Every finding on record at Aspire Senior Living Poplar Bluff

Based on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves during care for six residents (Residents #17, #32, #33, #35, #44, and #57) out of seven sampled residents, failed to follow Enhanced Barrier Precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for three residents (Residents #4, #5, and #44) out of four sampled residents, failed to do annual tuberculosis (TB - infectious disease caused by the tubercle bacillus) screenings for three residents (Residents #5, #8, and #9) out of five sampled residents, and failed to keep hot water temperatures between 110 degrees Fahrenheit ( F) and 120 F to inhibit the growth of Legionella (bacteria that can be present in building water systems under ideal conditions and cause a severe type of pneumonia and mild flu-like illness). The facility census was 50.Review of the facility's policy titled, Hand Hygiene, dated 10/01/25, showed: - All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors; - Hand hygiene means cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); - Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; - The use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to putting on gloves, and immediately after removing gloves; - Perform hand hygiene between resident contacts, after handling contaminated objects, before preparing or handling medications, before applying and after removing personal protective equipment (PPE), before and after handling clean or soiled dressings, after handling items potentially contaminated with fluids, when moving from a contaminated body site to a clean body site. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 10/01/25, showed: - It is the policy of this facility to implement EBP for the prevention of transmission of MDRO; - An order for EBP will be obtained for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; and infection or colonization with a Centers for Disease Control and Prevention (CDC)-targeted MDRO when contact precautions (precautions that reduce the risk of transmission of infectious materials by direct contact) do not otherwise apply; - Make gowns and gloves available for each resident requiring EBP; - PPE for EBP is only necessary when performing high-contact care activities and may not need to be put on prior to entering the resident's room; - High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. Review of the facility's policy titled, Guidelines for Screening for Tuberculosis In Long Term Care Facilities, dated May 2015, showed: - Residents are to be evaluated, at least annually, to ensure absence of signs and symptoms for tuberculosis disease. Review of the facility's policy titled, Legionella Surveillance, dated 04/14/22, showed: - Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system; - Cooling towers and potable water systems shall be routinely maintained; - Cold water shall be stored and distributed below 68 F; - Hot water shall be stored above 140 F and circulated at a minimum return temperature of 124 F. Review of the facility's Monthly Water Management Checklist, undated, showed: - Water heaters, showerheads, hoses, and sinks should have a hot water temperature between 110 F and 120 F. 1. Observation on 04/20/26 at 4:03 P.M. of Resident #4's intravenous (IV – administered into a vein) antibiotic administration showed: - No EBP signage and no PPE outside of the resident's room; - Licensed Practical Nurse (LPN) G and LPN L entered the resident's room, performed hand hygiene, put on gloves, and did not put on gowns; - LPN G removed the disinfection cap from the IV tubing port, disinfected the port with an alcohol pad, flushed the port with a normal saline (salt water) flush, did not disinfect the port, and attached the IV antibiotic to the port. During an interview on 04/21/26 at 12:25 P.M., LPN G said he/she was not familiar with EBP and did not know he/she needed to wear a gown for IV medication administration. 2. Observation on 04/21/26 at 8:43 A.M., of Resident #17's medication pass showed: - Certified Medication Technician (CMT) C performed hand hygiene, did not put on gloves, and administered fluticasone (a corticosteroid medication) 50 microgram (mcg) spray to each nostril for the resident; - CMT C performed hand hygiene, did not put on gloves, and applied a lidocaine (used to treat localized pain) external patch 4 percent (%) to the right back for the resident. During an interview on 04/23/26 at 9:08 A.M., CMT D said gloves were worn when administering nose sprays. Gloves should also be worn when applying lidocaine patches. During an interview on 04/23/26 at 4:00 P.M., the Director of Nursing (DON) said gloves should be worn when applying lidocaine patches or when administering nasal sprays. 3. Observation on 04/21/26 at 10:04 A.M., of Resident #57's incontinent care showed: - Certified Nurse Aide (CNA) E and CNA F entered the resident's room, performed hand hygiene, and put on gloves; - CNA F performed the resident's incontinent care, did not perform hand hygiene, did not change gloves, put a clean brief on the resident, changed gloves, did not perform hand hygiene, rolled the resident to the right and left side, placed clean linens under the resident, and pulled the resident up in bed; got a wipe and wiped Resident #57's front peri area with four wipes; - CNA E and CNA F removed gloves, performed hand hygiene, and exited the room. During an interview on 04/21/26 at 10:30 A.M., CNA E said he/she should wash hands when going from dirty to clean care. He/She said EBP was for precautions and should wear gowns and gloves during care. Residents with wounds and catheters were on EBP. He/She changed gloves and washed hands even more often with people on EBP. 4. Observation on 04/21/26 at 10:47 A.M., of Resident #44's urinary catheter (a sterile tube inserted into the bladder to drain urine) care and incontinent care showed: - EBP signage outside of the resident's room; - CNA I entered the resident's room, performed hand hygiene, put on gloves, and did not put on a gown; - CNA I removed the catheter stabilization device, unfastened the resident's brief and tucked the brief soiled with fecal material under the resident, did not perform hand hygiene, did not change gloves, wiped the catheter tubing away from insertion site with the same area of the washcloth twice, performed hand hygiene, changed gloves, wiped the catheter tubing away from the insertion site with the same area of the washcloth twice, did not perform hand hygiene, and did not change gloves; - CNA I removed the brief soiled with fecal material, cleaned the fecal material from the resident's buttocks, did not perform hand hygiene, did not change gloves, and placed a clean brief under the resident, fastened the brief, fastened the catheter stabilization device, and touched the bed sheet, the blanket, the bed control, the fall mat, the resident's drinking cup and straw, and the call light; - CNA I removed the gloves, performed hand hygiene, and exited the resident's room. 5. Observation on 04/21/25 at 12:05 P.M., of Resident #5's gastrostomy tube (g-tube – a tube surgically inserted into the stomach to provide hydration, nutrition, and medications) feeding administration, water flushes (used to maintain the resident's hydration and to prevent the g-tube from clogging), and g-tube site dressing change showed: - EBP signage outside of the resident's room; - LPN B and LPN E entered the resident's room, performed hand hygiene, put on gloves, and did not put on gowns; - LPN G administered the g-tube feeding and the water flushes and performed the g-tube site dressing change; - LPN B and LPN G removed the gloves, performed hand hygiene, and exited the resident's room. During an interview on 04/21/25 at 12:25 P.M., LPN G said gowns were not needed during g-tube feeding administration, water flushes, and g-tube site dressing changes. He/She said the EBP signage outside the resident's room must be old because he/she was not aware the resident required EBP. 6. Observation on 04/22/26 at 5:22 A.M., of Resident #32's incontinent care showed: - CNA I and CNA M entered the resident's room, performed hand hygiene, and put on gloves; - CNA I performed the resident's incontinent care, removed the brief soiled with urine, did not perform hand hygiene, did not change gloves, placed a clean brief under the resident, put clean pants on the resident, and rummaged through the resident's sock drawer; - CNA I and CNA M removed gloves, performed hand hygiene, and exited the resident's room. 7. Observation on 04/22/26 at 5:37 A.M., of Resident #35's incontinent care showed: - CNA I and CNA M entered the resident's room, performed hand hygiene, and put on gloves; - CNA I performed the resident's incontinent care, removed the brief soiled with urine, did not perform hand hygiene, did not change gloves, placed a clean brief under the resident, put clean pants on the resident, rummaged through the resident's sock drawer, put clean socks on the resident, and touched the resident's shirt; - CNA I and CNA M removed the gloves, performed hand hygiene, and exited the resident's room. During an interview on 04/22/26 at 1:57 P.M., CNA I said hand hygiene should be performed when entering and leaving a resident's room and between dirty to clean tasks. He/She said gloves should be changed from dirty to clean tasks. 8. Observation on 04/22/26 at 10:35 A.M., of Resident #33's incontinent and urinary catheter care showed: - No EBP signage outside of the resident's room; - CNA H and CNA I entered the resident's room, performed hand hygiene, and put on gowns and gloves; - CNA H performed the urinary catheter care, did not perform hand hygiene or change gloves, cleaned fecal material from the resident's buttocks, did not perform hand hygiene, did not change gloves, placed a clean brief on the resident, picked up the urinary catheter drainage bag and tubing and threaded it through the leg of the brief, and hung the urinary catheter drainage bag on the bedframe, and adjusted the resident's blankets; - CNA H and CNA I removed gloves, performed hand hygiene, and exited the resident's room. During an interview on 04/22/26 at 10:45 A.M., CNA H said he/she should have changed gloves and performed hand hygiene between dirty and clean tasks. 9. Review of Resident #5's medical record showed: - admission date of 05/21/20; - No annual screening for tuberculosis for February 2025 – April 2026. 10. Review of Resident #8's medical record showed: - admission date of 05/08/23; - No annual screening for tuberculosis for February 2025 – April 2026. 11. Review of Resident #9's medical record showed: - admission date of 11/14/19; - No annual screening for tuberculosis for February 2025 – April 2026. During an interview on 04/23/26 at 2:32 P.M., LPN J said he/she would expect tuberculosis screenings to be performed on all residents at least yearly. During an interview on 04/23/26 at 3:30 P.M., the DON said residents with indwelling devices and chronic wounds should be on EBP and staff should be wearing a gown and gloves during high-contact care. Hand hygiene should be performed when entering and exiting a room and between residents. She would expect yearly TB screenings to be performed on all residents. 12. Review of the facility's Water Temperature Checks, dated 03/30/26, showed: - Water temperature in room [ROOM NUMBER] of 96 F; - Water temperature in room [ROOM NUMBER] of 100 F; - Water temperature in room [ROOM NUMBER] of 109 F; - Water temperature in room [ROOM NUMBER] of 106 F; - Water temperature in room [ROOM NUMBER] of 108 F; - Water temperature in room [ROOM NUMBER] of 107 F; - Water temperature in room [ROOM NUMBER] of 105 F; - Water temperature in room [ROOM NUMBER] of 107 F; - Water temperature in room [ROOM NUMBER] of 104 F. Review of the facility's Water Temperature Checks, dated 04/06/26, showed: - Water temperature in room [ROOM NUMBER] of 96 F; - Water temperature in room [ROOM NUMBER] of 92 F; - Water temperature in room [ROOM NUMBER] of 102 F; - Water temperature in room [ROOM NUMBER] of 105 F; - Water temperature in room [ROOM NUMBER] of 102 F; - Water temperature in room [ROOM NUMBER] of 105 F; - Water temperature in room [ROOM NUMBER] of 100 F; - Water temperature in room [ROOM NUMBER] of 97 F. Review of the facility's Water Temperature Checks, dated 04/13/26, showed: - Water temperature in room [ROOM NUMBER] of 104 F; - Water temperature in room [ROOM NUMBER] of 70 F; - Water temperature in room [ROOM NUMBER] of 80 F; - Water temperature in room [ROOM NUMBER] of 80 F; - Water temperature in room [ROOM NUMBER] of 108 F; - Water temperature in room [ROOM NUMBER] of 108 F. Review of the facility's Water Temperature Checks, dated 04/21/26, showed: - Water temperature in room [ROOM NUMBER] of 90 F; - Water temperature in room [ROOM NUMBER] of 92 F; - Water temperature in room [ROOM NUMBER] of 106 F; - Water temperature in room [ROOM NUMBER] of 105 F; - Water temperature in room [ROOM NUMBER] of 105 F; - Water temperature in room [ROOM NUMBER] of 106 F; - Water temperature in room [ROOM NUMBER] of 95 F; - Water temperature in room [ROOM NUMBER] of 101 F. Observation on 04/23/26 at 8:44 A.M., of room [ROOM NUMBER] showed: - Water temperature from the sink of 73.7 F. Observation on 04/23/26 at 8:56 A.M., of room [ROOM NUMBER] showed: - Water temperature from the sink of 98 F. Observation on 04/23/26 at 9:24 A.M., of room [ROOM NUMBER] showed: - Water temperature from the shower of 92 F. Observation on 04/23/26 at 9:29 A.M., of room [ROOM NUMBER] showed: - Water temperature from the sink of 84.7 F. Observation on 04/23/26 at 9:35 A.M., of room [ROOM NUMBER] showed: - Water temperature from the sink of 98.5 F. During an interview on 04/23/26 at 2:35 P.M., the Maintenance Supervisor said water temperatures for Legionella growth was 105 F to 110 F. He said the water temperatures were adjusted at the water heater when they were out of range. During an interview on 04/23/26 at 3:30 P.M., the Administrator said hot water temperatures should be between 105 F and 120 F to inhibit growth of legionella. He said he would expect yearly TB screenings to be performed on all residents.

