Every finding on record at Avenue at Broadview Heights

Based on observation, closed record review, review of Emergency Medical Services report, review of hospital records, policy review and interview the facility failed to follow Resident #62's physician orders and implement care planned interventions to ensure Resident #62 was monitored appropriately and timely treated for an acute change of condition, and failed to ensure adequate skin monitoring was completed to timely identify and treat areas of Resident #62's skin breakdown. The facility also failed to ensure Resident #39's new medical diagnoses of type two diabetes was timely treated.Actual Harm occurred beginning on 02/18/25 at 7:47 P.M. when Resident #62 reported he had blood in his urine, a urine specimen for urinalysis and culture and sensitivity was ordered, but no further monitoring was completed from 02/18/25 through 02/22/25 including vital signs or monitoring of the resident's urinary status. On 02/22/25 at 7:40 A.M. Resident #62 was found in a stuporous state, was unable to make eye contact and answer questions appropriately, and his skin was pale, cool and clammy. Resident #62 had involuntary shaking of his right arm and was humming. Resident #62's blood pressure was 101/56 (hypotensive), heart rate 41 beats per minute (bradycardic) and blood sugar was 59 (hypoglycemic). The resident's temperature was not taken. Emergency medical services (EMS) were called. Resident #62 was transported to the local hospital emergency department (ED) where his temperature was found to be 90.0 degrees Fahrenheit (F) (hypothermic) and he was admitted to the hospital with altered mental status, urinary tract infection, sepsis, hypothermia, hypotension, and a newly identified right lower buttock pressure ulcer noted to be present at the time of admission to the hospital. This affected one resident (#62) of three residents reviewed for a change in condition, and one resident (Resident #39) out of three residents reviewed for blood sugar monitoring. The facility census was 61.Findings Include:1.Review of Resident #62's closed medical record revealed an initial admission date of 04/16/23 with diagnoses including type two diabetes mellitus with diabetic neuropathy, anxiety disorder, obstructive and reflux uropathy, acute osteomyelitis of the left ankle and foot. Resident #62 was transferred to the local hospital Emergency Department on 02/22/25 and did not return to the facility.Review of Resident #62's care plan dated 04/28/23 and revised on 03/13/25 included Resident #62 was at risk for bladder incontinence related to impaired mobility, impaired cognition and recent catheter use due to obstructive uropathy. The plan revealed Resident #62 had his catheter removed and was voiding without difficulty at this time. Resident #62 would be continent during waking hours through the review date. Interventions included monitor and document for signs and symptoms of a urinary tract infection (UTI) such as pain, burning, blood tinged urine, cloudiness, increased pulse, increased temperature, fever, chills, urinary frequency, foul smelling urine, altered mental status, change in behavior, or a change in eating patterns.Review of Resident #62's care plan dated 04/28/23 and revised on 03/13/25 included Resident #62 had the potential for skin integrity and pressure ulcer development related to diabetes mellitus, chronic venous insufficiency, impaired mobility and other diagnoses. The care plan included Resident #62 would pick at skin continuously despite education. Interventions included to administer treatments as ordered and monitor for effectiveness, follow facility policies, protocols for the prevention and treatment of skin breakdown, inform the resident, family, caregivers of any new area of skin breakdown, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate.Review of Resident #62's care plan dated 02/28/24 and revised 03/13/25 included Resident #62 would refuse medications and lab work, was non-compliant with wound care, non-compliant with ambulation and weight bearing status and would transfer without staff assistance. Resident #62 would pick at his skin and smear blood on the walls. Resident #62 would refuse care at times. Resident #62 would urinate in the computer room trash can. The goal developed included Resident #62 would have fewer episodes of behaviors by the review date. Interventions included to anticipate and meet Resident #62's needs, intervene as necessary to protect the rights and safety of others, approach and speak in calm manner and remove from the situation and take to alternate location as needed.Review of Resident #62's physician orders dated 04/02/24 revealed the resident received Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 300 units per milliliter, 32 units subcutaneously at bedtime for diabetes mellitus. The order was discontinued on 02/24/25.Review of Resident #62's physician's orders dated 04/03/24 revealed an order for Humalog KwikPen Subcutaneous Solution Pen-Injector 200 units per milliliter, per sliding scale. If the resident's blood sugar was 180 to 240 inject two units, if the blood sugar was 241 to 300 inject four units, if the blood sugar was 301 to 360 inject 6 units, if the blood sugar was 361 to 400 inject eight units, and if the blood sugar was greater than 400 inject 10 units and notify the physician, subcutaneously with meals for insulin. Review of Resident #62's physician orders dated 04/04/24 and revised 04/05/24 revealed the resident had an order for Enhanced Barrier Precautions due to a diagnosis of Candida Auris, every shift. The orders remained active until 02/24/25 (after the resident's discharge).Review of Resident #62's care plan dated 04/05/24 and revised on 03/13/25 included Resident #62 was on Enhanced Barrier Precautions related to Candida Auris. Enhanced Barrier Precautions would be maintained throughout the review period. Interventions included to educate the resident, family, and staff regarding Enhanced Barrier Precautions and wear gown and gloves when performing high contact resident care.Review of Resident #62's quarterly Minimum Data Set assessment dated [DATE] included Resident #62 was cognitively intact. The assessment revealed Resident #62 was dependent (on staff) for toileting hygiene and lower body dressing, required substantial to maximal (staff) assistance with bathing, and required partial to moderate (staff) assistance with personal hygiene. Resident #62 required substantial to maximal (staff) assistance for the ability to roll from lying on his back to the left and right side and return to lying on his back on the bed, for the ability to move from sitting on the side of the bed to lying flat on the bed, and the ability to move from lying on the back to sitting on the side of the bed and with no back support and the ability to transfer from a bed to a chair or wheelchair. Resident #62 used a wheelchair and required partial to moderate (staff) assistance for the ability to wheel at least 50 feet and make two turns. The assessment revealed Resident #62 did not reject care during the seven-day assessment look-back period.Record review revealed a wound care note dated 12/31/24 which reflected Resident #62 was receiving care for a left medial heel diabetic ulcer which showed complete epithelialization with no signs of infection or inflammation. Healing was complete and the wound was now closed. Resident #62 was discharged from the Wound Care service with a note to follow up as needed.Review of Resident #62's Braden Scale for Predicting Pressure Sore Risk dated 02/08/25 revealed Resident #62 was at mild risk for developing pressure ulcers, injuries.Review of Resident #62's progress note dated 02/08/25 at 2:04 P.M. included Resident #62 had a skin tear to the right middle knuckle. The area was cleansed with normal saline and a steri-strips was applied. The skin tear was reported to the Nurse Practitioner and staff were to continue to monitor Resident #62's knuckle for signs and symptoms of infection and to discontinue the order when the skin tear was resolved.Review of Resident #62's Weekly Skin Check dated 02/14/25 at 4:14 P.M. revealed no evidence of new skin problems.Review of Resident #62's Treatment Administration Record dated 02/09/25 through 02/22/25 when Resident #62 was transported to the local emergency room (ED) and admitted to the hospital revealed a treatment for Resident #62's right middle knuckle, steri-strip in place, monitor for signs and symptoms of infection, bleeding every shift for skin tear, discontinue when resolved was marked it was completed two times a day (except for during the night shift on 02/11/25) during this time period.Review of Resident #62's progress note dated 02/17/25 at 1:12 P.M. included the nurse collected a wound culture to confirm C. Auris (Candida Auris). The progress note did not specify where the wound was located or where the wound culture was taken from. Review of Resident #62's progress note dated 02/18/25 at 7:47 P.M. included Resident #62 stated he had blood in his urine, and an order was given by the Nurse Practitioner (NP) to collect a urine specimen for urinalysis and culture and sensitivity. Resident #62's progress note did not indicate if the urine was observed by an aide or a nurse and there was no description of the urine including amount or odor. The note only included Resident #62 told the staff he had blood in his urine.Review of Resident #62's medical record including progress notes and documentation revealed no evidence Nurse Practitioner #470 or Physician Assistant #471 evaluated Resident #62 following this complaint of blood in his urine.Review of Resident #62's progress notes dated 02/18/25 at 7:47 P.M. through 02/22/25 at 7:30 A.M. revealed no documented evidence Resident #62 was monitored for a change of condition or for urinary status. There was no staff assessments/documentation for blood in the resident's urine, vital signs including temperature, or mental status changes during this time period. There was no documented evidence as to whether or not Resident #62 voiced additional concerns about his urine including if there was blood in it during this time period.Review of Resident #62's progress note dated 02/19/25 at 4:27 A.M. revealed Resident #62's urinalysis (UA) was collected and sitting in the refrigerator for the lab. There was no documentation revealing why Resident #62's urine specimen was not picked up by the lab on 02/19/25. Review of Resident #62's progress note dated 02/19/25 at 1:02 P.M. included Resident #62 continued to be on enhanced barrier precautions due to scratching and picking at the skin of his arms and hands.Review of Resident #62's urine culture Lab Results Report included the resident's urine was collected on 02/20/25 at 12:00 A.M. and reported on 02/22/25 at 7:46 P.M. (Note: Resident #62 was transported to the hospital ED on 02/22/25 at 8:20 A.M.) Proteus Mirabilis was present at greater than 100,000 CFU (colony forming units) per milliliter. The results identified Extended-Spectrum Lactamases (ESBL) enzymes that showed resistance to Extended-Spectrum (third generation) cephalosporins) producing organism but did not affect carbapenems and meropenem or imipenem. Proteus Mirabilis was resistant greater than two to Ciprofloxicin (Cipro).Review of Resident #62's progress note dated 02/20/25 at 3:48 P.M. included lab results were reported to Physician Assistant (PA) #471 and a new order for Cipro 500 milligrams (mg) by mouth was ordered two times a day for seven days for elevated white blood cells.Review of Resident #62's Treatment Administration Record dated 02/21/25 revealed a Weekly Skin Check every Friday to be completed under the assessment tab was initiated it was completed. However, there was no evidence of a Weekly Skin Check form dated 02/21/25 in the assessment tab documenting Resident #62's skin was evaluated and/or details of an actual skin check/assessment.Review of Resident #62's blood sugars checked with each meal dated 02/21/25 revealed at 8:00 A.M. his blood sugar was 222 and two units of Humalog insulin was administered, at 12:00 P.M. his blood sugar was 147 and no insulin was administered, at 5:00 P.M. his blood sugar was 93 and no insulin was administered.Review of Resident #62's Treatment Administration Record dated 02/21/25 from 6:00 P.M. to 6:00 A.M. revealed observe Resident #62 for signs and symptoms of hyperglycemia and hypoglycemia related to diabetes mellitus every shift. The record was initiated as completed, but the time was not recorded.Review of Resident #62's progress note dated 02/22/25 at 7:30 A.M. revealed Resident #62 was resting in bed and when he was awakened he was making a humming noise while shaking his right arm involuntarily. The note revealed Resident #62's name was called repeatedly, and he kept humming and his arm was shaking. Resident #62's blood pressure was 101/56 (hypotensive), heart rate 41 (bradycardic) and blood sugar 59 (hypoglycemic). There was no evidence the resident's temperature or oxygen saturation level were checked. Resident #61 was asked what day it was, what the nurse's name was and he repeated Friday. Resident #62's physician and Power of Attorney were notified, and the POA stated to send the resident out.Review of Resident #62's progress note dated 02/22/25 at 7:40 A.M. revealed the nurse was called to Resident #62's room and noted Resident #62 to be pale with cool, clammy skin. Resident #62 was in a stuporous state and unable to make eye contact or answer questions appropriately. The note revealed staff initiated neuro checks and continuous monitoring of vital signs. Review of Resident #62's [NAME] Review report from the local Fire Department included a call was received on 02/22/25 at 7:50 A.M., EMS was dispatched at 7:51 A.M. and arrived to the facility and had contact with Resident #62 at 7:57 A.M. Resident #62's blood pressure was 91/62, pulse was 40, respirations 16 and oxygen saturation was 95 percent. Resident #62 was confused, somnolent and had slowness and poor responsiveness. EMS was dispatched for a chief complaint of altered mental status (AMS) and diabetic issue. EMS were told by the facility staff that Resident #62's blood sugar was low, and he was not acting normal. An intravenous line (IV) was established and 10 percent dextrose solution (D10) ran to keep open (TKO). Resident #62's initial blood glucose was 47 and a repeat blood sugar revealed 180. Resident #62 denied chest pain, shortness of breath, nausea and dizziness. However, Resident #62 unable to sign (paperwork) due to his AMS, was transported to the local hospital ED and care was transferred at 8:32 A.M. Review of Resident #62's progress note dated 02/22/25 at 8:00 A.M. revealed EMS arrived and stated they would start an IV and administer dextrose solution. If the intervention was unsuccessful EMS would transport Resident #62 to the ER.Review of Resident #62's progress note dated 02/22/25 at 8:20 A.M. revealed Resident #62's blood glucose was 180, but he continued to slur his words and answer questions inappropriately. Resident #62 was transported by EMS to the local ED.Review of Resident #62's Acute Care Hospital Transfer Form dated 02/22/25 at 8:24 A.M. included Resident #62 was lethargic and had seizure like activities. There was no evidence Resident #62's temperature was checked and the last time his temperature was checked on 02/15/25 at 1:34 P.M. it was documented to be 97.8 degrees F. There was no documentation on the form to indicate Resident #62 had skin tears on his bilateral upper extremities, any type of pressure ulcer to the right lower buttock, a right foot non-pressure ulcer or a left foot non-pressure ulcer. (Please note, the resident had orders for weekly skin checks which should have been completed on 02/21/25. However, there was no documented evidence this was actually completed).Review of Resident #62's Emergency Department Visit Note dated 02/22/25 at 8:35 A.M. included EMS was called to the facility where Resident #62 resided due to Resident #62's altered mental status and Resident #62 was found to be hypoglycemic with a blood sugar to 46. Resident #62 was administered D10, his blood sugar improved to 180, but facility staff stated Resident #62 was not acting like himself and was normally alert and feisty. Resident #62 did not recognize his nurse at the facility, which was very abnormal for him. Resident #62 stated he felt a little short of breath with a cough, he had chest pain with the cough and reported diffuse abdominal pain. Resident #62 thought he might be having diarrhea, had no nausea or vomiting, and believed his lower extremity edema was new (Resident #62 had bilateral two plus nonpitting edema to the mid shin). Resident #62 did not know how long he had felt unwell. Resident #62's blood pressure was 102/55, pulse 58, temperature 90.0 degrees Fahrenheit (hypothermic), respirations 14 and oxygen saturation was 96 percent. Resident #62 was hypotensive, hypothermic and bradycardic. Resident #62's core body temperature was 86.4 Fahrenheit and he was placed on a Bair Hugger (used forced-air warming to maintain a patient's normal body temperature). Recommend ED to ED transfer for Emergency General Surgery (EGS)- a critical field focused on urgent, non-trauma surgical needs of patients such as severe infections and complications requiring immediate attention) evaluation and admission to the intensive care unit. Review of Resident #62's Change in Condition assessment dated [DATE] at 8:39 A.M. included Resident #62 most recent blood pressure was 101/51 at 8:38 A.M., respirations 20 at 8:39 A.M., blood sugar was 51 at 8:36 A.M. Resident #62's most recent temperature was taken on 02/15/25 at 1:34 P.M. There was no evidence Resident #62's temperature was checked at this time. Staff noted a significant change in mental status and Resident #62 was unable to answer questions appropriately or follow commands. Resident #62 had cool, clammy skin. There was no documented evidence Resident #62 was assessed for or that staff identified skin tears on his bilateral upper extremities, an unstageable pressure ulcer of the right lower buttock, a right foot non-pressure ulcer or a left foot non-pressure ulcer.Review of Resident #62's progress notes dated 02/22/25 at 10:52 A.M. included the ED was contacted and the nurse was told Resident #62 was being admitted to the Intensive Care Unit related to atypical vital signs and mental status.Review of Resident #62's ED to Hospital admission dated 02/22/25 at 2:00 P.M. included Resident #62 had a change in mental status and was transported from the local ED to the main hospital ED for altered mental status, UTI, sepsis, hypothermia and hypotension. Resident #62's blood pressure was 98/61, pulse 66, temperature 90.9 Fahrenheit, respirations 18, and his oxygen saturation was 91 percent. Resident #62's visit diagnoses included sepsis with encephalopathy and septic shock due to unspecified organism, hypothermia, acute kidney injury, acute cystitis without hematuria, and type two diabetes with diabetic polyneuropathy. Resident #62 had prior left foot OM (osteomyelitis) s/o calcanectomy in 03/2024 (subtotal or total calcanectomy, a surgery removing part or all of the heel bone to treat severe, non-healing ulcers, often from diabetes), and was growing rare candida auris in March 2024. Resident #62 was admitted to the Medical Intensive Care Unit (MICU) with concerns for septic shock 2/2 urinary tract infection (UTI) (likely referring to experiencing two urinary tract infections in a short timeframe), Resident #62 had positive leukocyte esterases (white blood cells present signaling inflammation or infection) and nitrates (usually a sign of urinary tract infection) on UA (urinalysis). Resident #62 endorsed hematuria prior to arrival and had fevers, chills, excessive sweating. Resident #62 was treated empirically with antibiotics (Vancomycin, Zosyn, and then changed to ceftriaxone). Resident #62 had a high probability of sudden, clinically significant deterioration which required the highest level of physician preparedness to intervene urgently. Resident #62 had multiple wounds and had various skin tears to his bilateral upper extremities (BUE) and the dressings were left in place to avoid further trauma to the area. Resident #62 had an unstageable pressure injury to his right lower buttock area that was present on admission (to the hospital). When asked Resident #62 reported a two year history of wounds to his buttocks. Resident #62 had ulcerations to his left inner foot that appeared to be diabetic versus venous in nature. Resident #62 was unable to say how they originated, but believed it was after his amputation surgery. On 02/23/25 at 12:33 A.M. documentation revealed an unstageable pressure injury to Resident #62's right lower buttock which was present on admission. On 02/24/25 at 1:05 P.M. measurements revealed the length was 3.5 centimeters (cm), width was 2.4 cm and depth was 0.05 cm. The wound bed was moist, pink, yellow and had eschar, and a scant amount of serosanguineous and yellow drainage was noted. The wound was cleansed and a dressing was placed. On 02/23/25 at 12:33 A.M. documentation revealed a left foot non-pressure ulcer which was present on admission. On 02/24/25 at 1:05 P.M. the wound bed was described as moist, pink, slough, and yellow and there was a moderate amount of yellow drainage. The wound was cleansed and Aquacel AG (antimicrobial wound dressing) was applied. On 02/23/25 at 12:33 A.M. documentation revealed a right foot non-pressure ulcer which was present on admission. On 02/24/25 at 1:05 P.M. the wound bed was described as dry, burgundy/maroon, and black. There was no drainage. The wound was cleansed and a dressing was applied.Review of Resident #62's progress note dated 02/23/25 at 1:31 P.M. included Resident #62 was admitted to the hospital for urinary tract infection, sepsis and was receiving pressors, vancomycin and zosyn IV, had some confusion, and was sleepy. The resident did not return to the facility.Interview on 01/07/26 at 3:35 P.M. with the Director of Nursing (DON) and the Administrator revealed the lab the facility used picked up specimens on Monday, Tuesday, Thursday and Friday. The DON stated the lab would pick up STAT specimens on Wednesday, Saturday and Sunday, and would only do a STAT urinalysis, not a culture and sensitivity on those days. Lab results were faxed to the facility, and if there were critical lab results the lab would call and notify the facility. Lab results could also be obtained by checking the computer for lab results. The DON stated Resident #62 had wounds on his heels, he had diabetic foot ulcers, he had no toes, was non-compliant and would often get up and stand on his feet. The DON and Administrator verified (on 02/22/25) Resident #62 was transported and admitted to the local hospital. The resident did not return to the facility and had been subsequently transferred from the initial hospital to another hospital and then he passed away. Interview on 01/12/26 at 4:55 P.M. with Nurse Practitioner (NP) #470 revealed he worked with Medical Director #473, and Medical Director #473 was Resident #62's Primary Care Provider until 11/21/24 when Resident #62 and his family requested Physician #474 to be his Primary Care Provider. NP #470 stated sometimes the nurses incorrectly called him about Physician #474's residents. NP #470 stated he did not know why and could not speak to Resident #62's body temperature being 90.0 Fahrenheit, but in general septic shock could cause the body temperature to be lowered. Interview on 01/12/26 at 4:20 P.M. with Physician Assistant (PA) #471 revealed he worked with Physician #474 and Physician #474 had been Resident #62's Primary Care Physician since 11/21/24. PA #471 stated the Wound Care service was following Resident #62 in February 2025 for his wounds, and PA #471 stated he did not give an order for a wound culture. PA #471 stated Resident #62 had increased confusion, and he started antibiotics when his lab work was reported. Interview on 01/13/26 at 8:58 A.M. with Licensed Practical Nurse (LPN) #442 revealed she took care of Resident #62 on 02/22/25 when he was transported to the local hospital ED. LPN #442 stated on 02/22/25 Resident #62 seemed different when she went in his room and said good morning, and when she asked him what year it was he said 2025. LPN #442 asked Resident #62 a few questions, he seemed confused, and his response to each question was Friday. LPN #442 thought Resident #62 had wounds on his heels, but stated she could not remember for sure, and could not remember if he had other wounds.Interview on 01/13/26 at 8:22 A.M. with Registered Nurse (RN) #476 revealed on 02/17/25 she collected the wound culture for Candida Auris from an open area on Resident #62's arm where he was scratching. RN #476 stated Resident #62 was a one person assist, needed assistance with showers and was dependent on staff for hygiene. RN #476 stated Resident #62 had grab bars on his bed to help with mobility.Interview on 01/14/26 at 9:58 A.M. with RN #451 revealed Resident #62 needed more help around the time he went to the hospital on [DATE]. RN #451 indicated Resident #62 scratched his arms and had open areas. Interview on 01/14/26 at 12:43 P.M. with the DON revealed if Resident #62 had blood in his urine the physician should be notified and orders obtained. The DON stated after Resident #62 reported blood in his urine (on 02/18/25) he should have been monitored for things like additional blood in his urine and his vital signs should have been checked.Interview on 01/15/26 at 9:58 A.M. with the DON, RDCO #472 and Social Services Designee (SSD) #477 revealed SSD #477 confirmed Resident #62 had dressings on his arms from scratching and picking. RDCO #472 stated she thought the areas from scratching and picking were scratches and not gaping wounds. RDCO #472 confirmed she did not see an indication the staff were putting dressings on Resident #62's arms and any indication treatment was done.Interview on 01/15/26 at 1:16 P.M. with RDCO #472 and the Administrator confirmed Resident #62's record did not reveal evidence bilateral upper extremity skin tears or scratches were treated and had dressings applied during the time period above even though a culture of an area on his arm was obtained. RDCO #472 stated she could not refute that Resident #62's Treatment Administration Record stated his right middle knuckle skin tear was being monitored for signs and symptoms of infection, bleeding every shift from 02/09/25 through 02/22/25 when he was transported to the local ED. RDCO #472 stated after two weeks it was unlikely that the skin tear would still be on his hand. Review of the facility policy titled Resident Change in Condition dated 07/28/22 included the purpose was ensuring staff provided timely and appropriate care and services when residents experience a change in condition that had or was likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. The licensed nurse would take immediate action to ensure timely and appropriate care and services were met when a resident change in condition was identified. The appropriate level of care and treatment would be delivered as required to best manage a resident's change in condition and the effort to treat a residents physical or emotional status such as an illness or injury based on the outcome of severity during assessment. Change of condition might included but was not limited to urination and bowel patterns, confusion, lethargy, disorientation, unusual or strange behavior. The licensed nurse would document any changes in the resident's medical condition or status in the resident's medical record.Review of the facility policy titled Pressure Ulcer Prevention and Risk Identification revised 01/2023 included the licensed nurse would perform a head-to-toe skin assessment upon admission and every seven days thereafter to identify any new skin areas. The licensed nurse would document her findings in the medical record. The licensed nurse would assess for redness, rashes, ecchymosis, shearing and open areas with attention to surfaces of the skin that come in contact with the bed or chair, bony prominences, surfaces of the skin that come in contact with orthotic devices and skin folds. The physician and responsible party would be notified by the licensed nurse promptly of the newly identified skin area and a treatment would be initiated according to the physician order. 2. Review of Resident #39's medical record revealed an admission date of 05/10/22 and diagnoses included type two diabetes mellitus without complications, other specified muscular dystrophies, and primary progressive multiple sclerosis.Review of Resident #39's physician orders dated 10/05/23 revealed Resident #39 was able to self-medicate and narcotics and Interferon Beta Auto pen given by nursing. Review of Resident #39's lab report dated 09/05/25 revealed Resident #39's glycohemoglobin-HGBA1C was 7.2 and the reference range was 4.1 through 6.1. Review of Resident #39's progress notes dated 09/23/25 at 5:42 P.M. included Nurse Practitioner (NP) #470 was notified that Resident #39 refused Metformin (treatment for type two diabetes to help control high blood sugar levels). Resident #39 stated she wanted to try a diet for three months before taking another medication.Review of Resident #39's progress notes dated 09/23/25 at 6:03 P.M. revealed the dietician recommended Resident #39 obtain a Libre for glucose checks due to Resident #39 did not want to be pricked with lancets. NP #470 agreed and a new order was placed. Review of Resident #39's physician orders dated 09/23/25 revealed FreeStyle Libre 2 sensor (continuous glucose system sensor), inject one unit subcutaneously at bedtime every fourteen days for assist resident with ac (before meals) TID (three times a day) related to type two diabetes mellitus without complications.Review of Resident #39's medical record dated 09/23/25 through 01/08/26 including blood sugar summary, progress notes and Medication Administration Records and Treatment Administration records did not reveal evidence Resident #39's blood sugars were checked.Review of Resident #39's Medication Administration Record (MAR) dated 09/24/25 revealed FreeStyle Libre 2 Sensor, inject one unit subcutaneously at bedtime every fourteen days for assist resident with ac TID was not marked it was completed and the MAR stated to see nurses notes, but review of the progress notes did not reveal evidence why the order was not completed.Review of Resident #39's progress notes dated 10/09/25 at 5:43 A.M. included FreeStyle Libre 2 Sensor was on order and the physician was aware.Review of Resident #39's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 was dependent for toileting hygiene, bathing. Resident #39 required substantial to moderate assistance with dressing and partial to moderate assistance with personal hygiene. Review of Resident #39's Medication Administration Record (MAR) dated 12/03/25 and 12/31/25 revealed FreeStyle Libre 2 Sensor, inject one unit subcutaneously at bedtime every fourteen days for assist resident with ac TID was not marked it was completed and the MAR stated to see nurses notes. Review of the MAR progress notes regarding the Libre dated 12/03/25 stated Resident #39 doesn't have one, and there were no MAR progress notes dated 12/31/25 revealing a reason why the order was not completed. Resident #39's MAR dated 12/17/25 was not marked off it was completed and did not have the reason why the order was not completed.Observation on 01/07/26 at 2:32 P.M. of Resident #39 revealed she was in a motorized, padded wheelchair, her hair was brushed back from her face, and her clothes were clean. Resident #39 stated she was told she was a diabetic, but was given no education about diabetes, and no staff nurse checked her blood sugars. Resident #39 stated she didn't know what she was supposed to do about her diabetes.Interview on 01/14/26 at 10:50 A.M. with Medical Director #473 revealed when he was asked about Resident #39's FreeStyle Libre 2 sensor that was ordered on 09/23/25 not being available Medical Director #473 stated the Libre usually went through the insurance company and might not have been approved. Me[TRUNCATED]

