Every finding on record at Barnes-Jewish Extended Care

Based on observation, interview, and record review, the facility failed to ensure residents were provided with care in accordance with professional standards of practice when staff failed to obtain and follow physician orders for indwelling device use, care, and/or removal, and/or wound care for five residents (Residents #3, #4, #6, #8, and #11), and failed to follow-up with the surgeon's office for further instruction after identifying concern of wound infection for one resident (Resident #4). The sample size was 12. The census was 76.Review of the facility's Central Vascular Access Device (CVAD, devices inserted through a vein to enable administration of fluids, medications, and other therapies to the blood stream) removal policy, updated 06/01/21, showed:-To be performed by Licensed Nurses according to State law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organization policy;-Guidance:-A prescriber order is required to remove a CVAD;-Every effort should be made to obtain length of catheter prior to removal. If unable to obtain length of catheter, specific orders must be obtained to remove catheter in facility without knowledge of catheter length;-After catheter is removed, immediately place gauze dressing with sterile petroleum-based ointment centered over insertion site;-Secure gauze dressing with transparent dressing and instruct patient to leave in place;-Measure catheter length and assess catheter tip to ensure that entire catheter was removed;-Monitor site for bleeding through dressing every 15 minutes times two, and every-hour times two;-Leave dressing in place for 24 hours. Inspect for redness to site daily until site has epithelialized (scabbed over);-Documentation in the medical record includes, but is not limited to:--Date and time;--Reason for removal;--Length and condition of catheter and tip;--Site assessment;--Patient response;--Any action taken if catheter was removed due to complications;--Patient or significant other teaching. Review of the facility's Wound Treatment policy, last updated September 2022, showed:-The purpose is to provide guidelines for use in wound assessment, treatment and documentation;-Responsibility of the Director of Nursing (DON) to oversee this policy and procedure;-A physician's order is required for all wound treatment;-General principles of wound care include:-Monitoring of wounds:--When a wound is present monitoring should include the following:---An evaluation of the injury, if no dressing is present;--An evaluation of the status of the dressing, if present (whether it is intact if there is drainage, is it or is it not leaking);--All dressings will be dated and initialed by the nurse applying the dressing;-Documentation:--Documentation presence or absence of skin impairment of any kind on admission, transfer, and discharge. If present, describe the condition of wound thoroughly. Skin conditions should be assessed within two hours of admission, re-admission or return from leave of absence (LOA) and documented. Review of the facility's Physician Order policy, updated April 2024, showed:-The purpose is to establish guidelines for properly obtaining physician orders and processing these orders, and to provide guidelines to assure quality of monthly changeover of physician order sheet (POS), medication administration record (MAR), and treatment administration record (TAR);-Responsibility of the Licensed Nurse and Certified Medication Technician (CMT) to understand and comply with this procedure. It is the responsibility of the nurse manager to maintain, enforce and monitor the procedure;-Admission/Readmission/Discharge Orders;--Obtain admission orders from the physician. NOTE: Check the transfer sheet from the discharging facility as a reference. Transfer orders may only be used as a guide. They may not be used as admission orders. Check with the resident and/or family also to determine what medications the resident may have been on at home;-When obtaining admission orders from the physician, review the list of medications the resident has been on and clarify what the physician wants to be discontinued and what medications the resident is to remain on. Review of the facility's Short Peripheral Intravenous (IV) Catheter (PIVC, thin, plastic tube inserted into a peripheral vein) policy, updated June 2024, showed:-Considerations: The nurse should select a PIVC based on prescribed therapies, duration of treatment, usually for treatments of four days or less, availability of peripheral vascular access sites, and known diagnosis;-Procedure:--Verify prescriber order;--Label dressing with date and time, catheter gauge and length, nurse's initials;--Documentation in the medical record includes, but not limited to, date and time, informed verbal consent obtained, catheter type, gauge and length, site location site assessment, dressing type, patient response to procedure and or medication, patient/significant other teaching. 1. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/26/26, showed:-admitted from hospital on [DATE];-Cognitively intact;-Diagnoses included surgical aftercare following surgery on the circulatory system, aortocoronary bypass graft, heart failure, diabetes, dysrhythmia (irregular heartbeat), and end stage renal disease (ESRD, kidney failure). Review of the resident's care plan, in use at the time of survey, showed:-Problem: Surgical incisions and drains. At risk for skin impairment due to immobility;-Goal: Reduce the risk factors that could contribute to skin impairment and optimize wound healing through the next review period;-Approaches: Nursing responsible to notify nurse if dressings are not intact and complete treatments as ordered by physician. Review of the resident's electronic POS (ePOS) and TAR for June 2026, showed:-No physician orders for drain care or drain monitoring from 06/19/26 through 06/22/26;-An order, dated 06/23/26 through 06/26/26 for Jackson Pratt drain (JP drain, surgical suction drain used to empty excess blood and body fluid from a wound after surgery) to right lower extremity, empty JP drain and record output;--Treatment not documented as completed on three out of six opportunities;-An order, dated 06/23/26 through 06/26/26, to clean around drain insertion site and pat dry and apply split gauze once a day;--Treatment not documented as completed on three out of six opportunities;-No physician order for surgical wound care to the right lower extremity/calf from 06/19/26 through 06/22/26;-An order, dated 06/23/26 through 06/26/26, for surgical wound to right lower calf, clean with wound cleanser, pat dry, cover with island dressing once a day;--Treatment not documented as completed on five out of seven opportunities. Review of the resident's physician after visit summary, dated 06/26/26, showed:-Drain removal today in the office;-Wound care instructions:--Change right lower extremity dressing daily;--Apply ACE wraps (elastic bandages) or compression socks to right lower leg daily in the morning, reapply daily. Review of the resident's ePOS and TAR for July 2026, showed:-An order, dated 07/01/26 through 07/04/26, for surgical wound care to right lower extremity/calf, clean with wound cleaner, pat dry, and apply foam dressing once a day;--Treatment not documented as completed on five out of eight opportunities;-An order, dated 07/01/26 through 07/04/26, for right lower extremity/calf, wrap with ace wrap or compression sock every morning;--Treatment not documented as completed on five out of eight opportunities. During an interview on 07/02/26 at 2:24 P.M., the resident's family member said on 07/01/26, the resident told him/her that his/her leg was swollen and the bandage on it had not been changed in six or seven days. The resident's family member called the facility at 3:00 P.M. and spoke to Licensed Practical Nurse (LPN) D, who said the resident had gone three days without the dressing being changed. During an interview on 07/21/26 at 12:46 P.M., LPN D said on the afternoon of 07/01/26, he/she spoke with the resident's family member about his/her concerns with wound care not being completed. LPN D explained his/her 07/01/26 wound care findings to the resident's family member, and he/she was unsure if there was a date or initials on the resident's dressing when he/she provided care. The resident's leg was swollen when LPN D provided care. During an interview on 07/22/26 at 11:50 A.M., the DON said she was not at work the day the family member texted her on 07/01/26 regarding his/her concerns about the resident's right leg swelling and surgical wound care not being provided. The DON notified the floor supervisor, LPN E, and requested he/she address the issue. The DON also investigated the issue and found the wound care nurse discontinued the resident's orders for wound care to the lower extremity/calf on 06/26/26. The orders from the resident's surgical visit on 06/26/26 were missed and staff did not enter them into the resident's record until 07/01/26. These orders should have been entered the day resident returned from the physician visit. 2. Review of Resident #4's entry MDS, dated [DATE], showed:-admitted from hospital to facility 06/21/26;-Cognitively intact;-Diagnoses included displaced bimalleolar (involving both the medial and lateral malleolus-bump on both sides of ankle) fracture of the right lower leg/ankle, multiple fractured ribs of right side, fractured left ulna (inner bone of forearm), left foot fifth metatarsal (foot bone) fracture, kidney transplant, and diabetes. Review of resident's care plan, in use at the time of survey, showed no documentation related to the resident's right shin pin sites for external fixator (a stabilizing metal frame placed outside the body using pins or wires that screw directly into the bone), surgical treatments, or fracture treatments. Review of the resident's hospital discharge orders, dated 06/21/26, showed:-Take clindamycin (antibiotic) 300 milligram (mg) capsule, take one capsule every eight hours for eight days;-Ice to area left lower extremity/calf for comfort and bacitracin/antibiotic ointment to abrasions twice a day;-Pin wire site care, clean the area surrounding the pin gently with 50:50 mix solution of hydrogen peroxide and normal saline applied by cotton swab, do not probe into the pin site tract. Review of the resident's ePOS, showed:-An order, dated 06/22/26 through 06/30/26 for clindamycin 300 mg oral capsule, administer one capsule at 1:00 A.M., 9:00 A.M., 5:00 P.M., for local infection of the skin and subcutaneous (under the skin) tissue;-No physician order for pin care to right external fixator from 06/21/26 through 06/22/26;-No physician order for right arm fracture treatment from 06/21/26 through 06/22/26;-No physician order for right lateral ankle treatment from 06/21/26 through 06/22/26;-No physician order for right knee blister treatment from 06/21/26 through 06/22/26;-No physician order for left hand fracture from 06/21/26 through 06/22/26. Review of the resident's ePOS and TAR, dated June 2026, showed:-An order, dated 06/23/26 through 07/02/26, for pin care to right leg external fixator, cleanse all pin sites using cotton swab dipped in 50:50 mixture of hydrogen peroxide and normal saline twice a day, do not probe into the pin site, cover with kerlix (sterile gauze);--Treatment not completed 11 out of 25 opportunities;-An order, dated 06/23/26 through 07/02/26, for right arm fracture with splint, monitor for signs and symptoms compartment syndrome daily and maintain splint until orthopedic follow up appointment;--Treatment not completed six out of 13 opportunities;-An order, dated 06/23/26 through 07/02/26, for blister to right lateral ankle, clean with wound cleaner, pat dry, apply xeroform (a sterile non-adherent wound dressing with petrolatum blend gauze), cover with gauze daily and as needed;--Treatment not completed six out of 13 opportunities;-An order, dated 06/23/26 through 07/02/26, for blister to right knee, monitor for drainage and signs and symptoms of infection daily, leave open to air if nondraining;--Treatment not completed six out of 13 opportunities;-An order, dated 06/23/26 through 07/02/26, for left hand fifth metacarpal (pinky), monitor daily for signs and symptoms of infection, leave open to air;--Treatment not completed five out of 13 opportunities. Review of the resident's WoundZoom (an AI-powered digital wound management platform with mobile imaging) note, dated 06/29/26, documented by Registered Nurse (RN) A, showed right leg surgical wound, resident complains of pain to the pin insertion sites. Most proximal pin site on shin is within normal limits with crusting cleansed as ordered. Distal shin pin site with slough (dead tissue) and erythema (redness of the skin) noted around pin, minimal thick cloudy drainage noted with concern for infection. Edema (swelling) remains to the extremity. House physician was informed, who referred to surgeon. Called surgeon's office, the office was closed, will follow up tomorrow. Review of the resident's progress notes showed:-On 06/30/26 at 11:56 A.M., RN A called the surgeon's office and spoke with surgeon's nurse and reported redness, slough, and drainage from around pin sites and concern for possible infection. Physician nurse said he/she will return call after speaking with physician;-No documentation of follow up message or phone call from surgeon's office or nurse;-No documentation of resident leaving facility for follow up visit with surgeon;-On 07/02/26 at 12:30 P.M., surgeon's office called to inform facility resident is going to be a direct admit having surgery on his/her right foot. They do not currently have a bed available, so resident is going to return to facility, once a bed is available at the hospital, the hospital will call the resident and have facility return him/her to be admitted to the hospital;-On 07/02/26 at 1:29 P.M. call from hospital, hospital able to admit the resident from surgeon's office. During an interview on 07/23/26 at 8:52 A.M., RN A said he/she did not receive a return call from the surgeon's nurse about his/her concerns for possible infection. He/She did not follow up because he/she saw the resident had an appointment scheduled 07/02/26 and sometimes it takes 48 hours for physicians to return calls. He/She did not recheck the resident's surgical site after 06/29/26. During an interview on 07/23/26 at 9:23 A.M., Surgical Nurse I, the nurse from the resident's surgeon's office, said his/her documentation showed he/she received a call on from the facility 06/30/26 in regard to concerns with surgical pin site draining and showing signs and symptoms of possible infection. He/She spoke with the surgeon and received orders to continue clindamycin and current wound care orders and follow up with appointment. He/She did not have a note showing he/she returned a call to the facility to give physician orders. 