m.-10:30 p.m.). In a facility SBAR (Situation, Background, Assessment and Recommendation, an assessment and communication tool), dated 9/5/17, Licensed Nurse 2 (LN 2) documented Resident 1 as, non responsive verbally, cold and clammy, BS (blood sugar) @ 321, Recheck 304. BP (blood pressure), (the pressure that circulating blood exerts on the walls of blood vessels) barely palpable .unable to obtain O2 (oxygen saturation, a measure of the amount of oxygen in the blood) due to cold finger .decreased L[NAME] (level of consciousness) .called 911 . Review of Resident 1's general acute care hospital (GACH) clinical record, admitted [DATE], included: Emergency Department (ED) records, dated 9/5/17 at 1:10 p.m., recorded the following laboratory values: Sodium (an electrolyte in the body) 165 mEq/L (milliequivalents (a unit of measure) per liter) (reference range (normal range) is 135-145); Chloride (an electrolyte in the body) 127 mEq/L (reference range is 100-111); Glucose (blood sugar) 288 mg/dl (milligrams per deciliter (a unit of measurement)) (reference range is 60-159); BUN (blood urea nitrogen, a liver waste product produced from digesting protein) 54 mg/dl (reference range is 7-27); Creatinine (a waste product produced from the breakdown of muscle tissue 1.67 mg/dL (reference range is less than or equal to 1.11); Glomerular Filtration Rate (a measurement of kidney function) 39 mL/min (milliliters per minute) (reference range is greater than 60). ED records, dated 9/5/17, included initial admitting [DIAGNOSES REDACTED]. physician progress notes [REDACTED].Now seen after 3 liters (a unit of measure) normal saline (fluid compatible with normal blood components), bp (blood pressure) 118/70 .HR (heart rate) 74; Skin turgor (degree of elasticity of the skin) better but still clinically dry. physician progress notes [REDACTED].Will admit to ICU (intensive care unit) and hydrate patient. Free water (water that is not mixed with foods) loss about 5L (liters), will start with 0.45 saline, MILD AKI (acute kidney injury)/vol (volume) loss. ED Provider Notes, dated 9/5/17 at 5:59 p.m., indicated, Impression/Plan: 54 Y (year-old) female .found with aloc (altered level of consciousness) by caretakers .Eval reveals severe [MEDICAL CONDITION], dehydration . A Physician's H&P (History and Physical) History of Present Illness, dated 9/6/17 at 1:59 p.m., indicated, Patient .brought in from her .care facility with altered mental status .On arrival to ER hypotensive (low blood pressure), responsive to fluid resuccitation (sic). Severely hypernetremic (sic) .clinically [MEDICAL CONDITION] (infection in the body tissues) .Admit to ICU and replace free water slowly. Patient already had 3L normal saline iv (intravenous, directly into a vein) with stable bp . A Physician's H&P-Plan, dated 9/6/17 at 1:59 p.m., indicated, Admit to ICU .fluid resuccitated (sic). No longer hypotensive (low blood pressure) or [MEDICAL CONDITION] (fast heart rate) after 3L normal saline in ER .Replace free water loss with close monitoring of serum sodium .Monitor urine output and creatinine levels .Prognosis poor. A Physician's Progress Note, dated 9/6/17 at 2:11 p.m., indicated, Severe dehydration - severe hypernetremia (sic)resolving .Altered mental status chronic exacerbated by dehydration/sepsis .NONTRAUMATIC ACUTE KDNEY INJURY resolved with volume resuccitation (sic). Pre-discharge Laboratory (blood tests) Results, collected on 9/8/17 at 8:55 a.m., showed: Sodium 146 mEq/L (reference range (normal range) is 135-145); Chloride 108 mEq/L (reference range is 100-111); Glucose 251mg/dL reference range is 60-159); BUN 6 mg/dl (reference range is 7-27); Creatinine 0.49 mg/dL (reference range is less than or equal to 1.11 mg/dL); Glomerular Filtration Rate-not reported (reference range is greater than 60). The Hospital Course and Significant Findings portion of the Discharge Summary, dated 9/8/17 at 2:24 p.m., indicated, .54 Y female .who presents from SNF (skilled nursing facility) for alteration in mental status .was .found to be severely hypernatremic .After aggressive fluid resuscitation she was admitted to the ICU .