Based on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately documented and reconciled for one resident (Resident #21) out of five sampled residents. The facility census was 50.Review of the facility policy titled, Controlled Substance Administration and Accountability, dated 10/01/25, showed:- All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided;- All specially compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy;- In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record;- The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration;- The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy;- The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances;- Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it is discovered;- Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access;- Staff may not leave area until discrepancies are resolved or reported as unresolved discrepancies. 1. Review of Resident #21's April 2026 physician order sheet (POS) showed:- An order for morphine (narcotic pain medication used for moderate to severe pain) 20 milligram/1 milliliter (ml) 0.25 ml sublingually (administer under the tongue) every one hour as needed for pain, dated 05/16/25. Review of the resident's Narcotic Record for morphine 100 mg/5 ml 30 ml bottle on 04/22/26 at 11:11 A.M., showed:- On 04/21/26 at 6:30 A.M., Licensed Practical Nurse (LPN) A administered 0.25 ml of the resident's morphine with 7.25 ml remaining in the bottle. Observation on 04/22/26 at 11:11 A.M., of the nurse's narcotic medication cart showed:- One opened and undated with an unreadable label of the resident's 30 ml bottle of morphine 100 mg/5 ml with approximately 5 ml remaining in the bottle. During an interview on 04/22/26 at 11:11 A.M., LPN A said it looked like at least four doses of the resident's morphine 100 mg/5 ml were documented in the resident's medication administration record (MAR) as administered for April that were not documented on the resident's Narcotic Record. He/She did not know of any missing medication doses or discrepancies of the resident's morphine. He/She would expect the Narcotic Record to match the MAR. During an interview on 04/22/26 at 11:20 A.M., the Regional Nurse and the Director of Nursing (DON) said they would expect the Narcotic Record to align with the MAR. The nurses should document and look at the medication amount when doing the medication check off and count each time to ensure accuracy of the count. If there was a discrepancy found, staff should let the DON know. Correct math should be done when tracking the medication usage on the Narcotic Record as there was at least one time found where the remaining amount in the bottle was written incorrectly. During an interview on 04/22/26 at 11:30 A.M., LPN G said he/she was the last person to count the cart this morning and did not notice the discrepancies of the amounts between the Narcotic Record sheet amount of 7.25 ml and the bottle amount of approximately 5 ml. No one had been in the cart since he/she counted that morning that he/she knew of, and he/she had not given the morphine to the resident today. He/She would expect the Narcotic Record to match the amount in the bottle. The narcotic cart was counted at the end of each shift with the oncoming nurse and both nurses signed that it was counted. If there was a discrepancy, then the nurses could not leave until the DON was aware and the discrepancy was resolved.

Based on observation, interview, and record review, the facility failed to ensure an order for code status was consistently documented throughout the medical record for one resident (Resident #58) out of 15 sampled residents. The facility census was 50. Review of the facility's policy titled, Basic Life Support/Cardiopulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing), dated [DATE], showed:- Potential rescuers will initiate CPR, in addition to calling 911, unless a valid Do Not Resuscitate (DNR - does not want cardiopulmonary resuscitation) order is in place, obvious signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection or decomposition) are present, or initiating CPR could cause injury or peril to the rescuer; - If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services: in accordance with the resident's advance directives and any related physician order, such as code status or in the absence of advance directives or a DNR order;- Facility policy will address how resident preferences and physician orders related to CPR and other advance directive issues are communicated throughout the facility so that staff know immediately what action to take or not take when an emergency arises;- Resident wishes expressed through a resident representative must also be honored, although again physician orders should be obtained as soon as possible. 1. Review of Resident #58's medical record showed:- admission date of [DATE];- A DNR code status indicated on the Outside the Hospital Do Not Resuscitate Order (OHDNR) form, with verbal consent obtained from the resident representative and signed by the physician, dated [DATE];- An order to admit to hospice, dated [DATE];- An order for full code (wants CPR if the heart stops beating or the person stops breathing) status, dated [DATE]. Review of the resident's hospice binder showed:- A DNR code status. Review of the resident's care plan, initiated [DATE], showed:- Resident will be a full code;- Resident will receive full CPR interventions in the event of cardiac and respiratory arrest;- Code status will be reassessed on a quarterly basis and as needed. During an interview on [DATE] at 2:00 P.M., the Director of Nursing (DON) said she worked for the same hospice company prior to becoming the DON at the facility. She admitted the resident to hospice at the facility while she previously worked for hospice and the resident was a DNR at that time. The resident's responsible party wanted the resident's code status changed to full code because they were worried the resident wouldn't get good care as a DNR. The resident's code status was changed in the electronic medical record (EMR) to a full code, but the code status was not changed in the resident's hospice binder. It was the responsibility of the hospice staff to update the hospice binder. She would expect staff to look at the EMR or the code status book at the nurse's station to verify a resident's code status. She would also expect a resident's code status to be consistently documented throughout the medical record, including the hospice binder. During an interview on [DATE] at 9:00 A.M., Licensed Practical Nurse (LPN) A said Resident #58's hospice binder showed the resident was DNR and the EMR showed the resident was a full code. A resident's code status should be consistently documented throughout the medical record, including the hospice binder. During an interview on [DATE] at 3:45 P.M., LPN G said he/she would look in the EMR to verify a resident's code status. A resident's code status should be consistently documented throughout the medical record. During an interview on [DATE] at 1:04 P.M., the Medical Records Director said the Social Services Designee (SSD) or the admission Coordinator were responsible for asking the residents about Advance Directives and code status when they assist the resident to fill out the admission paperwork to the facility. She updated the EMR immediately with any changes and verified the EMR was correct every Monday. During an interview on [DATE] at 1:00 P.M., the Administrator said he would expect a resident's code status to be consistently documented throughout the medical record. Complaint #2985554

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices, failed to store medications in a safe and effective manner when staff left the medication refrigerator narcotic medication behind only one lock, and failed to check and maintain a daily refrigerator temperature log. This had the potential to affect all residents. The facility census was 50. Review of the facility policy titled, Labeling of Medications and Biologicals, dated 10/01/25, showed:- Medication labels must be legible at all times;- Any medication label that is soiled, incomplete, illegible, worn, or makeshift must be returned and replaced by the issuing pharmacy, not merely covered;- Labels for multi-use vials must include the date the vial was initially opened or accessed (needle-punctured), all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial, and unopened or unaccessed vials should be discarded according to the manufacturer's expiration date. Review of the facility policy titled, Controlled Substance Administration and Accountability, dated 10/01/25, showed:- Areas without automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use;- Resident specific controlled substances are stored under double lock until administered to the resident. 1. Observation of the medication storage room on 04/22/26 at 10:55 A.M., showed:- The lock box in the medication refrigerator unlocked with three 30 milliliters (ml) bottles of lorazepam (an antianxiety medication) 2 milligrams (mg)/ml with two of the three bottles opened and undated;- Four opened and undated 5 ml tuberculin (used to diagnosis tuberculosis (TB - infectious disease caused by the tubercle bacillus)) vials. Review of the temperature log for the medication refrigerator from February 2026 - April 2026 showed:- February temperatures not checked on 02/01/26, 02/06/26 - 02/08/26, 02/15/26, 02/19/26, and 02/24/26 - 02/27/26 for a total of 10 out of 28 opportunities missed;- March temperatures not checked on 03/09/26 - 03/11/26, and 03/16/26 - 03/31/26 for a total of 19 out of 31 opportunities missed;- April temperatures not checked on 04/01/26 - 04/03/26, 04/16/26, and 04/17/26 for a total of five out of 22 opportunities missed. 2. Observation on 04/22/26 at 11:11 A.M., of the nurse's narcotic medication cart showed:- One opened and undated with an unreadable label bottle of morphine (narcotic pain medication used for moderate to severe pain) 100 mg/5 ml. During an interview on 04/22/26 at 11:30 A.M., Licensed Practical Nurse (LPN) G said the refrigerator temperatures were done daily on the night shift. The narcotic medication in the lock box kept in the refrigerator should be locked at all times. He/She did not know about checking the medication carts for expired medications or other issues and should ask the Director of Nursing (DON). Medications should be labeled with the date and the staff's initials when opened. During an interview on 04/23/26 at 4:00 P.M., the DON said she would expect narcotic medications to be stored behind two locked devices. Pharmacy rounded monthly to check for expired medications. She would expect multidose medication vials to be labeled with a date and initials when opened. The refrigerator temperatures should be done at least daily.