3. Review of Resident #6's admission MDS, dated [DATE], showed:-admitted from hospital to facility 06/17/26;-Cognitively intact;-Diagnoses included infection and inflammatory reaction due to an internal left knee prosthesis with IV antibiotics, diabetes, anemia, and heart disease;-Special treatments included IV antibiotics, IV access, and central line (a long flexible tube inserted into a large vein in the chest, neck, or arm that leads directly toward the heart). Review of the resident's care plan, in use at the time of survey, showed:-Problem: Surgical incision to knee;-Goal: To reduce the risk factors that could contribute to skin impairment and optimize wound healing;-Approaches included inform nurse if dressing not intact and follow physician orders for treatments;-No documentation related to the resident's jugular central venous catheter. Review of the resident's hospital discharge orders, dated 06/17/26, showed:-Ceftriaxone (antibiotic), infuse 20 milliliters (ml)/2000 mg IV daily for five minutes at 240 ml/hour (hr) for bone/joint infection;-Dressing care, cover incision with dry dressing and change every other day until staples/sutures have been removed by surgeon;-No instructions related to the right jugular central venous catheter. Review of the resident's ePOS, showed:-No physician order for ceftriaxone on 06/18/26 and 06/19/26;-An order, dated 06/20/26 through 07/14/26, for ceftriaxone solution 2 grams, 20 ml/2000 mg IV daily, intravenous at 240 ml/hr for infection in left knee, once a day at 11:00 AM.;-An order, dated 06/18/26, for surgical wound to left lateral knee, clean with wound cleanser, pat dry, apply island dressing (sterile wound dressing) every other day and as needed;-An order, dated 06/18/26, for surgical wound to left anterior knee, clean with wound cleanser, pat dry, apply island dressing every other day and as needed;-No physician order to remove right jugular central venous catheter. Review of the resident's progress notes showed:-On 07/14/26 at 11:30 P.M., RN C removed sutures and IV access to right jugular. No bleeding noted, tip of catheter intact. Pressure placed to site, secure pressure dressing placed and to remain for 72 hours;-On 07/15/26 at 6:05 A.M., discontinued measurement of catheter centimeter (cm);-No documentation referencing the reason for right jugular catheter removal, the length of the catheter, the resident's response to catheter removal, or education provided to resident upon catheter removal. Observation on 07/20/26 at 6:07 A.M., showed a gauze dressing, dated 07/14/26, to the resident's right jugular. An undated dressing with no initials to the resident's left knee. During an interview, the resident said he/she thought the knee dressing was changed yesterday. Observation on 07/21/26 at 7:21 A.M., showed a gauze dressing, dated 07/14/26, to the resident's right jugular. During an interview, the resident said staff changed the dressing on his/her knee yesterday, but they had not looked at the dressing to his/her neck since the IV was removed. During an interview on 07/22/26 at 3:06 P.M., the DON said she expected staff to obtain orders on how to care for internal jugular central venous catheters and to follow the physician orders in managing surgical wound treatments and care. She expected staff to remove the pressure dressing from the right jugular IV site after 72 hours, per physician orders. 4. Review of Resident #8's admission MDS, dated [DATE], showed:-admitted from hospital to facility 07/13/26;-Cognitively intact;-Diagnoses included surgical aftercare following surgery on the digestive system, anemia, renal insufficiency, pneumonia, bilateral inguinal (lower portion of abdomen) hernia with obstruction, and coronary artery disease;-No documentation of diabetes or non-proliferative diabetic retinopathy (eye disease caused by diabetes). Review of the resident's ePOS, MAR, and TAR, showed:-An order, dated 07/17/26, for furosemide (diuretic) solution 10 mg/ml, administer 40 mg by IV one time for severe non-proliferative diabetic retinopathy;--Treatment marked as complete on the TAR;-No physician order for IV access or removal. Review of resident's progress notes showed no documentation related to peripheral IV access or removal, or new orders for furosemide. Observation on 07/20/26 at 8:40 A.M., showed the resident with an IV in his/her right forearm with no date, time, or initials on the dressing. During an interview, the resident said staff had not looked at the IV since it was inserted. He/She could not confirm how long the IV had been in, but he/she received it when his/her legs started to swell up. During an interview on 07/22/26 at 2:00 P.M., RN F said he/she received an order from the physician for the resident to receive furosemide due to increased edema in the resident's bilateral legs and feet. He/She inserted the IV and administered the medication. He/She did not enter a physician order in the resident's medical record for the IV insertion. During the interview, RN F observed the dressing over the IV in the resident's arm and said he/she must have forgotten to document the date, time, and his/her initials on the dressing. All dressings on IVs should be dated, timed, and initialed. He/She left the IV in the resident's arm, in case the resident needed another dose of medication. When asked how long a peripheral IV could be left in, RN F did not respond. During an interview on 07/22/26 at 2:05 P.M., LPN G said a peripheral IV should only be left in for three days. During an interview on 07/22/26 at 2:07 P.M., LPN H said all dressings on IVs should be dated, timed, and initialed. A physician order was required to insert an IV. He/She was not sure how long an IV can remain inserted, but all IVs required weekly dressing changes. During an interview on 07/22/26 at 3:06 P.M., the DON said she was not aware the resident had a peripheral IV inserted with no date, time, or initials on the dressing, and that the IV had been in since 07/17/26. A physician order was required to initiate IV access and she expected staff to an order for this with the physician order for medication. A peripheral IV was good for 72 hours. 5. Review of Resident #11's admission MDS, dated [DATE], showed:-admitted from hospital to facility 07/08/26;-Cognitively intact;-Diagnosis included orthopedic aftercare following surgical amputation of left leg above knee, peripheral vascular disease (PVD, circulation disorder), anemia, coronary artery disease, diabetes, and stroke. Review of resident's care plan, in use at the time of survey, showed:-Problem: Surgical amputation on left lower extremity due to history of gangrene;-Goal: Minimize risk factors that may contribute to impaired skin;-Approaches included notify the nurse if dressing comes off and complete treatments as ordered. Review of the resident's ePOS and TAR for July 2026, showed:-An order, dated 07/09/26, for left above knee amputation surgical site, clean with wound cleanser, pat dry, apply abdominal dressing and secure with kerlix daily;--On 07/17/26, staff documented unable to complete treatment. Review of the resident's progress notes showed no documentation related to why wound treatment was not completed on 07/17/26. Observation on 07/20/26 at 11:25 A.M., showed a dressing on the resident's leg with no date or no initials on the dressing. Observation on 07/21/26 at 7:50 A.M., showed a dressing on the resident's leg with no date or initials on the dressing. During an interview, the resident said the dressing was not changed yesterday. During an interview on 07/20/26 at 10:55 A.M., RN A said all wound dressings should be dated and initialed and physician orders should be followed. 6. During an interview on 07/22/26 at 3:06 P.M., the DON said she expected nursing staff to follow physician orders for wound care. When a resident returned from an appointment or hospital visit, it was the responsibility of the nursing staff to follow up with the physician offices and hospitals to make sure there were orders to address wounds, and to clarify orders, if necessary. 30414683067141

Based on observation, interview and record review, the facility failed to follow their policy regarding visitation and failed to ensure residents could receive visitors when the facility locked the front door entrance at 8:30 P.M. and did not allow resident families/visitors to freely enter and exit the facility. The census was 69.Review of the facility's Resident Right to Access and Visitation policy, reviewed 9/22, showed:-Purpose: To outline resident's rights regarding visitation practices within the communities to see that proper compliance with CMS (Centers for Medicare and Medicaid Services) guidelines exists;-Responsibility: It is the responsibility of the Administrator to see that all staff members follow the visitation guidelines within this policy;-Policy: It is the policy of this organization to support and facilitate the resident's right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable and in a manner that does not impose on the rights of another resident;-The community must provide immediate access to any resident by:-Any representative of Federal Human Health Services;-Any representative of the State; -Any representative of the Office of the State Long Term Care Ombudsman;-The resident's individual physician;-Any representative of the agency responsible for the protection and advocacy system for the developmentally disabled individuals or those with mental disorders;-The resident representative;-The community must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at the time;-The community must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;-The community will inform each resident and/or resident representative of his or her visitation rights and related policies and procedures, including any clinical or safety restriction or limitation of such rights, in a manner he or she understands;- The community will inform each resident of the right, subject to his or her consent, to receive the visitors whom he or she designates as well as deny visitation;-The community will not restrict, limit, otherwise deny visitation privileges based on race, color, national origin, religion, sex, gender identity, sexual orientation or disability;-The community will see that all visitors enjoy full and equal visitation privileges consistent with resident preferences;-The community shall provide 24-hour access to other non-relative visitors who are visiting with the consent of the resident. During a group interview on 3/3/26 at 10:30 A.M., three out of four residents who represented the resident council, said the facility did not allow visitors after 8:30 P.M. They said the staff would make announcements twice before 8:30 P.M., stating all visitors needed to leave and the front doors will be locked. During an interview on 3/4/26 12:11 P.M., Visitor E said he/she visited a resident every day for several hours but just needed to make sure he/she leaves before 8:30 P.M. in the evening because the facility locks the door. There are no other access doors for coming in and going out in the facility for visitors. He/She was told visiting hours were from 7:00 A.M. to 8:30 P.M. Observation on 3/5/26 at 3:05 P.M., showed a sign by the front doors, stated, Building Hours 7:00 A.M. - 8:30 P.M. If you need assistance, please use the intercom on the brick wall behind you. The sign was inside the building and seen after entering the first double-doors, and before the second double doors entering the lobby, to the receptionist desk. During an interview 3/5/26 at 3:10 P.M., Receptionist D said he/she worked when the front doors were open from 7:00 A.M. through 3:30 P.M., and another receptionist worked from 3:30 P.M. until 8:30 P.M. He/She said the facility's visiting hours were from 7:00 A.M., to 8:30 P.M. The front doors closed after the receptionist leaves. No visitors were allowed after the hours. The evening shift receptionist would make overhead announcements twice before 8:30 P.M., first at around 8:00 P.M., then at around 8:20 P.M., to let visitors know they needed to leave, unless they were spending the night. If visitors were unable to leave on time, and the front doors were locked, they would be escorted by staff to exit in the back door. The back door was for employees' access only. The receptionist said strictly no visitors were allowed after 8:30 P.M. unless permitted to stay overnight. The intercom in the front doors would not be accessible after 8:30 P.M. because both doors would be locked. If visitors arrived after the set time, they may call the facility but would still not be allowed to enter the facility. The receptionist said the visiting hours information was provided to the residents and family or whoever was with them upon admission or arrival to the facility. They would also remind the visitors of the visiting hours when they come in. During an interview on 3/6/26 at 3:48 P.M., the Corporate Director of Clinical Services (CDCS) said there should not be visiting hours. The visitors were allowed to enter the building at any time. The front doors were to be locked after 8:30 P.M., but the back door should be accessible to visitors. She expected the staff to follow the facility's visitation policy.

Based on observation, interview and record review, the facility failed to accommodate the needs of one resident (Resident #30) by failing to ensure the resident's call light was plugged in and accessible to the resident. The sample was 18. The census was 69. Review of the facility's Call Lights: Accessibility and Timely Response policy, revised 8/2024, showed:-Purpose: To establish a procedure to which the community adequately equips call lights at each residents' bedside, toilet and bathing areas to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response;-Policy: Each resident shall have access to summon assistance lights are answered timely;-Practice: Special accommodations will be identified on the resident's person-centered plan of care and provided accordingly. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. Review of the facility's Nursing Policy - A.M. and P.M. Care, revised 10/2022, showed the procedure during P.M care included attach call bell to bedside rail or within the resident's reach. Review of Resident #30's medical record, showed:-admission date 12/31/25;-Diagnosis included history of stroke, need for assistance with personal care, unspecified fall, generalized muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, cognitive communication deficit, paranoid schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and anxiety disorder. Review of the resident's care plan, in use at the time of survey, showed: -Focus: High risk for falls;-Goal: Reduce the risk factors that may contribute to falls and minimize injuries related to falls;-Interventions included: Call light within reach. Remind to use call light. Observations on 3/2/26 at 11:05 A.M., 3/3/26 at 9:15 A.M. and 3/4/26 at 11:33 A.M., showed the resident in bed. His/Her call light was unplugged to the right of the foot of the bed. Observation and interview on 3/4/26 at 12:26 P.M., showed the resident awake in bed with his/her head in between the mattress and bedrail, and body positioned at a diagonal angle on the mattress. His/Her call light was unplugged and to the right side of the foot of the bed. During an interview, the resident said he/she didn't know what happened to his/her call light but would be more comfortable if he/she was repositioned. Observation on 3/4/26 at 3:32 P.M., showed resident in bed with eyes closed. His/Her call light was unplugged and to the right side of the foot of the bed. During an interview on 3/4/26 at 6:21 P.M., Certified Nurse Aid (CNA) I said the resident depends on staff for assistance with all his/her activity of daily living (ADLs). Sometimes the resident has behaviors and yells out for help. The resident knows how to use the call light and is known to pull out his/her call light. During an interview on 3/4/26 at 6:24 P.M., Licensed Practical Nurse (LPN) C said the resident knows how to use his/her call light but has behaviors and yells out a lot for help and is known to pull the call light off the wall. Observation on 3/6/26 at 8:48 A.M., showed the resident scooted down toward the foot of the bed with his/her body positioned at a diagonal angle and his/her chin touching his/her chest. The call light was unplugged and sat in open view on top of the resident's dresser. During interview on 3/6/26 at 8:55 A.M., CNA J said the resident was unable to get out of bed without assistance and was dependent of staff for ADL care, but he/she knew how to use the call light to call for assistance. CNA J did not know why the call light was unplugged, or who unplugged it, but thought maybe nursing staff unplugged it because the resident was to be discharged later that day. It was important for residents to have access to their call lights so they could request assistance when needed. He/She did not know the facility's protocols when residents are being discharge and believes that's why staff unplugged it. During interview on 3/6/26 at 9:00 A.M., LPN B said the resident usually screams out for help or bangs on the wall for help. He/She is known to use the call light excessively and someone probably just unplugged it because they became annoyed. During an interview on 3/6/26 at 3:49 P.M., the Director of Nursing (DON) said she expected the staff to follow their policies and to ensure all residents had access to their call lights. It is not acceptable practice to remove a resident's call light.