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #11 received showers to her preference and in accordance with care planned interventions. This affected one resident (Resident #11) out of three reviewed for bathing. The facility census was 61.Findings include:Review of Resident #11's medical record revealed an admission date of 01/25/25 and diagnoses included cellulitis of left lower limb, peripheral vascular disease, and major depressive disorder. Review of Resident #11's care plan dated 03/06/25 included Resident #11 had an ADL self-care performance deficit related to impaired mobility, muscle weakness and other diagnoses. Resident #11 would improve her current level of function in ADL's through the review date. Interventions included to provide bathing, showering per shower schedule and as requested; provide a sponge bath when a full bath or shower cannot be tolerated. Review of Resident #11's physician orders dated 03/20/25 revealed Resident #11 was a two person assist using a mechanical lift.Review of Resident #11's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #11 was cognitively intact. Resident #11 required substantial to maximal assistance with toileting hygiene and bathing. Resident #11 used a wheelchair and was dependent for chair-to-bed-to-chair transfers and the ability to get in and out of a tub or shower. Resident #11 did not reject care during the seven-day assessment look-back period.Review of Resident #11's progress notes dated 12/08/25 through 01/08/26 did not reveal evidence Resident #11 refused showers or requested a bed bath instead of a shower. Review of Resident #11's shower sheets dated 12/09/25 through 01/08/26 revealed there was no shower sheet provided for 12/08/25 or 12/18/25. Resident #11 had bed baths on 12/22/25, 01/02/26 and 01/05/26. Resident #11 had showers on 12/11/25, 12/15/25, 12/25/25 and 12/29/25. Review of Resident #11's electronic medical record aide charting for bathing and showers dated 12/08/25 and 12/18/25 revealed there was no evidence Resident #11 received a shower or bed bath. Observation on 01/08/26 at 11:08 A.M. of Resident #11's room revealed a sign on the door to the bathroom stated to give Resident #11 showers on Monday and Thursday evenings.Observation on 01/08/25 at 11:08 A.M. of Resident #11 revealed she was lying in bed and Licensed Practical Nurse (LPN) #410 and Certified Nursing Assistant (CNA) #481 were providing care. Resident #11 sighed and stated she did not have a shower for three weeks and had only been given bed baths. Resident #11 sighed again and stated it is what it is and said she wanted showers and did not care what time it was when she got the shower. When asked why Resident #11 was not getting showers as requested LPN #410 and CNA #481 stated Resident #11 was scheduled for showers on Monday and Thursday in the evenings, and that was not their shift. CNA #481 and LPN #410 indicated they were not sure but thought she was not getting showers when she was scheduled because she used a mechanical lift and needed two staff to assist, and there might not have been enough staff available for a shower. Resident #11 stated she told the nurses and aides she preferred showers.Review of the facility policy titled Your Rights and Protections as a Nursing Home Resident undated included as a nursing home resident you have certain rights and protections under Federal and State law that help ensure you get the care and services you need. You have the right to be informed, make your own decisions, and have your personal information kept private. You have the right to be treated with dignity and respect, as well as to make your own schedule and participate in activities you choose. You have the right to decide when to go to bed, rise in the morning, and eat your meals. You have the right to take part in developing your care plan. You have the right to participate in the decisions that affected your care.This deficiency represents non-compliance investigated under Complaint Number 2683768.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #21 received adequate oral care. This affected one resident (Resident #21) out of three residents reviewed for oral care. The facility census was 61.Findings include:Review of Resident #21's medical record revealed an admission date of 10/08/24 and diagnoses included spastic quadriplegic cerebral palsy, adult failure to thrive, and quadriplegia.Review of Resident #21's care plan dated 11/04/24 included Resident #21 had an activities of daily living (ADL) self-care performance deficit related to impaired mobility, spastic cerebral palsy, quadriplegia and other diagnoses. Resident #21 would improve his current level of function in ADL's through the review date. Interventions included oral care every shift and as needed per facility policy; Resident #21 required one staff member to assist with personal hygiene and oral care. Review of Resident #21's Annual Minimum Data Set assessment dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 was dependent for eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene and bed mobility. Resident #21 was always incontinent of urine and bowel. Resident #21 did not reject care during the seven-day assessment look-back period.Observation on 01/08/26 at 7:49 A.M. of Certified Nursing Assistant (CNA) #481 revealed she was in the hall outside Resident #21's room and stated she just arrived for work and was completing resident rounds. CNA #481 stated she was new to the facility and had not taken care of the residents on this hall before including Resident #21.Observation on 01/08/26 at 8:18 A.M. of Resident #21 revealed he was lying in bed and slightly turned onto his left side and his head was tilted towards the left. Resident #21 stated sometimes he saw bugs flying around the room, and just saw them a little while ago. No observations of bugs were noted during the interview with Resident #21. Resident #21 stated some of the aides did not take care of him and he would like someone to brush his teeth. Observation of Resident #21's teeth revealed a large build up of yellowish-brown food material and what appeared to be tartar (hardened dental plaque, crusty and often yellowish or brownish deposit that formed on teeth when plaque wasn't removed by regular brushing and flossing) was seen at the base of all his teeth where the teeth met the gums. Resident #21's hair was matted at the back of his head, and his hands were contracted and drawn up towards his chest. Resident #21 was pleasant and answered questions appropriately.Observation and interview on 01/08/25 at 1:10 P.M. with CNA #481 of Resident #21 confirmed Resident #21's teeth had a large amount of yellowish-brown material on his teeth where the teeth meet the gums. CNA #481 confirmed Resident #21's teeth had really bad food build up, and confirmed his hair was matted at the back of his head. CNA #481 stated she noticed Resident #21's teeth when she was feeding him and it looked like they had not been brushed for a long time.Review of the facility policy titled Your Rights and Protections as a Nursing Home Resident undated included as a nursing home resident you have certain rights and protections under Federal and State law that help ensure you get the care and services you need. You have the right to be treated with dignity and respect, as well as to make your own schedule and participate in activities you choose. You have the right to decide when to go to bed, rise in the morning, and eat your meals.This deficiency represents non-compliance investigated under Complaint Number 2683768.

Based on interview and record review the facility failed to ensure Resident #62's nutritional care planned interventions, including record of meal intakes were implemented. This affected one resident (Resident #62) out of three residents reviewed for nutrition. The facility census was 61.Findings include:Review of Resident #62's closed medical record revealed an initial admission date of 04/16/23 and diagnoses included type two diabetes mellitus with diabetic neuropathy, anxiety disorder, obstructive and reflux uropathy, acute osteomyelitis of the left ankle and foot and Candida Auris. Resident #62 was transferred to the local hospital Emergency Department on 02/22/25 and did not return to the facility. Review of Resident #62's care plan dated 04/19/23 and revised on 03/13/25 included Resident #62 had the potential for altered nutrition, hydration related to type two diabetes mellitus, AMS, tremors, anxiety dysphagia, mechanically altered diet and other diagnoses. Resident #62 would not have unplanned significant weight changes through the next review. Resident #62 would consume more than 75 percent of two meals daily. Interventions included to monitor meal intakes and record on the STNA (CNA) flow record. Review of Resident #62's Quarterly Minimum Data Set assessment dated [DATE] included Resident #62 was cognitively intact. Resident #62 was dependent for toileting hygiene and lower body dressing, required substantial to maximal assistance with bathing, and required partial to moderate assistance with personal hygiene. Resident #62 required substantial to maximal assistance for the ability to roll from lying on his back to the left and right side and return to lying on his back on the bed, for the ability to move from sitting on the side of the bed to lying flat on the bed, and the ability to move from lying on the back to sitting on the side of the bed and with no back support and the ability to transfer from a bed to a chair or wheelchair. Resident #62 used a wheelchair and required partial to moderate assistance for the ability to wheel at least 50 feet and make two turns. Resident #62 did not reject care during the seven-day assessment look-back period. Review of Resident #62's aide charting dated 02/07/25 through 02/22/25 did not reveal evidence Resident #62 was eating and did not reveal evidence of monitoring Resident #62's meal intake and recording the percentage of his meals that were eaten. Review of Resident #62's progress notes dated 02/07/25 through 02/22/25 did not reveal evidence Resident #62 was eating, what his meal intake was or that he refused his meals. Interview on 01/15/25 at 9:58 A.M. with the Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #472 and Social Services Designee (SSD) #477 confirmed there was no evidence in Resident #62's medical record including aide charting that he was eating or his meal percentage intakes were recorded. RDCO #472 stated Resident #62's weights were stable and that was a good indicator he was eating, and the cafe was open when Resident #62 resided in the facility and he would often eat there.This deficiency represents non-compliance investigated under Complaint Number 2709129.

Based on observation, interview, record review and review of the local fire department report, the facility failed to ensure Resident #24's respiratory status was properly treated and monitored. This affected one resident (Resident #24) out of three residents reviewed for oxygen therapy. The facility census was 61.Findings include:Review of Resident #24's medical record revealed an admission date of 02/17/24 and diagnoses included nontraumatic subarachnoid hemorrhage, nontraumatic intracerebral hemorrhage in hemisphere, cortical, vascular dementia, and aphasia.Review of Resident #24's care plan dated 02/20/24 and revised 11/10/25 included Resident #24 had altered respiratory status, difficulty breathing related to respiratory failure, history of PE (pulmonary embolism), morbid obesity and history of trach. Resident #24 would have no symptoms of poor oxygen absorption and would have no complications related to SOB (shortness of breath) through the review date. Interventions included to monitor and document changes in orientation, increased restlessness, anxiety and air hunger; to monitor for signs and symptoms of respiratory distress and report to the physician as needed such as increased respirations, decreased pulse oximetry, increased heart rate, diaphoresis, headaches, lethargy, confusion and skin color changes; to administer medication, puffers as ordered and monitor for effectiveness and side effects.Review of Resident #24's Quarterly Minimum Data Set assessment dated [DATE] included Resident #24 had severe cognitive impairment. Resident #24 had impairments on both sides of her upper and lower extremities, was dependent for toileting hygiene and required substantial to moderate assistance with bathing, dressing and personal hygiene. Resident #24 did not reject care during the seven-day assessment look-back period. Resident #24 used oxygen therapy.Review of Resident #24's progress notes dated 11/11/25 at 11:45 A.M. revealed Resident #24 had new orders to discontinue oxygen due to continued refusals with oxygen saturations maintaining in the 90's. The power of attorney (POA) was notified.Review of Resident #24's medical record, including progress notes, blood pressures, pulse, and oxygen saturations on 11/12/25 and from 11/14/25 through 11/25/25 did not reveal evidence Resident #24 was monitored for respiratory distress including decreased pulse oximetry, increased heart rate, diaphoresis, headaches, lethargy, confusion and skin color changes.Review of Resident #24's progress notes dated 11/25/25 at 6:28 A.M. revealed Resident #24 was ordered a chest X-ray to rule out possible pneumonia. Findings show pneumothorax or pleural effusion which demonstrated much better depth of inspiration since prior exam. No new orders at this time. Resident #24 was updated and in agreement with plan of care. There was no evidence Resident #25 had vital signs checked including oxygen saturation level.Review of Resident #24's [NAME] Review dated 11/25/25 from the local fire department included a call was received from the facility at 9:01 A.M., EMS had patient contact at 9:04 A.M. and Resident #24 was transported to the local ED at 9:29 A.M. EMS was dispatched for an altered level of consciousness and shortness of breath. Upon arrival Resident #24 was found awaiting EMS. Resident #24 was conscious, and alert and oriented times three (time, place, person). Audible crackles could be heard from Resident #24. Resident #24's nurse stated Resident #24 was normally on continuous oxygen at two to four liters per minute via nasal cannula, and during her rounds she noticed Resident #24 did not have oxygen in the room. Resident #24's nurse indicated Resident #24 was normally more alert and today was presenting a little confused. Resident #24 stated she had been off her oxygen since last night. Resident #24's oxygen saturation level was 90 percent on room air and improved to 96 percent following oxygen administration of six liters per minute via nasal cannula. Resident #24's augmentation continued to improve following oxygen administration, and continued to improve during the transport. Resident #24 was given a DuoNeb treatment and her lung sounds cleared following the treatment. Resident #24's care was transferred to the receiving nurse and the receiving nurse and doctor were made aware of the incident at the nursing home pertaining to staff not giving Resident #24 her oxygen and Resident #24 wishes not to return there. Review of Resident #24's progress notes dated 11/25/25 at 9:10 A.M. included Resident #24's daughter was contacted to be notified Resident #24 was being sent to the ED, there was no answer and a voicemail was left. There was no evidence Resident #24's vital signs were checked or events leading up to the decision to send Resident #24 to the ED.Review of Resident #24's progress notes dated 11/25/25 at 9:38 A.M. revealed Resident #24 was sent to the ED for evaluation due to shortness of breath.Review of Resident #24's progress notes dated 11/25/25 at 4:53 P.M. included Resident #24 returned back from the ED. Resident #24 was diagnosed with chronic bronchitis and respiratory tract infection. Resident #24 returned to the facility and was receiving two liters of oxygen per minute due to oxygen levels were dropping and for comfort. New orders for Doxycycline (antibiotic) 100 mg to be given two times a day for ten days. Resident #24 had orders for Prednisone 50 mg every day for five days. Blood pressure was 160/60, 60 pulse, respirations 20 and Resident #24's oxygen saturation was 96 percent on oxygen at two liters per minute via nasal cannula, temperature 97.8 Fahrenheit.Review of Resident #24's physician orders dated 11/25/25 through 01/07/26 did not reveal orders for oxygen via nasal cannula.Review of Resident #24's oxygen saturation levels dated 11/27/25 at 7:45 P.M. revealed Resident #24's oxygen saturation level was 97 percent on oxygen via nasal cannula. It did not specify how many liters of oxygen per minute Resident #24 was receiving. Review of Resident #24's oxygen saturation levels dated 11/29/25 and oxygen saturation was 95 percent, 11/30/25 and oxygen saturation was 97 percent, 12/04/25 and oxygen saturation level was 98 percent and 12/30/25 and oxygen saturation level was 96 percent revealed Resident #24 was receiving oxygen via nasal cannula and it did not specify how many liters per minute she was receiving. On 11/28/25 at 7:26 P.M. the oxygen saturation level was 97 percent and Resident #24 was receiving oxygen at three liters per minute via nasal cannula. On 12/18/25 Resident #24's oxygen saturation level was 96 percent and she was receiving oxygen at two liters per minute via nasal cannula.Observation on 01/07/26 at 1:33 P.M. of Resident #24 revealed she was lying in her bed watching television. Resident #24 was well groomed and her room was clean and neat. When asked questions Resident #24's speech was somewhat garbled and it was hard to understand what she was saying. Observation of the room revealed an oxygen concentrator with a nasal cannula and tubing attached. The tubing and nasal cannula were lying on the floor with the oxygen being administered to the air and was running at three liters per minute nasal cannula.Observation on 01/07/26 at 1:43 P.M. of Resident #24 with Licensed Practical Nurse (LPN) #420 confirmed Resident #24 was not wearing her nasal cannula and the oxygen tubing and nasal cannula was lying on the floor with the oxygen being administered to the air. LPN #420 confirmed the oxygen was set to administer oxygen at three liters per minute via nasal cannula. When asked what it should be set at Resident #24 stated it should stay at two. LPN #420 checked Resident #24's physician orders and stated there were no physician orders for oxygen, and there had not been any orders since she went to the hospital on [DATE]. LPN #420 confirmed Resident #24 was administered oxygen without physician orders.Interview on 01/07/26 at 3:35 P.M. of the Director of Nursing (DON) and the Administrator revealed the DON stated Resident #24's oxygen was discontinued because she refused to wear it. The DON confirmed Resident #24 was not monitored for respiratory distress after the oxygen was discontinued, including oxygen saturation levels, blood pressures, respirations and was transported to the ED on 11/25/25 for shortness of breath. The DON confirmed there was no evidence Resident #24 had her vital signs checked on 11/25/25 when EMS was called for Resident #24's shortness of breath. The DON confirmed Resident #24 did not have a physician order for oxygen administration but that was corrected today. Review of the facility policy titled Oxygen Therapy revised 12/2022 included oxygen would be provided as needed and prescribed in a safe manner ensuring each resident received necessary respiratory care and services that were in accordance with professional standards of practice, the resident's care plan, and the resident's choice. Oxygen would be administered and titrated per physician orders. This deficiency represents non-compliance investigated under Complaint Number 2679739.