[MEDICATION NAME] normalized with IVF (intravenous, fluids) .HYPEROSMOLALITY (increased concentration of solids in a fluid) W (with) [MEDICAL CONDITION] .likely in setting of dehydration . Review of facility documents, dated between 9/8/17 and 9/13/17, (after readmission to the facility from the GACH) included: A facility INTAKE & OUTPUT/NUTRITIONAL/HYDRATION PROT[NAME]OL, dated 7/22/13, indicated, INTAKE AND OUTPUT WILL BE COMPLETED ON: New admissions x (times) 7 days and then Licensed Nurse will evaluate for the need to continue monitoring . Review of Resident 1's clinical record revealed no documented I&O (intake and output) for Resident 1 following the 9/8/17 readmission. In a Clinical Health Status document, dated 9/8/17 at 6 p.m., completed and signed by LN 6, Section H - Risk for Dehydration, was left blank. A Fluids Offered section of a CNA ADL Tracking Form, dated 9/17, indicated Resident 1 was offered and consumed: 600 mls of fluid on 9/9/17; 480 mls of fluid on 9/10/17; 380 mls of fluid on 9/11/17; and 360 mls of fluid on 9/12/17. In a Nursing Note, dated 9/10/17 at 11:30 p.m., LN 1 documented Resident 1 at 4 p.m. was slow to swallow .MD (medical doctor) in the facility made aware of swallowing problem . In a Speech Therapy Initial Evaluation, dated 9/11/17, the Speech Therapist (ST) documented, .Patient exhibits significant reduced intake. Long-term Goal was documented as, Patient will maintain adequate hydration/nutrition . In a Nursing Note, dated 9/11/17 at 2:30 p.m., LN 2 documented, .resident noted with difficulty swallowing during the shift . In an untimed Speech Therapy-Treatment Encounter Note, dated 9/12/17, ST documented, Pt (Patient, Resident) seen at bedside during breakfast .was difficult to arouse and appeared inappropriate for feeding. Pt showed no response to spoon in oral cavity and no gag reflex. Per charge nurse and CNA, pt has not eaten in three days. In a Speech Therapy-Treatment Encounter Note, dated 9/13/17, ST documented, Pt was difficult to arouse, however showed a slight lip movement in response to spoon in oral cavity. Per charge nurse, she was debating on sending pt to acute care hospital as pt continues to show decline in alertness, intake . An SBAR Communication Form, dated 9/13/17, indicated under Resident Evaluation: .Mental Status Evaluation (compared to baseline) Decreased level of consciousness .Functional Status Evaluation (compared to baseline) .Swallowing difficulty. The SBAR Communication Form, under Appearance specified, Resident's eyes closed won't open eyes even to call her name (sic); Review and Notify specified, .difficulty swallowing, Refused meal not opening her mouth. A Final Licensed Nurses Progress Note and Discharge Summary, dated 9/13/17 at 11:30 a.m., noted the second transfer to the GACH. Review of Resident 1's GACH clinical record, admitted [DATE], included: ED lab values, dated 9/13/17 at 12:30 p.m., were documented as follows: Sodium 162 mEq/L (reference range (normal range) is 135-145); Chloride 118 mEq/L (reference range is 100-111); Glucose 430 mg/dL (reference range is 60-159); CO2 (carbon [MEDICATION NAME]) 35 mEq/L (reference range is 24-33); BUN 38 mg/dl (reference range is 7-27); ED Physician Note, dated 9/14/17 at 10:41 a.m., indicated, Previous baseline reviewed and patient appears to be diminished from baseline .Chem 7 (a blood test) shows significant [MEDICAL CONDITION] (increased sodium in the blood) and hyperchloremia (increased chlorine in the blood), will give IVF bolus, calculate FWD (free water deficit, calculation used to assess the amount of water replacement needed to correct [MEDICAL CONDITION]) .attribute AMS (altered mental status) to severe [MEDICAL CONDITION] .Admit. The GACH Physician Note in Discharge Summary, dated 9/18/17 at 4:33 p.m., specified, Her (Resident 1's) leukocytosis (an increase in the number of white cells in the blood, as during an infection) may be from .her severe dehydration .She (Resident 1) is unable to express when she is thirsty, and also unable to acquire water for herself to drink. She may have become profoundly dehydrated in the setting of increased insensible (fluids that leave the body in small, unnoticed amounts) losses 2/2 (secondary to) fever as well as increased urine output in the setting of [MEDICAL CONDITION] (increased blood sugar) .Also