Based on interview and record review, the facility failed to ensure services provided met professional standards when staff failed to identify one resident's burn on admission which resulted in the treatment orders not being obtained for four days (Resident #101) and staff failed to identify/document one resident's wound on admission (Resident #53). The sample was 18. The census was 69. Review of the facility's admission of a Resident policy, date revised 2/26, showed:-The nurse should interview and assess the resident upon admission to determine high risk areas based on the resident's admission diagnosis. Assessment findings will be used to provide appropriate equipment or monitoring required. Nursing assessments include but are not limited to skin condition;-When assessing a resident and obtaining orders for a new admit the nurse should refer to the admission checklist and consider the following: skin and wound prevention protocol;-Review and discuss with resident/resident representative current medication orders present upon admission and reconcile discrepancies with most recent home or transferring facility medications by clarifying with the admitting physician what medications he/she wants the resident to be on;-Transcribe the physician's orders to the appropriate places;-The Nurse Manager should review all admissions 24 hours post admission, or Monday following weekend admissions for follow-up completion using the admission audit tool. Review of the facility's Assessments and Documentation Requirements policy, date revised 10/24, showed:-It is the responsibility of each licensed nursing employee to abide by this policy. lt is the responsibility of each Nurse Manager to monitor his/her employees regarding completion of required assessments;-The following documentation requirements will be completed on all residents: admission assessment for the skilled resident, head to toe assessment daily. Daily skilled head to toe assessment on every rehab and therapy patient;--Assessment for Long Term Care Resident: Head to toe assessment including vital signs daily for first 72 hours after admission and monthly thereafter. 1. Review of Resident #101's medical record, showed:-admitted on [DATE];-Alert and oriented times four (person, place, time and situation);-Diagnoses included: Urinary tract infection (UTI), atrial fibrillation (irregular heart rhythm), high cholesterol, and anemia (decreased number of red blood cells). Review of the admission Observation, dated 2/19/26, showed: Does resident have any alteration in skin? Burn was not checked. Review of the progress notes, dated 2/19/26 through 2/24/26, showed:-On 2/20/26 at 2:49 P.M., on 2/21/26 at 3:40 P.M., on 2/22/24 at 1:09 P.M., on 2/23/26 at 12:54 P.M., on 2/24/26 at 1:47 P.M. skin temperature was warm, skin integrity was intact; mucous membranes color: Pink, and mucous membrane description: Pink;-On 2/24/26 at 4:44 P.M., resident reported dressing to his/her left side was peeling off. No order for a treatment or care for this wound site. Office Manager notified, went with nurse to assess wound. Old dressing removed with moderate amount of serosanguineous drainage (yellowish drainage will small amounts of blood) with mild odor. Wound bed noted with 2nd degree burn (affects the outer most layer of skin and extends to the middle layer of skin) that resident reported occurred three weeks ago at home from hot grease while cooking French fries. The doctor was notified with new wound care orders. Cleanse wound with wound cleanser, pat dry, apply to wound, 4x4 (gauze), secure with tape every day for seven days. Nurse medicated resident with oxycodone (pain medication) 15 milligrams (mg) by mouth for side pain from dressing change. Review of the care plan in use at the time of survey, showed:-Problem: Resident had a burn to his/her left flank (side of the body between the upper abdomen and the back), dated 2/27/26;-Goal: To reduce the risk factors that could contribute to skin impairment and optimize wound healing through the next review period;-Interventions included: Please check the resident's skin daily with care and inform the nurse of any skin issues, new areas of redness, or skin breakdown. Let the nurse know if the dressings are not intact. Treatments as ordered by Medical Doctor (MD). During an interview on 3/5/26 at 12:30 P.M. the Director of Nursing (DON) said the resident did not obtain a burn at the facility. If the resident had a dressing on when he/she was admitted to the facility, the nurse should have removed the dressing and documented what the skin looked like, and staff should have called the Physician to review the wound with him. If the resident did not have a dressing on when he/she was admitted , staff should have documented what the skin looked like. If a resident was admitted with a burn/wound, staff should tell the Wound Nurse, call the on-call Physician for guidance or they could call the wound doctor to obtain orders. 2. Review of Resident #53's medical record, showed:-admitted on [DATE];-Alert and oriented times four;-Incontinent of bowel and bladder;-Diagnoses included: partially blind, high blood pressure, pressure ulcer of sacral region (the triangular region at the base of the spine, located between the lumbar vertebrae and the tailbone (coccyx), stage III (full-thickness wound extending through the skin into the subcutaneous fat layer, but not exposing muscle, tendon, or bone). Review of the care plan in use at the time of survey, showed:-Problem: Resident had a pressure ulcer to his/her coccyx and surgical incision to his/her neck, dated 2/27/26;-Goal: To reduce the risk factors that could contribute to skin impairment and optimize wound healing through the next review period;-Interventions included: Please check the skin daily with care and inform the nurse of any skin issues, new areas of redness, or skin breakdown. Let the nurse know if the dressings were not intact. Treatments as ordered by MD. Review of the physician order sheet, in use at the time of survey showed:-A physician order for left buttocks wound, cleanse area with soap and water, apply Calvida (barrier) every 12 hours and as needed every shift, dated 2/20/26;-A physician order for sacrum, clean with wound cleanser, pat dry. Apply Calvida every shift and as needed, dated 2/23/26. Review of the progress notes dated 2/20/26 through 2/24/26, showed:-On 2/20/26 at 6:37 A.M., resident arrived at facility via ambulance. Wound at the back of his/her neck. The note did not show the resident had a wound on his/her sacrum;-On 2/22/26 at 1:47 A.M., skin integrity: Localized abnormality, abnormality location: neck; note did show area on sacrum;-On 2/23/26 at 4:05 P.M., sacrum pressure injury noted in hospital, was unable to be assessed this date due to resident refusal. Wound consult placed. Educated patient on importance of repositioning every two hours;-On 2/24/26 at 4:00 P.M., sacrum pressure injury noted in hospital, was seen by wound doctor this date and renamed as stage III pressure injury to coccyx. Measured 1.3 centimeters (cm) x 7 cm x 0.1cm. Orders to continue barrier cream twice a day and as needed. Review of the hospital records, showed:-Wound 2/9/26, gluteal cleft (vertical crease between buttocks): On 2/18/26, site assessment: Dry and intact; -Wound 2/17/26, sacrum pressure injury: Pressure injury stage: Deep tissue pressure injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues);-Recommendations: Cleanse sacrum/bilateral buttocks, pat dry and apply a thin layer of barrier or zinc spray twice daily and as needed for soiling/stooling. Review of the admission Observation, dated 2/20/26, showed the form was blank. Review of the wound doctor note, dated 2/24/26, showed this was the wound doctor's initial assessment, and the information was provided by the caregiver. Wound #1 status was open. Original cause of wound was pressure injury. The date acquired was: 2/20/2026. The wound was currently classified as a category/stage III wound with etiology of pressure ulcer and is located on the coccyx. During an interview on 3/5/26 at 9:45 A.M. and at 1:56 P.M, the Wound Nurse said the nurse on the floor was responsible for completing the admission and weekly skin assessments. Both the floor nurse and the Wound Nurse provided wound care. During an interview on 3/5/26 Unit Manager K said when she went to print the admission assessment, she invalidated the assessment, since she helped with the admission, she entered the assessment in today. Review of the admission observation dated 3/5/26 showed: Does the resident have a pressure skin injury or any pressure ulcer injury? No was marked. 3. During an interview on 3/6/26 at 12:30 P.M. the Director of Nursing (DON) said when a resident was admitted to the facility, the nurse on the floor was responsible for completing all the assessments that pop up in the computer system. A head-to-toe assessment is one of the assessments that pops up. Staff should document any bruises, rashes or wounds the resident may have. Wounds should be documented in the progress notes and should include a description of the wound, if there was drainage, anything out of the ordinary. The wound nurses usually measure and stage the wounds. The DON did not know anything about Resident #53's wound on the sacrum. 4. During an interview on 3/6/26 at 3:49 P.M., the DON said she expected staff to follow the facility's policies and procedures.

Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards when the facility staff failed to complete/document neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) post fall per the facility's policy for four out of six residents sampled for falls (Residents #14, # 16, #10 and #15). In addition, staff failed to follow a physician order to monitor one resident's blood pressure (B/P) and notify the physician per the physician's order (Resident #14). The sample size was 16. The census was 63.Review of the facility's Fall Management/Reduction Program policy, last revised 9/24, showed:-It is the responsibility of all staff to know and follow this policy;-Once a fall occurs, it is important that an assessment and investigation occur to determine possible cause of the fall utilizing the designated form within the resident's medical record. The charge nurse will conduct a post fall huddle including all involved that witnessed the fall or had care responsibilities. Upon gathering the facts of the fall, current and proposed intervention(s) will be reviewed and implemented as necessary to attempt to reduce the potential for a subsequent occurrence;-A post-fall evaluation is to be completed after any resident fall. Additionally, Neuro checks per neuro check policy will also be completed;-Post Fall interventions will be developed and implemented after each fall and noted in the medical record;-Neuro Checks are to be completed with any fall at the following intervals: All unwitnessed falls or witnessed falls in which the head was struck: Initial assessment; Then every (Q) 15 minutes x (times) four; Then Q 30 minutes x two; Then Q hour x two; Then once per shift for 72 hours;-Nurses will document in the medical record routinely for seventy-two (72) hours after the fall to describe the post-fall condition, injury, interventions, etc. 1. Review of Resident #14's face sheet, showed:-readmitted [DATE];-Diagnoses included: malignant neoplasm (cancerous tumor), unsteadiness on feet, muscle weakness and needed assistance with personal care. Review of the Resident's progress notes, dated 3/24/26 through 3/25/26, showed:-On 3/24/26, no progress note entry that provided detail of the resident's unwitnessed fall;-On 3/25/26 at 12:29 A.M., a telemedicine physician from out of state was contacted regarding the resident being found at bedside uninjured after an unwitnessed fall. Assessment/plan for neuro checks as per facility protocols;-On 3/25/26 at 3:25 A.M., neuro check was performed. Review of the Resident's Medication Administration Record (MAR), dated 3/24/2026 through 3/26/26, showed:-A physician order, with a start date of 3/25/26 and stop date of 3/25/26, for neuro checks Q15 minutes x four, then every 30 minutes x two, Q one hour x two, then Q shift x 72 hours;--Documentation showed: at 10:45 A.M., vitals (temperature (T), pulse (P), respiration (R), blood pressure (B/P), and oxygen saturation (O2 sat)) and pain level were documented. No other vitals signs were documented. Review of the Resident's Event Report, dated 3/24/26 at 10:45 P.M. and completed on 3/27/26 at 12:19 P.M., showed:-Description: Unwitnessed fall from bed;-Neurological (neuro) check (level of consciousness, facial muscle, upper extremity movement, lower extremity movement, pupil size -reactive): showed a neuro check complete;-Nurse manager / Interdisciplinary Team (ITD) review note, showed resident had a history of muscle weakness, unsteadiness on feet, and cognitive communication deficit with increased confusion related to metastatic cancer. Client had been noted to roll out of bed. Staff encouraged to keep bed in lowest position;-Vitals signs completed, showed::--On 3/24/26 at 10:45 P.M.,11:00 P.M., 11:15 P.M., 11:30 P.M.;--On 3/25/26 at 12:00 A.M., 12:30 A.M., 1:30 A.M., 2:30 A.M. A B/P was recorded on 3/25/26 at 2:57 A.M;-Orders: Fall: Start date 3/25/26 and discontinue on 3/28/26, to:--Fall unwitnessed - neuro checks Q 15 minutes (mins) x four, then every 30 mins x two, Q one hour x two, then Q shift x 72 hours. Special instructions: Complete Neuro check progress note;-Notes: dated 3/25/26 at 3:25 A.M., showed a neuro check was completed. No other neuro checks were documented. Review of the Resident's vital signs tab in the medical record, dated 3/26/26, showed:-At 4:59 A.M. B/P as 97/68;-At 7:52 A.M. B/P was 87/62;-At 4:17 P.M. B/P was 120/62;-No other B/Ps were documented. Review of the Resident's Event Report, dated 3/26/26 at 4:15 A.M. and completed 3/27/26 at 12:17 P.M., showed:-Description: Unwitnessed fall;-Neurological Check: was completed;-Vitals: were completed on 3/26/26 at 4: 59 A.M.;-Orders: Start date 3/26/26 and discontinue on 3/28/26 to:--Fall unwitnessed - neuro checks Q 15 minutes (mins) x four, then every 30 mins x two, Q one hour x two, then Q shift x 72 hours. Special instructions: Complete Neuro check progress note;--Fall witnessed- neuro checks initially, then Q shift for 72 hours. Special instruction: Complete neuro check progress note. Review of the Residents' progress notes, dated 3/26/26 through 3/27/26, showed:-On 3/26/26 at 5:01 A.M., The nurse was called to patients' room by Certified Nurse Aide (CNA) patient was seen by the nurse laying on the floor on his/her stomach. Patient stated, I fell out of bed. Assessments, vitals, and range of motion are within normal limits for this patient. Patient was assisted to his/her recliner chair and is watching tv in the common area. Patients denied any pain or discomfort and show no signs and symptoms of distress at this time;-On 3/26/26 at 5:53 A.M., a