Based on record review, interview, review of facility policy and review of Centers for Disease Control and Prevention guidelines, after Resident #62 was found to be positive for Candida Auris (a fungal infection that can cause severe, often drug resistant infection, the facility failed to ensure the facility tracked the infection for signs/symptoms and control of the infection within their infection control program, and failed to ensure the resident and family were timely educated and knowledgeable of the treatment and/or precautionary mechanisms required for the infection. This affected one resident (Resident #62) out of three reviewed for infection control. The facility census was 61. Findings include: Review of Resident #62's closed medical record revealed an initial admission date of 04/16/23 and diagnoses included type two diabetes mellitus with diabetic neuropathy, anxiety disorder, obstructive and reflux uropathy, acute osteomyelitis of the left ankle and foot and Candida Auris. Resident #62 was transferred to the local hospital Emergency Department on 02/22/25 and did not return to the facility. Review of Resident #62's care plan dated 04/05/24 and revised on 03/13/25 revealed Resident #62 was on Enhanced Barrier Precautions related to Candida Auris. Enhanced Barrier Precautions would be maintained throughout the review period. Interventions included to educate the resident, family, and staff regarding Enhanced Barrier Precautions. Review of Resident #62's Quarterly Minimum Data Set assessment dated [DATE] included Resident #62 was cognitively intact. Resident #62 was dependent for toileting hygiene and lower body dressing, required substantial to maximal assistance with bathing, and required partial to moderate assistance with personal hygiene. Resident #62 required substantial to maximal assistance for the ability to roll from lying on his back to the left and right side and return to lying on his back on the bed, for the ability to move from sitting on the side of the bed to lying flat on the bed, and the ability to move from lying on the back to sitting on the side of the bed and with no back support and the ability to transfer from a bed to a chair or wheelchair. Resident #62 used a wheelchair and required partial to moderate assistance for the ability to wheel at least 50 feet and make two turns. Resident #62 did not reject care during the seven-day assessment look-back period. Review of Resident #62's physician orders revealed Enhanced Barrier Precautions due to Candida Auris was originally ordered on 04/04/24 and was an active order through 02/22/25 when Resident #62 was transported to the local ED. Review of Resident #62's medical record revealed Resident #62 was on lifelong precautions related to Candida Auris. The medical record contained no evidence the resident and/or resident representative received education on the infection, treatment for, and precautions necessary for the infection until 02/13/25. Review of Resident #62's medical record including progress notes dated 11/21/24 through 02/22/25 did not reveal evidence Resident #62 did not want his family to be including in his care and treatment. Attempted review of the facility infection control logs from 11/21/24 through 02/22/25 revealed the facility was unable to provide infection control logs for review. Review of Resident #62's Care Plan Conference Summary dated 12/11/24 revealed Resident #62's diagnoses and his plan of care was reviewed and there were no issues. The summary of the care plan discussion was blank and did not include information related to Candida Auris discussed. There was no evidence family members attended the care conference. Review of the facility Infection Control Detail Report dated 02/01/25 through 02/28/25 did not reveal evidence Resident #62 had Candida Auris.Review of Resident #62's physician orders dated 02/10/25 revealed orders Contact Precautions, all therapies, treatments, activities, to be completed in room at all times, every shift for Candida Auris.Review of Resident #62's medical record contained no evidence as to why the resident went from enhanced barrier precautions to contact precautions. Review of Resident #62's progress notes dated 02/13/25 at 5:25 P.M. revealed Resident #62's Power of Attorney (POA) #478 was contacted by telephone to address Contact isolation due to Candida Auris. POA #478 was verbally aggressive towards the nurse and Unit Manager and continued to talk over the nurse. When trying to educate and explain the plan of care for the order obtained to swab Resident #62's skin to recheck for Candida Auris, POA #478 remained verbally aggressive. The Unit Manager placed a follow-up call to POA #478 (the note did not explain what happened with the follow-up call). The nurse reached out to the Social Worker to schedule a care conference with the IDT (interdisciplinary team). Review of Resident #62's progress notes dated 02/13/25 at 5:43 P.M. included the nurse called to obtain an order to swab Resident #62 to recheck a culture previously obtained at the local hospital. The wound swab was to be obtained, and an order was placed in lab. All parties were notified. Review of Resident #62's progress notes dated 02/13/25 at 6:00 P.M. revealed the nurse contacted POA #478 to follow-up regarding the Candida Auris. POA #478 was immediately hostile, screaming at the top of her lungs and making it incredibly difficult for the nurse to effectively communicate and answer questions and address concerns. The nurse was unable to provide an explanation. POA #478 ended the call abruptly after 20 minutes and the nurse did not have an opportunity to address or report any circumstances related to this issue. Review of Resident #62's progress notes dated 02/16/25 at 1:27 A.M. revealed Resident #62's Contact precautions for Candida Auris were continued. Review of Resident #62's progress notes dated 02/17/25 at 1:12 P.M. included a wound culture was collected to confirm Candida Auris. The culture was placed for pick up and the facility was awaiting results. All parties were notified. Review of Resident #62's progress notes dated 02/19/25 at 1:02 P.M. included POA #478 was notified that lab results were negative, and Resident #62 was out of isolation. Resident #62 continued to be on Enhanced Barrier Precautions due to Resident #62 scratching and picking at skin of his arms and hands. Resident #62 was notified. Interview on 01/07/26 at 3:35 P.M. with the Director of Nursing (DON) and the Administrator revealed the DON confirmed Resident #62 had Candida Auris, she did not know where the Candida Auris was found on Resident #62, and she was not sure when the Candida Auris was first identified but thought it was in February 2025. Interview on 01/12/26 at 10:32 A.M. with Nurse Practitioner (NP) #470 revealed he worked with Medical Director #473 and on 11/21/24 Resident #62 requested that his Primary Care Physician be changed from Medical Director #473 to Physician 474. Interview on 01/12/26 at 4:55 P.M. with NP #470 revealed he was not sure why Resident #62 was on Enhanced Barrier Precautions and not sure when it was recommended that he stay on lifelong precautions related to Enhanced Barrier Precautions. Interview on 01/12/25 at 3:59 P.M. with Social Services Designee (SSD) #477 revealed she arranged Resident #62's care conferences, and on 12/11/24 the Administrator, the MDS Nurse and the Activity Director were present at the care conference meeting. Interview on 01/12/26 at 4:20 P.M. of Physician Assistant (PA) #471 revealed he worked with Physician #474 and on 11/21/24 Resident #62 requested a change and wanted Physician #474 to be his Primary Care Provider. PA #471 stated he was not informed of Resident #62's Candida Auris and was given no documentation about it when he started caring for Resident #62. PA #471 stated he did not see anything in the immediate chart when he took over and if he did see a past medical history for Candida Auris he would have documented it. PA #471 stated he was not aware of the Candida Auris and talked to Physician #474 when he found out Resident #62 had it and Physician #474 stated Resident #62 likely had a colonization. Interview on 01/12/26 at 5:39 P.M. with Regional Director of Clinical Operations (RDCO) #472 revealed a staff member, she didn't know which staff member but thought it was probably Registered Nurse (RN) #476 found that Resident #62 had Candida Auris while she was reviewing his medical record and contacted her. RDCO #472 stated the facility had private rooms and she told RN #476 to place Resident #62 in Contact isolation and to obtain an order for a repeat culture for Candida Auris. The culture was negative. RDCO #472 confirmed there was no evidence in Resident #62's medical record stating the family was notified he had Candida Auris and stated Resident #62 was found to have Candida Auris while he had a hospital admission, and the facility would not necessarily inform the family about the Candida Auris when he returned to the facility. RDCO #472 indicated Resident #62 was his own person, Resident #62's daughter was his POA and the POA did not kick in until Resident #62 could not make his own decisions. Interview on 01/13/25 at 9:51 A.M. with RDCO #472 revealed if Resident #62 had an active Candida Auris infection he would need Contact Precautions and if he was colonized with Candida Auris then he would need Enhanced Barrier Precautions. RDCO #472 stated the facility was not sure if Resident #62 had an active infection and placed him on Contact isolation until they knew. RDCO #472 indicated the wound swab was taken from the skin of Resident #62's arms. Interview on 01/13/25 at 10:42 A.M. with the Administrator and DON confirmed facility infection control logs from 12/2024 through 03/2025 could not be located, and it could not be determined if Resident #62's Candida Auris was tracked during those dates. The Administrator stated the former Infection Preventionist was RN #476 and she no longer worked for the facility. Interview on 01/13/26 at 8:22 A.M. with RN #476 revealed she was not the Infection Preventionist for the facility when she worked there. RN #476 stated she did a little bit of everything, was the Unit Manager for the vent floor and the nursing unit on the other side of the building. RN #476 stated she did some Infection Control work, but the traveling DON handled infection control and when the current DON began working in the facility, she took over the infection control work. RN #476 indicated when she left the facility around 09/2025 all the infection control material was in a binder and kept in the DON's office. RN #476 stated she was reviewing Resident #62's chart, found he had Candida Auris, contacted the corporate office, and was advised to put Resident #62 on Contact precautions. RN #476 stated she huddled with her staff and told them Resident #62 was on Contact precautions. RN #476 indicated Resident #62's family was angry when she contacted them to tell them he was being retested for Candida Auris and said if he had Candida Auris so long why was he just now put on Contact precautions. RN #476 revealed she took the culture from an open area on Resident #62's arm where he was scratching. RN #476 revealed one of the biggest reasons she left the facility was poor care and safety of the residents. Interview on 01/14/26 at 10:50 A.M. with Medical Director #473 revealed Resident #62 was his patient for awhile but he switched primary care providers in November 2024. Medical Director #473 revealed he did not remember anything about Resident #62 having Candida Auris, he was followed by the Podiatry service and had a lot of physicians. Medical Director #473 revealed he did not know why Infectious Disease Physician (IDP) #479 said Resident #62 should be on lifelong precautions related to Candida Auris, and for the small amount of Candida Auris he had that would not be concerning. Medical Director #473 revealed he did not think a meeting was needed to discuss Resident #62's Candida Auris, as it was common on everyone. If Resident #62 was spiking fevers and it could be determined he was infected and if none of that was from other things, then it can be said it was from Candida Auris. Interview on 01/15/26 at 9:58 A.M. with the DON, RDCO #472 and SSD #477 revealed SSD #477 stated she arranged care conferences and Resident #62's POA (POA #478) lived out of town and only came to the initial care conference meeting. SSD #477 stated Resident #62 was his own person and she asked him if he wanted his family involved in the care conferences and he stated no they did not need to be involved. SSD #477 stated she did not document anywhere in Resident #62's medical record that he declined to have his family involved in his care conferences. Review of CDC (Centers for Disease Control and Prevention) guidance titled Preventing the Spread of C. auris) dated 12/15/25 included C. auris could cause severe illness and spreads easily in healthcare facilities. Some patients carry C. auris on their skin and other body sites without it causing symptoms (colonization). Both infected and colonized patients could spread C. auris. Patients who were colonized could spread C. auris the same way that patients who were infected could. C. auris spreads easily in healthcare facilities and could cause life-threatening infections in some patients. Patients who were infected and patients who were colonized could spread C. auris onto nearby surfaces or objects including doorknobs, bedrails and medical equipment used for multiple patients. Other patients could get C. auris through contact with these items. C. auris could survive on surfaces for a long time and not all disinfectants could kill it. Patients could remain colonized for weeks, months or longer even if they never had symptoms. Outbreaks often began when a patient who became infected or colonized in one facility was admitted or transferred to another. Healthcare facilities use the same IPC (infection prevention and control) measures for patients who were colonized and infected to help prevent them from spreading C. auris to others. Frequent hand-cleaning with ABHS (alcohol-based hand sanitizer) and soap and water if hands were soiled or ABHS was not available. Wear gloves and gowns to deliver care and ensure visitors clean hands with ABHS or soap and water. Patients infected or colonized with C. auris often continue to have it on their skin or other body sites for a very long time. Precautions were taken until they were discharged . For patients living in settings like nursing homes, long-term measures were taken based on the facility's policy. Healthcare facilities should be informed if an incoming patient has ever tested positive for C. auris with or without symptoms. Patients who were colonized or infected might have C. auris on their skin or body sites after discharge. Patients and close contacts should frequently clean their hands with ABHS or soap and water. Review of the facility policy titled Your Rights and Protections as a Nursing Home Resident undated included as a nursing home resident, you have certain rights and protections under Federal and State law that helped ensure you get the care and services you need. You have the right to be informed, make your own decisions, and have our personal information kept private. You have the right to be fully informed about your total health status in a language you understand. You have the right to be fully informed about your medical condition, to participate in the decisions that affect your care. The nursing home must notify your doctor and if known your legal representative or an interested family member when the following occurred, your physical, mental, or psychosocial status starts to get worse, you have medical complications, your treatment needed to change significantly. This deficiency represents non-compliance investigated under Complaint Number 2709129.