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, when the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for five residents (Residents #4, #6, #18, #24, and #57) out of seven sampled residents. The facility census was 50. Review of the facility policy titled, Use of Psychotropic Medications, dated 10/01/25, showed: - Prior to initiating or increasing a psychotropic medication, the resident, family, and /or resident representative must be informed of the benefits, risks, and alternative for the medication; - The resident has the right to accept or decline the initiation on increase of a psychotropic medication; - The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternative or other options, and the preferred option to accept or decline in a format that facility deems to use. 1. Review of Resident #4's medical record showed: - admission date of 11/06/23; - Diagnoses of unspecified dementia (a cognitive decline such as memory loss, confusion, and communication problems exists, but the underlying cause cannot be clearly identified), major depressive disorder (persistent, severe sadness, low mood, or loss of interest in activities lasting at least two weeks), cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech), and anxiety disorder (excessive, persistent fear or worry that interferes with daily life); - An order for buspirone (an antianxiety medication) 15 milligrams (mg) by mouth three times a day for depression, dated 11/22/25; - An order for doxepin (an antidepressant medication) 10 mg by mouth one time a day for skin picking, dated of 04/09/26; - An order for duloxetine (an antidepressant medication) 30 mg by mouth one time a day for major depressive disorder, dated 12/02/24; - An order for Rexulti (an antipsychotic (medication used to treat psychosis – symptoms like hallucinations, delusions, and disorganized thinking) medications) 0.5 mg by mouth one time a day for dementia, dated 01/13/26; - No documentation consents or education on risks and benefits were provided to the resident and/or their representative for buspirone, doxepin, duloxetine, and Rexulti. 2. Review of Resident #6's medical record showed: - admission date of 09/03/24; - Diagnoses of adjustment disorder with depressed mood (a short-term mental health condition occurring when intense sadness, hopelessness, and sadness arise in response to a specific life stressor), anxiety disorder, and other amnesia (memory loss); - An order for buspirone 10 mg by mouth two times a day for anxiety, dated 12/10/24; - An order for citalopram (an antidepressant medication) 20 mg by mouth one time a day for depression, dated 04/04/26; - An order for mirtazapine (an antidepressant medication) 15 mg one tablet by mouth in the evening related to anxiety disorder, dated 11/18/24; - A psychotropic medication informed consent for citalopram, that did not list non-pharmacological approaches, beneficial effects, or possible side effects, dated 04/03/26; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the mirtazapine and buspirone medications. 3. Review of Resident #18's medical record showed: - admission date of 11/06/25; - Diagnoses of dementia, psychotic disorder with delusions, and anxiety; - An order for Seroquel (an antipsychotic medication) 50 mg by mouth at bedtime for psychotic disorder with delusions, dated 04/07/26; - An order for Zoloft (an antidepressant medication) 25 mg by mouth one time a day related to anxiety disorder, dated 01/11/26; - An order for lorazepam (an antianxiety medication) 0.5 mg by mouth two times a day related to anxiety, dated 01/28/26; - An order for Seroquel 50 mg by mouth three times a day related to psychotic disorders with delusions, dated 04/07/26; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the Seroquel, Zoloft, and lorazepam. 4. Review of Resident #24's medical record showed: - admission date of 02/13/26; - Diagnoses of Parkinson's disease (brain disorder causing unintended or uncontrolled movements) and psychophysiologic insomnia (difficulty sleeping due to excessive worry about sleep); - An order for buspirone 10 mg by mouth three times a day for anxiety and depression, dated 02/13/26; - An order for fluoxetine (an antidepressant medication) 20 mg by mouth one time a day for depression and anxiety, dated 03/08/26; - An order for olanzapine (an antipsychotic medication) 15 mg by mouth one time a day for bipolar disorder (mood disorder that can cause intense mood swings), dated 02/13/26; - An order for trazodone (an antidepressant medication) 50 mg by mouth one time a day for pain, dated 02/13/26; - No documentation of consents or education on risks and benefits were provided to the resident and/or their representative for buspirone, fluoxetine, olanzapine, and trazodone. 5. Review of Resident #57's medical record showed: - admission date of 04/13/26; - Diagnoses of chronic obstructive pulmonary disease (COPD – a lung disease) and atrial fibrillation (abnormal heart rhythm); - An order for amitriptyline (an antidepressant medication) 150 mg by mouth one time a day for depression, dated 04/14/26; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the amitriptyline. During an interview on 04/23/26 at 2:45 P.M., Licensed Practical Nurse (LPN) A and LPN J said they did psychotropic evaluations on admission but did not know if that was the same thing as consents. During an interview on 04/23/26 at 2:48 P.M., the Regional QA Nurse said psychotropic consents were going to be addressed by educating staff. Right now, some psychotropic consents were completed, some were filled out wrong, and some were not completed. During an interview on 04/23/26 at 3:30 P.M., the Administrator and the Director of Nursing (DON) said they have psychotropic medication consents, and they would expect the residents and/or their representatives to be informed, in advance of care, of the risks and benefits and possible alternative treatments for psychotropic medications. During an interview on 04/23/26 at 3:30 P.M., the DON said the Infection Preventionist was responsible for getting the psychotropic medication consents completed.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) form to the resident and/or the resident's representative in writing at least two calendar days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage services and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected one resident (Resident #29) out of three sampled residents. The facility census was 50.Review of the facility policy titled, Advance Beneficiary Notices, dated 10/01/25, showed:- The Business Office Manager is the contact person for information regarding Medicare eligibility, coverage, and applying for benefits;- The facility shall inform Medicare beneficiaries of his or her potential liability for payment;- A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay before the facility provides an item or service that is usually paid for by Medicare, but may not be paid for in a particular instance because it is not medically reasonable and necessary;- For Part A Medicare services, the facility shall use the SNF ABN form;- A NOMNC shall be issued to the resident or resident representative when Medicare covered services are ending, no matter if the resident is leaving the facility or remaining in the facility;- To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered stay;- The notices must not be provided while the resident/representative is under duress or in an emergency situation;- The Business Office Manager, or designee, is responsible for issuing notices;- The facility shall issue a notice each time, and as soon as, it makes the assessment that Medicare payment certainly or probably will not be made. 1. Review of Resident #29's medical record showed:- The resident discharged from skilled Medicare services on 04/11/26, and remained in the facility;- The resident received a SNF ABN on 04/11/26;- The resident received a NOMNC on 04/11/26;- The facility failed to provide the SNF ABN and NOMNC forms to the resident and/or the representative at least two calendar days before the skilled Medicare services ended. During an interview on 04/23/26 at 3:30 P.M., the Business Office Manager said the SNF ABN and NOMNC forms were to be given at least two days before a resident's benefits ended. During an interview on 04/23/26 at 3:30 P.M., the Administrator said he would expect SNF ABN and NOMNC forms be given two days before the end of skilled Medicare services ended. ervices.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the bed hold rates and reason for the transfer, for five residents (Residents #1, #4, #5, #12, and #26) out of 13 sampled residents. The facility's census was 50.The facility did not provide a policy for Transfer/Discharge Notices or Bed Hold Notices. 1. Review of Resident #1's medical record showed:- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- The reasons for the transfers were not included on the Transfer/Discharge Notices, dated 11/23/25, 12/23/25, and 02/13/26;- The bed hold daily rate was not included on the Bed Hold Notes, dated 11/23/25, 12/23/25, and 02/13/26. 2. Review of Resident #4's medical record showed:- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- The reasons for the transfers were not included on the Transfer/Discharge Notices, dated 02/03/26, 03/12/26, and 04/10/26;- The bed hold daily rate was not included on the Bed Hold Notes, dated 02/03/26, 03/12/26, and 04/10/26. 3. Review of Resident #5's medical record showed:- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- The reasons for the transfers did not include sufficient reasons for the transfers that could be understood by the resident and/or the resident representative on the Transfer/Discharge Notices, dated 11/26/25 and 04/04/26;- The bed hold daily rate was not included on the Bed Hold Notices, dated 11/26/25 and 04/04/26. 4. Review of Resident #12's medical record showed:- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge, including the reasons for transfer, to a hospital on [DATE] and 04/12/26;- The bed hold daily rate was not included on the Bed Hold Notice, dated 03/21/26. 5. Review of Resident #26's medical record showed:- Transferred to the hospital on [DATE], and readmitted to the facility on [DATE];- The reason for transfer was not included on the Transfer/Discharge Notice, dated 03/18/26;- The bed hold daily rate was not included on the Bed Hold Notice, dated 03/18/26. During an interview on 04/22/26 at 1:55 P.M., Licensed Practical Nurse (LPN) G said he/she printed and filled out the Transfer/Discharge Notice when a resident was sent to the hospital, but he/she did not give a copy of the Bed Hold Notice. During an interview on 04/22/26 at 2:00 P.M., LPN A said that he/she filled out the Transfer/Discharge Notice when a resident was sent to the hospital, but that he/she had never heard of a Bed Hold Notice. During an interview on 04/23/26 at 12:22 P.M., the Regional Quality Assurance Nurse said residents' representatives were notified by phone of the resident's transfer to the hospital. She said the Bed Hold Notice was mailed to the resident's responsible party. During an interview on 04/23/26 at 1:45 P.M., the Social Services Designee (SSD) said nurses filled out the Transfer/Discharge Notice, and that she filled out the Bed Hold Notice and either gave both forms to the resident or mailed them to the resident's responsible party. She said residents were informed at the time of admission of the Bed Hold rate. During an interview on 04/23/26 at 4:05 P.M., the Administrator and the Director of Nursing (DON) said they would expect the resident and their representative to be informed in writing, and in a language they understood, of a resident's transfer to the hospital. They would also expect the resident or their representative to be informed of the Bed Hold Notice, including the daily rate, when a resident was transferred to the hospital.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 34 opportunities with six errors made, for an error rate of 17.6% which affected three residents (Residents #12, #29, and #32) out of four sampled residents. The facility census was 50.The facility did not provide a policy for insulin administration. Review of the Humalog/insulin lispro (a rapid-acting insulin) and NovoLog/ insulin aspart (a rapid-acting insulin) Pen's Manufacturer Guidelines for Priming Before Each Injection and Administration, revised 02/2023, showed:- Turn the dose selector to select two units;- Hold the pen with the needle pointing up;- Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge;- Keep the needle pointing upwards, press the push-button all the way in;- The dose selector returns to zero;- A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. 1. Review of Resident #12's medical record showed:- Diagnosis of diabetes mellitus (DM - a metabolic disease ) with diabetic peripheral angiopathy (narrowing or blockage of blood vessels outside of heart);- An order for Humalog insulin pen inject as per sliding scale for blood sugar of 60 - 149 = 0 units, 2-10 units per sliding scale subcutaneously (beneath the skin) four times a day. Less than 60 = Glucagon (medication to raise blood sugar) 1 milligram (mg) intramuscular (IM - administered into the muscle) and call the physician, for 150 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 350 = 8 units, and 351 - 400 = 10 units subcutaneously four times a day related to DM with diabetic peripheral angiopathy, dated 03/26/26;- An order to prime the insulin pen with 2 units before use with meals related to DM with diabetic peripheral angiopathy, with no order date. Review of the resident's April 2026 medication administration record (MAR) showed:- Did not receive a blood sugar check and did not receive insulin as ordered prior to the lunch meal on 04/21/26. 2. Review of Resident #29's medical record showed:- Diagnosis of DM;- An order for Novolog insulin pen inject as per sliding scale for blood sugar of 1 - 150 = 0 units, 151 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 350 = 8 units, 351 - 400 = 10 units, 401 - 450 = 12 units subcutaneously four times a day for DM, dated 01/08/26; Review of the resident's April 2026 MAR showed:- Did not receive a blood sugar check and did not receive insulin as ordered prior to the lunch meal on 04/21/26. Observation on 04/22/26 at 11:45 A.M., of the resident's insulin administration showed:- Licensed Practical Nurse (LPN) A did not prime the resident's Novolog insulin pen;- LPN A administered 12 units of Novolog to the resident for a blood sugar of 515. During an interview on 04/22/26 at 11:46 A.M. LPN A said an insulin pen did not require anything to be done to it before dialing up the insulin dose for administration. He/She did not have time to do blood sugar checks and administer the insulin doses on 04/21/26 for the lunch meal for Residents #12 and #29 as ordered. He/She notified other staff of not having time to do the residents' blood sugars and insulin administration, but no one completed the tasks. He/She talked to the Director of Nursing (DON) and she said the residents were already eating or so the blood sugars and insulin should be held at that time. LPN A notified the physician later and was told to their check blood sugars at the next scheduled time and if there were any issues to call back. 3. Review of Resident # 32's medical record showed:- Diagnosis of DM with diabetic polyneuropathy (nerve or sensation issues);- An order for insulin lispro pen inject as per sliding scale for blood sugar of 0 - 150 = 0 units, 151 - 200 = 1 unit, 201 - 250 = 2 units, 251 - 300 = 3 units, 301 - 350 = 4 units, 351 - 400 = 5 units, 401 - 500 = 6 units. If over 400, give 6 units, then call the physician, subcutaneously four times a day related to DM with diabetic polyneuropathy, with no order date;- An order to prime the insulin pen with 2 units before use before meals and at bedtime related to DM with diabetic polyneuropathy, with no order date. Observation on 04/21/26 at 11:46 A.M., of Resident #32's insulin administration showed:- LPN B did not prime the insulin pen;- LPN B administered 4 units of insulin lispro to the resident for a blood sugar of 336. During an interview on 04/21/26 at 11:48 A.M., LPN B said he/she did not need to do anything before dialing up the dose on the insulin pen before administration. During an interview on 04/23/26 at 4:00 P.M., the DON and the Administrator said they would expect the medication error rate to be less than five percent. They would expect medications to be given as ordered and for insulin pens to be primed with two units before administration.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by facility staff) assessment within 14 days of a resident admitted to hospice. This affected one resident (Resident #22) out of two sampled residents. The facility census was 50.Review of the MDS 3.0 Resident Assessment Instrument (RAI) Users Manual, Chapter 5: Submission and Correction of the MDS Assessment, dated October 2025, showed:- Completion timing for Significant Change in Status Assessment, the Care Area Assessment (CAA) completion date must be no later than 14 days from the Assessment Reference Date (ARD) and no later than 14 days from the determination date of the significant change in status. The facility did not provide a policy regarding MDS Submission Timeframes. 1. Review of Resident #22's medical record showed:- An admission date of 09/09/24;- admitted to hospice on 10/21/25;- No significant change MDS dated on or after 10/21/25;- The facility failed to complete a significant change MDS within 14 days of admission to hospice. During an interview on 04/23/26 at 12:46 P.M., the MDS Coordinator said she started this position in November and then went on medical leave almost immediately after starting. Therefore, she has not completed her MDS training. She said a significant change MDS should be completed seven days after a resident's admission to hospice. During an interview on 04/23/26 at 1:30 P.M., the Director of Nursing (DON) said the facility did not have an on-site MDS Coordinator for several months and a nurse had helped fill in while the MDS Coordinator was on medical leave. She would expect a significant change MDS to be completed in the appropriate timeframe. During an interview on 04/23/26 at 3:50 P.M., the Administrator said he would expect a significant change MDS to be completed in the appropriate timeframe.