telemedicine physician from out of state was contacted regarding resident's fall:-Vital Signs: heart rate: 114 beats per minute (bpm) (normal is 60 through 100) ; blood pressure: multiple readings taken - 95/68 millimeters of mercury (mmHg) (normal 120/80 through 90/60), 96/62 mmHg, 94/63 mmHg, 84/59 mmHg;-Physical Examination, Alert, awake, and oriented times two, at baseline;-Assessment & Plan, patient who experienced a fall and is being evaluated for associated complications including hypotension (abnormally low blood pressure, defined as reading below 90/60 mmHg) and tachycardia (an abnormally fast resting heart rate, defined as over 100 beats per minute);-Plan: Monitor blood pressure and vital signs every hour, call back if further decline in blood pressure occurs;-Orders given / Nursing instructions: Perform neurological checks for monitoring; monitor blood pressure and vital signs every hour; Call back if further decline in blood pressure occurs. Review of the undated physician's order sheet, in use at the time of survey, showed there was no order to monitor blood pressure and vital signs every hour and to call back if further decline in blood pressure. Review of the Resident's progress notes, dated 3/26/26 through 3/27/26, showed there was no documentation showing the blood pressure was documented hourly or the physician was notified when the blood pressure fluctuated from 97/68 to 87/62, and there was no documentation showing the physician monitoring the blood pressure hourly was discontinued. Review of the Resident's MAR, dated 3/26/26 through 3/28/26, showed:-A physician order for Fall: Unwitnessed- Neuro checks Q15 minutes x four, then every 30 minutes x two, Q one hour x two, then Q shift x 72 hours;-Documentation showed: day shifts on 3/26 and 3/28 were blank;-A physician order for Fall: Witnessed- Neuro checks Initially, then Q shift x 72 hours;-Documentation showed: day shift on 3/26 and 3/28 were blank;-There was no physician to check the blood pressure and vital signs hourly to notify the physician if further decline in blood pressure occurred. Review of the vital signs tab dated 3/27/26, showed:-On 3/27/26 at 6:29 A.M. B/P was 98/58;--At 8:35 A.M., B/P was 98/67;--At 9:11 A.M. B/P was 98/61;--At 6:30 P.M., B/P was 90/61;--At 11:02 P.M., B/P was 100/68;--At 11:03 P.M. B/P was 100/64;-On 3/28/26 at 6:38 A.M. B/P was 100/64. Review of the Resident's care plan, in use at the time of the survey, showed:-Focus: Resident is at risk for falls due to unsteadiness on feet, muscle weakness and poor safety awareness, edited on 3/27/26;-Goal: Reduce the risk factors that may contribute to falls and minimize injuries related to falls;-Interventions: Ensure proper footwear while up, adequate lighting, call light within reach and low bed. Review of the progress notes dated 3/27/26 through 3/28/26, showed:-On 3/28/26 at 5:15 A.M., resident was sent to the hospital for rectal bleeding. Blood pressure 100/64;-There was no documentation showing the physician was notified when the blood pressure fluctuated from 98/61 to 90/60 and no documentation showing the physician order for hourly blood pressure and vital signs were discontinued. 2. Review of Resident #16's face sheet, showed:-readmitted : 4/8/26;-Diagnoses included dementia, glaucoma (a group of eye diseases that damage the optic nerve), diabetes, and chronic urinary retention (inability to completely or partially empty the bladder) with indwelling catheter (a sterile tube inserted into the bladder to drain urine). Review of the Resident's progress note, showed on 4/9/26 at 8:08 P.M., the CNA informed the nurse that patient was on the floor in dining room. Upon entering room patient was sitting on his/her left side, in front of his/her recliner. The nurse and CNA assisted patient to recliner, range of motion and body assessment performed with no injuries noted. T 97.9, P-71, R-16, B/P-102/52, O2 Sat 96% on room air. Placed call to on call doctor, instructed to continue with facility fall protocol. Review of Resident's MAR, dated 4/1/26 through 4/9/26, showed:-A physician order with a start date of 4/9/26 and stop date of 4/11/26 for neuro checks initially, then Q shift x 72 hours.-The record failed to reflect the pupil size - reactive. Review of the Resident's progress note, dated 4/11/26 at 7:13 A.M., showed neuro checks: Left Pupil Size: 3 millimeters (mm), Left pupil reaction: Reactive, Right Eye - Pupil Size: 3 mm, Right pupil reaction: Reactive. Review of the Resident's care plan, dated 4/16/26, and in use at the time of the survey, showed:--Focus: Resident is at risk for falls due to poor safety awareness;--Goal: Reduce the risk factors that may contribute to falls and minimize injuries related to falls;--Interventions: Falls mat at bedside. Grip mat in chair to prevent sliding. Frequent rounding and may sit at nursing station for closer monitoring. Call light in reach and low bed. Review of the Resident's progress note, dated 4/16/26 through 4/22/26, showed:-On 4/16/26 at 5:11 A.M., resident crawled out of bed and was found by nurse squatting down on the floor. Resident confused and not able to communicate the circumstances of his/her unwitnessed fall;-On 4/16/26 at 8:25 P.M., neuro checks: Left Pupil Size: 3 mm, Left pupil reaction: Reactive, Right Eye - Pupil Size: 3 mm, Right pupil reaction: Reactive;-On 4/18/26 at 10:57 P.M., neuro checks: Left Pupil Size: 3 mm, Left pupil reaction: Reactive, Right Eye - Pupil Size: 3 mm, Right pupil reaction: Reactive;-On 4/21/26 at 4:30 P.M., neuro checks: Left Pupil Size: 3 mm, Left pupil reaction: Reactive, Right Eye - Pupil Size: 3 mm, Right pupil reaction: Reactive;-On 4/21/26 at 5:24 P.M., resident found on the floor next to bed. Physician notified, order to continue monitoring resident for any change in condition and continue neuro checks;-On 4/21/26 at 8:42 P.M., post fall, no delayed injuries noted, neuros in process; neuro check details not included;-On 4/22/26 at 10:48 P.M., neuro checks: Left Pupil Size: 3 mm, Left pupil reaction: Reactive, Right Eye - Pupil Size: 3 mm, Right pupil reaction: Reactive. Review of the Resident's undated POS, in use at the time of survey, showed an order with a start date of 4/21/26 and end date 4/24/26. Unwitnessed fall, neuro checks Q15 minutes x four, then every 30 minutes x two, Q one hour x two, then Q shift x 72 hours. Special instructions: Complete neuro check progress notes every shift, day and night. Review of the Resident's MAR, dated 4/2026, showed a physician order with a start date of 4/21/2026 and stop date of 4/24/2026, for neuro checks Q15 minutes x four, then every 30 minutes x two, Q one hour x two, then Q shift x 72 hrs. The record failed to reflect the pupil size-Reactive. 3. Review of Resident #10's face sheet, showed:-admitted : 4/7/26;-Diagnoses: high cholesterol, high blood pressure, hypothyroidism (the thyroid is not making enough thyroid hormone), peripheral arterial disease (narrowed arteries reduce blood flow to the arms or legs) and left clavicular fracture (broken collar bone), cervical spine fractures, sternal fractures and rib fractures due to a motor vehicle collision (MVC). Review of the Resident's care plan, dated 4/8/26, and in use at the time of the survey, showed:--Focus: Resident at risk for falls with history of falls and impulsive movement;--Goal: Reduce the risk factors that may contribute to falls and minimize injuries related to falls;--Interventions: Fall mat, adequate lighting, call light within reach, keep items that are used frequently within reach for example- television remote and water pitcher, room free of clutter and low bed. Review of the Resident's progress notes, dated 4/8/26 through 4/11/26, showed:-On 4/8/26 at 8:28 A.M., Patient found on the floor by the nurse in a seating position sliding down the room towards the door. Assisted back to bed, patient confused and not able to communicate how he/she got on the floor. Treated as unwitnessed fall. Neuro checks within normal limit. No injuries noted and patients moved all extremities with no signs of pain.-On 4/9/26 at 1:53 P.M., neuro checks: Left Pupil Size: 3 mm, Left pupil reaction: Reactive, Right Eye - Pupil Size: 3 mm, Right pupil reaction: Reactive.- On 4/11/26 at 7:12 A.M., neuro checks: Left Pupil Size: 3 mm, Left pupil reaction: Reactive, Right Eye - Pupil Size: 3 mm, Right pupil reaction: Reactive. Review of Resident's MAR, dated 4/1/26 through 4/24/26, showed:-A physician order with a start date 4/8/2026 and stop date of 4/8/26 for neuro checks and vitals every hour (x2);-The record failed to reflect the pupil size - reactive;-A physician order with a start date 4/8/26 and stop date of 4/11/26 for neuro checks and vitals every 12 hours X six;-The record failed to reflect the pupil size - Reactive. 4. Review of Resident #15's face sheet, showed diagnoses included acute kidney failure (the kidneys suddenly can't filter waste products from the blood), dementia, muscle weakness, unsteadiness on feet and epilepsy (brain condition that causes recurring seizures). Review of the Resident's care plan, created 3/25/26, in use at the time of survey, showed:-Problem: Resident was at risk for falls. Last fall 4/2/26;-Goal: Reduce the risk factors that may contribute to falls and minimize injuries related to falls;-Interventions: Adequate lighting. Call light within reach. Keep items that are used frequently within reach. Low bed. Remind the resident to use call light. Keep room free of clutter. Geri (medical reclining chair) chair in common area for increased monitoring. Review of the Resident's progress notes, dated 4/3/26, showed:-At 12:14 A.M. orientation: disoriented; memory/recall: none of the above were recalled.-At 5:43 P.M., showed the nurse was charting when he/she heard a loud noise, looked up patient was on the floor next to recliner. Patients could not recall what happened. No complaint of pain or discomfort. Patient assessed and assisted back to recliner. No open areas. No bleeding. Notified physician, nurse manager and family. B/P 125/72, Pulse (P, normal 60 through 100) 100, Respirations (R, normal 12 through 18) 18, Temperature (T, normal 97.8 through 99.1) 98.4, Oxygen Saturation (O2 sat, normal 95% through 100%) 96% room air. In bed resting with call light in reach. Review of the Resident's MAR, dated 4/1/26 through 4/26/26, showed:-A physician order, dated 4/3/26 through 4/5/26, for Fall: Monitor status for 72 hours for bruising, change in mental status/condition, pain, or other injuries related to fall.--No documentation on 4/3/26. Documentation showed status for only 4/4 and 4/5;-A physician order, dated 4/3/36 through 4/6/26, for Fall: Unwitnessed- Neuro checks every 15 minutes x four; then every 30 minutes x two; then every one-hour x two; then Q shift X 72 hrs. Special instructions: Complete neuro check progress note;--Documentation showed: Day Shift: T, P, R, BP, O2 sat were documented once on 4/4, 4/5 and 4/6. Night Shift: T, P, R, BP, O2 sat were documented on 4/5 and 4/6. On 4/4, it was blank on night shift. Review of the Resident's progress notes, dated 4/3/26 through 4/6/26, showed:-On 4/3/26, neuro checks every 15 minutes x four, then every 30 minutes x two; then every one-hour x two, were not documented;-On 4/5/26, no vital signs or neuro checks were documented. Observation and interview on 4/24/26 at 4:25 P.M., showed the resident was up in a Geri Chair (reclining wheeled chair) sitting at the nurse's station. The nurse brought the resident to his/her room. The resident had a yellow bracelet around his/her wrist that showed he/she was a fall risk. The residents said he/she did not recall any recent falls. When the surveyor finished talking with the resident, he/she moved his/her legs over the side of the chair as he/she attempted to sit up. The nurse entered the room and repositioned the resident into his/her chair and moved the resident back to the nurse's station. 5. During an interview on 4/24/26 at 4:45 P.M., Certified Nurse Aide (CNA) A said if a resident fell, he/she would stay with the resident and tell the nurse. The nurse would assess the resident then they would get the resident up in a chair. If the residents hit their head they would do vital signs every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for four hours, then every eight hours. CNAs did the vital signs, but they also teamed up to get the vitals done. The CNA said Quality would notify staff if any new interventions were put into place post fall. 6. During an interview on 4/26/26 at 4:50 P.M., Licensed Practical Nurse (LPN) B said if a resident fell, he/she would assess the resident and ask the resident if he/she was hurt or if they hit their head. Falls were documented on the incident report and in the progress notes. The physician and family should be notified. Neuro checks were completed for any unwitnessed fall or if the residents hit their head. Neuro checks were done per protocol every 15 minutes X one hour, then every 30 minutes X two, then every hour X three days. Neuro checks included checking vital signs, pupils and range of motion. Neuro checks were documented in the computer. Once the order was entered into the computer, it would automatically pop up under tasks when the neuro check should be completed. 7. During an interview on 4/26/26 at 5:00 P.M., the Nurse Manager C said if a resident fell, the CNA would yell out for help and the nurse would assess the resident. The assessment included checking the pupils, Range of Motion (ROM), if there were breaks for pain, if there was head trauma, did the resident need to go to the emergency room or if they were safe to get up. Neuro checks were done for all unwitnessed falls or if the residents hit their head. Neuro checks popped up in the computer when it was due. Falls were documented under events, and it populated a note in the progress notes. She would also try to figure out why the residents fell to see if new interventions needed to be put into place. 8. During an interview on 4/24/26 at 5:34 P.M. the Director of Nursing (DON) said she did not know the fall policy off the top of her head. If a resident fell, the CNA should report it to the nurse. The nurse should do a fall assessment, and the template would guide the nurse through anything they needed to do. Neuro checks should be done for unwitnessed fall, a change in condition or if the residents hit their head. Neuro checks were completed in the computer, under the events tab. The physician and the resident representative should be notified. The facility utilized a telehealth service from 7 P.M. to 7 A.M. If the physician wrote orders in their notes, those orders would be communicated to the nurse, and the nurse would enter the orders into the computer. If the physician ordered vital signs, it would be documented under the vital signs tab. If the vital signs were not documented in the computer, she did not have the information. She would expect staff to follow the facility's policy and procedures.