Based on review of medical records, interviews, and review of facility policy, the facility failed to ensure appropriate and timely routine skin assessments were completed for two residents (#58 and #61) of three residents reviewed for appropriate care and treatment related to altered skin integrity. The facility census was 57.Findings include: 1. Review of the medical record for Resident #58 revealed an admission date of 05/19/25 and a discharge date of 07/29/25. Pertinent diagnoses included acute respiratory failure with hypoxia, headache syndrome, severe persistent asthma, type two diabetes mellitus with hyperglycemia, schizoaffective disorder, muscle weakness, acute kidney failure, and hypothyroidism.Review of the admission Minimum Data Set (MDS) assessment completed on 05/26/25 revealed Resident #58 had intact cognition and no rejection of care. Further review of the MDS revealed Resident #58 had an upper extremity impairment on one side, required moderate assistance rolling left and right in bed, sitting from a lying position, standing from a sitting position, and with all transfers. The MDS also indicated that Resident #58 was not at risk for pressure ulcers, had no unhealed pressure ulcers, and had no other skin alterations. Interventions listed included pressure reducing devices for the bed and chair and the application of ointments or medications other than to the feet.Review of Resident #58's physician orders revealed an order dated 05/19/25 for a Braden skin assessment on admission and every week for three weeks. Further review of the orders revealed medication or treatment orders related to various skin conditions, including:- Orders for Nystatin (an antifungal) powder, dated 05/19/25 to 06/14/25 and another order dated 06/14/25, to be applied to the groin, abdomen, and breast two times a day. - Orders for Temovate external ointment (a topical corticosteroid), 0.05 percent (%), dated 05/20/25 through 06/14/25 and 06/16/25 through facility discharge, to be applied topically to the hands every Monday, Tuesday, Wednesday, Thursday, and Friday to reduce inflammation. Listed instructions noted to avoid application of the ointment to the face, breasts, groin, or armpits. - An order dated 06/14/25 for MetroCream External 0.75% (an antimicrobial cream), to be applied to the face topically every morning and at bedtime for redness. - An order for ketoconazole (an antifungal) external shampoo, 2%, dated 06/16/25, to be applied to the scalp one time a day every Monday, Tuesday, Wednesday, Thursday, and Friday. Review of the Nursing: admission Assessment completed on 05/19/25 revealed Resident #58 had a red area on the right buttock. The assessment included no information related to size, etiology, or contributing factors, presence of drainage, or the state of the surrounding tissue. Furthermore, the assessment revealed no indication the resident's physician was notified of the skin area or indication that treatments or interventions were put into place at the time the reddened area was identified. Review of the Braden scale assessment (a tool used by healthcare professionals to assess a patient's risk of developing a pressure ulcer) revealed the facility completed a Braden Scale assessment for Resident #58 on 05/19/25. There was no evidence subsequent assessments were completed once a week for three weeks following the admission assessment, as ordered. Review of this Braden scale assessment further indicated that Resident #58 had no mobility limitations and had sufficient strength to lift herself up from a chair and move independently in the bed and the chair (The admission MDS listed a mobility impairment and the need for moderate assistance). The assessment notes did not account for the presence of the reddened area that was assessed this same date on Resident #58's right buttock.Review of all assessments completed between 05/19/25 and 07/29/25 revealed no non-pressure skin grid assessments or pressure skin grid assessments were completed throughout the duration of Resident #58's time at the facility, despite the reddened area to the right buttock being identified upon admission. There was no indication of ongoing assessment or resolution of the altered skin integrity. Review of the Weekly Skin Check assessment revealed only one weekly skin assessment was completed, dated 07/21/25, in which no new skin problems were identified. The medical record contained no skin assessments, other than the admission assessment completed on 05/19/25. There were no ongoing assessments to show the reddened area was reassessed, tracked, or treated. Additionally, there were no skin assessments to indicate the necessity for use of antifungal, antimicrobial, or corticosteroid creams, lotions, powders, or shampoos as ordered. Review of the care plan from 05/20/25 through 09/14/25 revealed Resident #58 had actual impairment of skin integrity related to the right buttocks being reddened. Interventions included administration of treatments as ordered, adding a pressure-reducing device to the mattress and the chair, and follow facility protocols for treatment of skin injury. The care plan for actual skin integrity impairment was not resolved at any time during the duration of Resident #58's facility stay. Further review of the care plan revealed the facility initiated a care plan focus for antifungal therapy related to a yeast infection on 07/23/25 and resolved this focus on 07/24/25 (Resident #58 had orders for twice daily Nystatin powder for antifungal treatment from 05/19/25 through 07/29/25 and for Ketoconazole shampoo from 06/16/25 through 07/29/25). Review of the progress notes dated 05/19/25 revealed an admission note at 3:28 P.M. which indicated Resident #58 had a red area on the right buttock with no pain and a note at 11:15 P.M. which indicated Resident #58 had a reddened area to the center of the right buttock by the intergluteal cleft and a reference to see a new order for Triad Cream. Further review of the progress notes revealed a note dated 06/11/25 at 2:00 P.M. that Resident #58 had returned from an appointment with a dermatologist with new orders for ketoconazole and metrogel. There were no notes related to the reason for the appointment or reason for the new topical medications. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from May 2025, June 2025, and July 20205 revealed no documentation of weekly skin assessments being completed. Interview on 11/24/25 at 10:08 P.M. with the Director of Nursing (DON) confirmed that any completed weekly skin assessments should be found in the electronic medical record (EMR) under weekly skin checks. Interview on 11/24/25 at 3:10 P.M. with Registered Nurse (RN) #327 confirmed skin assessments were to be completed once a week by the nurses and that the order should pop up on the MAR or the TAR weekly to remind the nurse to complete the assessment. Interview on 11/25/25 at 3:35 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #346 revealed initial skin assessments were to be performed by the admitting floor nurse and then weekly thereafter by the floor nurse, and she was not certain of the process for notifying the wound nurse when residents were found to have altered skin integrity. LPN UM #346 further explained that the nurses should be prompted within the electronic medical record (EMR) to do a complete skin assessment, found under the clinical assessments tab. During the interview, LPN UM #346 confirmed being the wound care nurse for the facility since August 2025 and verbalized not always knowing when a resident developed a new skin concern, adding that she was uncertain as to whether the nursing staff had ever been instructed to pass the information along to the wound nurse. A follow-up interview with the DON on 11/25/25 between 4:00 P.M. and 4:30 P.M. confirmed the presence of the order dated 05/19/25 for a Braden scale assessment to be completed for Resident #58 on admission and then weekly for three weeks and confirmed that only Braden scale assessment one was completed, dated 05/19/25. During the interview, the DON also confirmed only one weekly skin assessment had been performed, dated 07/21/25, and that the red area reported on admission, as well as any other skin alteration, should have been assessed at least weekly, and there was no evidence the assessments were completed by nursing staff. 2. Review of the medical record for Resident #61 revealed an initial admission date of 03/07/25 and a discharge date of 11/12/25. Review of the Clinical Census revealed Resident #61 was out of the facility for greater than 24 hours, beginning on 10/13/25, with re-entry listed as 10/15/25. Pertinent diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of the bladder, type two diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure, Stage three chronic kidney disease, anxiety disorder, major depressive disorder, post laminectomy syndrome, and primary osteoarthritis of the right knee.Review of the care plan dated 03/11/25 revealed Resident #61 had an actual impairment of skin integrity of the coccyx. Interventions included encouragement of good nutrition and hydration, medication as ordered, monitoring skin integrity, documentation of the location, size, and treatment of the skin injury, reporting abnormalities, incontinence care as needed, and turning and repositioning as tolerated. Further review of the care plan revealed no care plan was put into place related to Resident #61 being at risk for impaired skin integrity secondary to mobility issues, MS, and bowel and bladder incontinence, just actual skin impairments noted during Resident #61's facility stay. Review of the Discharge Return Anticipated Minimum Data Set (MDS) 3.0 assessment completed on 10/13/25 revealed Resident #61 had moderate cognitive impairment and was dependent for transfers and required maximum assistance with toileting hygiene, bathing, and rolling left and right in bed. Further review of the MDS revealed Resident #61 had one unstageable pressure injury which presented as a deep tissue injury that was not present on admission.Review of the Skin: Pressure Ulcer/Wound Record Area #1 dated 09/30/25 revealed documentation that a new skin area on Resident #61's coccyx was first observed on 09/30/25. The assessment further revealed the pressure ulcer was unstageable and measured five centimeters (cm) by 3.7 cm by 0.1 cm. Wound care consisted of cleansing with normal saline solution, patting dry, and application of triad paste while leaving open to air. Further review of the assessment revealed that the wound reassessment frequency was to be every shift by the floor nurse and weekly by the wound Nurse Practitioner (NP). Review of all Weekly Skin Check - V 2 assessments from 03/07/25 (admission) to 09/30/25 (the date the new unstageable pressure ulcer was identified) revealed only two assessments, dated 07/22/25 and 09/19/25, had been completed. Review of the progress notes revealed a dietary note dated 09/30/25 at 1:19 P.M. indicating staff reported Resident #61 had a new deep tissue injury (DTI) on the right buttock. There were no nursing progress notes related to the new altered skin integrity identified on 09/30/25. Review of the orders revealed an order dated 10/16/25 for a Braden skin assessment to be completed on admission and every week for three weeks. Review of the Braden scale assessments revealed no Braden skin assessments were completed, as ordered, after re-entry on 10/15/25.Interview on 11/24/25 at 10:08 P.M. with the DON confirmed completed weekly skin assessments were kept in the electronic medical record (EMR) under weekly skin checks. During the interview, the DON confirmed that there were only two weekly assessments in the EMR completed for Resident #61, dated 07/22/25 and 09/19/25. Review of the policy titled Pressure Ulcer Prevention and Interventions, last revised January 2023, revealed all residents were to have skin assessed on a routine basis, which included a daily skin inspection, especially over bony prominences, for residents who had non-blanchable erythema (reddening of the skin), and documentation of findings no less frequently than weekly. This deficiency represents non-compliance investigated under Complaint Number 1401318.

Based on record review, interview, and facility policy review, the facility failed to ensure physician orders for weights were completed as ordered for one resident (#58). This had the potential to affect all residents residing in the facility. The facility census was 57. Findings include: Review of the closed medical record for Resident #58 revealed an admission date of 05/19/25 and a discharge date of 07/29/25. Diagnoses included but were not limited to acute respiratory failure with hypoxia, severe persistent asthma, type II diabetes with hyperglycemia, long term use of insulin, congestive heart failure, hypertensive heart disease and schizoaffective disorder, and post bariatric surgery status. Review of the 07/29/25 discharge Minimum Data Set (MDS) 3.0 for Resident #58 revealed a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. Review of the activities of daily living (ADLs) revealed Resident #58 was independent for meals. No weight was recorded on the MDS.Review of Resident #58's care plan last reviewed on 05/20/25 revealed potential for altered nutrition and hydration related to diagnosis of acute hypoxic respiratory failure, type II diabetes mellitus and history of bariatric surgery. Resident #58 also had physician-directed weight loss through the use of diuretics. A listed intervention included to monitor and record weights as physician ordered.Review of Resident #58's physician orders revealed an order dated 05/23/25 for daily weights to be obtained. Review of the Medication Administration Record (MAR) for July 2025 revealed staff were signing of Resident #58's daily weights on the MAR as being complete with the exception of 07/11/25 which was blank and 07/26/25 where it noted the resident refused. There were no actual weights recorded on the MAR. Review of Resident #58's weights under the weights tab in the electronic medical record revealed the last recorded weight was 05/27/25 which listed Resident #58's weight at 260.2 pounds.Interview on 11/19/25 at 2:30 P.M. with Registered Dietitian #369 confirmed the actual daily weights were not recorded on the resident's MAR, rather they were just checked off as complete. Registered Dietician #369 stated the weights should have been completed and recorded daily. Interview on 11/19/25 at 2:45 P.M. with the Director of Nursing (DON) confirmed daily weights were signed off but no weights were recorded in Resident #58's medical record as ordered by the physician. Review of the October 2024 revised facility policy called; Weight Policy and Procedure revealed residents will be weight monthly unless ordered otherwise by a physician. Weights will be recorded in the resident's medical record.

Based on interview, review of the medical record, and review of facility policy, the facility failed to ensure resident drug regimens did not include the unnecessary use of opioids. This affected one resident (#13) of four residents reviewed for appropriate pain management. The facility census was 57. Findings include:Review of the medical record for Resident #13 revealed an admission date of 02/17/24. Pertinent diagnoses included nontraumatic subarachnoid hemorrhage, nontraumatic intracerebral hemorrhage in the cortical hemisphere, dysphagia, aphasia, epilepsy, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment completed on 08/26/25 revealed Resident #13 had severe cognitive impairment but was usually able to make herself understood and usually understood others. Further review of the MDS revealed Resident #13 was on a scheduled pain regimen, received as needed analgesics (pain medications), and reported pain occurred almost constantly but rarely affected sleep or day-to-day activities. The MDS indicated that Resident #13 received medications from high-risk categories, including antidepressant, anticoagulant, antibiotic, anticonvulsant, and opioid. Review of the orders revealed Resident #13 had one routine order for control of neuropathy that included an order dated 01/21/25 for Gabapentin, 300 milligrams (mg), one capsule by mouth three times a day for neuropathic pain. The orders also included two PRN (as needed) analgesics (pain-relief medications): 1) orders dated 02/28/25 to 10/09/25 and 10/09/25 for acetaminophen oral tablet, 325 mg, give two tablets (650 mg) by mouth every six hours as needed for pain, and 2) orders dated 12/17/24 to 10/09/25 and 10/09/25 for oxycodone hydrochloride (an opioid typically prescribed to treat moderate to severe pain), five milligram tablet, give 5 mg by mouth every eight hours as needed for pain. Further review of the orders revealed consecutive orders, dated 02/17/24 to 10/09/25 and 10/09/25 through current, for staff to assess Resident #61 for pain every shift. The order specified that if pain was present, documentation was required and non-pharmacological interventions were to be attempted prior to administration of analgesics. Review of the care plan from 02/18/24 to 12/14/25 revealed Resident #13 was at risk for pain. Interventions included anticipating need for pain relief and responding immediately to any complaints of pain, documenting non-pharmacological intervention attempts prior to administration of pharmacological intervention, documenting probable cause of pain and removing or limiting causes where possible. The interventions further specify that non-pharmacological techniques to offer prior to administration of analgesics included relaxation techniques, meditation, guided imagery, soft music, dim lights, repositioning for comfort, offering a back rub, providing a quiet atmosphere, and instructing in deep breathing exercises.Review of the Medication Administration Record (MAR) from July 2025 revealed Resident #13 was administered oxycodone on 07/03/25 at 7:36 A.M. and 5:06 P.M., on 07/09/25 at 3:28 P.M., on 07/15/25 at 8:31 A.M. and 4:46 P.M., on 07/19/25 at 9:49 P.M. and on 07/20/25 at 5:51 A.M. with a pain assessment documented with the oxycodone administration as NA. No non-pharmacological interventions were noted on the MAR as being attempted prior to the administration of oxycodone during the corresponding shifts on 07/03/25, 07/09/25, 07/15/25, and 07/19/25 to 07/20/25 and the overall pain rating for the shifts was documented as zero for each of the corresponding shifts. Furthermore, Resident #13 did not receive acetaminophen, a non-opioid analgesic, prior to receiving acetaminophen. Review of the MAR also revealed that only two (07/13/25 at 11:23 P.M. and 07/26/25 at 9:36 P.M.) of the total 22 doses of oxycodone administered to Resident #13 in July 2022 had documentation of attempted non-pharmacological interventions prior to medication administration. Review of the linked electronic MAR (eMAR) progress notes dated 07/03/25 at 7:36 A.M., 07/09/25 at 3:28 P.M., 07/15/25 at 8:31 A.M. and at 4:46 P.M., 07/19/25 at 9:49 P.M., and 07/20/25 at 5:51 A.M. revealed no assessments that indicated Resident #13 experienced moderate to severe pain or requested to receive oxycodone. Further review of the notes revealed no non-pharmacological intervention attempts were made prior to medication administration. Review of the MAR from August 2025 revealed Resident #13 was administered 5 mg of oxycodone by mouth on 08/11/125 at 7:35 P.M., on 08/12/25 at 11:12 A.M., and on 08/26/25 at 1:18 P.M. with the corresponding pain scale rated as NA. No non-pharmacological interventions were noted on the MAR as being attempted prior to the administration of oxycodone during the corresponding shifts on 08/11/25, 08/12/25, or 08/26/25 with an overall pain assessment for the shift rated as zero on 08/11/25 and 08/12/25 and as NA on 08/26/25. Further review of the MAR revealed that out of the total of 13 doses of oxycodone administered to Resident #13 in August 2025, only three doses, the doses administered on 08/01/25 at 7:07 A.M. and 7:17 P.M., and on 08/09/25 at 8:09 P.M., had corresponding documentation of non-pharmacological intervention attempts prior to medication administration.Review of the linked eMAR progress notes dated 08/11/125 at 7:35 P.M., on 08/12/25 at 11:12 A.M., and on 08/26/25 at 1:18 P.M. revealed no indication that non-pharmacological interventions were attempted prior to medication administration or that Resident #13 experienced moderate to severe pain during care that did not subside after completion of personal care. Review of the MAR from September 2025 revealed Resident #13 was administered 5 mg of oxycodone by mouth on 09/06/25 at 7:46 P.M., on 09/09/25 at 8:00 A.M., and on 09/14/25 at 7:50 A.M. with pain rated as NA at the time of the medication administration. There were no pain interventions documented on the correlating shifts prior to the administration of the oxycodone. Further review of the MAR also revealed that no interventions were documented prior to the administration of oxycodone that was administered on 09/15/25 at 11:47 A.M. or on 09/18/25 at 10:15 P.M.Review of the linked eMAR progress notes dated 09/06/25 at 7:46 A.M., on 09/09/25 at 8:00 A.M., and on 09/14/25 at 7:50 A.M. revealed no indications Resident #13 experienced moderate to severe pain that did not subside with repositioning or completion of personal care or that any non-pharmacological interventions were attempted prior to administering Resident #13 oxycodone. Review of the MAR from October 2025 revealed Resident #13 was administered 5 mg of oxycodone by mouth on 10/05/25 at 9:29 P.M. and on 10/15/25 at 12:07 P.M. for pain rated between an five and six on a numerical pain rating scale (indicating moderate pain); however, there was no documentation that non-pharmacological interventions were attempted before medication administration and the corresponding eMAR progress notes contained no documentation of non-pharmacological intervention attempts. Review of the MAR from November 2025 revealed Resident #13 was administered 5 mg of oxycodone by mouth on 11/05/25 at 7:19 P.M. for a pain rated a one out of ten on the numerical pain rating scale (indicating mild discomfort) with no documented non-pharmacological interventions, no administration of acetaminophen for discomfort, and no progress note identifying that Resident #13 had uncontrolled pain which required administration of an opioid analgesic. Observation on 11/19/25 at 11:15 A.M. revealed Resident #13 resting soundly with no signs of discomfort and no stirring to verbal stimuli. Interview with Resident #13 on 11/20/25 from 9:37 A.M. to 9:47 A.M. revealed no report of pain and a history of neuropathy, for which Gabapentin was administered three times a day. During the interview, Resident #13 confirmed feeling pain during the provision of personal care by facility staff when they do not take their time or follow the resident's instructions. Resident #13 further stated that the staff who listen and take their time do not cause her to experience pain and that when pain does occur, the pain ceases once the care is completed or will, on occasion, last for a few minutes afterward but then settles without intervention or medication. Resident #13 verbalized that the intervention that most helps with pain is for staff to take their time during personal care and render care in the manner directed by Resident #13. During the interview, Resident #13 confirmed the use of oxycodone was not a preferred intervention. Interview on 11/25/25 at 1:24 P.M. with Certified Nurse Aide (CNA) #356 denied knowledge of Resident #13 requiring opioids for pain control, adding that Resident #13 does not experience much pain when care is performed properly and that the pain subsides once care is completed. Interview on 11/25/25 at 2:05 P.M. with CNA #322 confirmed that Resident #13 was able to make her needs known to staff well, when staff are patient and take their time. Further interview with CNA #322 revealed the only time Resident #13 complains of pain is during personal care and repositioning and that the pain subsides when care is completed. CNA #322 also stated Resident #13 likes her legs to be rubbed and does not like her feet touching the footboard, and if staff pull Resident #13 up in bed when needed and take the time to ease anxiety during care, there were no longer any signs or verbalization of discomfort. Interview on 11/25/25 at 2:27 P.M. with CNA #306 confirmed Resident #13 understood others and was easy to understand when staff took the time to listen. During the interview, CNA #306 stated that Resident #13 seemed to experience anxiety, versus pain, during personal care, and that the anxiety and signs of discomfort go away once care is completed. Interview on 11/25/25 at 2:34 P.M. with CNA #357 confirmed Resident #13 was able to make her needs known to staff and that it was anxiety, not pain, exhibited by Resident #13 during care. During the interview, CNA #357 further revealed Resident #13 typically exhibits no signs of pain once care is completed and Resident #13 is repositioned as she specified to staff. Interview on 11/25/25 at 4:00 P.M. with the Director of Nursing (DON) confirmed NA meant not applicable and was not an approved method of documenting a pain assessment. The DON further revealed a pain assessment should be conducted to assess and understand the level of pain experienced by the resident prior to administering pain medication and then confirmed, regarding NA on the MAR, that she was seeing that all over the place on the pain assessments. During the interview, the DON confirmed the MAR reflected the lack of consistent pain assessments prior to administration of an opioid analgesic and the lack of intervention attempts documented prior to pain medication administration to Resident #13. Further interview revealed Resident #13 was capable of making her needs known to staff and that the DON was aware that Resident #13 did not like the use of controlled substances. Review of the policy titled Pain Management last updated February 2023 revealed if a resident was assessed to have pain, the nurse was to explore both pharmacological and non-pharmacological interventions and implement the interventions listed in the resident's comprehensive care plan and professional standards of practice. The policy further specified that pain relief strategies should be appropriate for the type of pain or pain related symptoms. This deficiency represents non-compliance identified while investigating Complaint Number 1401319.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure a medication error rate of less than five percent (%). This affected two residents (Residents #12 and #39) of five residents (Residents #5, #12, #13, #30, and #39) observed during medication administration when the observation resulted in an error rate of 8.33%. The facility census was 57.1. Review of the medical record for Resident #12 revealed an admission date of 12/06/23 with pertinent diagnoses including spinal stenosis, depression, type two diabetes mellitus, repeated falls, polyarthritis, nonexudative age-related macular degeneration, hyperlipidemia, obstructive reflux uropathy, essential (primary) hypertension, benign prostatic hyperplasia without lower urinary tract symptoms and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 09/02/25 revealed Resident #12 had intact cognition with no observed behaviors. Further review of the MDS revealed Resident #12 required setup or clean-up assistance for eating, oral care, and personal hygiene. High-risk medications included drugs from the antibiotic category. Review of the care plan dated 09/16/25 revealed Resident #12 had the potential for impaired skin integrity. Interventions included administration of medications and treatments as ordered. Further review of the care plan revealed Resident #12 had impaired cognitive function and impaired visual function with interventions including administration of medications as ordered and monitoring for side effects of medications. Review of the medication orders revealed the following medications were to be administered to Resident #12 in the mornings:- Acidophilus oral capsule, give one capsule by mouth two times daily for supplement, dated 02/10/25, scheduled for 7:00 A.M. to be administered by a clinician- Cipro 500 milligram (mg) oral tablet, give one tablet by mouth two times daily for seven days for urinary tract infection (UTI), dated 11/16/25 and scheduled for administration by a clinician in the mornings between 7:00 A.M. and 11:00 A.M.- PreserVision AREDS2 oral capsule, give one capsule by mouth two times a day related to macular degeneration, dated 07/10/24, scheduled for morning administration by a clinician, which included tome span between 7:00 A.M. and 11:00 A.M.- Oyster calcium with vitamin D3 tablet, 500 mg - five micrograms (mcg), give one tablet by mouth in the morning for supplement, dated 07/10/24, to be administered by a clinician between 7:00 A.M. and 11:00 A.M. - Atenolol 25 mg oral tablet, give one tablet by mouth each morning for hypertension, dated 07/10/24, to be clinician-administered between 7:00 A.M. and 11:00 A.M. - Senna 8.6 mg tablet, give one tablet by mouth in the morning for constipation, dated 08/28/25, to be clinician-administered between 7:00 A.M. and 11:00 A.M.- Lac-Hydrin five external lotion five percent (%) to be applied topically to bilateral lower extremities twice a day for dry skin, dated 04/18/25 in the morning at 8:00 A.M. by the clinician- Multivitamin with minerals oral tablet, give one tablet by mouth in the morning for supplement, dated 07/20/24 to be administered daily at 8:00 A.M. by the clinician- Vitamin D3 tablet 1,000 units, give one tablet by mouth in the morning for health maintenance, dated 07/16/24, scheduled for 8:00 A.M. for clinician administration- Fish oil 1,000 mg oral capsule by mouth two times a day for supplement, dated 06/27/25, scheduled for clinician administration at 8:00 A.M. Observation on 11/20/25 of Licensed Practical Nurse (LPN) #303 preparing and administering medications for Resident #12 revealed, after checking Resident #12's blood pressure and pulse, LPN #303 dispensed the following medications into a clear plastic medicine cup between 9:03 A.M. and 9:08 A.M.:- Acidophilus 1billion units, one capsule- Multivitamin with minerals, one tablet- Atenolol 25 mg, one tablet- Vitamin D, 25 micrograms (mcg) (1,000 units), one tablet- Ciprofloxacin 500mg, one tablet- ProSight with zinc (the facility substitute for PresserVision AREDS2), one capsule- Oystershell 500-5mg plus D, one tabletInterview on 11/20/25 at 9:08 A.M. with LPN #303 revealed the ordered Senna, 8.6 mg, was not in the medication cart. Observation at this time revealed LPN #303 locking the prepared medication in the cart and leaving the unit at 9:09 A.M until returning at 9:15 A.M. Continued observation at that time revealed the new bottle of Senna was opened, dated, then one tablet was dispensed into the same medicine cup as the other seven pills. At 9:18 A.M., LPN #303 confirmed a total of eight pills were in the medication cup. Continued observation on 11/20/25 at 9:18 A.M. revealed LPN #303 entered the room of Resident #12, handed Resident #12 the medicine cup with the eight pills, verified Resident #12 had water, then left the room. Interview on 11/20/25 at 12:51 P.M. with Resident #12 revealed only pills were given at the time of the observation (at 9:19 A.M.) and Resident #12 was usure if lotion was applied to the legs that morning, stating I really can't remember getting it put on this morning.Interview on 11/20/25 at 3:29 P.M. with LPN #303 confirmed that Resident #12 had an order for Fish Oil that was supposed to be given twice daily, at 8:00 A.M. and at 8:00 P.M. Review of the progress note dated 11/20 25 at 3:57 P.M. revealed LPN #303 had identified the missed morning dose of fish oil and notified the Nurse Practitioner. Review of the Medication Administration Audit Report (MAAR) for Resident #12 for the morning medication administration pass on 11/20/25 revealed LPN #303 documented at 9:08 A.M. that all medications that were scheduled at 7:00 A.M. and 8:00 A.M., except Senna 8.6 mg fish oil 1,000 mg, were administered between 9:05 A.M. and 9:06 A.M. (these medications were observed being handed to Resident #12 at 9:19 A.M.). The documentation indicated Lac-Hydrin 5% lotion was administered to Resident #12's bilateral lower legs at 9:06 A.M., at the same time the oral medications were listed as administered. The MAAR further contained documentation that Senna 8.6 mg was administered to Resident #12 at 9:16 A.M. (documentation entered at 9:18 A.M.). There was no entry on the MAAR that fish oil 1,000 mg (scheduled for 8:00 A.M.) was administered the morning of 11/20/25. Review of the policy titled Medication Administration - General Guidelines last revised August 2014 revealed medications were to be administered as prescribed, the medication order should be verified against the medication label, and the person giving the medication was to ensure the right medication was given to the right resident, adhering to the right dose, right route, and right time. Further review of the policy revealed medications were to be administered within 60 minutes of the scheduled time, unless otherwise specified by the prescriber. The policy specified that the person administering the medications was to record medication administration on the MAR directly after the medications was administered.2. Review of the medical record for Resident #39 revealed an admission date of 12/20/24 with diagnoses including ossification of muscle, multiple sites (abnormal formation of bone within muscle tissue), subsequent encounter for closed fracture with routine healing of part of the neck of the right femur, paraplegia, neuromuscular dysfunction of the bladder, anemia, major depressive disorder, unspecified injury of the thoracic spinal cord from thoracic vertebrae seven through ten, and chronic pain due to trauma. Review of the annual Minimum Data Set (MDS) 3.0 assessment completed on 11/04/25 revealed Resident #39 had intact cognition. Further review of the MDS revealed Resident #39 required setup or cleanup for eating and received medications from high-risk categories, including antidepressant, opioid, antiplatelet, and anticonvulsant. Review of the orders revealed an order dated 12/20/24 for aspirin, 81 milligram (mg) capsules, give Resident #39 one capsule by mouth in the mornings for mild pain. Review of the care plan dated 11/23/25 revealed Resident #39 was at risk for pain related to paraplegia, neuropathy, spinal cord injury, right femoral neck fracture, ossification of the hip, and gout. Interventions included responding appropriately and timely to complaints of pain and assessing pain relief measures. Further review of the care plan revealed Resident #39 had an alteration in musculoskeletal status and interventions included providing analgesics as ordered by the physician. Observation on 11/20/25 from 8:15 A.M. to 8:25 A.M. of Resident #39's morning medication administration by Registered Nurse (RN) #361 revealed that when the ordered aspirin, 81 mg oral capsule, was prepared for administration, the aspirin was dispensed from a bottled labeled aspirin 81 mg chewable tablet and placed in the same medication cup as the other morning medications in oral tablet and oral capsule forms. Further observation revealed Resident #39 poured the cupful of pills in his mouth, including the chewable aspirin, and swallowed the pills together with a gulp of water. Interview on 11/20/25 at 8:45 A.M. with RN #361 confirmed the aspirin was dispensed from a bottle indicating it was a chewable tablet and that the aspirin was placed in the same medication cup as the other oral tablets and capsules. Further interview confirmed that Resident #39 swallowed the aspirin, instead of chewing the aspirin. During the interview, RN #361 also confirmed the order was for an oral capsule and not chewable tablet and added that the facility did not carry the low dose aspirin in capsule form, just the enteric coated aspirin and the chewable tablets.Review of the policy titled Medication Administration - General Guidelines last revised August 2014 revealed medications were to be administered as prescribed, the medication order should be verified against the medication label, and the person giving the medication was to ensure the right medication was given to the right resident, adhering to the right dose, right route, and right time. This deficiency represents non-compliance investigated under Complaint #1401318.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure medications were not left with a resident to take independently who was not approved to safely store or self-administer medications. This affected one resident (#12) of five residents observed and reviewed for medication administration. The facility census was 57.Findings include: Review of the medical record for Resident #12 revealed an admission date of 12/06/23 with pertinent diagnoses including spinal stenosis, depression, type two diabetes mellitus, repeated falls, polyarthritis, nonexudative age-related macular degeneration, hyperlipidemia, obstructive reflux uropathy, essential (primary) hypertension, benign prostatic hyperplasia without lower urinary tract symptoms and gastro-esophageal reflux disease.Review of the assessments revealed a Nursing: Self-Administration of Medications evaluation completed on 01/26/25 indicated Resident #12 could not safely administer all medications but could safely administer Pantoprazole and Synthroid only. The assessment did not indicate the ability to safely store medications at the bedside. Further review of the assessments revealed no follow-up evaluation was completed with the quarterly assessments.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 09/02/25 revealed Resident #12 had intact cognition with no observed behaviors. Further review of the MDS revealed Resident #12 required setup or clean-up assistance for eating, oral care, and personal hygiene. High-risk medications included drugs from the antibiotic category. Review of the active medication orders revealed the following medications were to be administered to Resident #12 by a clinician with the morning medication pass:- Acidophilus oral capsule, give one capsule by mouth two times daily for supplement, dated 02/10/25, scheduled for 7:00 A.M. to be administered by a clinician- Cipro 500 milligram (mg) oral tablet, give one tablet by mouth two times daily for seven days for urinary tract infection (UTI), dated 11/16/25 and scheduled for administration by a clinician in the mornings between 7:00 A.M. and 11:00 A.M.- Preservision AREDS2 oral capsule, give one capsule by mouth two times a day related to macular degeneration, dated 07/10/24, scheduled for morning administration by a clinician, which included tome span between 7:00 A.M. and 11:00 A.M.- Oyster calcium with vitamin D3 tablet, 500 mg - five micrograms (mcg), give one tablet by mouth in the morning for supplement, dated 07/10/24, to be administered by a clinician between 7:00 A.M. and 11:00 A.M.- Atenolol 25 mg oral tablet, give one tablet by mouth each morning for hypertension, dated 07/10/24, to be clinician-administered between 7:00 A.M. and 11:00 A.M.- Senna 8.6 mg tablet, give one tablet by mouth in the morning for constipation, dated 08/28/25, to be clinician-administered between 7:00 A.M. and 11:00 A.M.- Lac-Hydrin five external lotion five percent (%) to be applied topically to bilateral lower extremities twice a day for dry skin, dated 04/18/25 in the morning at 8:00 A.M. by the clinician- Multivitamin with minerals oral tablet, give one tablet by mouth in the morning for supplement, dated 07/20/24 to be administered daily at 8:00 A.M. by the clinician- Vitamin D3 tablet 1,000 units, give one tablet by mouth in the morning for health maintenance, dated 07/16/24, scheduled for 8:00 A.M. for clinician administration- Fish oil 1,000 mg oral capsule by mouth two times a day for supplement, dated 06/27/25, scheduled for clinician administration at 8:00 A.M.Observation on 11/20/25 from 9:03 A.M. to 9:18 A.M. of Licensed Practical Nurse (LPN) #303 preparing and administering medications for Resident #12 revealed the following medications were placed in a clear plastic medication cup: Acidophilus 1 billion units, one capsule; multivitamin with minerals, one tablet; Atenolol 25 mg, one tablet; vitamin D, 25 micrograms (mcg) or 1,000 units, one tablet; Ciprofloxacin 500 mg, one tablet; ProSight with zinc (the facility substitute for Preservision AREDS2), one capsule; and Oystershell 500-5 mg plus D, one tablet. Interview with LPN #303 at the time of observation confirmed a total of eight pills were in the medicine cup for Resident #12. Observation on 11/20/25 between 9:18 A.M. and 9:19 A.M. revealed LPN #303 entered the room of Resident #12, handed Resident #12 the medicine cup containing eight pills, verified Resident #12 had water, and then left the room as Resident #12 was picking up the first pill from the medicine cup and placing it into his mouth. Continued observation revealed LPN #303 returned to the medication cart and began preparing medications for another resident in the hallway, with no view of Resident #12, from 9:19 A.M. to 9:20 A.M. LPN #303 then locked the medications cart and left the unit, stating a needed medication was not on the cart and needed picked up from the pharmacy. As LPN #303 was observed walking away from the unit at 9:20 A.M., Resident #12 was observed continuing to independently take the medications handed to him, one by one, until the last one was swallowed at 9:22 A.M. (LPN #303 was not on the unit at that time). Interview on 11/20/25 at 9:23 A.M. with Resident #12 confirmed the medicine cup with pills is sometimes left in the room for him and reported that some nurses did that because they know they can count on me and then added, I just took them all, referring to the pills. Interview on 11/20/25 at 9:35 A.M. with LPN #303 confirmed Resident #12 liked to take time to look at each pill, one by one, and let his wife know what each pill was that he received. During the interview, LPN #303 confirmed handing the medication cup with pills to Resident #12, verifying a drink was available to help swallow the pills, and leaving after he began taking the pills, though LPN #303 also denied that the medication was left at the bedside or that the medications were not considered nurse-administered, reasoning that the pills were handed directly to Resident #12 in the medication cup, after already being dispensed by the nurse from the containers. Further interview confirmed LPN #303 did leave the unit just after leaving the medications with Resident #12.Review of the list of residents the facility identified as able to self-administer medications did not include Resident #12. Review of the policy titled Self-Administration of Medications last revised August 2014 revealed the ability to self-administer medications was to be reassessed on a quarterly basis and with a significant change in condition.This deficiency represents non-compliance investigated under Complaint Number 1401318.