Based on observation, interview, and record review, the facility failed to obtain an order for a urinary catheter (a sterile tube inserted into the bladder to drain urine) and failed to provide a diagnosis for the use of a urinary catheter for two residents (Residents #33 and #44) out of two sampled residents. The facility census was 50. Review of the facility's policy titled, Indwelling Catheter Use and Removal, implemented on 10/01/25, showed: - It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice; - A resident will not be catheterized unless the resident's clinical condition demonstrates that catheterization is necessary; - If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include documentation of the involvement of the resident representative in the discussion of the risks and benefits of the use of the catheter, removal of the catheter when criteria or indication for use is no longer present, timely and appropriate assessments related to the indication for use of an indwelling catheter, identification and documentation of clinical indications for the use of the catheter, insertion, ongoing care and catheter removal protocols, response of the resident during the use of the catheter, and ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections; - Appropriate indications for indwelling catheter use include acute urinary retention or bladder obstruction, need for accurate measurements of urinary output, assistance in healing of open sacral (triangular bone above the coccyx) or perineal wounds in incontinent residents, residents that require prolong immobilization, and to improve comfort for end-of-life care if needed. 1. Review of Resident #33's medical record showed: - admitted on [DATE]; - admitted to the hospital on [DATE], and returned to the facility on [DATE], with a urinary catheter; - No diagnosis for a urinary catheter; - No physician order for the urinary catheter; - The facility failed to obtain a diagnosis and a physician order for the urinary catheter. Review of the resident's care plan, undated, showed: - Did not address the urinary catheter with individualized goals and interventions. Observation of the resident on 04/20/26 at 10:38 A.M., showed: - The resident lay in the bed with a urinary catheter. During an interview on 04/20/26 12:15 P.M., the resident's representative said he/she was unsure why the resident had a urinary catheter. 2. Review of Resident #44's medical record showed: - An admission date of 03/27/26; - No physician order for a urinary catheter; - An order to monitor urine output collected in the urinary catheter every shift, dated 03/30/26; - No diagnosis for the urinary catheter; - The facility failed to obtain a diagnosis and an order for the urinary catheter. Review of the resident's care plan, dated 04/23/26, showed: - Did not address the urinary catheter with individualized goals and interventions. Observation of the resident on 04/20/26 at 3:06 P.M., showed: - The resident lay in bed with a urinary catheter. During an interview on 04/21/26 at 9:12 A.M., the resident said he/she was unsure of the reason for the urinary catheter. During an interview on 04/23/26 at 10:05 A.M., Licensed Practical Nurse (LPN) A said residents with urinary catheters should have an order and a diagnosis for the urinary catheter. During an interview on 04/23/26 at 10:37 A.M., the Director of Nursing (DON) said residents with urinary catheters should have an order and a diagnosis for the urinary catheter.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medications for one resident (Resident #6), failed to provide an appropriate diagnosis for the use of an antipsychotic (medications used to treat psychosis, a mental health condition characterized by delusions, hallucinations, and disorganized thinking) medication for one resident (Resident #27), and failed to get a physician's response to the GDR recommendation for one resident (Resident #4) out of five sampled residents. The facility census was 50. Review of the facility policy titled, Gradual Dose Reduction of Psychotropic Drugs, dated 10/01/25, showed: - Residents who use psychotropic drugs receive gradual dose reductions and behavioral intervention, unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs; - Within the first year in which a resident is admitted on a psychotropic medication, or after the prescribing practitioner has initiated a psychotropic medication, the facility will attempt a GDR according to pharmacy consultant recommendations, unless clinically contraindicated; - After the first year, a GDR will be attempted annually unless clinically contraindicated; - Opportunities during the care process to consider whether the medications should be continued, reduced, discontinued, or otherwise modified include during the monthly medication regimen review by the pharmacist, when the physician or prescribing practitioner evaluates the resident's progress, and during the quarterly Minimum Data Set (MDS – a federally mandated assessment instrument completed by facility staff) review by the interdisciplinary team. 1. Review of Resident #4's medical record showed: - admission date of 11/06/23; - Diagnoses of unspecified dementia (a cognitive decline such as memory loss, confusion, and communication problems exists, but the underlying cause cannot be clearly identified), major depressive disorder (persistent, severe sadness, low mood, or loss of interest in activities lasting at least two weeks), cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech), and anxiety disorder (excessive, persistent fear or worry that interferes with daily life); - An order for buspirone (an antianxiety medication) 15 milligrams (mg) by mouth three times a day for depression, dated 11/22/25; - An order for duloxetine (an antidepressant medication) 30 mg by mouth one time a day for major depressive disorder, dated 12/02/24; - An order for Rexulti (an antipsychotic (medication used to treat psychosis – symptoms like hallucinations, delusions, and disorganized thinking) medications) 0.5 mg by mouth one time a day for dementia, dated 01/13/26. Review of the resident's monthly medication review showed: - On 02/05/26, the pharmacist recommended the reduction of Rexulti, buspirone, and duloxetine to ensure the resident was using the lowest possible effective/optimal dose; - On 02/11/26, the physician's response showed the request should be sent to psychiatry; - No response from the psychiatrist for the requested GDRs. During an interview on 04/23/26 at 3:30 P.M., the Director of Nursing (DON) said she would expect nurses to make sure the physicians responded to GDR requests. 2. Review of Resident #6's medical record showed: - admission date of 09/03/24; - Diagnoses of adjustment disorder with depressed mood (a short-term mental health condition occurring when intense sadness, hopelessness, and sadness arise in response to a specific life stressor), anxiety disorder, and other amnesia (memory loss); - An order for buspirone 10 mg by mouth two times a day for anxiety, dated 12/10/24; - An order for mirtazapine (an antidepressant medication) 15 mg one tablet by mouth in the evening related to anxiety disorder, dated 11/18/24. Review of the resident's monthly medication reviews showed: - On 05/04/25, the pharmacist recommended the reduction of buspirone or mirtazapine to ensure the resident was using the lowest possible effective/optimal dose; - On 08/01/25, the pharmacist recommended the reduction of buspirone or mirtazapine to ensure the resident was using the lowest possible effective/optimal dose; - No response from the physician noted for the GDR requests for 05/04/25 and 08/01/25; - No GDRs or contraindications documented for buspirone or mirtazapine. During a phone interview on 04/27/26 at 12:30 P.M., the Pharmacy Consultant said the residents' medical records were reviewed monthly and the recommendations were sent to the facility for follow up. 3. Review of Resident #27's medical record showed: - admission date of 01/14/26; - Diagnoses of altered mental status, cerebral infarction (stroke), depression, and ataxia (poor muscle control that causes clumsy movements); - An order for aripiprazole (an antipsychotic medication) 5 mg by mouth one time a day related to altered mental status, dated 01/15/26; - An order for buspirone 5 mg by mouth one time a day related to altered mental status, dated 02/07/26; - An order for mirtazapine 15 mg by mouth at bedtime related to altered mental status, dated 01/14/26; - No monthly medication reviews by pharmacy that addressed an appropriate diagnosis for aripiprazole, buspirone, and mirtazapine. During an interview on 04/28/26 at 1:50 P.M., the Consultant Pharmacist said Resident #27 did not have appropriate diagnosis for aripiprazole, mirtazapine, and buspirone. The diagnosis altered mental status was too vague of a diagnosis even though the resident had a stroke and altered mental status as diagnoses in his/her medical record. e/She would do a recommendation for better diagnoses for the provider to address.

Based on interview and record review, the facility failed to provide documentation of a physician's order and on-going assessments and monitoring after dialysis (a process for removing waste and excess water from the blood) for one resident (Resident #8) out of one sampled resident. The facility's census was 50.Review of the facility's policy titled, Dialysis, approved 01/30/24, showed:- This facility will ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences;- The facility will ensure appropriate monitoring of the dialysis resident's status before, during, and after the treatments;- If this facility does not employ a qualified professional person to furnish dialysis treatments, the facility will enter into an agreement with a person or agency outside of the facility. This agreement constructs a connection between both entities and fosters accountability that is vital to the health of each resident and the success of their plan of care. Each end-stage renal disease (ESRD - a medical condition where the kidneys can no longer function to filter wastes or excess fluids from the blood) facility is responsible for ensuring the dialysis resident's needs and goals are addressed. The care plan will specify shared responsibilities divided between the nursing home and the ESRD facility, e.g., adhering to certain renal dietary restrictions based on the resident's fluid status.1. Review of Resident #8's physician's order sheet (POS), dated April 2026, showed:- admitted on [DATE];- Diagnosis of ESRD;- No order for dialysis;- No order to assess the dialysis site and/or dressing before and after dialysis;- No order for vital signs before and after dialysis. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/04/26, showed:- The resident received dialysis. Review of the resident's care plan, undated, showed:- At risk of complications due to receiving dialysis with interventions of assess the thrill (a palpable vibration felt on the skin over a dialysis access site) and bruit (the swooshing sound heard with a stethoscope over a dialysis access site) as ordered, assess vital signs and weight before and after dialysis and record, and monitor dialysis port access and ensure dressing is clean, dry and intact;- Dependent on dialysis due to ESRD, dialysis days Tuesday, Thursdays, and Fridays, with interventions to assess vital signs and weight before and after dialysis appointments, monitor the dialysis port (dialysis access site) in the chest to ensure the dressing is clean dry and intact, monitor the dialysis fistula (a surgically created connection between an artery and a vein for dialysis use) in the left arm for the thrill and bruit. Review of the resident's Dialysis Communication Reports, dated 03/03/26 - 04/21/26, showed:- Six out of 23 opportunities missed for the assessment of the dialysis site/dressing before dialysis;- 20 out of 23 opportunities missed for the vital signs, weights, and assessment of the dialysis site/dressing after dialysis.During an interview on 04/20/25 at 10:46 A.M., the resident said he/she went to dialysis on Tuesdays, Thursdays, and Saturdays, had a port on the right side of his/her chest, and an access in the left arm. Staff did look at the port and the access sometimes, and took his/her vital signs sometimes, just not always on dialysis days. During an interview on 04/23/26 at 10:05 A.M., Licensed Practical Nurse (LPN) A said residents that went to dialysis should have an order for dialysis and to assess the dialysis access site or sites. Vital signs and weights before and after dialysis were documented on the dialysis communication form.During an interview on 04/23/26 at 10:35 A.M., the Director of Nursing (DON) said residents who went to dialysis should have an order for dialysis and an order to monitor the dialysis access site. The nurses were to document the dialysis resident's vital signs, weights, and access assessments on the dialysis communication forms before and after each dialysis treatment.

Based on record review and interview the facility failed to provide prescription medications as ordered and notify the physician of the medications not available for administration, in accordance with standards of practice, for one resident (Resident #1) of three sampled residents. The facility census was 50.Review of the facilities undated policy regarding unavailable medications directs staff to:-Maintain a contract with a pharmacy provider to supply the facility with routine, as needed (prn) and emergency medications;- Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication;- Notify physician of inability to obtain medication, upon notification or awareness that the medication is not available. Obtain alternative treatment order and or/ or specific orders for monitoring resident while medication is on hold;- If a resident misses a scheduled dose of medication, staff shall follow procedures for medication errors, including physician/family notifications, completion of medication error reports, and monitoring the resident for adverse reactions to omission of the medication. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, not completed a the time of review. Review of the Physician Order Sheet (POS) dated February 2026, showed:- Diagnoses of atrial fibrillation (a common, often chronic arrhythmia characterized by a rapid, chaotic, and quivering heartbeat in the heart's upper chambers), atherosclerotic heart disease (caused by plaque buildup in arterial walls), Hypertension (high blood pressure), venous thrombosis and embolism (a serious, often fatal condition comprising deep vein blood clots, usually legs and that travel to the lungs), Pulmonary embolism, (a sudden blockage in a lung artery), pulmonary hypertension (a serious, progressive condition characterized by high blood pressure in the lung arteries, forcing the right side of the heart to work harder, which can lead to heart failure), Osteoarthritis (a chronic degenerative disease where protective joint cartilage wears down over time, causing pain, stiffness, and reduced motion in hands, knees, hips, and spine) , anemia (a common, treatable blood disorder characterized by a lack of healthy red blood cells or hemoglobin, leading to reduced oxygen transport to body tissues) orthostatic hypotension (a rapid drop in blood pressure upon standing), Myocardia; infarction (heart attack)benign prostatic hyperplasia (a common, noncancerous enlargement of the prostate gland in men over 50), gastro-esophageal reflux disease (GERD) (a chronic condition where stomach acid frequently flows back into the esophagus, causing symptoms like heartburn, chest pain, and regurgitation), Sciatica ( pain, weakness, or numbness along the sciatic nerve, running from the lower back down the leg, usually on one side), neuropathy ( damage to nerves outside the brain/spinal cord, causing tingling, numbness, stabbing pain, and muscle weakness, often starting in hands or feet), congestive heart failure (a chronic condition where the heart cannot pump blood efficiently, causing blood to back up and fluid to accumulate in the lungs, legs, and body), posterial orthostatic tachycardia syndrome (a chronic autonomic nervous system disorder causing a rapid heart rate increase within 10 minutes of standing). Chronic respiratory failure (a long-term, progressive condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide), cellulitis of left lower leg a common, serious bacterial infection of the skin and underlying tissues, typically causing rapid-onset redness, intense pain, swelling, and warmth), unstable angina (a high-risk medical emergency characterized by sudden, unpredictable chest pain that often occurs at rest or worsens in intensity, frequency, or duration, signaling severely reduced blood flow to the heart);- An order dated 02/18/2026 for Eliquis Oral Tablet 5 milligram (MG) (used for heart disease). Give 1 tablet by mouth (p.o.) two times a day:- An order dated 02/18/2026, Midodrine HCl Oral Tablet 5 MG (used to treat orthostatic hypotension) Give three tablets by mouth before meals;- An order dated 02/18/2026 for Protein Oral Powder 80 % (Protein) Give 2 scoop bymouth two times a day for SUPPLEMENT;- An order dated 02/18/2026 for Methocarbamol 500 MG (Methocarbamol)Give 2 tablet p.o. three times a day for muscle spasm;- An order dated 02/18/2026 for Finasteride Oral Tablet 5 MG (Finasteride) Give 1tablet by mouth at bedtime for benign prostatic hyperplasia with lower urinary tract infection;- An order dated 02/18/2026 for Lasix Oral Tablet 40 MG give 1 tabletp.o. two times a day for congestive heart failure;- An order dated 02/18/2026 for Hydrocodone-Acetaminophen 5-325MG give 1 tablet P.O. every 6 hours as needed for pain;- An order dated 02/18/2026 for Protonix Oral Tablet Delayed Release 40 MG(Pantoprazole Sodium) Give 1 tablet p.o. two times a day for GERD;- An order dated 02/18/2026 for Gabapentin Oral Tablet 100 MG (Gabapentin) Give 2tablet by mouth two times a day for neuropathy. Review of the Medication Administration Record (MAR) dated February 2026, showed:- Eliquis Oral Tablet 5 MG was not administered one of 10 opportunities;- Gabapentin Oral Tablet 100 MG was not administer one of 10 opportunities;- Hydrocodone-Acetaminophen Tablet 5-325 MG was not administered one of 4 opportunities;- Lasix Oral Tablet 40 MG was not administered one of 10 opportunities;- Protein Oral Powder 80 %, was not administered four of 10 opportunities;- Protonix Oral Tablet Delayed Release4 0 MG was not administered one of 10 opportunities;- Methocarbamol 500 MG, Midodrine HCl 5 MG was not administered eight of 15 opportunities;- Midodrine HCl Oral Tablet 5 MG was not administered three of 15 opportunities; Review of Resident #1 progress noted, showed:- On 02/18/2026, Resident #1 arrived to the facility at 3:54 P.M.;- On 02/18/2026 3:30 P.M., Midodrine 5 MG on order;- On 02/18/2026 at 3:25 P.M. Eliquis 5 MG on order;- On 02/18/2026 at 3:26 P.M., Methocarbamol 500 MG, Finasteride 5 MG, for Protein Oral Powder 80 %, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG, Lasix Oral Tablet 40 MG, Gabapentin 100 MG, Protonix 40 MG, on order;- On 02/19/2026 at 8:34 P.M., Protein Oral Powder 80 %, on order;- On 02/19/2026 at 8:44 P.M., Methocarbamol 500 mg on order;- On 02/20/2026 at 8:47 A.M., Methocarbamol 500 mg on order;- On 02/20/2026 at 12:17 P.M., Methocarbamol 500 mg on order;- On 02/20/2026 at 7:59 P.M., Methocarbamol 500 mg on order; - On 02/20/2026 at 8:01 P.M., Protein Oral Powder 80 %, on order;- On 02/21/2026 at 10:35 A.M., Methocarbamol 500 mg on order. During an interview on 03/02/2026 at 1:00 P.M., the Director of Nursing (DON) said she would have expected the nursing staff to notify the pharmacy of medications not available and attempt to retrieve the medications from the local pharmacy. The nurse should have notified the physician immediately for further direction regarding the medications not available. During an interview on 03/02/2026 at 1:15 P.M. the Administrator said he would expect the nursing staff to know what the facility policy is regarding medications not being available and follow the guidelines and/or notify the DON or himself. During an interview on 03/02/2026 at 2:20 P.M., the Family Nurse Practioner (FNP) said she would have expected the nursing staff to notify her if any resident's medications were not available for further directions. MO2784796