Based on observation, interview and record review, the facility failed to ensure one resident with a pressure wound/injury (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) had necessary treatments and services to promote healing (Resident #30). The sample size was 18. The census was 69.Review of the facility's Wounds: Treatment of Pressure and Non-Pressure policy, revised 6/25/25, showed:-Purpose: To provide guidelines for use in wound assessment, treatment, and documentation;-Policy: The facility's Wound Product Selection Guide will be used as guidelines to determine appropriate treatments. A physician's order is required for all wound treatment; -Interventions should be taken to reduce edema and pressure related to the wound such as offloading heels (critical practice of removing or redistributing pressure from a wound site) and repositioning;-All dressings will be dated and initialed by the nurse applying the dressing. Review of Resident #30's Comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/26, showed:-Cognitively intact-Diagnosis included: Diagnosis included paranoid schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder, and benign prostatic hyperplasia (enlarged prostate gland). Review of Resident's care plan, in use at the time of survey, showed:-Focus: Resident has pressure ulcers and is at risk for skin impairment due to immobility and incontinence;-Goal: Goal is to reduce the risk factors that could contribute to skin impairment and optimize wound healing through the next review period;-Interventions included: Reposition frequently. Keep resident clean and dry. Low air loss mattress for weight distribution and gel cushion when up in chair. Check skin daily with care and inform the nurse of any skin issues. Let the nurse know if his/her dressing was not intact or any new areas of redness and/or skin breakdown. Treatments as ordered by physician. The care plan failed to show his/her heels should be always floated. (A care technique that involves elevating a bedridden patient's heels off the mattress surface to prevent or treat pressure ulcers). Review of the resident's Braden Scale (a tool used to assess a resident's risk of developing a pressure wound), dated 2/11/26, showed the resident scored 16, indicating at mild risk. Review of the resident's daily skilled assessments, dated 2/18/26 through 2/20/26, showed:-On 2/18/26 at 10:28 P.M., the resident's skin color assessment was usual for ethnicity, skin temperature warm and dry, and skin integrity intact. -On 2/20/26 at 11:53 P.M., the resident's skin color assessment was usual for ethnicity, skin temperature warm, and skin integrity localized abnormality. Review of the resident's wound progress notes dated 2/24/26, showed: -History of Present Illness (HPI): admitted after hospitalization for repeated falls after Lumbar (L) 4-5-disc herniation status post-surgery (a surgical procedure to treat a herniated disc located between the 4th and 5th lumbar vertebrae) 12/29/25. Sacral (sacrum-large triangular bone at the base of the spine, located between the two hip bones)) DTI (developing deep tissue pressure injury)- evolving, appears fairly extensive and Right buttock DTI- continue zinc barrier cream and offloading. Left heel serosanguinous (a thin and watery fluid with a pink color) blister- continue skin prep (protective dressing) and floating. Has low air loss mattress (a specialized therapeutic support surface designed to prevent and treat pressure ulcers by combining, controlling, and managing skin moisture and pressure, honeycomb wheelchair cushion (a flexible, gel-like, or plastic seating pad designed to evenly distribute weight, reduce pressure points, and promote airflow). Braden originally reported as 16 (inaccurate) recalculated as 13 on 2/23/26. A score of 13 indicates a moderate risk for developing pressure injuries;-Wound #1 status is open. Original cause of wound was Pressure Injury. The date acquired was: 2/20/2026. The wound is currently classified as an unstageable/unclassified (an obscured full-thickness skin and tissue loss) wound with etiology of Pressure Ulcer (what was the cause) and is located on the sacrum. The wound measures11cm length x 9.5cm width; -Wound #2 status is Open. Original cause of wound was Pressure Injury. The date acquired was: 2/20/2026. The wound has etiology of pressure ulcer and is located on the right gluteus (buttock muscle). The wound measures 2.5cm length x 0.8cm width; -Wound #3 status is open. Original cause of wound was pressure Injury. The date acquired was: 2/20/2026. The wound has etiology of pressure ulcer and is located on the left calcaneus (heel bone). The wound measures 3.3cm length x 5.5cm width. Review of the resident's re-admission nursing assessment, dated 1/21/26 at 9:43 P.M., showed a skin assessment was completed, and skin was intact. Review of the resident's physician order sheet (POS), showed:-An order, dated 2/20/26, wound care pressure, left buttock extending to bilateral gluteal cleft, clean with wound cleanser, pat dry, apply barrier cream every shift and as needed;-An order, dated 2/20/26, wound care pressure, left heel, apply skin prep daily and float heels at all times;-An order, dated 2/20/26, wound care pressure, right buttock, clean with wound cleanser, pat dry, apply barrier cream every shift and as needed. Observations on 3/2/26 through 3/5/26, showed:-On 3/2/26 at 6:34 A.M., resident lay flat on his/her back in bed; heels rested on bed with no elevation; -On 3/2/26 at 10:19 A.M., resident lay flat on his/her back in bed; heels rested on bed with no elevation; -On 3/3/26 at 9:15 A.M., resident lay flat on his/her back in bed; heels rested on bed with no elevation; -On 3/3/26 at 9:20 A.M., Certified Nurse Aide (CNA) H entered the room to provide morning care;-On 3/3/26 at 11:00 A.M., the head of the bed was slightly elevated, and the resident lay on his/her back; heels rested on bed with no elevation;-On 3/4/26 at 11:30 A.M., the head of the bed was elevated at a 45-degree angle and foot of bed slightly elevated, and resident lay on his/her back at an angle with head wedged between the mattress and bedrail against the wall; heels rested on bed with no elevation; -On 3/4/26 at 3:32 P.M., the head of the bed was elevated at a 45-degree angle and the foot of bed slightly elevated, and the resident lay on his/her back; heels rested on the bed with no elevation;-On 3/5/26 at 8:50 A.M., the head of the bed was slightly elevated, and resident lay on his/her back; heels rested on the bed with no elevation. Observation and interview on 3/5/26 at 10:15 A.M., showed the resident in bed. CNA H rolled the resident onto his/her side. There was a dressing on the resident's sacrum area extending down each buttock. The dressing had a brownish discoloration of the inner edges. The dressing was dated 3/3/26. CNA H said he/she did not know the resident had drainage like that. On the left heel was a roundish shaped dollar size blister. The blister was approximately half filled with fluid. The resident's heels were positioned on the mattress, there was no pillow under the resident's heels, and he/she did not have heel protectors on. Observation and interview on 3/5/26 at 12:30 P.M., showed the Director of Nursing (DON) checked the dressing on the sacrum and said the dressing was dated 3/3/26. Observation on 3/6/26 at 8:48 A.M., showed the head of the bed was elevated at a 45-degree angle. The resident had scooted down and was laying on his/her back at an angle with his/her chin touching his/her chest. The heels rested on the bed with no elevation. During an interview on 3/4/26 at 6:21 P.M., CNA I said when resident first moved in, he/she was able to use a walker and walk around but now the resident is incontinent and sleeps a lot. The resident was dependent on staff with all his/her activity of daily living (ADLs, grooming, dressing, toileting, and bathing) and now he/she had a pressure ulcer. He/she was not sure when it was discovered. CNA I said if he/she saw an issue with the wound dressing while providing personal care, he/she was to report it to the nurse. He/She was unaware of any special instructions needed for the resident's wound other than keeping the resident clean and dry. During an interview on 3/5/26 at 9:45 A.M. and at 1:56 P.M, the Wound Nurse said both her and the floor nurse was responsible for providing wound care. She made a list daily of residents who she will provide wound care to, and this was communicated to the floor nurse. If the floor nurse was unable to complete the wound care, they could report it to the wound nurse or pass it on to the next shift to complete. During an interview on 3/6/26 at 1:45 P.M., Unit Manager (Unit Mgr.) A said she would expect the staff to follow the physician orders to float the heels, which is ensuring the resident's heels are elevated off the surface to relieve pressure on the heels. During an interview on 3/6/26 at 3:49 P.M., the DON said if a resident had an order to float their heel or for off-loading, she would expect the resident's heels to be elevated off the mattress, even if the resident had an air loss mattress. She would expect for staff to follow physician orders and the facility's policies and procedures. 2692303

Based on observation, interview and record review, the facility failed to evaluate and address the hydration needs for one of 18 sampled residents (Resident #30). The census was 69.Review of the facility's Nursing Policy-A.M. and P.M. Care, revised 10/22, showed the procedure during A.M. and P.M care to be sure water is within reach. Offer and encourage fluid intake with care. Review of Resident #30's Comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/26, showed:-Cognitively intact-Diagnoses included paranoid schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder, and benign prostatic hyperplasia (enlarged prostate gland);-Independent of eating. Review of most current care plan, showed:-Focus: Resident is at risk for weight loss;-Goal: Minimize the risk factors that could contribute to weight loss;-Interventions included: Allow adequate time to eat, assist with positioning during meals, house supplements and snacks, and report to nurse if meal intake decreases. Review of resident's progress notes, showed:On 2/12/26 at 3:22 P.M. the physician note said last admission, per registered nurse (RN), patient (pt) drank excessive amounts of water. Pt is uncertain how much he/she is drinking. Will ask Nurse Sup if we are able to do urine na (NA, urine sodium, urine test to evaluate kidney function, fluid balance, and the cause of abnormal blood sodium levels) and urine osm (OSM, Urine osmolality, urine test to measures the concentration of all particles in urine, indicating how well kidneys balance water in the body). Will do a trial of fluid restriction 1500cc/day and repeat Na in 2-3 days. UA (urine analysis) pending and to notify physician of any changes;-On 2/13/26 - Unable to collect urine patient voided prior to collection;On 2/19/26 at 10:16 A.M., the physician note said he do not see a fluid restriction in resident's orders; however, patient no longer needs fluid restriction. Review of the resident's medication administration record dated 2/1/2026 through 2/28/2026, showed an order dated 2/12/26 and was discontinued on 2/19/26, for 1500cc fluid restriction daily every shift order. Observation on 03/2/26 at 11:05 A.M., showed resident lay on his/her back in bed that was in the lowest position. The resident's call light was unplugged and lay at the right side of the foot of the bed, a pitcher of water was on the bedside table that was approximately four feet from the ground out of resident's reach. The resident could be heard saying, Please, I am so thirsty. Please give me some water. Observation on 03/3/26 at 9:15 A.M., showed resident lay on his/her back in bed that was in the lowest position. The resident's call light was unplugged and lay at the right side of foot of the bed. On the resident's bedside table sat a small cup with approximately four ounces of light brown liquid and an empty pitcher. The bedside table was approximately four feet from the ground, out of resident's reach. The Resident could be heard saying, Please, I want some water. Observation and interview on 03/4/26 at 6:10 P.M., showed resident's bedside table with a half full pitcher of water, placed at the end of the room next to resident's closet in front of the window. The resident said he/she would like a bottle of water because he/she was thirsty. During an interview on 3/4/26 at 6:21 P.M., Certified Nurse Aid (CNA) I said when the resident first moved in, he/she was able to use a walker and walk around but now the resident is incontinent and sleeps a lot. The resident depends on staff with all his/her activity of daily living (ADLs). The CNA said he/she knows the resident does not eat much and is on a fluid restriction, but the nurse would have more detail. During an interview on 3/4/26 at 6:24 P.M., Licensed Practical Nurse (LPN) C said the resident has behavior and yells out a lot for help but nine of out ten times, the reason is the resident wants something to drink. The LPN C said the resident is on fluid restrictions because the resident urinates a lot, so the resident is given sips of water throughout the day. During an interview on 03/6/26 at 3:49 P.M., the Director of Nursing said she would expect the staff to follow their policies and ensure all residents receive proper hydration by assisting those who are dependent on staff by offering fluid intake during care or when entering the room.