Based on medical record review, interview, and facility policy review, the facility failed to ensure a resident's admission was timely completed and failed to ensure routine assessments were completed as required. This affected three residents (#60, #2, and #61) of six residents reviewed for accuracy of medical records. The facility census was 57. Findings include: 1. Review of the closed medical record for Resident #60 revealed an admission date of 07/12/25 and a discharge date of 07/24/25. Diagnoses included but were not limited to rhabdomyolysis, sepsis, hydronephrosis, dysfunction of bladder, and elevated white blood cell count. Review of the hospital discharge instructions dated 07/11/25 for Resident #60 revealed medication orders for Albuterol 90 micrograms (mcg) inhaler as needed, Amlodipine 5 milligram (mg) oral tablet to be taken by mouth twice a day, Ceftriaxone 500 mg oral tablet to be given by mouth twice daily for ten days. Doxazosin 2 mg oral tablet to be given by mouth twice daily, finasteride 5 mg oral tablet to be given by mouth daily, Metoprolol tartrate 50 mg oral tablet to be given by mouth twice daily, multivitamin one tablet by mouth once daily, Protonix 40 mg delayed release tablet to be given by mouth daily, Xarelto 20 mg tablet by mouth daily with evening meal, Zocor 40 mg tablet to be given by mouth at bedtime, Spironolactone 50 mg oral tablet to be given by mouth at breakfast, tamsulosin 0.4 mg oral capsule to be given by mouth twice daily, and Spiriva Respimat 60 mcg per inhalation aerosol two puffs to be given daily as needed for shortness of breath. Review of the admission assessment dated [DATE] timed at 10:07 A.M. opened by Licensed Practical Nurse (LPN) #319 for Resident #60 revealed the assessment was not complete. The information contained in the assessment was populated from a previous admission in 2023 and did not contain current information. Review of the physician orders for Resident #60 revealed an order dated 07/12/25 timed at 7:09 P.M. had been entered for Amlodipine Besylate tablet 10 mg by mouth one time a day for hypertension, Pantoprazole sodium tablet delayed release 40 mg by mouth one time a day for acid reflux, Simvastatin tablet 40 mg tablet by mouth at bedtime for hyperlipidemia, and Tamsulosin hydrochloride capsule 0.4 mg by mouth one time a day for benign prostatic hyperplasia (BPH). Review of the physician orders for Resident #60 revealed an order dated 07/12/25 timed at 7:29 P.M. entered for Doxazosin Mesylate 4 mg oral tablet by mouth two times a day for blood pressure. Review of the physician order for Resident #60 revealed an order dated 07/12/25 timed at 7:31 P.M. for Finasteride 5 mg oral tablet by mouth in the evening for BPH. Review of the physician order for Resident #60 revealed an order dated 07/12/25 timed at 7:41 P.M. for Rivaroxaban 20 mg oral tablet by mouth in the evening for anticoagulation. Review of the nursing progress note dated 07/12/25 timed at 8:08 P.M. written by LPN #319 for Resident #60 revealed he was admitted to the facility at 10:00 A.M. Vitals and a head-to-toe assessment were noted to be completed and documented. Review of the nursing progress noted dated 07/13/25 timed at 8:40 A.M. revealed Licensed Practical Nurse (LPN) #371 assisted LPN #372 with Resident #60 who was found to be sideways wedged between the two head rails and there was noted blood on the floor. Resident #60 was able to be repositioned in the bed and was noted to have a dent on the top of his head with a small lump on the side of the dent. Resident #60 stated he had been hallucinating. LPN #371 called the physician and received an order to send Resident #60 out to a local hospital for evaluation. Review of the nursing progress note dated 07/13/25 timed at 10:38 A.M. revealed LPN #371 spoke with the emergency room physician who stated Resident #60 was sent to the hospital without paperwork. LPN #371 updated the physician on Resident #60's status. Review of the July 2025 Medication Administration Record (MAR) for Resident #60 revealed only three of the physician-ordered medications with a start date of 07/12/25 were listed. Two Amlodipine Besylate oral tablet 2.5 mg oral tablets were noted as being given at 8:00 P.M. on 07/12/25, Doxazosin Mesylate oral tablet 4 mg by mouth was noted as not being given and to see nurses notes, and Tamsulosin HCl oral capsule 0.4 mg was given at 8:00 P.M. Review of Resident #60's care plan revealed it was initiated on 07/12/25 but not completed. Review of the 07/18/25 admission Minimum Data Set (MDS) 3.0 for Resident #60 revealed he had intact cognition. Resident #60 was noted to require maximum assistance from staff for toileting, bathing, dressing and transfers and was also noted to have an indwelling catheter. Telephone interview on 11/24/25 at 11:10 A.M. with LPN #371 revealed on the night of 07/12/25, she was working on another unit and was approached by two other nurses for help. When she entered Resident #60's room, there was blood on the floor, Resident #60 was sideways in the bed with his head wedged against the bed rail and his feet pushing against the other bed rail. They were able to get Resident #60 turned in the bed and noticed an indentation on his head from being wedged against the bed rail. The blood was noted to be from his intravenous (IV) access site. LPN #371 stated she attempted to review the physician orders, but they were in the queue and not completed or activated. LPN #371 called the physician and received orders to send Resident #60 out for evaluation. LPN #371 told LPN #372 to call for transport. LPN #371 also confirmed she received a phone call from Resident #60's hospital physician later the same day stating he was sent without any paperwork and asked for information as to what had happened prior to being sent to the hospital. Telephone interview on 11/24/25 at 12:25 P.M. with LPN #372 revealed she worked on the night of 07/12/25, it was her first day at the facility and she was having difficulty with her computer access for medical records and had notified management. LPN #372 had flushed Resident #60's IV as ordered and left his room to assist another resident. An aide, whom she did not recall their name, stated she needed help. When she entered Resident #60's room, he had turned himself sideways in the bed and was wedged between the railings near the top of the bed and he was pushing with his feet which pushed his head further against the other railing. Resident #60 had torn his IV site cap off and it bled onto the floor. LPN #372 stated she called 911 due to him being confused, pulling out the IV cap, and due to the indentation on his head from being wedged in the bed railings. LPN #372 stated she tried to find his initial nursing assessment but was unable to and confirmed no paperwork was sent with Resident #60 when he was transported to the local hospital. Telephone interview on 11/24/25 at 1:45 P.M. with LPN #319 confirmed when a resident is admitted they do a head-to-toe assessment, obtain vital signs, complete the admission assessment, and make a documentation note in the electronic medical record. LPN #319 confirmed the admission assessment should be completed within an hour of a resident's admission to the facility. LPN #319 did not recall Resident #60 and did not recall if admission paperwork or an assessment was completed. Interview on 11/24/25 at 2:02 P.M. with the Director of Nursing (DON) confirmed the admission assessment for Resident #60 was not completed and also confirmed physician orders for medications were not entered until at least 10 hours after admission and not all ordered medications were entered. Interview on 11/24/25 at 4:06 P.M. with Regional Director of Clinical #373 confirmed the admission assessment for Resident #60 was not completed and only had information from his previous admission in 2023. Regional Director of Clinical #373 also confirmed the admission assessment should have been completed within a couple hours of admission, medications should have been entered sooner than 10 hours after admission, and paperwork should have been sent with Resident #60 when he was sent to the hospital. Review of the November 2022 revised facility policy called; Admission, Discharge and Transfer revealed the facility will provide for a safe and appropriate admission, transfer and discharge as needed. Review of the December 2022 facility policy called; EHR Records and Documentation revealed the medical record shall reflect a resident's progress toward achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status. The licensed nurse will document on all new admissions by documenting in the admission UDA (PCC) within 24 hours. The medical record should provide sufficient information for staff to respond to the changing status and needs of the resident. 2. Resident #2 was admitted on [DATE] and had a re-entry date of 12/11/24. Diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, obstructive sleep apnea, anxiety disorder, cirrhosis of the liver, asthma, anemia, essential (primary) hypertension, personal history of neoplasm of the bladder, centrilobular emphysema, dependence on supplemental oxygen, gastrostomy status, and chronic pain syndrome. Review of the facility incident logs revealed Resident #2 had an unwitnessed fall on 07/05/25. Review of the clinical assessment history revealed the Nursing: Fall Risk Assessment - V 1 was completed on 09/22/24, 12/08/24, and 07/05/25 (Resident #2 was discharged and readmitted to the facility on [DATE]). There was no evidence that the fall risk assessment had been completed upon facility readmission or quarterly for Resident #2 for the current facility stay, until the fall that occurred on 07/05/25. Review of the quarterly MDS 3.0 assessment completed on 11/04/25 revealed Resident #2 had intact cognition, used a wheelchair for locomotion, and required moderate assistance with transfers. Further review of the MDS revealed Resident #2 had no history of falls since admission, re-entry, or completion of the previous comprehensive assessment. Interview on 11/24/25 from 9:00 A.M. to 9:15 A.M. with the DON revealed uncertainty as to the frequency that the fall risk assessments were to be completed, but would be checking the policy to make that determination. A follow-up interview on 11/25/25 between 4:20 P.M. and 4:30 P.M. with the DON confirmed no admission or quarterly fall risk assessments had been completed since Resident #2's rea-entry date of 12/11/24 and that the only assessment completed since re-entry was on 07/05/25, after Resident #2's fall. 3. Review of the medical record for Resident #61 revealed an initial admission date of 03/07/25 and a discharge date of 11/12/25. Review of the Clinical Census revealed Resident #61 was out of the facility for greater than 24 hours, beginning on 10/13/25, with re-entry listed as 10/15/25. Pertinent diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of the bladder, type two diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure, Stage three chronic kidney disease, anxiety disorder, major depressive disorder, post laminectomy syndrome, and primary osteoarthritis of the right knee. Review of the incident logs revealed Resident #61 had an unwitnessed fall on 09/20/25. Review of the clinical assessment history revealed Resident #61 had a Nursing: Fall Risk Assessment - V 1 completed on 03/11/25 for the initial admission and did not have another fall risk assessment completed until 09/20/25 after sustaining an unwitnessed fall. There was no record of quarterly fall risk assessments or a fall risk assessment being completed with readmission on [DATE]. Review of the Discharge with Return Anticipated Minimum Data Set (MDS) 3.0 assessment completed on 10/13/25 revealed Resident #61 had moderate cognitive impairment and was dependent for transfers. Further review of the MDS revealed Resident #61 had one fall with injury since admission, re-entry or the last assessment. Interview on 11/25/25 between 4:20 P.M. and 4:30 P.M. with the DON confirmed there had been no quarterly or readmission fall risk assessments completed between Resident #61's initial admission date and the date of the fall (09/20/25). Review of the policy titled Fall Management last updated December 2022 revealed a licensed nurse was to assess each resident for fall risk through the Fall Risk Assessment on admission, quarterly, and with significant changes. This deficiency represents non-compliance investigated under Complaint Numbers 2560788 and 1401316.