Based on observation, interview and record review, the facility failed to follow physician's orders for one resident (Resident #1) out of five sampled residents by not administering the resident his/her medications in a timely manner. The facility census was 55. The administration was notified on 09/09/25 of the Past Non-Compliance which occurred on 08/17/25. On 08/31/25, upon notification, the facility administration started an investigation and completed a medication error report. In-serviced staff on Medication Administration Compliance. The non-compliance was corrected on 09/02/25, as the facility in-serviced the nursing staff responsible for medication administration on the facility's policy and procedures for Medication Administration Compliance. The facility policy titled, Physician/Practitioner Orders, undated, showed:- For all physician/practitioner orders received via telephone, the nurse will:a. Document the order notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order;b. Follow facility procedures for verbal or telephone orders including, noting the order, submitting to pharmacy and transcribing to medication or treatment administration record.The facility policy titled, Medication Administration, undated, showed:- Review Medication Administration Record (MAR) to identify medications to be administered;- If any discrepancies noted, report to nurse manager. 1. Review of Resident #1's medical record showed:- Date of admission [DATE];- Diagnoses of dementia (a progressive mental deterioration) disease, schizoaffective (a condition characterized by abnormal thought processes and deregulated emotions) disorder, anxiety (worry and fear about everyday situations), depression, and persistent mood disorder (a chronic form of depression characterized by persistent low mood and other symptoms that last for at least two years).Review of the resident's September 2025 Physician Order Sheet (POS) showed:- An order for Invega Sustenna (an antipsychotic (a medication that alters thoughts and perceptions) medication) intramuscular (IM - an injection into the muscle) suspension 78 milligram (mg)/0.5 milliliter (ml) starting and ending on the 17th of every month for bipolar (a mental health condition that causes extreme mood swings), dated 08/01/25, and discontinued on 08/31/25;- An order for Invega Sustenna 78mg/0.5ml IM one time a day starting on the 1st of every month for bipolar, dated 08/31/25.Review of the resident's August 2025 Treatment Administration Record (TAR) showed:- Documentation to see the resident's progress note dated 08/17/25. Review of the resident's Progress Notes, dated 08/17/25, showed:- No documentation of the administration of the Invega injection or the reporting to the charge nurse of the medication not being administered as ordered. During an interview on 09/09/25 at 11:00 A.M., Licensed Practical Nurse (LPN) A said the Invega order had been changed due to a recent gradual dose reduction on 08/01/25. When the new order was put into the medical record, the Invega injection was populated on the Certified Medication Technician (CMT) MAR. When the injection populated on the CMT MAR, the CMT documented not given on the resident's MAR and did not report the medication wasn't given to the charge nurse. A CMT would not administer an Invega injection. The CMT should have notified the charge nurse the medication wasn't given so the charge nurse could administer it and document on it. During an interview on 09/09/25 at 11:03 A.M., LPN B said he/she was the charge nurse on 08/17/25, and the CMT never reported the medication was not given. During an interview on 09/09/25 at 11:47 A.M., the Director of Nursing (DON) said there was only one resident on Invega. On 08/01/25, the order was put into the medical record, and was due on 08/17/25. When a new order was put in the medical record, there were choices as to where it populated on a CMT MAR, CMT TAR, or the Licensed MAR. The medication populated on the CMT MAR. When the medication came due, the CMT did not pass onto the nurse that the medication was not given. She was not aware the Invega wasn't given until 08/31/25, when the resident's family called the facility regarding the injection. The facility worked with the corporate pharmacy to get the medication promptly. The psychiatric provider was notified immediately and gave an order to administer the medication on 09/01/25. During an interview on 09/09/25 at 12: 30 P.M., the Administrator said she expects staff to follow physician orders. Complaint #2609996

Based on observation, interview, and record review, the facility failed to provide scheduled showers for three residents (Residents #5, #24 and #32) out of four sampled residents for activities of daily living (ADLs). The facility census was 47. Review of the facility's policy titled, Necessary Care and Services, dated 01/20/24, showed: - The facility will ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. 1. Review of Resident #5's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 10/08/24, showed: - Dependent for personal hygiene and showers. Review of the resident's care plan, revised 10/13/24, showed: - Did not address showers/bathing frequency; - Did not address assistance required for showers/bathing. Review of the shower schedule, dated 12/01/24 - 01/07/25, showed the resident's showers were scheduled for Monday and Thursday night shifts. Review of the resident's shower sheets, dated 12/01/24 - 01/07/25, showed: - No documentation of completion for scheduled showers on 12/02/24, 12/05/24, 12/12/24, 12/19/24, 12/23/24, 12/26/24, 12/30/24, 01/02/25, and 01/06/25; - A bed bath documented with hair not washed and face not shaved on 12/09/24; - Nine opportunities missed out of 11 opportunities for scheduled showers; - 10 opportunities missed out of 11 opportunities for scheduled facial shaving and hair washing; - The facility failed to provide showers two times per week as scheduled. Observation of the resident on 01/07/25 at 10:20 A.M., and on 01/08/25 at 9:04 A.M., showed: - On 01/07/25 at 10:20 A.M., the resident with unkempt, unshaven facial hair approximately 1/4 inch long, with dry flakes of skin in/on his/her hair, face, and facial hair; - The resident with dry skin flakes on his/her shirt. During an interview on 01/07/25 at 10:20 A.M., Resident #5 said he/she did not like the facial hair and would like to be shaved. During an interview on 01/08/25 at 9:04 A.M., Resident #5 said he/she would like a shower and shave today and if it would happen. During an interview on 01/08/25 at 9:00 A.M., the Administrator said Resident #5 should be showered and shaved as scheduled and as needed/wanted. 2. Review of Resident #24's quarterly MDS, dated [DATE], showed: - Dependent for personal hygiene and showers. Review of the resident's care plan, revised 11/08/24, showed: - Did not address showers/bathing frequency; - Did not address assistance required for showers/bathing. Review of the resident's shower schedule, dated 12/01/24 - 01/07/25, showed the resident's showers were scheduled for Tuesday and Friday. Review of the resident's shower sheets, dated 12/01/24 - 01/06/25, showed: - No documentation of completion for scheduled showers on 12/03/24, 12/17/24, 12/27/24, 12/31/24, 01/03/25 and 01/06/24; - Six opportunities missed out of 11 opportunities for scheduled showers; - The facility failed to provide showers two times per week as scheduled. 3. Review of Resident #32's significant change MDS, dated [DATE], showed: - Substantial/maximal assist for personal hygiene; - Dependent for showers. Review of the resident's care plan, revised 08/21/24, showed: - Did not address showers/bathing frequency; - Did not address assistance required for showers/bathing. Review of the resident's shower schedule, dated 12/01/24 - 01/06/25, showed the resident's showers were scheduled for Mondays and Thursdays. Review of the resident's shower sheets, dated 12/01/24 - 01/06/25, showed: - No documentation for completion of scheduled showers on 12/02/24, 12/12/24, 12/16/24, 12/26/24, 12/30/24 and 01/06/24; - Six opportunities missed out of 11 opportunities for scheduled showers; - The facility failed to provide showers two times per week as scheduled. During an interview on 01/08/24 at 1:41 P.M., Resident #32 said showers were not being given two times a week as scheduled. It was more like once a week. During an interview on 01/08/25 at 3:25 P.M., the Administrator said she was aware the facility was having issues with showers being completed and they were trying to come up with a remedy for that. She would hope the residents were at least getting one shower a week if not the two that were scheduled. During an interview on 01/09/25 at 09:18 A.M., Certified Nursing Assistant (CNA) B said the showers were probably not always being completed two times a week. During an interview on 01/09/25 at 11:34 A.M., the Director of Nursing said showers were an issue and they were working to try and find a solution to fix it. 45693 47445

Based on interview and record review, the facility failed to ensure staff utilized safe transfer techniques for one resident (Resident #29) when staff failed to transfer the resident with assist of a gait belt (a device used to aid in the safe movement of a person from one place to another) of one sampled resident. The facility census was 47. Review of the facility's policy titled, Policy on the Use of Gait Belts in Long-Term Care Facilities, dated 01/30/24, showed: - Purpose is to ensure the safe and effective use of gait belts in assisting residents with mobility and transfers, thereby reducing the risk of injury to both residents and staff in long-term care facilities; - Gait belts must be used when assisting residents who require help with walking, standing, or transferring; - Gait belts should be used for residents with unsteady gait, those at risk of falls, or those who need support during mobility activities; - Residents who refuse the use of a gait belt must be accommodated with alternative methods of assistance. 1. Review of Resident #29's medical record showed: - An admitted [DATE]; - Diagnoses of spinal stenosis (a narrowing of the spinal canal that occurs when the spaces in the spine narrow, putting pressure on the spinal cord and nerve roots), moderate protein-calorie malnutrition, anxiety (persistent worry and fear about everyday situations), muscle weakness, contracture (damage to muscle tissue or joint that prevents normal mobility) of the left hand, and a history of wedge compression fracture (a type of spinal compression fracture that occurs when the front of a vertebra collapses, giving the bone a wedge shape) of the fourth lumbar (refers to the lower back, or the five vertebrae (L1-L5) in that region of the spine) vertebra. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 10/09/24, showed: - Moderately cognitively impaired; - Total dependence of staff for bed mobility, dressing, personal hygiene, and bathing; - Total dependence of staff for transfers and toilet use; - Always incontinent of bowel and bladder. Review of the resident's Care Plan, dated 10/13/24, showed: - Resident experienced severe pain in the neck, left arm and right hip; - Resident required activities of daily living (ADL) assistance regarding bowel irregularity; - Resident at risk of pressure ulcer/injury due to need of assistance with bed mobility; - The resident's transfer and mobility needs were not addressed. Observation on 01/08/25 at 3:00 P.M., of the resident's transfer from the wheelchair to the bed showed: - Certified Nursing Assistant (CNA) B attempted to a place gait on the resident but the resident expressed significant pain; - CNA B said he/she was going to do what he/she normally did; - CNA B put one of his/her legs between the resident's legs, one of his/her arm's under the resident's right arm, and one of his/her arm's around the resident's left upper arm/shoulder; - CNA B lifted the resident from the wheelchair and transferred him/her to the bed; - The resident's right foot made partial contact with the floor, the left foot didn't make contact with the floor for half of the transfer, and the resident did not bear any weight during the transfer. During an interview on 01/08/25 at 3:10 P.M., CNA B said the resident's left arm was contracted and caused so much pain. The way CNA B transferred the resident was the only way to do it without causing extreme pain. During an interview on 01/08/25 at 3:30 P.M., Certified Occupational Therapy Assistant (COTA) E said if a gait belt couldn't be used on a resident, then they should be transferred by a Hoyer (a mechanical device used to move or transfer a person) lift. A gait belt should be used in all physical transfers. Residents should not be lifted under the arms as it could cause damage to the shoulder. During an interview on 01/09/25 at 2:30 P.M., the Director of Nursing (DON) said staff should always use a gait belt during transfers. If a gait belt couldn't be used, then they should use a hoyer lift. During an interview on 01/09/25 at 2:45 P.M., the Administrator said staff should use a gait belt during all transfers. If a gait belt couldn't be used due to pain or unable to bear weight, then a Hoyer lift should be used instead.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #12) out of five sampled residents who were incontinent of bowel and bladder, received appropriate treatment and services after an incontinent episode. Resident #12 was left without personal care for over six hours, resulting in the resident's brief soaked with dark urine and a strong urine odor. The census was 47. Review of the facility's policy titled, Necessary Care and Services, dated, 01/20/24, showed: - The facility will ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. 1. Review of Resident #12's quarterly Minimum Data Sets (MDS - a federally mandated assessment instrument completed by the facility staff), dated 07/26/24 and 10/25/24, showed: - Severe cognitive impairment; - Impairment on both sides of the upper and lower extremities; - Dependent, full assist for sit to stand and transfers; - Totally dependent for personal hygiene; - Totally incontinent of bowel and bladder. Review of the resident's care plan, revised 10/27/24, showed: - Resident required extensive assist with ADLs; - Incontinent care was not addressed. Review of the resident's medical record showed: - Diagnoses of intellectual disability (a chronic condition that affects a person's ability to learn and function in daily life), mood disorder (a mental health problem that primarily affects a person's emotional state), restlessness and agitation, anxiety (persistent worry and fear about everyday situations), conduct disorder (a mental health condition that involves a pattern of aggressive and antisocial behaviors), and aphasia (loss of ability to understand or express speech caused by brain damage); Review of the facility assignment sheet for 01/08/25 day shift showed: - Certified Nursing Assistant (CNA) B was the only assigned staff for the hall where Resident #12 resided. Observations of the resident on 01/08/25 showed: - At 8:00 A.M., the resident sat in the merry walker in the dining room and assisted to eat by staff; - At 10:30 A.M., the resident sat in the merry walker in the tv room and ran it into another resident in a wheelchair; - On 01/08/25 at 10:45 A.M., the resident sat in the merry walker in the tv room and ran it into an empty couch numerous times; - On 01/08/25 at 11:55 A.M., the resident sat in the merry walker in the dining room and ran into the piano numerous times; - On 01/08/25 at 1:30 P.M., the resident sat in the merry walker in the tv room; - On 01/08/25 at 2:48 P.M., CNA B pushed the resident in the merry walker to his/her room. CNA B transferred the resident from the merry walker to the bed. CNA B performed incontinent care. The resident's brief was soaked with dark urine and a strong urine odor. During an interview on 01/08/25 at 3:00 P.M., CNA B said the resident got up in the morning around 6:45 A.M., went to the dining room for breakfast, to the tv room, to the dining room for lunch, and then went to bed afterwards. The resident was put to bed today at 2:48 P.M. The resident was changed then when he/she was put to bed. The resident was checked for incontinence before getting up for supper and again at bedtime. The resident really should be checked for incontinence more often between breakfast and after lunch. During an interview on 01/08/25 at 4:35 P.M. the Administrator said all residents, including Resident #12, should be checked every two hours or at least once in between meals during the day for incontinence. Resident #12 should not have gone eight hours between being checked for incontinence and changed. During an interview on 01/09/25 at 2:00 P.M., the Director of Nursing (DON) said residents should be checked every two hours if they were incontinent and changed if they were soiled.