wonder if she is receiving enough free water at her SNF. Free water deficit at arrival (was approximately) 4.9 L. GACH SNF Orders (orders written at a GACH for readmission to a SNF), dated 9/20/17, documented, Principal Diagnosis-Hyperosmolality with [MEDICAL CONDITION], Altered Mental Status .please diligently feed the patient and hydrate the pt throughout the day up to 8 cups of liquid per day. In an interview on 11/21/17, at 3:55 p.m., CNA 1 stated Resident 1 was, not eating or drinking for four days. She normally drinks a lot. The whole four days I told the nurses (she was not eating and drinking) . In an interview on 11/28/17, at 12:30 p.m., LN 2 stated she was caring for Resident 1 on the day shift when she (Resident 1) was transferred to the GACH on 9/5/17. LN 2 stated she did not look at the ADL documentation, which included fluid intake, for that shift. In an interview on 12/13/17, at 10:35 a.m., the Director of Nursing (DON) stated, Per policy she, (Resident 1) would have been on I&Os when she came back from the hospital. When asked for a care plan for hydration for Resident 1, the DON stated there was not one. In an interview on 12/18/17, at 10:30 a.m., when asked for a Nutritional Screening for the 9/8/17 re-admitted , the Food Services Director (FSD) stated, If they (residents) are gone 3 days or more a new screening would be done. When asked if she could find the screening form for Resident 1 the FSD was unable to do so. When asked if there was a hydration care plan, the FSD looked through the documentation and stated, No. In an interview on 12/18/17, at 11:30 a.m., the DON stated the Dehydration Risk Assessment should have been done within 72 hours of Resident 1's readmission from the GACH (on 9/8/17). When asked for a copy of the I&Os from Resident 1's readmission, the DON stated, I did not find a copy of I&Os. The DON further confirmed that per the policy, Resident 1 should have been on I&Os between 9/8/17 and 9/13/17. When asked if it could be inferred that the amounts recorded on the CNA ADL Tracking Form, dated (MONTH) (YEAR), would be Resident 1's intake for the documented time periods, the DON stated, Yes. In a continuation of the 12/18/17 interview at 11:30 a.m., the DON confirmed that because Resident 1 was out of the facility for greater then 72 hours, she should have been on I&Os. The DON confirmed that facility staff saw a change in condition before 9/5/17. When asked if staff reported Resident 1's condition to her during this time period, the DON stated staff, .did not come to me regarding this event. In a continuation of the 12/18/17 11:30 a.m. interview, The DON stated the facility, didn't address dehydration (on the nursing assessment) when she (Resident 1) came back in .the MD didn't address dehydration on the initial physical. The DON confirmed that a nutrition assessment had not been done when Resident 1 was readmitted on [DATE]. When asked if dehydration was addressed on the care plan, the DON answered, No. When asked if there was any documentation demonstrating hydration/dehydration was addressed when Resident 1 first returned to the facility on [DATE], the DON stated, Not proof on paper. In a continuation of the 12/18/17 interview at 11:30 a.m., when asked if there was any documentation to refute the conclusions that Resident 1 become dehydrated at the facility and was sent to the GACH, returned to the facility and became dehydrated again, and was transferred again to the GACH, the DON responded, No. We really missed some things. We really screwed up. In a follow-up interview with the RD on 12/19/17 at 9:10 a.m., while referencing her 7/13/17 note content, the RD confirmed that approximately 2100 mls of fluid were required every 24 hours to meet Resident 1's hydration needs. In an interview on 2/26/18 at 11:50 a.m., regarding Resident 1's 9/13/17 GACH admission, the GACH ED MD 1 stated, Yes, I took care of her. MD 1 stated Resident 1, Was basically a re-admit. She came in on 9/13/17 with altered mental status .had [MEDICAL CONDITION] and met criteria for admission. MD 1 stated, Any time someone is compromised and who presents with increased sodium and dehydration, there is (a) possibility that nutrition and hydration needs have not been met.