Based on observation, interview, record review, review of the facility policy, and review of hospital records, the facility failed to properly assess and monitor Resident #43 and Resident #59's urinary condition to timely identify and treat signs and symptoms of a urinary tract infection. Actual Harm occurred on 06/13/25 at 9:07 A.M to Resident #59 when the resident's care planned interventions to monitor urine output and orders to irrigate the catheter were not implemented, symptoms of a UTI were not timely identified, and the resident presented with an emesis, tachycardia with a heart rate of 143, complaints of being cold, had a large diarrhea bowel movement and chills. On 06/13/25 at 1:12 P.M. Resident #59 requested to be transported to the hospital after she started having difficulty breathing and her oxygen saturations were 87 to 88 percent. Resident #59 was transported to the hospital emergency department (ED) and was found to have septic shock secondary to catheter associated urinary tract infection (CAUTI) and acute kidney injury. Resident #59 had positive urine cultures for enterococcus and positive urine and blood cultures for Citrobacter. Resident #59 was treated with vasopressors and broad spectrum antibiotics. This affected two residents (Resident's #43 and #59) out of three residents reviewed for urinary tract infections. The facility census was 58.Findings include:1.Review of Resident #59's closed medical record revealed an admission date of 11/14/24 and diagnoses included chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypercapnia, obstructive and reflux uropathy, and retention of urine. Resident #59 was discharged from the facility on 07/11/25.Review of Resident #59's care plan dated 11/19/24 included Resident #59 had bowel and bladder incontinence, and required catheter care. Resident #59 would establish an individual bowel, bladder routine. Interventions initiated on 06/29/25 included to monitor intake and output; catheter care per policy.Review of Resident #59's care plan dated 12/19/24 and revised 07/24/25 included Resident #59 had an 18 French, five milliliter (ml) balloon indwelling catheter related to obstructive uropathy. Resident #59 would be, remain free from catheter related trauma through the review date. Interventions included monitor and document intake and output as per facility policy; monitor, record, report to the physician signs and symptoms of UTI (urinary tract infection) including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.Review of Resident #59's care plan dated 12/19/24 and revised on 07/24/25 included Resident #59 had hypertension. Resident #59 would remain free from signs and symptoms of hypertension through the review date. Interventions included to monitor, document abnormalities for urinary output and report significant changes to the physician.Review of Resident #59's medical record including progress notes, Medication Administration Record and Treatment Administration Record dated 12/19/24 through 06/29/25 did not reveal evidence Resident #59's urine outputs were monitored and recorded.Review of Resident #59's progress notes dated 12/28/24 at 5:28 P.M. revealed an aide reported to the nurse concerns Resident #59's urine was dark in color. The nurse observed Resident #59's urine was dark in color and Resident #59 stated this happened when she needed water. Resident #59 requested ice, cranberry juice and water. No blood was observed in Resident #59's urine at this time.Review of Resident #59's progress notes dated 12/30/24 at 8:49 A.M. revealed new orders to encourage fluids in place at this time.Review of Resident #59's progress notes dated 12/28/24 through 01/27/25 did not reveal evidence further observations of Resident #59's urine were made including consistency, color and urine output amount.Review of Resident #59's progress notes dated 01/27/25 at 4:56 A.M. revealed Resident #59 called the nurse into her room. Resident #59 was screaming out in pain saying her catheter was not working right. An unsuccessful attempt was made to flush the catheter, the catheter was removed and an unsuccessful attempt was made to insert a new catheter due to resistance. No urine output returned during the attempt to place a new catheter. Resident #59's abdomen was noticeably distended and Resident #59 was in excruciating pain. Resident #59's on call Nurse Practitioner was contacted and Resident #59 was transported via 911 to the ED at 4:45 A.M. Resident #59's daughter was notified via voicemail.Review of Resident #59's hospital ED Provider notes dated 01/27/25 at 5:11 A.M. revealed Resident #59 was transported to the ED for evaluation of her indwelling catheter becoming obstructed and nursing staff at the facility were unable to replace the catheter. Apparently there was blood in it and it did not appear to be draining. Onset of symptoms was several hours ago and Resident #59 was having little urine output and more discomfort. Resident #59 has had catheter in place for several months. Resident #59 reported she had pain in her suprapubic area and felt like her bladder was distended. Resident #59 had an indwelling catheter reinserted with over 500 cc of urine output, and her suprapubic tenderness resolved. Resident #59's urinalysis showed moderate leuks (leukocytes, white blood cells), cloudy appearance and moderate blood. Would treat for catheter associated UTI by starting Bactrim (antibiotic). The Impression and Disposition were foley (indwelling) catheter problem, hematuria, acute chronic urinary retention and urinary tract infection associated with indwelling urethral catheter.Review of Resident #59's progress notes dated 01/27/25 at 6:37 A.M. revealed Resident #59 returned from the ED with new orders for Bactrim (antibiotic) 800-160 milligrams (mg) twice a day for seven days for a UTI. Resident #59's foley (indwelling catheter) was replaced. Resident #59's daughter was updated.Review of Resident #59's physician orders dated 01/27/25 revealed Sulfamethoxazole Trimethoprim oral tablet 800-160 mg, give one tablet by mouth two times a day for UTI for seven days.Review of Resident #59's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 required partial to moderate assistance with toileting hygiene, bathing, and upper body dressing. Resident #59 required supervision or touching assistance with personal hygiene. Resident #59 required substantial to maximal assistance to roll left and right and return to lying on her back on the bed. Resident #59 had an indwelling catheter and was frequently incontinent of bowel. Resident #59 did not reject care during the seven-day assessment look-back period. Resident #59 used oxygen therapy.Review of Resident #59's progress notes dated 05/22/25 through 06/13/25 did not reveal evidence observations of Resident #59's urine were made including color, consistency, amount.Review of Resident #59's Medication Administration Record (MAR), TAR, progress notes and weights and vital signs dated 05/01/25 through 06/13/25 did not reveal evidence Resident #59's vital signs including blood pressure, temperature, pulse, respirations were checked.Review of Resident #59's MAR dated 05/04/25 and 06/04/25 revealed monthly vital signs, every day shift every one month on the fourth day of the month were to be checked. The vital signs were marked they were completed but Resident #59's medical record including MAR, TAR, progress notes, weights and vital signs did not reveal evidence the vital signs were recorded.Review of Resident #59's Treatment Administration Record (TAR) dated 06/01/25 through 06/13/25 did not reveal evidence Resident #59's indwelling catheter was irrigated with 50 cc normal saline every shift as needed for obstruction, increased sediment.Review of Resident #59's progress notes dated 06/13/25 at 9:07 A.M. revealed Resident #59 vomited, was complaining of being cold, and the heat was turned up in her room. Resident #59 was provided an extra cover. Resident #59's blood pressure was 135/70, heart rate was 143, respirations 20, temperature 97.9 Fahrenheit, and oxygen saturation was 97 percent. Resident #59's Nurse Practitioner was notified and new orders for CBC with diff, BMP, and UA CS stat (urinalysis and culture and sensitivity). A chest X-ray was ordered at 9:47 A.M.Review of Resident #59's progress notes dated 06/13/25 at 1:12 P.M. revealed Resident #59 was having trouble breathing, a second breathing treatment was administered, and Resident #59's oxygen saturations were from 87 to 88 percent. Resident #59 was administered oxygen via nasal cannula. Resident #59 requested to go to the hospital and was transported to the local hospital.Review of Resident #59's Resident Acute Change in Condition assessment dated [DATE] at 1:27 P.M. revealed Resident #59 had vomiting, chills, large diarrhea and shortness of breath.Review of Resident #59's hospital progress notes and discharge summary for a hospital stay dated 06/13/25 through 06/22/25 included Resident #59 had a chronic indwelling catheter, OSA (obstructive sleep apnea) and COPD (chronic obstructive pulmonary disease) complicated by chronic respiratory failure who presented to the ED from the facility with shortness of breath and was found to have septic shock secondary to CAUTI (catheter associated urinary tract infection), status post dual pressors (vasopressors) and broad-spectrum antibiotics with foley exchange. Resident #59 had acute kidney injury. Resident #59 was ill-appearing and diaphoretic. Cultures positive for enterococcus (urine) and citrobacter (urine and blood), antibiotic stewardship guided therapy with Cefepime (antibiotic) only. Episode of atrial fibrillation with rvr (rapid ventricular response), was initially on amiodarone but terminated as believed it to be sepsis induced. Resident #59's urine culture reported greater than 100,000 CFU (colony forming units) per ml citrobacter freundii and 50,000 to 100,000 CFU per ml enterococcus faecalis. Infection Disease was consulted for antibiotics and her catheter was replaced due to retention. Resident #59 needed a Urology referral scheduled on discharge. Resident #59's white blood cell count on 06/13/25 at 2:06 P.M. was 41.6 (normal was typically between 4.5 and 11, 41.6 was extremely high, leukocytosis). Resident #59's lactate was 3.1 (greater than 2.0 is a key diagnostic criterion in septic shock) on 06/13/25 at 3:16 P.M.Review of Resident #59's medical record including physician orders, progress notes, MAR and TAR dated 06/22/25 through 07/11/25 did not reveal evidence Resident #59 had a urology referral scheduled prior to the resident's discharge.Interview on 10/15/25 at 11:31 A.M. of Family Member (FM) #302 revealed the nurses were not flushing Resident #59's catheter every week. FM #302 indicated Resident #59 was transported to the hospital in January 2025 for a catheter issue, but she did not know the details of the visit. FM #302 stated she was called by the facility in June 2025 because her mom was rushed to the hospital due to shortness of breath and when she got to the hospital Resident #59's catheter was full of pus leading to sepsis, she was on life support meds, and her blood pressure was either too high or too low.Interview on 10/16/25 at 2:04 P.M. of Resident #59 revealed she told the nurses and aides two weeks before she went to the hospital on [DATE] that there was something wrong with her catheter. Resident #59 stated there was something off, it felt weird but the nurses and aides did nothing. Resident #59 could not remember the names of the nurses and aides she told about the catheter not feeling right. Resident #59 stated she was now really paranoid about her catheter, and makes sure it gets flushed like it is supposed to. Resident #59 indicated when she went to the hospital her blood pressure was almost nonexistent and she was septic.Interview on 10/16/25 at 2:35 P.M. of the Director of Nursing (DON) and the Administrator revealed the DON stated she did not remember anything about Resident #59's catheter or her urine. The Administrator stated orders were given on 06/13/25 for STAT labs, and Resident #59 was transported to the hospital on [DATE] at around 1:00 P.M.Interview on 10/20/25 at 2:31 P.M. of the Administrator and the DON revealed the DON confirmed Resident #59 did not have urine outputs documented from 11/14/24 through 06/2925. The DON stated urine outputs were not obtained if there was no order and Resident #59 did not have an order to monitor urine outputs until 06/29/25.Interview on 10/20/25 at 3:09 P.M. of Nurse Practitioner (NP) #301 revealed Resident #59 would have definitely have had symptoms with sepsis including hypotensive tachycardia, elevated white count and if she was that sick he would think she would have symptoms like a fever, altered mental status.Interview on 10/20/25 at 3:45 P.M. of Medical Director #306 revealed if Resident #59 had an indwelling catheter and she was not managing the catheter herself the nurses and aides should be monitoring Resident #59's urine and should write down how much urine was in the catheter bag when they emptied it. Medical Director #306 stated the documentation should be completed at least one time per shift, and the urine output should be recorded when a resident had an indwelling catheter. Medical Director #306 stated he did not remember Resident #59, but if she was admitted to the hospital with sepsis she would have symptoms such as fevers, altered mental status.Review of the facility policy titled Foley Catheter Care revised 08/2022 included the facility would promote urinary health and management to the resident with an indwelling catheter and ensure the appropriate care and services were provided to prevent urinary tract infections to the extent possible. The staff would observe and report to the licensed nurse any signs or symptoms of infection to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output. 2. Review of Resident #43's medical record revealed an admission date of 05/12/25 and diagnoses included traumatic subdural hemorrhage with loss of consciousness of unspecified duration, neuromuscular dysfunction of the bladder, Crohn's Disease and type two diabetes mellitus.Review of Resident #43's care plan dated 08/04/25 revealed Resident #43 had an indwelling catheter related to neurogenic bladder. Resident #43 would be, remain free from catheter related trauma through the review date of 12/14/25. Resident #43 would show no signs and symptoms of a urinary tract infection through the review date. Interventions included observe and document intake and output as per facility policy; observe and report to the physician signs and symptoms of a urinary tract infection including blood tinged urine, cloudiness, deepening of urine color, increased pulse, fever, chills.Review of Resident #43's Quarterly Minimum Data Set assessment dated [DATE] revealed A Brief Interview for Mental Status was not completed due to resident was rarely or never understood. Resident #43 was dependent for toileting hygiene, bathing, dressing and personal hygiene. Resident #43 was dependent for rolling to the left and right and return to lying on her back on the bed. Resident #43 had an indwelling catheter and was always incontinent of bowel.Review of Resident #43's progress notes dated 09/26/25 at 7:00 P.M. revealed an attempt was made to irrigate Resident #43's indwelling catheter because her incontinence brief was wet. The irrigation was unsuccessful due to the indwelling catheter being completely obstructed. The catheter was removed, a new indwelling catheter was inserted, and urine was returned right away. Resident #43's urine was slightly hazy yellow with a small amount of sediment. There was no evidence Resident #43's physician was notified of the slightly hazy yellow urine with a small amount of sediment.Review of Resident #43's medical record including progress notes dated 09/26/25 at 7:00 P.M. through 10/02/25 at 11:36 P.M. did not reveal evidence Resident #43's urine was monitored for color or consistency.Review of Resident #43's progress notes dated 10/02/25 at 11:36 P.M. revealed Resident #43's indwelling catheter was changed, and a new catheter was inserted. Resident #43's catheter was draining thick, milky looking urine. The Nurse Practitioner was contacted, and urine was collected, placed in the refrigerator, and was awaiting pick up from the lab.Review of Resident #43's progress notes from 10/02/25 at 11:36 P.M. through 10/06/25 at 10:00 P.M. did not reveal evidence Resident #43's urine was monitored for color, consistency.Review of Resident #43's lab results revealed Resident #43's urine for urinalysis and culture if indicated was collected on 10/03/25 at 12:00 A.M. and reported on 10/06/25 at 1:49 P.M. The report contained abnormal results, and the urine was extra turbid, had three plus blood, one plus protein, four plus leukocytes, RBC were greater than 50, WBC were greater than 50. The urine had probable contamination, and a urine culture was not completed. Review of Resident #43's progress notes dated 10/06/25 at 10:00 P.M. revealed Resident #43's catheter was changed and a new indwelling catheter was inserted. The catheter was draining thick, yellow looking urine. The nurse collected a urine sample and irrigated the catheter with no difficulties.Review of Resident #43's lab results for a urine culture included the urine was collected on 10/06/25 at 10:00 A.M. and reported on 10/09/25 at 1:45 P.M. Resident #43's urine had greater than 100,000 CFU per ml of Klebsiella Pneumoniae. Review of Resident #43's progress notes dated 10/10/25 at 11:40 P.M. revealed Resident #43's urine culture result was reported to the on-call physician, klebsiella pneumoniae was found and a new order for Bactrim DS (antibiotic) 800-160 mg two times a day for five dates due to a urinary tract infection was given. Resident #43's urine culture results were reported to the on-call physician approximately 34 hours after the results were reported. Resident #43's daughter was updated with the urine culture results and the new order for Bactrim DS.Review of Resident #43's physician order dated 10/11/25 at 12:16 A.M. revealed orders for Bactrim DS oral tablet 800-160 mg (Sulfamethoxazole-Trimethoprim), give one table via PEG tube two times a day for UTI for five days. Observation on 10/15/25 at 3:31 P.M. of Resident #43 with Certified Nursing Assistant (CNA) #307 and Unit Manager (UM) #308 revealed Resident #43 was lying in bed and smiled pleasantly when asked questions. Resident #43 did not speak but could nod head in a yes manner and shake her head to the right or left when the answer was no. CNA #307 provided appropriate incontinence care and catheter care with UM #308's assistance. UM #308 noticed Resident #43's catheter bag was full and emptied the catheter bag for 600 cc of cloudy, yellow orange urine.Interview on 10/16/25 at 12:04 P.M. of the Director of Nursing (DON) revealed resident's lab values do not pop up on the electronic record screen to let the nurses know the results were reported. The DON stated lab results were typically faxed and if the results were critical the lab called the facility. The DON revealed the facility had to keep checking for lab results and passed the information during shift change report if the nurses were waiting on lab results.Interview on 10/16/25 at 2:35 P.M. of the DON and the Administrator revealed Resident #43's first urine was contaminated and another urine needed to be sent. The DON confirmed Resident #43's second urine was reported to the facility on [DATE] at 1:45 P.M., but she did not know what time it was faxed to the facility. The DON stated faxes were not kept so she could not check to see when the report was faxed. The DON confirmed the results were not reported to Resident #43's physician for about 34 hours and could not explain why it took so long. The DON confirmed the nurse did not start Resident #43's antibiotics until the next morning, and confirmed the antibiotic Bactrim was stocked in the automated dispensing system at the facility. The DON did not know why the nurse did not start the Bactrim as soon as she got the order and stated maybe the Bactrim was empty in the automated dispensing system.Interview on 10/20/25 at 4:15 P.M. of Pharmacist #309 revealed Resident #43's Bactrim (Sulfamethoxazole-Trimethoprim) was filled on 10/11/25 at 12:19 A.M. and delivered timely to the facility. Pharmacist #309 stated Bactrim was available in the automated dispensing system on 10/10/25 and 10/11/25 and it was not taken out of the system by the nurses for Resident #43.Interview on 10/20/25 at 10:54 A.M. of Licensed Practical Nurse (LPN) #311 revealed Resident #43's indwelling catheter became occluded frequently, and it was common for her to have sediment in her urine and that was probably why she changed Resident #43's catheter on 09/26/25. LPN #311 stated she did not remember changing the catheter on 09/26/25 or if Resident #43's urine was hazy and amber colored. LPN #311 revealed if she reported Resident #43's urine to the Physician or Nurse Practitioner she would have documented it. LPN #311 stated she remembered reporting Resident #43's urine culture results as soon as she received the lab report to the Physician on 10/10/25. LPN #311 stated she did not recall details of the lab report and why it took so long for her to receive it. LPN #311 revealed someone else might have printed it off for her.Interview on 10/20/25 at 3:50 P.M. of Nurse Practitioner (NP) #301 revealed if Resident #43's urine was slightly hazy yellow and had some sediment in it he should have been notified. NP #301 revealed any time there was a change in urine clarity and consistency it could warrant further looking into. NP #301 revealed it seemed like it took a long time for the on-call Physician to be notified of the urine results which were reported on 10/09/25 at 1:45 P.M. NP #301 stated if Resident #43's urine was positive for a urinary tract infection the Bactrim could have been administered sooner.Review of the facility policy titled Foley Catheter Care revised 08/2022 included the facility would promote urinary health and management to the resident with an indwelling catheter and ensure the appropriate care and services were provided to prevent urinary tract infections to the extent possible. The staff would observe and report to the licensed nurse any signs or symptoms of infection to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output.This deficiency represents non-compliance investigated under Complaint Number 1401320.