Based on interview and record review, the facility failed to ensure two residents were free from significant medication errors when staff failed to administer medications per physician orders and failed to notify the physician when the medications were not administered (Resident #10 and #30). The sample was 18. The census was 69.Review of the facility's Medication Administration Policy, dated revised on 6/23, showed: -Only a licensed nurse or Certified Medication Technician (CMT) may prepare, administer and/or record the administration of medications. Medications must be administered in accordance with a physician's orders (i.e., the right resident, the right medication, the right dosage, the right route and the right time). Medications must always be prepared, administered and recorded by the same nurse/CMT;-Each resident will have his/her own supply of medications, excluding stock medications;-Initial on Medication Administration Record (MAR) after each dose is administered;-Reorder (medication) when three-to-five-day supply remains;-Reordering and refilling is a daily task for the nurse/CMT at the end of each medication pass. The day shift shall have the primary responsibility for re-ordering medications. Other shifts need to reorder medications that might be given only on their shift and as needed medications, as needed.-If a medication is needed immediately, add need by time to the pharmacy refill sheet and fax (do not scan) to pharmacy;-If the medication is unavailable any time, the nursing supervisor should be contacted and may obtain medication from the emergency drug supply (e-kit, a secured, on-site container or electronic cabinet holding a limited supply of pre-approved medications to allow nurses to immediately administer essential, time-sensitive medications to residents without waiting for a, pharmacy delivery) or contact the physician to try to obtain an alternate order. Review of the facility's Medication-Related Error policy, dated 04/00, showed:-Definitions: medication error will be defined as a departure from the accepted standards of practice for medication use, which includes transcription, dispensing and administration;-Significant medication error as one causing a resident discomfort or jeopardizing his/her health and safety;-Examples of medications errors include, but are not limited to: errors may be by commission or omission;-When a medication error is discovered, the employee noting the error must notify the supervisor, the physician, the resident and, when applicable, the resident's representative. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/24/26, showed:-Cognitively intact-Diagnoses included: diabetes, hypertensive heart and chronic kidney disease with heart failure. Review of Resident's care plan, in use at the time of survey, showed:-Focus: Patient observed hoarding medication at the bedside;-Goal: Patient will not hoard medications during the review period;-Interventions included: Medication times will be changed and will reevaluate at a later date. Review of the physician order summary, in use during the survey, showed:-A physician order dated 11/7/25, for insulin lispro pen 100 unit/milliliter (ml) (rapid acting insulin), subcutaneously (under the skin) three times daily with meals, for type 2 diabetes mellitus; If Blood Sugar is less than 70, call physician ; If Blood Sugar is 150 to 200, give 2 Units; If Blood Sugar is 201 to 250, give 4 Units; If Blood Sugar is 251 to 300, give 6 Units;If Blood Sugar is 301 to 350, give 8 Units ;If Blood Sugar is 351 to 400, give 10 Units;If Blood Sugar is greater than 400, call physician. Review of the MAR, dated 2/13/26 through 3/4/26, showed:-A physician order, dated 11/7/25, for insulin lispro pen 100 unit/milliliter (ml) (rapid acting insulin), subcutaneously (under the skin) three times daily with meals, for type 2 diabetes mellitus; If Blood Sugar is less than 70, call physician; If Blood Sugar is 150 to 200, give 2 Units; If Blood Sugar is 201 to 250, give 4 Units; If Blood Sugar is 251 to 300, give 6 Units;If Blood Sugar is 301 to 350, give 8 Units ;If Blood Sugar is 351 to 400, give 10 Units;If Blood Sugar is greater than 400, call physician.-Documentation showed: -On 2/13/26 at 11:30 A.M., insulin was not administrated; reason resident was asleep;-On 2/18/26 at 11:30 A.M., insulin was not administered; reason resident refused;-On 2/27/26 at 11:30 A.M., was not administered; reason blank;-On 2/27/26 at 4:22 pm, blood sugar was 456; -On 3/2/26 at 8:03 am blood sugar was 413; -On 3/4/26 at 4:22 pm blood sugar was 401. During an interview on 3/6/26 at approximately 12:32 P.M., the resident said he/she has never refused to take his/her insulin because he/she knew how important this medication was, and he/she could become very ill without it. During an interview on 3/6/26 at approximately 12:02 P.M., the License Practical Nurse (LPN) B said residents should receive their insulin as ordered, he/she did not know why the insulin was not administered. During an interview on 3/6/26 at approximately 1:45 P.M., the Unit Manager A said he/she was not aware Resident #10 missed insulin.2. Review of Resident #30's comprehensive MDS, dated [DATE], showed:-Cognitively intact-Diagnosis included paranoid schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder, and benign prostatic hyperplasia (enlarged prostate gland). Review of care plan, in use at the time of survey, showed:-Focus: The resident displays behaviors related to paranoid schizophrenia;-Goal: Reduce the risk factors that lead to behaviors;-Interventions included: Notify the nurse and/or physician if his/her behaviors increase or interfere with his/her care. Review of the physician order summary, in use during the survey, showed:-A physician order, dated 1/21/26, for clozapine 100 mg tablet, take two at bedtime for paranoid schizophrenia;-A physician order, dated 1/21/26, memantine 10 mg tablet, one tablet twice a day for schizophrenia;-A physician order dated 2/2/26 and discontinued on 2/15/26, for Diazepam 5mg, take one tablet two times a day, for anxiety;-A physician order dated 2/15/26 and discontinued on 2/21/26, for Diazepam 5mg, 1 tablet two times a day; -A physician order dated 1/22/26 for finasteride 5 mg tablet once a day for enlarged prostate gland; -A physician order dated 2/5/26 and discontinued on 2/21/26, for Hydroxyurea 500 mg, two tablets every other day for chronic myeloproliferative disease (overproduction of blood cells which could cause blood clots, strokes, or organ damage);-A physician order dated 2/6/26 and discontinued on 2/21/26, for Hydroxyurea 500 mg, two tablets every three days. Review of the MAR dated 2/6/26 through 3/4/26, showed:-A physician order, dated 1/21/26, for clozapine 100 mg tablet, take two at bedtime for paranoid schizophrenia; -Documentation showed: on 2/6, 2/7, 2/8, 2/9, 2/10, 2/11 and 2/12/26 medication was not administered; reason medication was unavailable;-A physician order, dated 1/21/26, memantine 10 mg one tablet twice a day for schizophrenia; -Documentation showed: -A.M.: on 2/22/26 through 3/2/26 medication was not administered; reason not available. -P.M.: on 2/24, 2/25, and 2/28 through 3/2/26 medication was not administered; reason not available;-A physician order dated 2/2/26 and discontinued on 2/15/26, for Diazepam 5mg, take one tablet two times a day, for anxiety; -Documentation showed: on 2/4/26 through 2/15/26 the medication was not administered; reason medication was unavailable.-A physician order dated 2/15/26 and discontinued on 2/21/26, for Diazepam 5mg, 1 tablet two times a day; -Documentation showed: on 2/15, 2/16 and 2/17/26 the medication was not administered; reason medication was unavailable;-A physician order dated 1/22/26 for finasteride 5 mg tablet once a day for enlarged prostate gland; -Documentation showed: -On 2/23, 2/24 and 2/27 medication were not administered; reason resupply. On 2/28 medication was not administered; reason called pharmacy to reorder; -On 2/25, 2/26, 3/2 and 3/4 medication was not administered; reason unavailable;-A physician order dated 2/5/26 and discontinued on 2/21/26, for Hydroxyurea 500 mg, two tablets every other day for chronic myeloproliferative disease; -Documentation showed: on 2/5 and 2/9/26 the medication was not administered; reason medication was unavailable; -A physician order dated 2/6/26 and discontinued on 2/21/26, for Hydroxyurea 500 mg, two tablets every three days; -Documentation showed: -On 2/6 and 2/8/26 the medication was not administered; reason unavailable; -On 2/21/26 discontinued duplicate order; -Documentation showed the Hydroxyurea was documented as administer on 2/15/26 for both every other day dose and every 3 days dose. Review of the list of medications available in the facility's e-kit, provided by the facility, dated 9/29/25, showed, the e-kit had five tablets of Finasteride 5 milligrams (mg) tablets. No other medications were in the e-kit. During an interview on 3/6/26 at approximately 1:45 P.M., the Pharmacy Technician said the pharmacy records reflect the following:-The pharmacy sent 60 tablets of clozapine on 1/21 and 2/13/26;-The pharmacy sent 60 tablets of Memantine 10 mg, on 1/21/26 and 3/2/26. The pharmacy attempted to refill the medication on 2/18 and 2/28/26 but the medication was suspended. There was no reason showing why the medication was suspended; -The pharmacy sent 60 tablets of Diazepam 5mg on 2/15/26. The order was changed to a half tablet on 2/21/26 and the pharmacy sent 30 half tablets. -The pharmacy sent 30 tablets of Finasteride 5mg on 12/31/25. The order changed on 1/21/26 and 30 tablets were sent. On 3/4/26 the pharmacy sent a 14-day supply; -The pharmacy sent 15 tablets of Hydroxyurea on 12/31/25 and on 1/21/26. On 2/21/26 a new order wasn't filled because it was suspended until 3/2/26. No notes on why. During an interview on 3/6/26 at approximately 12:02 P.M., the License Practical Nurse (LPN) B said medications should be documented after they were administered. If a resident refused their medications, it should be documented on the MAR. If a medication was unavailable, he/she would check the overflow. If the medication was not there, he/she would check to see if the medication was in the pyxis (e-kit). If the medication was not in the e-kit, he/she would call the pharmacy to check the status of the medication and order the medication to be sent out immediately, if needed. If the pharmacy was called, it would be documented in the progress notes. During an interview on 3/6/26 at 12:44 P.M., Unit Manager K said staff should click on complete after they administer the resident's medications to document the medication was administered. If a resident refused, he/she would talk to the resident and if they were their own responsible party he/she would educate the resident, ask a peer to try, if the resident continued to refuse, he/she would call the family to see if they could talk to the resident. If the resident continued to refuse, he/she would notify the physician and the resident representative, if the resident was their own responsible party, and monitor if anything needed to be monitored such as a blood pressure if a blood pressure medication was missed. He/she would document why the medication was not administered and what interventions she had attempted and what was said to the physician and any orders the physician may have given. All nurses can order/reorder medications. Medication can be order through the computer or the nurse can call the pharmacy. He/she would expect for staff to check the pyxis if a medication was unavailable. The nurse usually notified the unit manager when a medication was not available. Then, he/she would check the bottom of the cart to see if the medication was in the overflow and if not, he/she would try to figure out what happened. During an interview on 3/6/26 at approximately 1:45 P.M., Unit Manager A said he/she was not aware Resident #30's medications were unavailable or there was an issue with obtaining his/her medications. If a resident missed his/her clozapine or diazepam it could cause an increase in behaviors. During an interview on 3/6/26 at 3:49 P.M., the Director of Nursing (DON) said she would expect for staff to follow physician orders and the facility's policy's and procedures.

Based on observation and interview, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable standards of practice. The facility identified two medication rooms, six medication carts, and six treatment carts. Both medication rooms, five medication carts and one treatment cart were checked for medication storage. Issues were found in one medication room and two medication carts. Staff failed to double-lock the emergency kit for controlled substances. In addition, staff failed to dispose of expired over-the-counter (OTC) medications. The census was 69.Review of the facility's Delivery, Receipt, Storage, and Inventory of Facility Products policy, reviewed 8/2022, showed:-Subject and Addendum: Storage and expiration date of medications, biologicals, syringes and needles;-The policy failed to provide guidance regarding ensuring medication rooms and medication carts were free from expired medications, or storage of controlled substances under double lock, in accordance with State regulations. 1. Observation on 3/4/26 at 11:33 A.M., showed a controlled substance e-kit drawer in the medication room. The drawer was unlocked. During an interview, Unit Manager L said the key broke off the day prior. He/She said the medication room door was always locked but the e-kit drawer has been unlocked since the key broke off. Controlled substances should be double-locked. The maintenance staff was aware of the broken key, and a replacement was to be provided the following day, 3/5/26. There was no alternative lock or a locked container for the controlled substances while waiting for the replacement key. During an interview on 3/4/26 at approximately 3:00 P.M., Unit Manager L said the key to the controlled substances e-kit drawer has been replaced. Observation on 3/5/26 at 12:57 P.M., showed Unit Manager L obtained the medication room key from the nurse's station top drawer. The drawer was unlocked. No staff was at the nurse's station. Unit Manager L opened the medication room, then the controlled substances e-kit drawer, using keys from the set of keys he/she obtained from the nurses' station unlocked drawer. 2. Observation on 3/4/26 at 12:50 P.M. of the third floor medication cart, showed:-Three open bottles of acetaminophen (Tylenol) 650 milligrams (mg) with an expiration date of 12/2025;-One bottle of Vitamin B-12 1000 micrograms (mcg) (supplement) opened with an expiration date of 11/2025;-One bottle of sodium chloride 1 gram (gm) (supplement) opened with an expiration date of 12/2025;-One bottle of oyster shell calcium 500 mg (supplement) opened with an expiration date of 7/2025;-One bottle of aspirin extended release 81 mg opened with an expiration date of 10/2025;-One bottle of Geri-Dryl 25 mg (antihistamine) opened with an expiration date of 12/2025;-One bottle of high potency multivitamin opened with an expiration date of 10/2025. 3. Observation on 3/4/26 at approximately 1:00 P.M. of the third floor medication room, showed three bottles of Ferric X-150 (iron supplement) opened with an expiration date of 2/2026. 4. During an interview on 3/3/26 at 1:00 P.M., Licensed Practical Nurse (LPN) C said nurse management and the floor nurse were responsible for checking expiration dates on the medication carts. 5. During an interview on 3/6/26 the Director of Nursing (DON) said she expected staff to follow the facility's policies and procedures on proper medication storage. Controlled substances should be double-locked. 6. During email correspondence on 3/9/26 at 5:05 P.M., the Administrator said all policies related to medication storage had been provided.