Based on interview and record review, the facility failed to prevent the formation and progression of a pressure ulcer (open area on the skin, usually over bony prominances, resulting from pressure on the area for an extended amount of time) on 1 of 2 sampled residents (Resident 1), when she remained seated in her wheelchair for extended periods of time. This failure resulted in the formation of a pressure ulcer that required the resident to remain in bed for several weeks. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/9/15 Minimum Data Set, an assessment tool, indicated she had no memory problems and she had no history of refusing care. A nursing note, dated 10/2/15 and written at 9:40 p.m., indicated Resident 1 needed moderate to maximum assistance with her self-care and required the use of a mechanical lift for transfers to and from bed. (The lift uses a sling placed under a resident and is lifted by its 4 corners. Lifting must be performed by staff and not a resident themselves.) A Non-pressure Skin Condition Report, dated 10/3/15, indicated Resident 1 had redness at her sacral area. On 10/5/15, the Non-pressure Skin Condition Report, dated 10/3/15, had been updated to indicate the skin was pink and intact. A care plan for Skin Integrity, Potential, initiated on 10/5/15, indicated Resident 1 was at risk for developing pressure ulcers due to her paralysis, [MEDICAL CONDITION], and pain. The area of the care plan that attributed the risk of the development of pressure ulcers to non-compliance with turning and repositioning had been left blank. The nursing approaches to achieving the goal of preventing pressure ulcers included turning the resident every two hours and educating the resident/family on the consequences of non-compliance with the plan of care. Nursing staff was expected to assess the resident's skin every day and notify the physician if there were skin impairments. The area of the care plan recommending the use of pressure relieving devices was left blank. A nursing note, dated 10/7/15 and written at 10 a.m., indicted nursing staff had obtained new orders for the treatment of [REDACTED]. A low air loss mattress had been ordered and provided for Resident 1. (A low air loss mattress helps minimize pressure on bony body parts to minimize risk of the development of pressure ulcers.) On 10/7/15, Resident 1's plan of care was updated with a short-term care plan to address an open area on Resident 1's left buttock. The care plan directed nursing staff to monitor the open area for signs or symptoms of complications and notify the Medical Doctor (MD) if the open area is worsening. Provide a low air loss mattress. There was no documented evidence the nursing staff included limiting Resident 1's time up in her wheelchair at the time the open area was discovered. The care plan was updated on 10/12/15 to identify changed MD orders. A Non-Pressure Skin Condition Report, dated 10/7/15, indicated the wound on Resident 1's left buttock measured 1 centimeter (cm) by 1 cm. On 10/12/15 the report was updated to indicate the wound had deteriorated and measured 5 cm by 9.5 cm. Resident 1 had reported to the nurse she had been up in her wheelchair from 10 a.m. to 7:30 p.m. A nursing note, dated 10/12/15 and written at 3 p.m., indicated Resident 1 had an open wound to her sacral area. It was categorized as UTD (Unable to Determine - a pressure ulcer category that indicates the wound is the full thickness of the skin, with possible underlying tissue damage. The exact nature of the wound is unknown as it is covered with a film (slough) or a black crust (echar) that prevents a full visual inspection of the wound.) The nursing note indicated the wound measured 5.0 cm by 9.5 cm. Resident 1 was instructed to maintain strict bed rest and was educated about pressure relieving measures. There was no documented evidence the education that was to be provided to Resident 1, as indicated in the care plan for Skin Integrity, initiated 10/5/15, was done. Furthermore, there was no documented evidence staff had identified Resident 1 was spending too much time in her wheelchair from the time the wound was first discovered on 10/7/15 until 10/12/15. The Treatment Administration Record (TAR) indicated Licensed Nurse (LN) 1 noted the open areas to Resident 1's buttock on 10/7/15 and had performed the treatments on 10/7/15, 10/8/15, and 10/9/15. LN 2 had completed the treatment on 10/10/15 and LN 3 had completed the treatment on 10/11/15. On 10/12/15 LN 1 again completed the treatment, identifying the change of condition of the wound at that time. A form titled Braden Scale - For Predicting Pressure Sore Risk, dated 10/9/15, indicated Resident 1's risk score was 12. A total score of 12 or less represented high risk. A pressure ulcer assessment, completed on 10/9/15, indicated Resident 1 was at high risk for developing a pressure ulcer. A physicians Wound Summary note, dated 10/19/15, indicated, While she has been here, she has been in her wheelchair for more than 14 hours a day! She admitted to more than 7 hours, which is still way beyond what is appropriate. I explained to her that with that sitting for the extended period of time, this has resulted in moisture, friction, shear and pressure to the sacral region. An interview was conducted with the Director of Nursing on 2/2/16 at 12:45 p.m. She reviewed Resident 1's clinical record and confirmed there was no documented evidence Resident 1 had been provided with education on the need to avoid sitting in the wheelchair for extended periods of time, until 10/12/15 after the wound had already deteriorated. An interview was conducted with the Unit Manager on 2/2/16 at 1:05 p.m. She reported she did not recall if she had provided any education to Resident 1 regarding avoiding sitting in her wheelchair for extended periods of time. An interview was conducted with Resident 1 on 2/2/16 at 1:30 p.m. She reported she had no feeling below the waist as a result of her paralysis and she was not aware of the open area on her buttocks. She reported staff would get her up about 10 a.m. and put her to bed after dinner. She reported she could not walk or stand up and required the staff to lift her using the mechanical lift. Furthermore, she stated nobody had told her she was spending too much time in her wheelchair until 10/12/15, when she was told she had to remain on bedrest.

Based on staff interview, physician interview, and clinical record review, the facility failed to: 1. Ensure interventions were obtained for one of three sampled residents (A) from Physician 2, in response to Resident A's critical lab value (results outside the normal range that need to be addressed immediately) for her low platelet count (component of the blood that is required for clotting to occur) and nose bleeds. 2. Notify Resident A and her family member of the critically low platelet count. 3. Contact the Medical Director to obtain interventions when none were received from Physician 2. This failure resulted in a further decline in Resident A's health, as evidenced by a further decrease in her platelet count, subsequent transfer to the emergency room for transfusion of platelets, admission to the hospital, and death four days later. Findings: Resident A was admitted to the facility on [DATE] at 4 p.m. following a hospital stay. Resident A's [DIAGNOSES REDACTED]. Blood test results, dated [DATE], indicated Resident A had a low platelet count of 35 units(reference range ,[DATE] units). Resident A's physician's orders [REDACTED]. There was also an order [REDACTED]. The infusion center would have immediately notified Physician 1 of the critically low platelet count. Blood test results, dated [DATE] (Friday), indicated Resident A had a platelet count of 12 units. This was 65% lower than previously measured; a critically low level. There was no documented evidence Resident A or her family member was notified of the critically low platelet level. An interview was conducted with Licensed Nurse (LN) 5 on [DATE] at 2:45 p.m. LN 5 stated she knew the results were critical and spoke with her charge nurse. LN 5 stated on [DATE] she faxed the lab results to, and immediately phoned, Physician 3. Physician 2 (the on call physician) answered because Physician 3 was out of town. LN 5 read Physician 2 the lab results for Resident A. Physician 2 said to call Physician 3 on Monday. When asked if this physician contact was documented, LN 5 said, "When there