Based on interview, record review, review of facility policy and review of hospital records the facility failed to ensure Resident #59's care planned interventions were implemented and physician orders were followed for oxygen therapy. This affected one resident (Resident #59) out of three residents reviewed for oxygen therapy. The facility census was 58. Findings include:Review of Resident #59's closed medical record revealed an admission date of 11/14/24 and diagnoses included chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypercapnia, obstructive and reflux uropathy, and retention of urine. Resident #59 had a left pneumonectomy in December, 1989. Resident #59 was discharged from the facility on 07/11/25.Review of Resident #59's care plan dated 12/19/24 and revised on 07/24/25 (Resident #59 was discharged from the facility on 07/11/25) revealed Resident #59 had an altered respiratory status and difficulty breathing related to COPD (chronic obstructive pulmonary disease) and chronic respiratory failure. Resident #59 would maintain a normal breathing pattern as evidenced by normal respirations, normal skin color and a regular respiratory rate, pattern through the review date of 09/14/25. Interventions included to administer oxygen as ordered; auto BIPAP (Bilevel Positive Airway Pressure, a non-invasive ventilation technique that provided respiratory support by delivering two different levels of air pressure during inhalation and exhalation) 20/10 cmH2O (centimeters of water and is a unit of pressure) with 3L O2 (three liters of oxygen) at bedtime and as needed; observe for changes in orientation, increased restlessness, anxiety and air hunger; observe for signs and symptoms of respiratory distress (including increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, skin color changes to blue-gray) and report to the physician as needed Review of Resident #59's medical record including progress notes, MAR and TAR dated 03/04/25 revealed Resident #59 refused her BIPAP, but no reason for refusing the BIPAP was documented in her medical record.Review of Resident #59's medical record including progress notes, Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated 03/05/25 through 06/23/25 did not reveal evidence Resident #59 refused her BiPAP therapy.Review of Resident #59's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 required partial to moderate assistance with toileting hygiene, bathing, and upper body dressing. Resident #59 required supervision or touching assistance with personal hygiene. Resident #59 required substantial to maximal assistance to roll left and right and return to lying on her back on the bed. Resident #59 had an indwelling catheter and was frequently incontinent of bowel. Resident #59 did not reject care during the seven-day assessment look-back period. Resident #59 used oxygen therapy.Review of Resident #59's hospital Discharge Instructions for a hospital stay dated 06/13/25 through 06/22/25 included Resident #59's hospital problems as of 06/22/25 included the principal problem was septic shock secondary to CAUTI (catheter associated urinary tract infection) and citrobacter bacteremia (resolved) and other problems included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, chronic indwelling catheter and obstructive and reflux uropathy. Resident #59's condition at discharge was improved and symptoms to look out for after discharge was new or severe pain, fever, shortness of breath and unable to keep down fluids. Resident #59's oxygen requirements were three liters oxygen per minute via nasal cannula during the day and BIPAP overnight. Resident #59's BIPAP settings were 12/6. Encourage nightly BIPAP. Review of Resident #59's progress notes dated 06/22/25 at 8:00 P.M. revealed Resident #59 came back from the hospital via stretcher with EMS and was accompanied by her daughter. Resident #59's blood pressure was 117/65, pulse 91, respirations 17, temperature was 97.6 Fahrenheit, and her oxygen saturation was 98 percent on three liters of oxygen per minute via nasal cannula.Review of Resident #59's MAR and TAR dated 06/22/25 at 8:00 P.M. through 06/23/25 at 9:20 A.M. did not reveal evidence Resident #59 had BIPAP administered at 12/6 cmH20 with three liters oxygen at bedtime and as needed per physician orders. Review of Resident #59's medical record including progress notes, assessments, MAR and TAR dated 06/22/25 at 8:00 P.M. through 06/23/25 at 9:20 A.M. did not reveal evidence Resident #59 was monitored or assessed for fever, shortness of breath, lethargy, vital signs including respirations and oxygen saturation levels.Review of Resident #59's progress notes dated 06/23/25 at 9:20 A.M. revealed Registered Nurse/Unit Manager (RN/UM) #300 entered Resident #59's room to assist with getting Resident #59 up and ready for the day. Upon entering the room Resident #59 was observed sitting in her wheelchair with her eyes closed and her head down. RN/UM #300 asked Resident #59 if she felt okay and Resident #59 attempted to respond verbally, but opened her mouth and could not speak. Resident #59's skin was pale and warm with moderate edema of the left upper and lower extremities. Resident #59 opened her eyes halfway and her eyes looked glazed over. Resident #59's temperature was 98.1 Fahrenheit, blood pressure was 141/64, heart rate was 99, respirations 20 per minute. Resident #59 was wearing oxygen at 3 liters per minute via nasal cannula and her oxygen saturation was 66 percent.Review of Resident #59's progress notes dated 06/23/25 at 9:22 A.M. revealed Resident #59's daughter was contacted to confirm Resident #59's code status as the resident was unable to answer questions. Resident #59's daughter stated she did not know Resident #59's code status and immediately hung up on the nurse.Review of Resident #59's progress notes dated 06/23/25 at 9:23 A.M. revealed Certified Nurse Practitioner (CNP) #301 was notified of Resident #59's current status and a new order was given to send Resident #59 to the ED for evaluation.Review of Resident #59's progress notes dated 06/23/25 at 9:42 A.M. revealed Resident #59 was accompanied by EMS personnel and was transported to the hospital ED.Review of Resident #59's progress notes dated 06/23/25 at 9:44 A.M. revealed Resident #59's daughter was notified Resident #59 was transported to the hospital ED.Review of Resident #59's progress notes dated 06/23/25 at 9:55 A.M. revealed when RN/UM #300 contacted Resident #59's daughter the floor nurse administered a breathing treatment, increased her oxygen and Resident #59's oxygen saturation increased to 90 percent.Review of Resident #59's progress notes dated 06/23/25 at 10:30 A.M. revealed Resident #59's daughter was in Resident #59's room, returned to the lobby and stated you guys are going down, I set you up and hid the BIPAP. Resident #59's daughter refused to speak to the Administrator and left the facility.Review of Resident #59's progress notes dated 06/23/25 at 11:20 A.M. revealed on 06/22/25 at 10:00 P.M. the nurse was unable to encourage Resident #59 to wear her BIPAP machine. The machine was not located in the resident's room.Review of Resident #59's hospital records for a hospital stay dated 06/23/25 through 06/29/25 revealed Resident #59's admission diagnosis was hypercapnia (too much carbon dioxide in the bloodstream). Resident #59 had a past medical history of COPD and other diagnoses and was on home 3LNC (three liters oxygen per minute via nasal cannula) and BIPAP at night. Resident #59 was discharged from the hospital on [DATE] after a prolonged hospitalization due to septic shock from a CAUTI and Resident #59 had positive blood cultures. Resident #59 was discharged on antibiotics after consultation with Infectious Disease. Resident #59 was discovered on 06/23/25 in the morning, was poorly responsive and had left-sided weakness. On arrival Resident #59 was lethargic, able to answer questions, follow commands and complained of left arm weakness. Blood pressure was 171/98, pulse 133, respirations 12 and oxygen saturation was 97 percent on oxygen via nasal cannula. Resident #59's CO2 was 43 mmol/L (indicates an electrolyte and acid-base imbalance in the body, the normal range is typically 23 to 29 mmol/L) on 06/23/25 at 10:33 A.M. Resident #59 was admitted to the ICU for treatment and workup of stroke-like symptoms and acute hypoxic hypercapnic respiratory failure (life-threatening condition characterized by a deficiency in oxygen and an excess of carbon dioxide). Resident #59's hospital course included Resident #59 was intubated in the ED and admitted to the ICU due to encephalopathy from hypercapnia and bacteremia. Resident #59 had acute hypercapnic and hypoxic respiratory failure requiring intubation. Resident #59 had a CXR and the radiologist found a questionable small, right pneumothorax versus a prominent skin fold. Review of Resident #59's progress notes dated 06/23/25 at 4:21 P.M. revealed Resident #59 was admitted to the local hospital.Interview on 10/16/25 at 10:50 A.M. with Family Member (FM) #302 revealed she accompanied Resident #59 to the facility from the hospital on [DATE] at around 6:00 P.M. to 8:00 P.M. when she was readmitted , and FM #302's daughter was also present. FM #302 stated she saw the EMS staff give Resident #59's nurse a manila envelope with her hospital discharge instructions in it. FM #302 stated Resident #59's BIPAP machine was on the windowsill when Resident #59 returned to the facility on [DATE], and none of the nurses asked Resident #59 if she wanted her BIPAP or attempted to put the BIPAP on her. FM #302 stated she never touched Resident #59's BIPAP machine and did not hide it from the staff. FM #302 stated the next morning on 06/23/25 before Resident #59 was transported to the ED she was called by a facility nurse and asked if Resident #59 was a full code, and an unidentified male physician called her and asked if Resident #59 had a BIPAP order. FM #302 stated she rushed to the facility after she was called and when she arrived the Director of Nursing (DON) told her Resident #59 did not have a BIPAP order. FM #302 stated she was so upset, the conversation escalated because the facility staff lied to my face and almost killed my mom. FM #302 revealed she snapped because she was furious and I do not remember what I said because I was so mad they lied to me and I know for a fact she was not getting her BIPAP. FM #302 stated the BIPAP machine was bone dry and dirty. Interview on 10/16/25 at 2:04 P.M. with Resident #59 revealed when she returned to the facility on [DATE] her BIPAP was in the room, and they did not put it on me. Resident #59 stated she did not refuse to wear her BIPAP, but a couple times she was wearing it, it was not working right, she felt it shoot hot air onto her face, and she could not breathe properly. Resident #59 indicated when that happened she panicked and asked her to take it off. The nurse tried again, it did not work, and she panicked again. After that Resident #59 told the nurse to come back later, and she would try again, but the nurse did not return. Resident #59 revealed she told the nurses if she was sleeping to wake her up and put the BIPAP on, and I absolutely did not tell the nurses I did not want to wear the BIPAP. Resident #59 indicated the doctor told her he wanted the instructions followed to a t. Interview on 10/16/25 at 2:35 P.M. with the Director of Nursing (DON) and the Administrator revealed on 06/23/25 Resident #59 was not feeling well and was sent to the hospital ED. The DON stated she talked to FM #302 on the phone and FM #302 indicated Resident #59 did not have her BIPAP on and said don't lie to me. FM #302 came to the facility, went to Resident #59's room, then came back to where the DON was and blew up. FM #302 stated I know the nurse did not put her on the BIPAP because I hid it, then she left the facility. The Administrator stated neither the Ombudsman nor Physician were notified FM #302 made this statement because it sounded like FM #302 was trying to trap us. The DON stated the nurse documented he tried to put Resident #59's BIPAP on. The DON stated Resident #59 had a diagnosis of pneumothorax.Interview on 10/29/25 at 9:39 A.M. with the DON revealed Resident #59's BIPAP was found at the bedside and she was not sure where it was. The DON indicated she would expect vital signs and oxygen saturations to be monitored if Resident #59 was unable to be placed on the BIPAP because it could not be found. The DON stated Resident #59 was only back in the facility about 12 hours before she went back to the hospital. The DON confirmed Resident #59's vital signs and oxygen saturations were not checked between 06/22/25 at 8:00 P.M. and 06/23/25 at 9:20 A.M.Interview on 10/20/25 at 10:01 A.M. with Registered Nurse/Unit Manager (RN/UM) #300 revealed she was not the Unit Manager now, had recently left the position, but still worked at the facility. RN/UM #300 stated she did not remember much about the day Resident #59 was sent to the hospital. RN/Um #300 indicated she remembered FM #302 was upset and super emotional and said she hid Resident #59's BIPAP machine and we were going down.Interview on 10/20/25 at 10:20 A.M. with MDS Nurse #303 revealed care plans were updated when there were changes and Quarterly as well. MDS Nurse #303 stated she tried to update care plans the next day, but were typically updated within a week. MDS Nurse #303 confirmed Resident #59's care plan was updated on 07/24/25 after she was discharged from the facility. MDS #303 stated Resident #59's care plan was closed on 07/24/25. MDS Nurse #303 indicated she would typically try to update a residents BIPAP orders and she might not have got to Resident #59's BIPAP right away.Interview on 10/20/25 at 10:36 A.M. with Registered Nurse (RN) #304 revealed he was working on 06/22/25 when Resident #59 was readmitted to the facility. RN #304 stated Resident #59's daughter and granddaughter were with her. RN #304 indicated EMS gave him her papers from the hospital. RN #304 stated the papers included BIPAP orders, and when he looked for Resident #59's BIPAP machine on the bedside table where her oxygen tubing and nebulizer was he did not see it. RN #304 stated Resident #59's room was very cluttered with boxes and other things and he did not look other places for the BIPAP because it should be on the bedside table with the oxygen tubing and nebulizer. RN #304 indicated he was a new nurse and he highlighted the BIPAP orders because he was taught to do that if he didn't know how to facilitate items, and then he would put a report in for his supervisor and the supervisor would take care of it. RN #304 did not remember if a supervisor was working that night, and did not know who took care of the highlighted BIPAP order. RN #304 stated he was not able to find the BIPAP machine and that was why he highlighted the BIPAP orders. RN #304 indicated Resident #59 was tired from her transfer and he did not ask Resident #59 if she knew where her BiPAP machine was. RN #304 stated Resident #59 did not tell him she did not want to wear her BIPAP. RN #304 indicated he gave her pain medications and a nebulizer treatment during the night and she did not seem to be having a hard time and if she did he would ask for help. RN #304 confirmed he checked Resident #59's vital signs and oxygen saturation when she was admitted but did not check Resident #59's oxygen saturation or vital signs after that. RN #304 clarified the nursing progress note he wrote on 06/23/25 and stated he meant Resident #59 did not always wear her BIPAP the recommended amount of time. Interview on 10/20/25 at 3:50 P.M. with Nurse Practitioner (NP) #301 revealed if Resident #59's BiPAP was not available he should have been notified. NP #301 stated he should be notified with any resident change of condition. NP #301 indicated Resident #59's BIPAP helped blow off CO2 and symptoms of high CO2 included increased lethargy, confusion and change of mental status. NP #301 stated a build up of CO2 could manifest like stroke symptoms. NP #301 stated Resident #59 absolutely should have been monitored and should have had more frequent assessments during the night.Review of the facility policy titled Resident Change in Condition dated 07/28/22 included the purpose was to ensure staff provided timely and appropriate care and services when residents experience a change in condition that had or was likely to cause serious life-threatening harm or injuries and, or adverse negative health outcomes. The facility would promptly notify the resident, his or her attending physician and responsible party of changes in the resident's condition and, or status. The licensed nurse would take immediate action to ensure timely and appropriate care and services were met when a resident change in condition was identified.Review of the facility policy titled Oxygen Therapy revised 12/2022 included oxygen would be provided as needed and prescribed in a safe manner ensuring each resident received necessary respiratory care and services that was in accordance with professional standards of practice, the resident's care plan and resident's choice. Oxygen would be administered and titrated per physician order. The residents medical record should reflect ongoing assessment of the resident's respiratory status, response to oxygen therapy and the attending practitioner's orders and indication for use.This deficiency represents non-compliance investigated under Complaint Number 1401320.

Based on interview and closed record review, and hospital paperwork review, the facility failed to ensure they discharged a resident in a safe and orderly manner. This affected one resident (Resident #73) out of five residents reviewed for discharge. The facility census was 72. Findings include: Review of the closed medical record for the former resident (Resident #73) revealed an admitted [DATE] with a hospital stay from 12/03/24 to 12/04/24 and a final discharge date of [DATE] where she discharged home with her daughter. Diagnoses included urinary tract infection (UTI), altered mental status, history of pulmonary embolism, anxiety, major depressive disorder, type II diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and aortic valve stenosis. Review of Resident #73 hospital paperwork revealed the resident had some cognitive deficit. Review of Resident #73's Care Plan revealed there was not a 48 hour Care Plan initiated for the resident. Review of Resident #73's progress note dated 12/03/24 at 5:09 P.M. created on 12/04/24 at 10:11 A.M. by the Director of Nursing (DON) revealed upon admission the resident was pleasantly confused, being treated for a UTI. After being oriented to room and dining area the resident became very aggressive with staff, hitting multiple staff members, exit seeking, screaming at the staff that she wanted to leave. The note stated the resident was a fall risk and was currently on anticoagulation therapy. The resident was unable to be redirected. A call was placed to Nurse Practitioner (NP) #810 and gave order to send the resident to the emergency room (ER) for a psych eval as the resident is a harm to others and herself. The unit manager to call nonemergent transport and call report to the ER. Further review of Resident #73's progress notes dated 12/03/24 at 5:18 P.M. authored by Registered Nurse (RN) #805 revealed the resident left the facility via facility van and Certified Nursing Assistant (CNA)/ Van Driver #804. The progress note stated the daughter was to meet CNA/Van Driver #804 at the emergency room (ER). Review of assignment sheets from 12/04/24 to 12/09/24 revealed there was a CNA designated to be one on one with Resident #73 every night until she discharged and during the day the resident was kept in common areas in direct supervision of nursing staff at all times and would be taken to a less stimulating environment such as her room, or the activity room when needed and staff would sit with her until behaviors passed. Interview on 12/11/24 at 12:40 P.M. with Resident #73's daughter revealed she was not given any paperwork and did tell the facility staff she would have to stop at home to let the dogs out and to get some clothing for her mother before going to the hospital. Interview on 12/12/24 at 12:24 P.M. with CNA/ Van Driver #804 revealed he overheard RN #805 state Resident #73 needed to go to the ER but could not find a nonemergent transport to take her and would have to wait hours. So, he volunteered to take her. CNA/Van Driver #804 stated the daughter of Resident #73 stated she was going to meet her at the ER but had to stop at home to get clothes first. CNA/Van Driver #804 stated he arrived at the ER and the daughter was not there, so he waited 10 minutes before he took her in. He was met at the door by the security guard, and they asked if he was going to stay, CNA/Van Driver #804 stated he told the security guard No, and the security guard told him it was ok, and he could leave the resident with him and the security guard would check her in. CNA/Van Driver #804 stated he waited an additional 20 minutes out in the van before he left. He stated no paperwork was sent with the resident, the daughter never showed before he left and the only person he spoke to was the security guard. Interview on 12/12/24 at 1:27 P.M. with RN #805 revealed she spoke with Licensed Practical Nurse (LPN) #807 regarding Resident #73 and LPN #807 stated the resident had become very agitated and adamant about leaving she was exit seeking, hitting and yelling at staff. LPN #807 stated the resident stated she felt they were trying to keep her from her family, she was here against her will. RN #805 went to Resident #73's room and asked the staff who were in the room to leave and sat one on one with her, she stated she pulled Resident #73 close to her and the resident slapped her. RN #805 stated she made sure the resident was safe and gave her some space, she reapproached her and tried to reorient the resident unsuccessfully, the daughter showed up and the resident's mood improved and then became much worse. RN #805 went to the DON and spoke to her and during that time Resident #73 called the police a few times. RN #805 stated she was scared the resident would elope, so the DON and the Admission Director made a plan with the daughters consent to make plans to discharge the resident to a sister facility with a locked unit. However, Nurse Practitioner and the daughter wanted her sent to the ER for evaluation. RN #805 stated the daughter was in the facility and aware they were sending her to the ER for a psych evaluation. The daughter stated she would met at the ER. RN #805 stated the daughter never stated she had to stop at home for any reason. RN #805 stated she was unsure if she printed the paperwork to send with the resident or not. RN #805 stated she thought LPN #807 printed it. RN 805 stated she called for a nonemergent transport to the ER but would have to wait for hours, CNA/Van Driver #804 overheard this and volunteered to take the resident. Interview on 12/12/24 at 1:55 P.M. with LPN #807 revealed she did not print the discharge paperwork or call nurse to nurse to the ER. They stated RN #805 was handling her discharge. LPN #807 stated she did not hear the daughter say she was going to meet the Resident at the ER or that she had to stop at home. This deficiency represents non-compliance investigated under Complaint Number OH00160463.