Based on observation, interview and record review, the facility failed to follow standards of practice when licensed staff didn't assess one resident's (Resident #12) gastrostomy tube (G-tube) (a small tube that's surgically inserted into the stomach through the abdomen) out of one sampled resident upon readmission to the facility from the emergency room (ER) when the G-tube was replaced after the resident pulled it out at the facility. This resulted in the facility holding the resident's feedings without a physician order for 11 days. The facility also failed to follow physician orders in obtaining weekly weights. The facility census was 47. Review of the facility's policy titled, Enteral Nutrition, dated 01/20/24, showed: - Responsibility of licensed nurse; - Assessment guidelines include; condition of mouth and gums, consistency of feces, condition of skin around feeding tube, weight, nutritional status, hydration, ability to chew and swallow, obstruction of esophagus; - Documentation guidelines: reason feeding was held if applicable, physician notification as necessary. 1. Review of Resident #12's Physician's Order Sheet (POS), dated December 2024, showed: - An order for enteral (any method of feeding that uses the gastrointestinal tract to deliver nutrition) feed every day and night shift, start date 12/02/24, hold dates 12/13/24 - 12/18/24; - An order to check the G-tube placement before initiation of formula, medication administration and flushing the G-tube or at least every eight hours, start date 12/02/24, hold date 12/13/24 - 12/18/24; - An order to flush the G-tube with 60 milliliters (ml) of water after each bolus feed, every night shift, start date 12/02/24, hold date 12/13/24 - 12/18/24; - An order for Jevity 1.5 cal (oral liquid nutritional supplement) 200 ml via G-tube every night shift related to abnormal weight loss. Administer at 8 P.M. and 2 A.M., start date 12/01/24; - Weekly weights every Monday, dated 02/26/24; - No physician orders to hold the G-tube feedings and the water flushes from 12/02/24 - 12/13/24. Review of the resident's Treatment Administration Record (TAR), dated December 2024, showed: - Check the G-tube placement before initiation of formula, medication administration and flushing the G-tube or at least every eight hours, start date 12/02/24, hold date 12/13/24 - 12/18/24, with 19 opportunities missed out of 22 opportunities for 12/02/24 - 12/13/24; - Flush G-tube with 60 milliliters (ml) of water after each bolus feed, every night shift, start date 12/02/24, hold date 12/13/24 - 12/18/24, with nine opportunities missed out of 12 opportunities for 12/02/24 - 12/13/24; - Jevity 1.5 cal 200 ml via G-tube every night shift related to abnormal weight loss. Administer at 8 P.M. and 2 A.M., start date 12/01/24, with nine opportunities missed out of 12 opportunities for 12/02/24 - 12/13/24. - Weigh weekly every day shift every Monday, dated 02/26/24. No documentation of weights on 12/02/24, 12/09/24, 12/16/24, 12/23/24, and 12/30/24, with five opportunities missed out of five opportunities; - The facility held the order for flushing and enteral feeding from 12/02/24 to 12/13/24 without an order. Review of the resident's emergency room Discharge paperwork, dated 12/01/24, showed: - Resident discharged from theER on [DATE]; - Reason for the ER visit was a G-tube replacement; - Received abdomen x-ray, kidney, ureter, and bladder (KUB - abdominal x-ray) for tube placement. Review of the resident's emergency room paperwork, dated 12/01/24, showed: - Resident admitted to the hospital emergency outpatient on 12/01/24 at 7:14 P.M., and discharged to the facility on [DATE] at 9:37 P.M.; - Resident admitted due to having pulled out G-tube; - History of illness: Resident presented after pulling G-tube out. Patient reportedly pulled out an 18 French G-tube this afternoon, unsure of exact time; - Abdomen was normal, soft, nondistended, and nontender with skin turgor good; - At 8:12 P.M., front view of the abdomen showed the G-tube was in satisfactory position; - At 8:41 P.M., the G-tube was replaced, KUB done showing proper placement. Resident will be discharged back to nursing home to follow up with primary care physician. Review of the resident's progress notes showed: - On 12/01/22 at 6:55 P.M., while certified nursing assistant (CNA) got the resident into bed, the resident grabbed his/her G-tube and pulled it out with the bulb intact. Placed a dry dressing on the site after cleaning the area. Sent the resident to the ER via an ambulance; - On 12/02/22 at 2:22 A.M., the resident came back to the facility after having a new G-tube placed in the ER. The ER called said they had replaced the G-tube using a catheter (a flexible tube inserted into the bladder to drain urine) for the new G-tube and the facility would need to let his/her primary care provider know about this in the morning. The resident came back on 12/1/24 at around 10:00 P.M., was awake and in good spirits upon returning. The resident slept well throughout the night so far. Faxed the physician to let him/her know; - On 12/04/24, Jevity and flush not administered as resident did not have a G-tube at this time, waiting for appointment with physician; - On 12/05/24, Jevity and flush not administered as unable to give at this time. Physician was aware; - On 12/06/24, an appointment with general surgery obtained for 12/13/24 at 1:30 P.M., for consult regarding G-tube replacement; - On 12/07/24, unable to access G-tube to check for placement; - On 12/08/24, unable to access G-tube; - On 12/09/24, no feedings during this shift, not able to give feeding due to not having the correct G-tube; - On 12/10/24, unable to check placement due to having urinary catheter from ER, resident had wrong type of G-tube. Director of Nursing (DON) was aware; - On 12/11/24, primary care physician was rounding on residents and unable to provide check, flush or feeding due to a catheter in place. Appointment for replacement already scheduled; - On 12/12/24, no changes see prior notes; - On 12/13/24, new order from physician to hold bolus feedings and flushes. Review of the resident's medical record showed: - No assessment of the G-tube site after the readmission from theER on [DATE]; - No skin assessment completed after the resident returned from theER on [DATE]. Review of the resident's weights, dated 11/4/24 - 01/08/25, showed: - On 11/04/24, a weight of 119.8 pounds; - On 11/12/24, a weight of 120.2 pounds; - On 11/26/24, a weight of 116.0 pounds; - On 12/06/24, a weight 117.2 pounds; - On 12/24/24, a weight of 118 pounds; - On 01/03/25, a weight of 116.2 pounds; - On 01/09/25, a weight of 118.2 pounds. Review of the resident's General Surgeon paperwork, dated 12/17/24, showed: - Physical exam showed G-tube in place, migrated in all the way, with an over inflated balloon; - Plan: G-tube adjusted at bedside, balloon was emptied and 10 ml of sterile water placed in; - The G-tube balloon was over inflated and migrated all the way in, it was believed this was obstructing the duodenum (first part of the small intestine). During an interview on 12/31/24 at 2:04 P.M., the DON said Resident #12 pulled out his/her G-tube on 12/01/24, and was sent to the ER. She received report from two different ER nurses when the resident returned from the ER. Both ER nurses told her they were not able to replace the resident's G-tube and the resident had a catheter in the opening to hold it open until it could be replaced. Based on the information she received from the ER, she made the resident an appointment as soon as possible to have the G-tube replaced. The resident did take in food orally and she discussed with the Registered Dietician (RD) to see if the G-tube could be discontinued, but the RD felt the resident was not ready for that yet. The RD did recommend the resident's feeding be reduced from twice a day to once a day. The DON said she was told by another facility nurse the physician had been notified about the resident not receiving the feedings and flushes. She did not have documentation of the physician notification before 12/13/24, when the physician ordered to hold the G-tube feedings until the resident's appointment with the surgeon. During an interview on 01/08/24 at 3:00 P.M., CNA D said he/she returned to work a day or two after Resident #12 returned from the ER with the new G-tube. The resident had the same G-tube that was there now, with purple caps on the end, the whole time. During an interview on 01/09/24 at 7:45 A.M., the Physician said he/she had not been notified of the facility holding Resident #12's G-tube feedings until 01/13/24. Thankfully, this resident also ate orally so there wasn't a bad outcome, but there was the potential. Based on the ER paperwork, the ER replaced the G-tube and the feedings and flushes shouldn't have been held to begin with. He/She did not assess the resident's G-tube on 01/13/24, and gave orders to hold the feedings and flushes from the nurse's report. It was the nurse's responsibility to assess the resident before contacting him/her. The resident's meals should have been documented and all weights completed, especially during that time frame. The resident should have been assessed after the resident returned from the ER to verify what tube the resident received. During an interview on 01/09/24 at 2:40 P.M., the DON said she could not remember which nurse told her the physician had been contacted prior to 12/13/24. She never looked at the resident's abdomen or tube to confirm it was a catheter and not a G-tube. She just went off the report from the ER. She didn't look at the ER discharge paperwork and no other nurses ever said anything different. It was the nurse's responsibility that accepted the resident from the ER to do a full assessment, look at the ER discharge paperwork, and ensure everything was correct. It was the DON's responsibility to ensure that happened. The DON said she should have assessed the resident's abdomen and viewed the tube. If she had done that, she would have known it was a G-tube. During an interview on 01/09/24 at 2:55 P.M., the Administrator said the resident should have been assessed and the tube looked at upon readmission. The discharge paperwork should have been looked at as well. The DON was in charge of ensuring the nurse on duty during readmission did that. A physician order to hold the feeding should have been received as well.

Based on interview and record review, the facility failed to provide documentation of on-going assessments and monitoring after dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #36) out of one sampled resident. The facility's census was 47. Review of the facility's policy, Dialysis, undated showed: - This facility will ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences; - The facility will ensure appropriate monitoring of the dialysis resident's status before, during, and after the treatments; - If this facility does not employ a qualified professional person to furnish dialysis treatments, the facility will enter into an agreement with a person or agency outside of the facility. This agreement constructs a connection between both entities and fosters accountability that is vital to the health of each resident and the success of their plan of care. Each end-stage renal disease (ESRD - a medical condition where the kidneys can no longer function to filter wastes or excess fluids from the blood) facility is responsible for ensuring the dialysis resident's needs and goals are addressed. The care plan will specify shared responsibilities divided between the nursing home and the ESRD facility, e.g., adhering to certain renal dietary restrictions based on the resident's fluid status. 1. Review of Resident #36's Physician's Order Sheet (POS), dated January 2025, showed: - admitted on [DATE]; - Diagnosis of ESRD; - No order for dialysis. - No order to assess the dialysis site and/or dressing before and after dialysis; - No order for vital signs and weights before and after dialysis. Review of the resident's quarterly Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 11/25/24, showed: - The resident received dialysis. Review of the resdient's Care Plan, dated 08/27/24, showed: - Problem of dehydration and fluid maintenance with interventions to assess the resident's weight and vital signs before and after dialysis appointments, report concerns to the physician, and the resident received dialysis three times a week on Monday, Wednesday and Friday; - Did not address monitoring the resident's dialysis port (an implanted venous access device) dressing/site. Review of the resident's Dialysis Communication Reports, dated 12/09/24 - 01/08/25, showed: - Eight out of 14 opportunities missed for the vital signs and weights after dialysis; - Four out of 14 opportunities missed for the assessment of the dialysis site/dressing before dialysis; - Nine out of 14 opportunities missed for the assessment of the dialysis site/dressing after dialysis. During an interview on 01/07/25 at 9:45 A.M., Resident #36 said he/she went to dialysis on Mondays, Wednesdays, and Fridays. Staff did not observe his/her dialysis port every time but did sometimes. Staff sometimes took his/her vitals upon returning to the facility after dialysis, but not all of the time. During an interview on 01/09/25 at 2:40 P.M., Licensed Practical Nurse (LPN) D said the facility used a Dialysis Communication form that was filled out with the resident's vital signs, weight, and any changes the dialysis center should know prior to the resident leaving the facility for dialysis. The dialysis center filled out the second portion with the resident's vital signs and any changes the facility should know about prior to the resident leaving dialysis and returning to the facility. Upon the resident's return, staff should get a weight, vital signs, and look at the dressing covering the dialysis port since the site can't be seen. The form had another area at the bottom for the resident's return information. The receiving nurse was responsible for obtaining that information and documenting it. During an interview on 01/09/25 at 2:45 P.M., the Director of Nursing (DON) said the facility used a Dialysis Communication form that was filled out by the facility and the dialysis center to communicate back and forth. There was a final portion of the form at the bottom that should be filled out when the resident returned from dialysis. The last portion contained a weight, vital signs, and an assessment of the dialysis port dressing/site. A lot of of the time, she received the resident back after dialysis, but if not, then the nurse receiving the resident back into the facility should complete the information. It was the DON's responsibility to ensure the form was completed. During an interview on 01/09/25 at 2:50 P.M., the Administrator said the facility used a Dialysis Communication form to communicate back and forth with the dialysis center. When the resident returned, the receiving nurse should fill out the bottom part of the form and assess the dialysis port dressing/site. It was the DON's responsibility to ensure the nurses were completing the form.