Based on observation, interview and record review, the facility staff failed to provide choices for meals and to offer substitutions for two residents (Residents #2 and #128). The sample was 18. The census was 69.Review of the facility's Menu Posting and Menu Substitution policy, dated 1/2025, showed: -Menu Posting:-Menus should include daily choices available for each meal;-An always available or a la carte menu is posted or made available to all residents;-Menu Substitutions:-Menu changes or substitutions for situations such as an emergency event, food unavailability or special dining events will be posted or otherwise communicated prior to meal service;--Menu substitute should be consistent with the usual and/or ordinary food items provided.Review of the facility posted menu, dated 3/2/26 through 3/5/26, showed:-Any additional request for lunch on the same day must be submitted before 10:00 A.M. and dinner request submitted before 2:00 P.M.;-Breakfast entree consisted of scrambled eggs for three out of four days, with oatmeal and grits alternating on each day of the week;-No information regarding evening snack availability or choices. Review of the facility's substitution Always Available Menu, undated, showed:-Center of the plate: Classic cheeseburger, hot dog on a bun, chicken tenders, grilled cheese sandwich, deli sandwich (turkey or ham), grilled chicken breast;-Lighter fare: Chef salad, fruit and cottage cheese plate, yogurt parfait;-Sides: French fries, side salad, cottage cheese, fresh fruit;-Beverages: Milk, water, coffee, ice tea, hot tea, fruit juice, and Shasta. 1. Review of Resident #2's medical record, showed:-admission date 2/1/26;-Diagnoses included chronic kidney disease and diabetes. Review of the resident's care plan, in use at the time of survey, showed:, -Focus: Resident is at risk for weight loss;-Goal: Resident to meet 75 to 100% of needs for majority of admission. During an interview on 3/4/26 at 10:45 A.M., the resident said he/she did not receive a menu, so he/she never knew if he/she would like what was being served at meals. Sometimes when he/she called down to the kitchen for a substitution, he/she was told it was too late and the kitchen was closed. This is why he/she saves half of his/her morning sandwich to eat later in the day when he/she gets hungry. During an interview on 3/4/26 at 11:45 A.M., Dietary Aide (DA) R said he/she met with all the residents on the resident's floor and completed each of their individual meal tickets for 3/5/26. Review of the resident's meal ticket for 3/5/26, showed:-Under breakfast, X marked for orange juice, grits, hashbrowns, bacon strips, orange muffin, and salted margarine;-Under lunch, a check mark next to tomato Florentine soup, pork tenderloin, brown rice, brussels sprouts, biscuit and pineapple;--Under dinner, a check mark next to catfish, tartar sauce, potato wedges, coleslaw, cornbread, and peanut butter cookies. During an interview on 3/4/26 at 11:50 A.M., the resident said he/she had not seen or spoken with anyone from dietary that morning. When shown the meal ticket dated 3/5/26, he/she denied giving input and said the meal ticket showed a check mark by brussels sprouts and brown rice, which he/she dislikes greatly and would never eat. He/She said he/she would have requested an alternative, if given the option. 2. Review of Resident #128's medical record, showed:-admission date 3/3/26 ;-Diagnoses included chronic kidney disease, high blood pressure, and heart disease. Observation and interview on 03/6/26 at 8:05 A.M., showed the resident said he/she is unaware of an Always Available Menu and he/she has not been given a menu since he/she was admitted on [DATE]. He/She spoke with someone about meals on his/her first day, but not since then. He/She would like a menu so he/she would know what to expect at meals, and to have a choice if substitution was available. He/She has been a coffee drinker his/her whole life and really missed drinking coffee at breakfast and in the evening. He/She has asked for coffee every day but is told the staff are waiting for more cups or they will bring some, but it never comes. Observations of breakfast on 3/6/26, showed:-At 8:14 A.M., the resident's breakfast tray delivered to the resident with one pancake, scrambled eggs, a bowl of oatmeal, and one cup of juice, with no coffee;-At 8:45 A.M., the resident's oatmeal untouched. The resident's meal ticket showed decaf coffee indicated under Beverages. During an interview, the resident said he/she requested coffee and was told it was coming but it still hasn't come. He/She did not like oatmeal or grits and would have eaten cold cereal if given the choice. 3. During an interview on 3/6/26 at 2:22 P.M., the Dietary Manager (DM) said every morning, a member of the dietary department is to go to each floor with each resident's individual meal ticket and meet with each resident to go over the next day's menu. The dietary employee should mark any changes the resident requested on the resident's meal ticket. The meal tickets would be entered into the facility's software program to reflect the next day's meal changes or requests. He expected the staff to ensure each resident was given a menu along with the substitution, Always Available Menu, to ensure the residents' choices are honored.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS)), for one resident who required EBP for Intravenous (IV) medications (Resident #59) and when staff positioned one resident's urinary drainage bag (a medical device designed to collect urine from a catheter (a tube that is inserted into the bladder, allowing your urine to drain freely) on the rim of the trash can (Resident #39). In addition, clean linens were transported in an uncovered cart to the hall linen closets. The sample was 18. The census was 69.Review of the facility's EBP policy, revised on 2/24, showed: -Purpose: To provide direction for the implementation of precautions to prevent transmission of novel or targeted multidrug-resistant organisms utilizing guidelines from CDC; -Policy: To implement enhanced barrier precautions to prevent transmission of novel or targeted multidrug-resistant organisms as defined by CDC to residents, staff, volunteers, visitors or any other individuals providing services under a contractual agreement; -EBP - refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (such as, residents with wounds or indwelling medical devices); -EBP shall be implemented for residents with any of the following: -Wounds (such as, chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO; -Infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions do not apply; - High-contact resident care activities are dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing). Review of the facility's Catheter, Insertion of Indwelling and Straight Catheter policy, date revised 5/23, did not show how the drainage tubing should be positioned. Review of the facility's Linen, Infection Control policy, date revised 5/23, showed, clean linen on carts must be covered before the carts are moved out of the clean linen room. All carts must remain covered at all times during transportation. Clean linen carts must be covered on the top and bottom as well as all four sides during transportation. 1. Review of Resident #59's medical records, showed: -admitted on [DATE]; -Diagnoses included infection following a procedure with surgical site, squamous cell carcinoma (skin cancer); -On 2/14/26, an order of micafungin (antifungal medication) 200 milligrams (mg) in 0.9% sodium chloride, to give intravenous piggyback (IVPB) daily for 11 days; -On 3/1/26, an order of heparin (blood thinner) lock flush, 10 unit per milliliter (unit/ml) solution, give intravenous twice a day, via peripherally inserted central catheter (PICC line, a thin, flexible tube inserted into an upper arm vein and advanced to a large vein near the heart for long-term IV access.) Review of the resident's care plan in use at the time of survey, showed: -Problem: Resident on EBP isolation due to PICC line; -Goal: Provide guidance to the resident, family and staff providing care; -Approaches included: Educate the resident and family on precautions, follow the precaution directives posted outside of the resident's room: I am on isolation per policy. Please ensure to keep my door closed as much as possible. Please ensure to use the proper hand hygiene and personal protective equipment (PPE) during my care. Please ensure that I wear a mask during my care. Observation on 3/2/26 at 10:21 A.M., showed the resident's IV pump was beeping. License Practical Nurse (LPN) O entered the resident's room with no PPE on. He/She adjusted the IV tubing and touched the resident's IV site. During an interview on 3/6/26 at 3:45 P.M., the Director of Nursing (DON) said the resident was on contact and EBP precautions. The staff should be wearing PPE when providing care to residents with an IV line. Staff should not be touching the IV or PICC line sites without the required PPE. 2. Review of Resident #39's medical record, showed: -admitted on [DATE]; -Diagnoses included multiple myeloma (cancer of plasma cells, a type of blood cell, affecting bone & bone marrow), diabetes and urinary retention (the inability to fully or partially empty the bladder). Review of the resident's care plan in use at the time of survey, showed: -Problem: Resident required an indwelling urinary catheter related to urinary retention, dated 3/2/26; -Goal: Resident will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma; -Approach included: Position bag below level of bladder and store collection bag inside a protective dignity pouch. Observation on 3/3/26 at 1:15 P.M., showed the resident was sitting up in his/her wheelchair in his/her room eating lunch. The catheter drainage bag was not inside a protective dignity pouch and was hanging on the rim of the trash can next to the resident. During an interview on 3/6/26 at 9:42 A.M. the Infection Control Preventionist (ICP) said catheter drainage bags should not be hanging on the rim of the trash can. There was a place on the wheelchair where the drainage bag could be attached. If the drainage bags were not positioned correctly, there could be a risk for infection. 3. Observation on 3/2/26 at 7:17 A.M., showed Housekeeper F, pushing a blue cart with linens and gowns in it, in the hallway, to the second-floor linen closet. The cart was uncovered. Observation on 3/3/26 at 7:20 A.M., showed Housekeeper G pushing an uncovered linen cart down Blueberry Hill Hall to the linen closet. He/She stocked the linen closet, then pushed the uncovered linen cart to Sunshine Lane linen closet. At 7:30 A.M., he/she pushed the uncovered cart to the elevator. During an interview on 3/6/26 at 9:43 A.M., the ICP said laundry should be transported per the facility's policy. During an interview on 3/3/26 at 8:45 A.M., the Housekeeping Manager said the linen carts should be covered. 4. During an interview on 3/6/26 at 3:49 P.M., the Director of Nursing (DON) said she expected staff to follow the facility's policies and procedures.