Based on interview and closed record review, the facility failed to ensure there was a baseline care plan put in place. This affected one resident (Resident #73) out of five residents reviewed for care plans. The facility census was 72. Findings include: Review of the closed medical record for the former resident (Resident #73) revealed an admitted [DATE] with a hospital stay from 12/03/24 to 12/04/24 and a final discharge date of [DATE] where she discharged home with her daughter. Diagnoses included urinary tract infection, altered mental status, history of pulmonary embolism, anxiety, major depressive disorder, type II diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and aortic valve stenosis. Review of Resident #73 hospital paperwork revealed the resident had some cognitive deficit. Review of Resident #73's Care Plan revealed there was not a 48 hour Care Plan initiated for the resident. Interview on 12/11/24 at 1:50 P.M. with the Administrator revealed she verified there was no baseline care plan in place for Resident #73. Interview on 12/11/24 at 2:37 P.M. with the Minimum Data Set (MDS) nurse/ Registered Nurse (RN) #811 verified there was not a baseline careplan completed for Resident #73. RN #811 stated the entire list of MDS's, and care plans were behind since some time in November 2024. This deficiency represents non-compliance investigated under Complaint Number OH00160463.

Based on observation, interview, record review, review of resident shower sheets, and review of facility policy,the facility failed to ensure residents received showers per facility schedule and preference. This affected one resident (Resident #25) out of five residents reviewed for showers. The facility census was 72. Findings include: Review of Resident #25's medical record revealed an admitted [DATE]. Diagnoses included sacrum fracture with routine healing, spinal stenosis lumbar region, repeated falls, diabetes mellitus type II, hypertension, atrial fibrillation, and chronic kidney disease. Review of Resident #25's Medicare five-day Minimum Data Set (MDS) 3.0 dated 12/12/24 revealed the resident had intact cognition. Resident #25 required partial to moderate assistance by one staff member for transferring, showers, dressing, and toileting. Resident #25 required setup help only for eating. Review of Resident #25's care plan dated 12/10/24 revealed a care plan initiated related to the resident reaching maximum functional mobility. Interventions and goals included transferring, showering, dressing, and toileting with assistance by one staff member providing partial to moderate assistance. Review of the undated facility shower schedule revealed Resident #25 was to receive a shower on Tuesdays and Fridays. Review of facility shower documentation revealed documentation on Monday 12/09/24 Resident #25 received a shower. Interview on 12/12/24 at 11:30 A.M. with Resident #25 revealed she had not had a shower since she was admitted on [DATE]. She stated the last time she had a bed bath was in the hospital and the last time she had a shower was when she was at home. Resident #25 stated she is aware she is supposed to get a shower twice a week on Tuesday and Friday per the facility schedule. Resident #25 stated when asked about the alleged shower she had on 12/09/24 she denied having a shower. Additionally, an interview was conducted with Resident #25 on 12/16/24 at 10:15 A.M. revealed she had not received a shower on Friday 12/13/24 or at any time over the weekend. Resident #25 stated she knows her hair is greasy and she had body odor. Interview on 12/12/24 at 2:00 P.M. with the Director of Nursing (DON) revealed she confirmed there was only one shower sheet filled out for Resident #25 for Monday 12/09/24 which was not her shower day. Observation on 12/12/24 at 11:35 A.M. of Resident #25 revealed she appeared to have greasy hair and there was a smell of body odor coming from the resident when she would move her arms when talking. Observation on 12/16/24 at 10:00 A.M. of Resident #25 revealed she appeared to have greasy, unkept hair. Review of the facility policy titled Bathing-Personal Care, last revised August 2022 revealed The Residents of health care facilities of Progressive Quality Care will receive personal care in the facility according to the Resident's plan of care to promote dignity, cleanliness, and general well-being. Under the procedure bullet point one Shower, Bath or Tub is offered to the resident twice a week and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00159935.

Based on observation, interview, record review, and review of manufacturer instructions revealed the facility failed to ensure proper administration of insulin was followed. This affected one resident (Resident #52) out of five residents reviewed for medication administration. The facility census was 72. Findings include: Based on review of the medical record for Resident #52 revealed an admitted [DATE]. Diagnoses included cellulitis of left lower limb, Methicillin Resistant Staphylococcus Aureus infection, type II diabetes mellitus insulin dependent, anxiety disorder, heart failure, diabetic retinopathy, and hypertension. Review of Resident #52's quarterly Minimum Data Set (MDS) 3.0 dated 10/12/24 revealed the resident had intact cognition. Resident #52 required set up or clean up assistance with eating, oral hygiene, and upper body dressing. They required partial to moderate assistance with personal hygiene, and substantial to maximal assistance with toileting and showers. Resident #52 was dependent on nursing staff for administration of medication including insulin. Review of Resident #52's physician orders dated December 2024 revealed she was to receive Humalog insulin 100 units/Milliliter (mL) inject 15 units subcutaneously before meals and at bed time for diabetes mellitus and Humalog insulin 100 Units/mL per sliding scale if blood sugar result is 151-200 give two units, 201-250 give four units, 251-300 give six units, 301-350 eight units, 351-400 give 10 units and if over 400 administer 10 units and contact the physician. Sliding scale is to be given in addition to the 15 units. Observation on 12/12/24 at 11:25 A.M. of medication administration by Registered Nurse (RN) #803 for Resident #52 revealed RN #803 performed a blood sugar check with results of 204 milligrams (mg)/ Deciliter (dL) indicating the residents was to receive Humalog insulin 15 units/mL plus four additional units to equal 19 units/mL. During the observation RN #803 did not cleanse the top of the pen with alcohol prior to applying the needle and did not prime the needle with two units of insulin prior to administering the accurate dose per the manufacturers instructions. Interview on 12/12/24 at 11:28 A.M. with RN #803 revealed she verified she did not cleanse the insulin pen with alcohol prior to applying the needle and she verified she did not prime the needle with two units of insulin prior to administering the accurate dose per the manufactures instructions. Review of the manufacturer's instructions for the Humalog insulin pen under the category titled Priming your Pen revealed the pen was to be primed before each injection by turning the dosing knob to select two units, hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, continue holding the pen with the needle pointing up, push the dose knob in until it stops and 0 is seen in the dose window and count to five slowly, you will see insulin at the tip of the needle. If you do not see insulin at the tip of the needle repeat priming steps no more than for times. This violation was issued relative to incidental findings that were discovered during this complaint investigation completed form 12/11/24 to 12/16/24.

Based on observation, interview and record review, the facility failed to ensure staff followed infection control policy and procedures related to hand hygiene and proper use of Personal Protective Equipment when administering medications and when administering medications to residents in Enhanced Barrier Precaution isolation rooms. This affected three residents (Residents #4, #25, and #33) out of five residents reviewed for infection control related to hand hygiene and proper Personal Protective Equipment. The facility census was 72. Findings include: 1. Review of Resident #4's medical record revealed and admitted [DATE]. Diagnoses included nontraumatic intercerebral hemorrhage, acute respiratory failure, moderate protein-calorie malnutrition with gastrostomy tube placement, cardiac murmur, and personal history or other infectious and parasitic diseases. Review of Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition and was dependent on staff for all Activities of Daily Living (ADLs). Review of Resident #4's care plan dated 10/17/24 revealed the resident was to be in Enhanced Barrier Precautions (EBP) related to gastrostomy tube, tracheostomy, and history of infectious disease process. Interventions included EBP will be maintained through the review period, perform hand hygiene before and after glove use, remove gowns and gloves promptly after care activities and dispose of in proper receptacle, and train healthcare personnel on the rationale, indications, and proper use of EBP. Observation on 12/12/24 at 8:50 A.M. of Registered Nurse (RN) #801 administering medications to Resident #4 revealed they did not perform hand hygiene prior to applying gloves to administer medications through Resident #4's gastrostomy tube and did not wear proper Personal Protective Equipment (PPE) including a gown while administering medications through the gastrostomy tube. Interview on 12/12/24 at 9:00 A.M. with RN #801 revealed they verified they did not perform hand hygiene prior to applying gloves and did not wear proper PPE while administering medications through Resident #4's gastrostomy tube including a gown due to resident being in EBP. 2. Review of Resident #25's medical record revealed an admitted [DATE]. Diagnoses include sacrum fracture with routine healing, spinal stenosis lumbar region, repeated falls, diabetes mellitus type II, hypertension, atrial fibrillation, and chronic kidney disease. Review of Resident #25's Medicare five-day Minimum Data Set (MDS) 3.0 dated 12/12/24 revealed the resident had intact cognition. Resident #25 required partial to moderate assistance by one staff member for transferring, showers, dressing, and toileting. Resident #25 required setup help only for eating. Review of Resident #25's care plan dated 12/10/24 revealed a care plan initiated related to the resident reaching maximum functional mobility. Interventions and goals included transferring, showering, dressing, and toileting with assistance by one staff member providing partial to moderate assistance. 3. Review of Resident #33's medical record revealed an admitted [DATE]. Diagnoses included severe protein-calorie malnutrition with gastrostomy tube placement, dysphagia, polyneuropathy, gastric ulcer and spinal stenosis. Review of Resident #33's quarterly MDS dated [DATE] revealed the resident has some cognitive impairment but could make needs known. Resident #33 required partial to moderate assistance by staff for all ADLs including medication administration. Review of Resident #33's care plan revealed the resident required Enhanced Barrier Precautions to reduce transmission of multidrug-resistant organisms (MDROs) related to indwelling devices. interventions included EBP will be maintained through the review period, perform hand hygiene before and after glove use, remove gowns and gloves promptly after care activities and dispose of in proper receptacle, and train healthcare personnel on the rationale, indications, and proper use of EBP. Observation made on 12/12/24 at 9:10 A.M. of Licensed Practical Nurse (LPN) #802 administering medications to Resident #25 and at 1:00 P.M. administering medications to Resident #33 revealed they did not perform hand hygiene prior to pulling Resident #25's medication from the medication cart. Additionally LPN #802 did not perform hand hygiene prior to applying gloves to administer medications through Resident #33's gastrostomy tube and did not apply proper PPE including a gown prior to administering medications through Resident #33 who was in EBP. Interview on 12/12/24 at 1:15 P.M. with LPN #802 revealed they confirmed they did not perform hand hygiene prior to pulling Resident #25's medications and they confirmed they did not perform hand hygiene prior to applying gloves to administer medications through Resident #33's gastrostomy tube and did not apply proper PPE including a gown while in Resident #33's room who was in EBP. Review of the facility policy titled Medication Administration-General Guidelines last revised October 2017 revealed under Preparation bullet point number two Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medications, after coming into direct contact with a resident, before and after administration of medications via enteral tubes. This deficiency was issued relative to incidental findings that were discovered during this complaint investigation completed on 12/20/24.

Based on record review, observation and interview, the facility failed to ensure Resident #19's choices were honored with rising out of bed in the morning. This affected one (Resident #19) out of two residents reviewed for choices concerning care. The facility census was 67. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including cerebral infarction (stroke) and difficulty walking. Review of the care plan dated 07/09/24 for Resident #19 revealed he had self-care performance deficit with activities of daily living related to impaired mobility and muscle weakness. Interventions stated Resident #19 required one staff member to dress and assist with personal hygiene. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition, staff were able to understand him, he required partial to moderate assistance from staff for toileting, showers and dressing. Resident #19 also needed substantial to maximum assist from staff for transferring in and out of bed. Interview on 10/04/24 at 9:56 A.M. with Resident #19 revealed he was still in bed waiting for staff to assist him with care. He stated it took staff a long time to come assist him with getting out of bed for the day. Resident #19 placed his call light on at 10:02 A.M. while the surveyor was in the room for staff to come assist him out of bed for the day. Observation on 10/04/24 from 10:02 A.M. through 10:09 A.M. revealed Resident #19's call light to be on. Registered Nurse (RN) #384 went to Resident #19's room at 10:09 A.M., spoke to the resident, and then returned to the nursing station. On 11/04/24 at 10:37 A.M. Resident #19 was observed to still be in bed. Interview on 11/04/24 at 10:39 A.M. with RN #384 revealed she went to Resident #19's room and answered the call light at 10:09 A.M. She stated he wished to get out of bed for the day and needed assistance. She stated his aide was busy assisting other residents on the unit and would go when she had time. Interview on 11/04/24 at 10:40 A.M. with Licensed Practical Nurse (LPN) #301 revealed she was the aide taking care of Resident #19. She stated the aide had called off for the day so she was working the floor in her place. She stated she was unaware that Resident #19 had wanted out of bed as he did not have his call light on and she was not updated by another staff member that he had called wanting out of bed. Review of the facility policy titled, Activities of Daily Living, dated March 2023, revealed that the facility would provide necessary care and services based on the resident's assessment and choices. This deficiency represents non-compliance investigated under Complaint Number OH00159219.

Based on record review, interview, and facility policy review the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, to timely identify new pressure ulcers, and to ensure wound care was completed as ordered to ensure Resident #72 skin was maintained and the resident did not develop an in-house stage three pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to the left buttock. Actual Harm occurred on [DATE] when Resident #72's, who was dependent for eating, shower/bathing, upper and lower body dressing, and personal hygiene, and was incontinent of bowel and bladder, developed an in-house pressure ulcer identified at a stage three. This finding affected one resident (#72) of three residents reviewed for pressure wounds. The facility census was 69. Findings include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] and expired in the facility on [DATE] with diagnoses including metabolic encephalopathy, cerebral infarction, and dysphagia. Review of the nursing admission assessment form dated [DATE] authored by Registered Nurse (RN) Unit Manager (UM) #834 revealed Resident #72 had a skin tear to the left elbow, an abrasion on the right ankle, and an abrasion on the left ankle. Review of the progress note dated [DATE] at 7:47 P.M. authored by RN UM #834 revealed Resident #72 arrived at the facility at 3:40 P.M. via a stretcher. The resident was alert and oriented times one to two with multiple skin tears and bruising noted to the bilateral upper extremities and abrasions noted to the bilateral outer ankles. Bilateral heel protector boots were in place. There was no documented evidence of a pressure ulcer to Resident #72's left buttock. Review of the physician's orders revealed an order dated [DATE] for a pressure reducing cushion to wheelchair, a pressure reducing mattress to the bed, and to float the heels while in bed as tolerated. Review of Resident #72's care plans dated [DATE] revealed the resident was admitted with a stage three pressure ulcer to the sacrum. Interventions dated [DATE] included to administer medications, administer treatments as ordered and monitor for effectiveness, monitor/document/report changes, treat pain as ordered and weekly treatment documentation. (There were no treatment orders until [DATE]). Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 exhibited a memory impairment, was dependent on eating, oral hygiene, toileting, shower/bathing, upper and lower body dressing, and personal hygiene. Review of Resident #72's Braden Scale for Predicting Pressure Sore Risk form dated [DATE] revealed the resident was high risk for developing pressure ulcer wounds. Review of the initial pressure ulcer wound evaluation form dated [DATE] at 1:31 P.M. completed by Nurse Practitioner (NP) #908 indicated the [AGE] year-old male was a new admission who was incontinent of bowel and bladder. The resident had a left buttock stage three full-thickness pressure ulcer which was present upon admission and measured 4.4 centimeters (cm) length by 6.5 cm width by 0.1 cm depth with 30% granulation and 70% pink with scant bloody exudate. The peri wound was moist and excoriated, and new orders for zinc oxide cream and a clean dry dressing were ordered daily and as needed. Review of the physician's orders revealed an order dated [DATE] for ProHeal 30 milliliters (ml) two times a day for supplement (discontinued [DATE]); and an order dated [DATE] for an air mattress to the bed with bolsters. Review of Resident #72's progress note dated [DATE] at 5:21 P.M. authored by Dietitian #908 revealed she was made aware of a stage three pressure ulcer to the left buttocks. Review of Resident #72's physician's orders revealed an order dated [DATE] (discontinued [DATE]) to cleanse the left buttock with normal saline, pat dry, apply zinc oxide and cover with a foam dressing daily and as needed. Review of the medical record revealed no progress note regarding Resident #72 being sent to the hospital on [DATE]. Review of Resident #72's hospital Encounter Summary Note dated [DATE] from 10:25 A.M. to 2:43 P.M. revealed the [AGE] year-old male with a significant past medical history for a cerebrovascular accident (CVA) with a left hemiplegia/hemiparesis diagnosis was DNRCCA was evaluated at the bedside for anemia. The resident's hemoglobin was 6.7 at the SNF earlier in the day and was sent in for a transfusion. The resident's heart rate was 115 and the oxygen level was 100%. The resident only responded to pain. The daughter requested the resident receive fluids and be discharged back to the SNF. The resident had significantly deteriorated, and she was the POA and wanted the code status changed to DNRCC. Review of the progress note dated [DATE] at 2:00 P.M. authored by RN UM #817 indicated Resident #72's daughter requested to not send the resident to the emergency room (ER) going forward. She wanted to keep the resident comfortable. Review of Resident #72's progress note dated [DATE] at 3:24 P.M. revealed the resident arrived back to the facility via an ambulette. Review of the progress note dated [DATE] at 3:38 A.M. authored by Licensed Practical Nurse (LPN) #851 revealed Resident #72 was in respiratory distress and was put on ten liters oxygen. The physician was notified, and the resident was sent out at 3:25 A.M. to the ER. The daughter was notified. Review of Resident #72's progress note dated [DATE] at 5:36 A.M. revealed authored by LPN #851 revealed the resident returned at 5:00 A.M. and the code status was updated. Review of the progress note dated [DATE] at 8:10 A.M. authored by LPN #816 revealed the nurse called Resident #72's daughter and gave the nurse an update from the hospital documentation (following the resident's return to the facility). The nurse also updated the daughter that the resident's fingers were cyanotic, and the nurse could not get an oxygen level on the resident. The daughter requested the resident remain comfortable. Review of the Pressure Ulcer/Wound Record form dated [DATE] at 8:52 A.M. revealed Resident #72 had a left buttock stage three pressure wound which measured 3.9 cm length by 4.7 cm width by 0.1 cm depth with moderate serosanguinous exudate with a wound bed of 60% granulation and 40% slough. The surrounding skin color and surrounding tissue/wound edges were excoriated, and the wound had deteriorated. A new order was placed to cleanse the wound with normal saline, pat dry, apply silver alginate (antibacterial absorbent wound dressing) and cover with a foam dressing daily and as needed. Review of the physician's orders revealed an order dated [DATE] (discontinued [DATE]) to cleanse Resident #72's left buttock with normal saline, pat dry, apply silver alginate, and cover with a foam dressing daily and as needed. Review of the progress note dated [DATE] at 7:35 A.M. authored by LPN #816 revealed Resident #72 was observed without a pulse which was verified with other staff members. The daughter was updated, and the administrative staff were updated. Interview on [DATE] at 11:51 A.M. with NP #908 stated she first assessed Resident #72's skin and determined the resident had a stage three left buttock pressure wound on [DATE] and placed orders for wound care at that time. NP #908 could not remember if the resident had a dressing on his left buttock when she went into assess the resident's left buttock pressure wound. Interviews on [DATE] at 12:22 P.M. with LPN UM #886 and the Administrator confirmed Resident #72's hospital documentation dated [DATE] did not contain evidence of a pressure wound to Resident #72's left buttock as documented in the [DATE] care plan. She confirmed she had placed pressure ulcer wound assessments in Resident #72's electronic health record (EHR) for the dates of [DATE] and [DATE] which documented the left buttock pressure wound as a stage three but could not remember what the left buttock pressure wound looked like on [DATE]. She stated she must have found out the left buttock pressure wound was a stage three from the report obtained from the hospital during Resident #72's nurse to nurse report as she did not stage pressure wounds, and the wound NP completed staging of resident pressure wounds. Interviews on [DATE] at 1:46 P.M. with RN UM #834 indicated she admitted Resident #72 on [DATE], and he did not have skin impairments to his left buttock. She stated the wound assessment dated [DATE] was placed in the resident's record in error. RN UM #834 confirmed the resident was on a every two hour turn and barrier cream as needed. She verified the first treatment order was implement on [DATE]. An additional interview on [DATE] at 2:40 P.M. with RN UM #834 confirmed Resident #72's left buttock pressure wound assessments dated [DATE] and [DATE] were documented in error and struck out of the resident's medical record. RN UM #834 confirmed the facility first identified Resident #72's left buttock stage three pressure wound on [DATE] when the wound NP assessed the resident. RN UM #834 stated wound NP #908 ordered zinc oxide for the left buttock pressure wound following identification on [DATE], and she did not agree with NP #908's determination that the left buttock pressure wound was identified at a stage three. Review of Resident #72's medication administration records (MARS) and treatment administration records (TARS) revealed documentation from [DATE] to [DATE] to encourage the resident to float heels while in bed as tolerated and encourage the resident to offload pressure while in bed or chair as tolerated every shift. The MARS and TARS indicated the wound care was completed from [DATE] to [DATE] (when the resident expired in the facility). Review of the Pressure Ulcer Prevention and Interventions policy, revised ,d+[DATE], revealed the policy was to implement preventative skin measures for all resident's based on the levels and areas of risk to include moisture, nutrition, activity, mobility, mental status, psychosocial status and general physical condition. This deficiency represents non-compliance investigated under Complaint Number OH00157185.