Based on observation, interview, and record review, the facility failed to assess the use of a merry walker (an enclosed framed wheeled walker with a seat) to determine if it was a restraint, and failed to document an ongoing re-evaluation for the use of the merry walker for one resident (Resident #12) out of one sampled resident with a restraint. The facility census was 47. Review of the facility's policy titled, Use of Restraints, undated, showed: - Purpose is to ensure that physical and/or chemical restraints are used only when needed to treat the resident's medical symptoms and then, only use the least restrictive alternative for the least amount of time; - The resident's record includes ongoing re-evaluation for the need for a restraint and is effective in treating the medical symptom; - The resident's comprehensive care plan will reflect the resident's goals and the interventions/services needed for the safe use of a restraint as long as it is medically necessary. The facility did not provide a policy regarding merry walkers. 1 Review of Resident #12's April 2024 Physician's Order Sheet (POS), showed: - Diagnoses of intellectual disability (a chronic condition that affects a person's ability to learn and function in daily life), mood disorder (a mental health problem that primarily affects a person's emotional state), restlessness and agitation, anxiety (persistent worry and fear about everyday situations), conduct disorder (a mental health condition that involves a pattern of aggressive and antisocial behaviors), and aphasia (loss of ability to understand or express speech caused by brain damage); - Requires merry walker due to unsteady gait and inability to understand that he/she is unable to ambulate independently. Maintain 100 pounds to the merry walker as ordered, dated 11/26/24, with the original order date of 12/31/19. Review of the resident's quarterly Minimum Data Sets (MDS - a federally mandated assessment instrument completed by the facility staff), dated 07/26/24 and 10/25/24, showed: - Severe cognitive impairment; - Impairment on both sides of the upper and lower extremities; - Dependent with full assist for sit to stand and transfers; - No restraint use. Review of the resident's medical record showed: - No assessment for the merry walker to determine if used as a restraint for 01/01/24 - 12/31/24, and 01/01/25-01/09/25; - No documentation of alternatives tried prior to the merry walker use; - No documentation of the least restrictive use for the merry walker; - No documentation of ongoing re-evaluations for the use of the merry walker tray; - No documentation of consent for the restraint use. Review of the resident's Physical Therapy Evaluation Summary, dated 05/11/22, showed: - Resident referred to physical therapy due to a merry walker re-assessment needed to continue the use in the facility and to determine the resident was still safe; - Resident was a fall risk; - Resident used the merry walker for all ambulation tasks and was independent throughout the facility; - Resident wanted to walk, had appropriate hand placement, appropriate sit to stand technique, was able to maneuver around objects, and didn't ambulate at a fast pace; - Resident continued to independently perform sit to stand transfers and ambulation tasks with the merry walker. Resident was able to move around objects. Resident was able to maintain proper position and balance in sitting/standing when using the merry walker. The device continued to be very appropriate and safe for the resident at this time. The merry walker allowed for the highest level of functioning without restrictions. This device was the correct size and weight for the resident. Review of the resident's care plan, revised on 10/27/24, showed: - Resident was a fall risk; - Resident had behavioral symptoms and would use the merry walker to bump up against other residents; - Resident had physical restraints and used a merry walker restraint when out of bed for increased mobility and independence. It was used due to an unsteady gait and inability to understand the resident couldn't ambulate independently due to a medical diagnosis of mental retardation (a condition that affects a person's ability to think, learn, and adapt to their environment.). The merry walker enabled the resident to safely stand and walk short distances and didn't have a restraining effect. The resident was not able to use a traditional wheelchair or geri chair (supportive recliners and medical recliners provide more substantial support and comfort than conventional wheelchairs) due to constantly attempting to get up and down from it risking injury. Encourage participation of therapy in assessing, re-assessing, and determining the least restrictive restraint to use. Maintain 100 pound weights to the merry walker. Observations of the resident showed: - On 01/07/25 at 9:20 A.M., and 1:30 P.M., and on 01/08/25 at 1:30 P.M., the resident sat in the merry walker in the tv room; - On 01/07/25 at 11:45 A.M., the resident sat in the merry walker and pushed by staff into the dining room; - On 01/08/25 at 8:00 A.M., and on 01/09/25 at 7:50 A.M., the resident sat in the merry walker in the dining room and assisted to eat by staff; - On 01/08/25 at 10:30 A.M., the resident sat in the merry walker in the tv room and ran it into another resident in a wheelchair; - On 01/08/25 at 10:45 A.M., the resident sat in the merry walker in the tv room and ran it into an empty couch numerous times; - On 01/08/25 at 11:55 A.M., the resident sat in the merry walker in the dining room and ran into the piano numerous times; - On 01/08/25 at 2:48 P.M., Certified Nursing Assistant (CNA) B unlatched the closure of the merry walker and transferred the resident from the merry walker to the bed. During a telephone interview on 01/08/25 at 4:30 P.M., Certified Occupational Therapy Assistant (COTA) D said therapy had completed an evaluation a few years back on the resident for the merry walker. There had not been a recent one done that he/she was aware of. The resident had a history of falls and the merry walker kept that from happening. The resident also stood and walked on his/her tip toes. During an interview on 01/09/25 at 1:30 P.M., the Director of Nursing (DON) said a merry walker should be assessed quarterly as a restraint device to ensure it was still appropriate for the resident. During an interview on 01/09/25 at 2:00 P.M., the Administrator said she would expect the resident to have quarterly assessments and documentation regarding the merry walker and restraint assessment. The documentation should include all the required information to show the merry walker was the correct device for the resident.

Based on record review and interviews the facility failed to obtain necessary treatment and services to promote healing for pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device), for one resident (Resident #1) out of six sampled residents. The facility census was 75. Review of the Admission to the Facility Policy, dated 3/2015, showed: - The resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders covering routine care, orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. The facility Wound Care and Treatment policy, dated (MONTH) (YEAR), showed: - The physician will specifically order the treatment to be provided. Record review of Resident #1's Physician order [REDACTED]. - admitted to the facility from the hospital on [DATE]; - [DIAGNOSES REDACTED]. - Orders for physical therapy and occupational therapy; - Foley Catheter present (a urinary diversion tube) present; - No wound treatment orders on admission. Record review of the facility's Observation Detail List Report of resident's skin condition completed by the DON showed: - Description: right posterior lower leg; - Type of skin condition: pressure sore; - Description: right posterior lower leg; - Date of onset 4/05/19; - Present on admission; - Observation date 4/12/19 - Measurement: 1.5 centimeters (cm) length x 1.5 cm width x 0.0 depth; - Measurement for prior week: marked none; - Stage 2 pressure ulcer (partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer); - Report completed 4/30/19 - Interventions: pressure ulcer care. Record Review of the POS [REDACTED] - On 4/10/19 orders for left lower extremity open blister to cleanse with facility cleanser, pat dry, apply [MEDICATION NAME] (medical-grade honey products for the management of wounds) to wound bed, cover with [MEDICATION NAME] (a foam dressing) and secure with tape; - On 4/10/19 orders for left hip open blister to clean with faciltiy choice of cleanser, pat dry, apply [MEDICATION NAME] to wound bed, cover with [MEDICATION NAME], secure with tape and change daily and as needed (prn); - On 4/10/19 order for coccyx wound to cleanse area with facility choice of cleanser and pat dry, apply [MEDICATION NAME] to wound bed and cover with [MEDICATION NAME], secure with tape twice a day (BID) and prn; - On 4/10/19 order for left foot 3rd toe nail leave open to air and monitor for sign and symptoms for infection every shift until resolved; - On 4/11/19 orders for right hip surgical site to clean with faciltiy cleanser of choice, pat dry, top and secure island dressing and change daily and prn. The facility failed to acquire treatment orders for the Stage 2 pressure ulcer and other wounds until 4/10/19, five days after admission. Record review of a Skin Monitoring Sheet, dated 4/5/19, and signed by Licensed Practical Nurse (LPN) A showed: - Surgical wound with 23 staples; - Pressure ulcer to coccyx, approximately 3.5 centimeters (cm) x 1.5 cm; - Dark purple bruise to left hip, 11 cm x 4.5 cm; - Dark purple bruise to inner aspect of right leg, 10.5 cm x 3 cm; - A V shaped skin tear to right wrist; - Callous to right outer ankle; - Scab to top of right foot; - Two-three [MEDICAL CONDITION]. Record review of the resident's baseline care plan, dated 4/6/19, instructed staff to: - Implement a specialty pressure relieving mattress; - Follow wound/skin treatment orders. Record review of LPN A's Nurses Note, dated 4/6/19 at 4:10 A.M., showed the following: - Surgical wound with 23 staples; - Pressure ulcer to coccyx, approximately 3.5 centimeters (cm) x 1.5 cm with yellow slough; - Dark purple bruise to left hip, 11 cm x 4.5 cm; - Dark purple bruise to inner aspect of right leg, 10.5 cm x 3 cm; - A V shaped skin tear to right wrist; - Callous to right outer ankle; - Scab to top of right foot. Record review of Medical Doctor (MD) D's Initial Evaluation note, dated 4/9/19, showed the staples in the resident's right hip intact and no [MEDICAL CONDITION] in the lower extremities. No other mention of the resident's skin issues. Record review of Nurse's Notes showed: - On 4/7/19, staff noted the surgical incision; - On 4/8/19, the resident experienced a witnessed fall. Staff noted a 11.5 cm x 2.5 cm dark purple bruise with unopened blister posterior to the bruise and a 1 cm skin tear to the left ankle. Staff sent a fax to the doctor; - On 4/10/19, staff noted an open blister to the left hip, an open blister on the right lower extremity with a treatment in place (no mention of the specific treatment); - No documentation of any orders regarding skin or wound treatments; - On 5/1/19 a specialty pressure relieving mattress obtained, (26 days after admission). Record review of the Treatment Administration Record showed: - Treatment orders received on 4/10/19 and started on 4/11/19, six days after admission, for the coccyx wound, left foot 3rd toe, left lower extremity open blister, and the left hip open blister; - Orders for treatment to the right hip surgical site received on 4/11/19. Review of the Initial and Weekly Wound Documentation Form, dated 4/12/19 (six days after admission), showed the Director of Nursing (DON) documented the following: - Surgical wound 13.5 cm in length, with slough. - Stage 2 coccyx, 2 cm x 2 cm x 0, present on admission - Stage 2 blister, right lower extremity, present on admission, - Stage 2 left hip, 2.5 cm x 2.5 cm x 0, present on admission. - Stage 2 Pressure ulcer, posterior left leg, 1.5 cm x 1.5 cm x 0, present on admission. Review of a Weekly Wound Documentation, dated 4/19/19, showed the DON documented the following: - The wound on the coccyx had grown to 2.2 cm x 2 cm; - There were no other changes in the measurements. Review of the POS [REDACTED]. The resident was evaluated on 4/22/19 and per their evaluation, the resident had the following wounds: - Wound 1-right posterior lower leg- Stage 3 (full thickness tissue loss involving subcutaneous tissue, but not fascia or muscle). 2 cm x 1 cm x 0.1 cm - Wound 2- Right medial ankle deep tissue injury 0.9 cm x 0.8 cm - Wound 3 Right medial lower leg Stage 3 8.5 cm x 6.5 cm x 0.1 cm. - Wound 4 coccyx unstageable pressure ulcer 4.5 cm x 3 cm x 0.1 cm - Wound 5 left hip unstageable pressure ulcer 6 cm x 2.8 cm - Wound 6 left lateral ankle unstageable pressure injury 1 cm x 1.2 cm. Review of the Weekly Wound Documentation, prepared by the DON and dated 5/10/19, showed; - Right inner calf- unstageable- foul odor-redness 4.8 cm x 4.5 cm x 0.1 cm - Right groin crease- acquired in house- foul odor Stage 2- 3 cm x 1.5 cm - Right Inner ankle- unstageable 1.5 cm x 1.7 cm - Left outer ankle- Unstageable- 1 cm x 1 cm - Left Ischium- Stage 3 -foul odor 3.5 cm x 5.4 cm - Right hip surgical- 4.8 cm x 7.5 cm x 8.8 cm foul odor - Coccyx- Stage 3- 8 cm x 6 cm x 0.4 cm - Left hip- unstageable- 8 cm x 5 cm x 0.1 cm - On 5/13/19, a wound on the left hip was measured. The date of onset was given as 4/19/19. 2.5 cm x 2.5 cm. It was documented as present on admission. Review of the nurse's note, dated 5/11/19, showed Resident #1 was sent to the hospital per family request for increased confusion. The resident was admitted to the hospital with [REDACTED]. During an interview on 5/15/19 at 11:05 AM, Assistant Director of Nursing (ADON) B said he/she expected the nurses to call and get orders for new admissions with wounds, regardless if it is on the weekend or the time. He/she said DON is supposed to review the new admits on Monday morning to ensure the admission is complete. He/she said any Stage 3 or above or an unstageable wound calls for a specialty mattress and Resident #1 should have had a specialty mattress. During an interview on 5/15/19 at 9:30 AM, Registered Nurse (RN) C said he/she assessed the resident on 4/12/19 for the Admission MDS. RN C said he/she had told staff the dark purple areas noted on the resident's lower extremities were deep tissue injuries, not bruises He/she believed the pressure ulcer on the posterior right leg was due to lying on the catheter. RN C said the resident should have had a specialty mattress on admission. During an interview on 5/15/19 at 10:45 AM, MD D said he/she saw Resident #1 on (MONTH) 9, 2019. The resident was post operative right hip surgery and the staples were intact and he/she had only looked at the surgical site. He/she was aware a wound consult had been initiated. The resident was malnourished on admission and had several other co-morbidities including [MEDICAL CONDITION], history of heart failure, and [MEDICAL CONDITION]. During an interview on 5/15/19 at 10:25 A.M., LPN [NAME] said he/she provided treatment to Resident #1 after admission but did not recall exactly what treatments he/she provided. He/she did not contact the physician for orders for the Resident #1's wounds. During an interview on 5/15/19 at 3:05 P.M., LPN [NAME] said the nurse who finds the wound is responsible for notifying the physician. During an interview on 5/15/19 at 10:25 AM, LPN [NAME] said he/she worked Resident #1's hall Monday through Friday after the resident's admission. LPN [NAME] said he/she is sure he/she did treatments on the resident. LPN [NAME] did not know why there were no orders for treatments. LPN [NAME] did not recall exactly what treatments he/she provided. LPN [NAME] did no contact the physician for orders on Resident #1's wounds. In a later interview at 3:05 PM, LPN [NAME] said the nurse that finds the wound is responsible for notifying the doctor. During an interview on 5/15/19 at 11:25 A.M., the DON said when a resident is admitted on the weekend the staff should use the nursing protocol, which instructs them in acceptable treatments for specific types of wounds. The physician should be contacted as soon as possible for orders and/or clarification. He/she would reviews any new admissions on Monday morning. He/she could not recall if he/she reviewed Resident #1's information. He/she said here is no documentation or physician's orders [REDACTED].#1's wounds were treated appropriately. He/she didn't realize Resident #1 had so many wounds and no one had told him/her. He/she ordered the mattress on 5/1/19, (26 days after the resident was admitted ). During an interview on 5/23/19 at 2:54 P.M., LPN A said Resident #1 was admitted late at night. The resident came from the hospital with no treatment orders. He/she did a full skin assessment using the nursing protocol and then applied cream to the resident's coccyx and placed a dry dressing to cover the right hip. Because the resident arrived so late, he/she instructed the oncoming shift nurse to contact the physician for orders. During a telephone interview on 5/29/19 at 4:25 P.M., LPN F said he/she worked a 12 hour shift on 4/6/19. He/she does not recall being told to contact the doctor for orders. If it had been on his/her shift report, he/she would have called the physician. Complaint #MO 8 and 0