are no new orders we just write it on the lab slip." LN 5 was asked whether any new orders were obtained from Physician 2. LN 5 said, "No." The lab results, dated [DATE], included a handwritten note at the bottom indicating, "(Physician 2) notified - to call (Physician 3) on (Monday)." There were no orders to transfer Resident A to the acute care hospital for a transfusion. The facility did not contact the Medical Director when no orders were received from Physician 2 to address the critically low platelet count. An interview was conducted with LN 3, the charge nurse, on [DATE] at 3 p.m. LN 3 stated, "LN 5 said Resident A's labs were critical and I made sure LN 5 phoned the physician." An interview was conducted with the facility's Director of Nursing (DON) on [DATE] at 3 p.m. The DON stated, "The on call physician was contacted when Resident A's platelets were observed to be out of range and Physician 2 stated, per LN 5's report, to contact Physician 3 on Monday." When asked to state concerns for a resident with a platelet count of 12 units, the DON said, "Bleeding and not clotting." A Shift Activity report, dated [DATE], reflected Resident A had two nose bleeds on the night shift. Nurse's Notes, dated [DATE] at 6:33 a.m., reflected Resident A bled from the nose. There was no documented evidence the nose bleeds were relayed to the physician. There was no documented evidence the resident or her family member was notified of the nose bleeds. An interview was conducted with LN 4 on [DATE] at 3:05 p.m. LN 4 was asked what happened. LN 4 stated on Sunday, [DATE], Resident A's family member phoned the facility and asked about Resident A's lab values and if her hematologist had been notified. The family member then phoned Physician 1 (the hematologist). Physician 1 told the family member to transfer Resident A out of the facility. A Nurse's Notes, dated [DATE] at 10:15 p.m., reflected Resident A was sent out as ordered by Physician 1 for transfusion. LN 4 stated Physician 2 telephoned the facility on [DATE] (Sunday) and stated, "A conversation must be conducted with Resident A's family because at this point, [MEDICAL CONDITION] are the only thing that would keep Resident A alive." On Resident A's History and Physical from a hospital admission, dated [DATE], Resident A was noted to have a platelet count of 2 units. This was 83% lower than the critically low value determined on [DATE]. A platelet transfusion was ordered by the emergency room physician. A telephone interview was conducted with Physician 2 on [DATE] at 1:30 p.m. Physician 2 was asked if LN 5 notified him about Resident A's critical platelet value of 12 units. Physician 2 stated he had "a very vague memory of such a call." Physician 2 stated he had a feeling he would want Resident A's hematologist to have been made aware. Physician 2 was asked whether his response to LN 5 was to contact Resident A's physician on Monday. Physician 2 stated there was probably more to it than that, and normally he wouldn't wait until Monday. Physician 2 stated, with this [DIAGNOSES REDACTED]. Resident A has MDS, bone marrow failure. The only thing that can save Resident A is a bone marrow transplant, which, at Resident A's age, she would never survive. A telephone interview was conducted with Physician 1 on [DATE] at 1:15 p.m. Physician 1 stated, "Resident A was sent to the emergency room (ER). At the ER her platelet count was 2. Resident A was getting sick due to decreased white blood cells. Platelets below 20 is critical. The nurse is a connection point. The labs were critical. The nurse should catch this. The nurse should report to their supervisor or to the doctor. The nurse should have insisted that some action be taken. The connection failed." Resident A had a decrease in her white blood cell count. White blood cells are produced to aid the body in fighting off infection. On [DATE], her white blood count was 0.4 K/uL (thousands per cubic milliliter) (Normal range 4.4 - 11.0 K/uL). On [DATE], her white blood count was 0.4 K/uL. On [DATE], her white blood cell count was 0.3 K/uL. As a result of the low white blood cell count, Resident A [MEDICAL CONDITION] (blood infection). Resident A expired at the acute care hospital on [DATE].