Based on interview and record review, the facility failed to ensure the highest level of well-being for two (Residents #1 and #2) of four reviewed residents identified as experiencing pain. The facility did not assess and/or implement measures to promote pain control. The facility's census was 81. 1. Record review of Resident #1's face sheet and physician's orders [REDACTED]. On 2/15/14, the physician ordered staff to administer [MEDICATION NAME]/[MEDICATION NAME] (a narcotic pain reliever for moderate to severe pain) 5/325 milligrams (mg) tablets, two per day and two every six hours as needed for pain. Review of the care plan, updated 2/13/14, showed the resident received Hospice services and had a history of [REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/21/14, showed staff identified the resident as severely cognitively impaired, received routine pain medication, did not receive as needed pain medication and did not exhibit signs and symptoms of pain. Review of the POS [REDACTED]. Review of the POS [REDACTED]. Review of nurses' notes, dated 4/25/14, 4/26/14 and 4/27/14, showed the resident reported having pain, wandered and became confused and combative. Staff administered [MEDICATION NAME] and [MEDICATION NAME] which were ineffective. During an interview on 5/7/14 at 2:15 P.M. the Director of Nursing (DON) said the resident had continuous pain due to untreated suspected [MEDICAL CONDITION] and hurt if touched. The family insisted [MEDICATION NAME]/[MEDICATION NAME] administration be discontinued following falls and [MEDICATION NAME] was ordered. The DON did not think the [MEDICATION NAME] was effective in managing the resident's pain. Staff did not complete pain assessments prior to discontinuing the [MEDICATION NAME]/[MEDICATION NAME] or following the initiation of the [MEDICATION NAME]. During an interview on 5/7/14 at 3:10 P.M., the Administrator and DON said staff should have completed pain assessments for the resident and placed the assessments in the medical records. Staff completed pain assessments quarterly as part of the MDS. During an interview on 5/13/14 at 3:09 P.M., the DON said the Hospice nurse contacted the Hospice physician following family's request to discontinue the resident's [MEDICATION NAME]/[MEDICATION NAME]. The DON said she was not aware of anyone notifying the physician when the resident continued to experience pain with the [MEDICATION NAME]. During a care plan meeting, conducted 5/7/14 while SLCR staff were on-site, the Hospice nurse said they would consider ordering a low dose pain patch but would wait a few more days to determine the effectiveness of the [MEDICATION NAME]. The DON said the resident continued to experience pain and no changes had been made in the resident's medication regimen. 2. Record review of Resident #2's face sheet and POS, dated 4/15/14 through 5/14/14, showed the resident had [DIAGNOSES REDACTED]. The physician ordered the administration of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg every eight hours as needed for pain since 1/17/14. Review of the medication administration records (MAR), dated 2/15/14 through 5/15/14, showed staff administered the as needed [MEDICATION NAME]/[MEDICATION NAME] on 56 occasions from 2/15/14 to 5/7/14. Review of a faxed telephone order sheet, dated 4/22/14, showed the resident exhibited moderate to severe pain while taking the as needed [MEDICATION NAME]/[MEDICATION NAME]. Staff requested the physician consider adding additional medication. The physician did not respond and staff did not follow-up on the request. Review of a pain assessment, dated 4/25/14, showed staff identified the resident had almost constant pain which made it hard to sleep at night and limited day-to-day activities. The resident rated the pain as severe. During an interview on 5/7/14 at 11:50 A.M., Resident #2 said she had been experiencing increased pain and needed additional pain medication. During an interview on 5/7/14 at 12:20 P.M., Licensed Practical Nurse (LPN) A said Resident #2 had been experiencing increased pain and received as needed pain medication. LPN A faxed a note to the physician requesting a change in the resident's pain medication regimen (on 4/22/14) but had not yet received a reply. LPN A said she had not followed up on the request. During an interview on 5/7/14 at 12:29 P.M., the Assistant Director of Nursing (ADON) said staff should have followed up with the physician sooner. During an interview on 5/7/14 at 2:15 P.M., the DON said she was unaware Resident #2 reported experiencing pain and not getting good pain management. The DON said staff should have contacted the physician within a couple of days if they had not received a reply. 3. Record review of the facility's policy for pain management showed it directed nursing staff to complete an assessment of pain for residents experiencing pain according to need and use of medication and notify the physician of a change in condition. MO 586

Based on observation, interview and record review, the facility failed to provide adequate supervision to reduce the risk of falls for one (Resident #4) of six reviewed residents. The facility census was 95. 1. Record review of Resident #4's face sheet showed a [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/2/11, did not indicate the resident experienced falls. Review of a nurse's note, dated 11/14/11, showed the resident fell while attempting to take self to the bathroom with no injuries noted. The nurse's note did not address interventions to reduce the risk of further falls. Review of a 72 hour monitoring report, dated 11/14/11, showed staff did not address interventions to reduce the risk of falls. Review of the care plan, dated 11/14/11, showed interventions included to assist with all transfers and monitor for decline in mobility or increased need for assistance with transfers or ambulation. Staff did not revise the care plan to address interventions related to fall prevention following each subsequent fall. Review of a nurses' notes, dated 11/29/11, showed staff found the resident lying in floor by bed with no injuries noted. The nurse's notes did not address interventions to reduce the risk of falls. Review of a 72 hour monitoring report, dated 11/29/11, showed staff did not address interventions to reduce the risk of falls. Review of a nurses' note, dated 12/14/11, showed the resident attempted to go to the bathroom, urinated and slipped in the floor by the bed. The resident experienced a skin tear. Review of the care plan, updated 12/14/11, showed staff noted the resident urinated in the floor and fell resulting in a skin tear to the right forearm. Staff did not address interventions to reduce the risk of falls. Review of a 72 hour monitoring report, dated 12/14/11, showed staff did not address interventions to reduce the risk of falls. Review of nurse's notes, dated 12/24/11, showed the resident fell in the floor by the bed. The resident experienced an abrasion to the back of the head. Staff did not address interventions to reduce the risk of falls. Review of the 72 hour monitoring report, dated 12/24/11, showed staff did not address interventions to reduce the risk of falls. Review of the care plan, updated 12/25/11, showed staff noted the resident fell and experienced a skin tear to the right hand. Staff did not address interventions to reduce the risk of falls. Review of a nurses' notes, dated 12/28/11, showed staff found the resident lying in the floor in the day room with a pool of blood under his/her head. The resident received four stitches to the back of his/her head. Staff did not address interventions to reduce the risk of falls. Review of the 72 hour monitoring report, dated 12/28/11, showed staff did not address interventions to reduce the risk of falls. Review of the care plan, updated 12/28/11, showed staff updated the care plan and directed staff to use a wheelchair as need for locomotion, use bed and body always, put bed against the wall on one side and use wheelchair for unsteady gait. Review of the physician's orders [REDACTED]. On 1/3/12, the physician ordered a physical therapy consult and treatment. Review of a Physical Therapist's note (PT), dated 1/3/12, showed the resident had an unsteady gate, low foot clearance and uneven gait and had been referred due to multiple falls. The PT initiated education on safety awareness, therapeutic exercised, neuromuscular reeducation and gait training five times a week for four weeks. Review of a nurse's note, dated 1/8/12, showed staff found the resident sitting in the floor of the bathroom with no injuries noted. Staff did not address interventions to reduce the risk of falls. Review of a nurse's note, dated 1/11/12, showed the resident missed chair while attempting to sit with no injuries noted. Staff did not address interventions to reduce the risk of falls. Review of a nurse's note, dated 1/24/12, showed staff found the resident lying on the floor by the couch near his/her wheelchair with no injuries noted. Staff did not address interventions to reduce the risk of falls. Review of the 72 hour monitoring report, dated 1/24/12, showed staff did not address interventions to reduce the risk of falls. Review of nurse's notes, dated 1/29/12, showed staff found the resident lying in the floor by the bed. The resident experienced three skin tears and a busted upper lip. Staff did not address interventions to reduce the risk of falls. Review of the 72 hour monitoring report, dated 1/29/12, showed staff did not address interventions to reduce the risk of falls. Review of nurse's notes, dated 1/30/12, showed staff found the resident sitting in the floor by the bed. The resident experienced a skin tear. Staff did not address interventions to reduce the risk of falls. Observation on 1/31/12 at 12:50 P.M., showed Certified Nurse Aide (CNA) B propelled resident in a wheelchair to the bathroom in his/her room. CNA B assisted the resident to the toilet, pushed the wheelchair into the hallway and returned to the dining room leaving the resident unattended in the bathroom. At 1:00 P.M., the resident lay on the edge of the open side of the bed with his/her upper shoulder hanging over the side. The resident's wheelchair remained in the hall. During an interview on 1/31/12 at 1:06 P.M., CNA B said he/she usually went back and forth checking on the resident because he/she usually spent about thirty minutes in the bathroom. During an interview on 1/311/12 at 1:08 P.M., Licensed Practical Nurse (LPN) A said the resident should not have been left unattended due to falls. LPN A said staff applied the alarms to the resident's bed and chair due to falls. Observation on 1/31/12 at 3:40 P.M., the resident was in the bathroom unattended with his/her wheelchair in the hall. During an interview on 1/31/12 at 3:41 P.M., CNA F said the nurse helped the resident to the toilet then left. CNA F said the resident could toilet self. During an interview on 1/31/12 at 3:45 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said the resident could transfer self but should not do so due to recent falls. Alarms had been implemented and staff should not leave the resident unattended in the bathroom. During an interview on 2/8/12 at 9:00 A.M., the ADON said staff should have supervised the resident when toileting and provided guidance with ambulation. The ADON said staff completed post fall 72 hour monitoring reports following most of the resident's falls. The facility did not complete further assessments related to investigation of the falls. Complaint MO 499