Based on observation, interview and record review, facility staff failed to provide treatment and care in accordance with professional standards of practice, for six of twelve residents sampled. Two residents (Residents #5 and #8) did not have orders for wound care, three residents (Residents #6, #7, #9) wound care orders were not followed, and five residents (Residents #4, #6, #7, #8, #9) wound dressings were not dated or initialed per facility policy. The facility census was 62. Review of the facility's policy and procedure for Physician Order, revised 4/2025, showed:-Purpose: To establish guidelines for properly obtaining physician orders and processing these orders;-Policy: Telephone and verbal orders should be documented in the resident's electronic medical record then read back to the ordering physician or independent practitioner for verification;-It is the responsibility of the licensed nurse and Certified Medical Technician (CMT) to understand and comply with this procedure;-It is the responsibility of the Nurse Manager to maintain, enforce and monitor the procedure. Review of the facility's policy and procedure for Wound Care, revised 6/25/2025, showed:-To provide guidelines for use in wound assessment, treatment, and documentation;-Policy: A physician's order is required for all wound treatment;-Responsibility: It is the responsibility of the Director of Nursing (DON) to oversee this policy and procedure;-Practice: All dressings will be dated and initialed by the nurse applying the dressing. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/27/25, showed:-Cognitively intact;-Medical diagnoses and treatments: Right knee fracture, history of hip and knee fractures, obesity, heart failure, surgical wound, intravenous (IV) antibiotics. Review of resident's care plan, in use at the time of the investigation, showed:-Surgical incision at risk for skin impairment due to immobility. Reposition resident frequently. Keep resident clean and dry. Check resident skin daily with care and inform the nurse of any skin issues. Please let the nurse know if resident dressing is not intact or any new areas of redness/skin breakdown. Treatments as ordered by physician;-Goal is to reduce the risks factors that could contribute to skin impairment and/or optimize wound healing through this next review period;-No care plan for skin tears or fragile skin. Review of resident's physician orders, reviewed on 7/7/25, showed no order for left lower leg/calf dressing. Review of the resident's physician and nursing progress notes, showed no documentation of orders received for a skin tear to the left calf. Observation and interview with the resident on 7/7/2025 at 8:23 A.M., showed the resident had a wound dressing to the left lateral (outer side) of his/her calf, dated 7/4/25 and staff initials labeled on it. The resident said he/she thinks it gets changed every couple of days. 2. Review of Resident #8's admission MDS, dated [DATE], showed:-Intact cognition;-Medical diagnoses and treatments: surgical wound, skin tears, anemia, heart failure, and history of falls. Review of resident's care plan, in use at the time of the investigation, showed:-Surgical incision on right hip/thigh and right elbow skin tear;-Reposition frequently, check skin daily with care and inform the nurse of any skin issues. Let the nurse know if dressing is not intact or any new areas of redness or skin breakdown. Review of the resident's physician's orders, showed the following:-Wound care order dated 7/2/25: Skin tear on the left arm, leave Tegaderm (transparent dressing) in place for 21 days and change as needed, monitor daily for signs and symptoms of infection;-No order for Tegaderm dressing to right elbow. Observation and interview with the resident on 7/7/25 at 10:15 A.M., showed the resident had Tegaderm dressings to the right elbow and left wrist, both dated 7/2/25, no staff initials. The resident said he/she thinks they get changed every few days but is not sure. 3. Review of Resident #6's admission MDS, dated [DATE], showed:-Moderate cognitive impairment;-Medical diagnoses and treatments: heart disease, history of falls, kidney disease, and diabetes. Review of resident's care plan, in use at the time of the investigation, showed:-Surgical incision to right ankle. Risk for skin impairment due to immobility. Reposition frequently. Keep resident clean and dry. Check skin daily with care and inform the nurse of any skin issues. Let the nurse know if dressing is not intact or any new areas of redness or skin breakdown. Treatments as ordered by physician;-Risk for bleeding due to anticoagulant use. Monitor urine for blood and monitor body for excessive bleeding or bruising and contact nurse with changes;-No care plan for skin tears or fragile skin. Review of the resident's physician orders, showed the following:-Wound care order dated 7/6/25: Left arm skin tear, apply adherent film (a type of wound dressing that has an adhesive layer or border, allowing it to stick to the skin and stay in place for up to seven days), change every seven days and as needed if soiled. Monitor daily;-Wound care order dated 6/26/25: Right ankle surgical incision, cleanse with wound cleanser, pat dry and apply a dry gauze dressing daily. Observation and interview with the resident on 7/7/25 at 8:58 A.M., showed the resident had a left arm skin tear covered with a Tegaderm dressing, with no date or staff initials. The resident said he/she fell yesterday in the bathroom and the nurse applied the dressing. During an interview on 7/7/25 at 8:59 A.M., Registered Nurse (RN) A observed the wound and said that it is a Tegaderm dressing, and it is supposed to be dated and initialed. 4. Review of Resident #7's admission MDS, dated [DATE], showed:-Intact cognition;-Diagnoses and treatments included pressure ulcers to sacrum (top of buttocks), right thigh, and right upper back, intravenous (IV) antibiotic, surgical wound, wound dressing, and malnutrition. Review of resident's care plan, in use at the time of the investigation, showed:-Pressure ulcers at risk for skin impairment due to immobility;-Reposition frequently. Keep resident clean and dry. Check skin daily with care and inform the nurse of any skin issues. Let the nurse know if dressing is not intact or any new areas of redness or skin breakdown;-No care plan for the presence and care of the IV. Review of the resident's physician's orders, showed the following:-Wound care order dated 6/25/25, showed:-Sacrum pressure ulcer, cleanse with wound cleanser, pack with moistened gauze being sure to pack tunnelling, cover with abdominal dressing pad and secure with tape every 12 hours; -Peripherally inserted central line, change dressing using transparent dressing, measure line external length every Tuesday. Observation and interview with the resident on 7/7/25 at 9:13 A.M., showed Certified Nursing Assistant (CNA) B provided incontinence care to the resident. The Resident had a dressing on his/her sacrum with no initials and no date. He/she also has a transparent IV dressing on the right upper arm with no initials or date. The resident said the nurse last night tried something new to help keep the dressing on his/her bottom, to prevent stool from getting into it. He/she did not know exactly what the nurse tried. The IV dressing is changed every Tuesday. CNA B confirmed there was no date or initials on the sacrum and IV dressing. 5. Review of Resident #9's medical record, showed:-Moderate cognitive impairment;-Diagnoses included dementia, Parkinson's disease, fall, tremors, and urinary retention. Review of the resident's physician orders, showed:-Wound care order dated 7/2/25: Left ankle abrasion, clean with wound cleanser, pat dry apply Xerofoam (fine mesh gauze occlusive dressing for use on low draining wounds), cover with gauze daily and as needed. Observation and interview with the resident and family on 7/7/25 at 10:25 A.M., showed the resident had a Tegaderm dressing to the left ankle dated 7/4/25, with no staff initials. The family said they think the dressing is changed every three to four days but are not sure. 6. Review of Resident #4's admission MDS dated [DATE], showed:-Cognitively intact;-Diagnoses and treatments included acute pancreatitis with infected necrosis (infected pancreases), surgical wound with drainage tube, non-surgical dressings, and wound ointments/medications. Review of resident's care plan, in use at the time of the investigation, showed:-Excoriation (redness) on left flank (side of body between bottom of rib cage to the hip) at biliary drain (a tube placed to help drain bile from the liver and gallbladder), location. Please check resident skin daily with care and inform the nurse of any skin issues. Please reposition resident frequently;-Goal is to reduce the risks factors that could contribute to skin impairment and/or optimize wound healing through this next review period. Review of the resident's physician orders, showed:-Wound care order dated 6/29/25: Provide wound care for surgical incision on left flank, clean site with wound cleaner, pat dry, apply split gauze around drainage tube, cover with abdominal dressing, secure with tape every six hours, and as needed. Use Kerlix roll (gauze roll) to support tube to decrease leaking around the tube;-Wound care order dated 6/29/25: Flank excoriation, clean with soap and water, pat dry and apply Miconazole (antifungal medication) every 12 hours, and as needed;-Wound care order dated 6/29/25: Left flank surgical incision and left flank interventional radiology (IR) drain (a tube inserted into the body to drain fluid), used alcohol pad to clean the connection between the drainage catheter and bag. Flush drainage tube with 10 milliliters (ml) of normal saline (NS) twice a day. Reconnect the drainage tube to the drainage bag. Observation on 7/7/25 at 8:50 A.M., showed the resident had a wound dressing and drain to the left flank with no date or staff initials labeled on it. During an interview on 7/7/25 at 8:55 A.M., RN A observed the resident's wound and drainage cite and said the wound and drainage cite are supposed to be dated and initialed. 7. During an interview with Administrator and Director of nursing on 7/8/25 at 1:17 P.M., they said nursing staff should receive wound care orders or follow standing order sets from a physician or NP prior to providing wound care. Nursing staff are expected to know the difference between the types of wound dressings, to follow wound care orders, and document date and time on all wounds per facility policy and procedures, including IV dressings. If the nursing staff is unclear of the order, they are responsible to call and clarify the order with the ordering physician or NP. In addition, if a dressing has a date of 7/2/25 and the order says to change every three days it should have been changed on 7/5/25. MO00253503

Based on observation, interview and record review, the facility failed to provide appealing meal options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice, by failing to provide alternate meals per resident preference (Residents #10, #11, and #12). The sample size was 12. The facility census was 62. Review of the facility's menu for the week of 7/7/25 through 7/13/25, showed:-Breakfast for 7/7/25: Oatmeal, scrambled eggs, pancake with maple syrup;-Lunch for 7/7/25: Tomato Florentine soup, maple glazed ham, rice pilaf, green beans, blonde bar;-Breakfast for 7/8/25: Grits, scrambled eggs, bacon strips, biscuit;-Lunch for 7/8/25: Garden vegetable soup, beef sirloin steak, green peas, wheat roll, chocolate pudding;-Breakfast for 7/9/25: Oatmeal, scrambled eggs, orange bread;-Breakfast for 7/10/25: Grits, scrambled eggs, pancake with maple syrup, minestrone;-Breakfast for 7/11/25: Oatmeal, scrambled eggs, biscuit and gravy;-Breakfast for 7/12/25: Grits, scrambled eggs, cinnamon muffin;-Breakfast for 7/13/25: Oatmeal, scrambled eggs, bacon strips, French toast. Review of the facility's Always Available menu, showed:-Center of Plate: Classic cheeseburger, Hot dog on bun, Chicken tenders, Grilled Cheese sandwich, Deli sandwich, Grilled chicken breast;-Lighter Fare: Chef salad, fruit & cottage cheese plate, yogurt parfait;-Sides: French fries, side salad, cottage cheese, fresh fruit;-Beverages: Milk, water, coffee, iced tea, fruit juice, soda. Review of the facility's posted menu and menu substitution, showed: -When menu items are unavailable substitutions of comparable nutritional value are made;-Menus should include daily choices available for each meal;-Menu changes or substitutions for situations such as an emergency event, food unavailability or special dining events will be posted or otherwise communicated prior to meal service;-Menus for resident advanced ordering will be delivered to the resident;-Completed menus are collected and reviewed by dietary staff for diet congruency and honored. 1. Review of Resident #10's medical record, showed the following:-No cognitive impairment;-Consistent carbohydrate diet (CCHO) with Regular texture;-Diagnoses includes stroke and diabetes. Observation and interview on 7/7/25 at 10:05 A.M., showed the resident lay in bed with his/her breakfast tray that contained scrambled eggs, one pancake and a bowl of oatmeal, untouched with the lid half on that exposed half of the plate, on the resident's bedside table. Various different cereals and snacks were stored on the resident's windowsill. The resident said he/she just woke up and pushed the call light for the certified nurse aid (CNA) to reheat his/her breakfast tray. The resident said, I hate those powered eggs and oatmeal, but I do like the pancakes. The resident said although he/she continues to tell the facility that he/she dislikes oatmeal or grits he/she continues to get it every morning. At 10:10 A.M., CNA E said he/she could not reheat the breakfast tray because it would be considered cross contamination but would ask the kitchen for another breakfast tray. The CNA removed the breakfast tray and exited the room. At 10:20 A.M., CNA E returned to the room and said the kitchen could only offer a sandwich. The resident said he/she did not want a sandwich and if the CNA could please bring some milk so he/she could eat the cereal that was sitting on his/her windowsill. The resident said this was why he/she had to personally buy his/her own food to keep in his/her room. He/She has just given up on making requests because the facility never listens, so he/she just has his/her family bring food. 2. Review of Resident #11's medical record, showed the following:-No cognitive impairment;-Consistent Diet Therapy (CDT) and Low Concentrated Sweets (LCS);-Diagnosis includes Diabetes and cancer. Observation and interview on 7/7/25 at 1:10 P.M., showed the resident sat up in bed being fed by his/her spouse. The lunch tray contained two slices of ham and a large portion of green beans. A separate plate contained what appeared to be a blondie bar that was approximately two-inches by two-inches square and one mid-size cup of liquid. On the table a diet ticket showed the following:-Tomato Florentine soup, crossed out in blue ink;-Maple glazed ham;-Rice pilaf, crossed out with the wording mash potatoes in blue ink. Above the wording rice pilaf in a different handwriting and in black ink was do not have;-Seasoned green beans, crossed out in blue ink;-Blondie bar;-Saltine crackers;-Ice water;The spouse said he/she continues to voice frustration with the staff over not following the resident's requests or providing an acceptable alternative. The resident shook his/her head in acknowledgement. The spouse said all that happens when the facility does not have an alternative, they will double up on something else verses offering a comparable alternative. Filling out the diet tickets is pointless. They had filled out the diet ticket requesting the resident not have rice or green beans because these items upset the resident's stomach. However, all the facility did was write do not have above where he/she wrote mash potatoes and gave the resident a double amount of ham and green beans. He/She is very concerned for the resident nutrition needs. His/Her other concern was since the resident cannot have carbonation and is a diabetic all the facility has to offer him/her to drink at meals is tea or water. The facility does not offer any other diabetic alternative. Since the resident does not like tea this is why the resident is only served water for lunch and dinner. 3. Review of Resident #12's medical record, showed the following:-No cognitive impairment;-CDT and LCS diet, thin liquids;-Diagnoses included spinal stenosis and type 2 diabetes Observation and interview on 7/7/25 at 10:05 A.M., showed the resident sat in his/her wheelchair in his/her room and watched television. The resident said the food is horrible, it is not seasoned so it is very bland and has no flavor. On 7/6/25 he/she only got one piece of French toast with no meat and that is one meal he/she looks forward to because every day he/she is served powered eggs and either grits or oatmeal, all of which he/she does not like at all. He/She wishes the facility would offer cereal and more diabetic options. He/She was unaware the facility offered cereal as an alternative. 4. During an interview on 7/7/25 at 10:20 A.M., CNA E said that the dietary concierge meets with the residents and helps them fill out their menu ticket. If the resident wants a substitution, they can pick something off the Always Available menu and mark it on the menu ticket. The concierge gives all the completed tickets to the kitchen. However, the residents sometimes do not get what they asked for, but he/she lets the kitchen know when that happens. 5. During an interview on 7/7/25 at 1:45 P.M., the dietary manager said the dietary concierge is responsible for assisting the residents in completing three days of individualized menu tickets and returning the completed tickets to the kitchen. When the dietary concierge is off, a dietary staff member will ensure the menu tickets are completed and returned to the kitchen for processing. If a resident wants a substitution the facility has an Always Available menu that has a list of food alternatives for the resident to choose from. If a resident has a physician order for a dietary restriction the facility's software will automatically generate the restriction on the resident's menu slip. The dietary manager said the Always Available does not include breakfast or identify cereal as an alternative. If a resident wants a breakfast substitution, he/she expects the concierge or dietary staff to mark it on the menu ticket. All food on the meal ticket was verified by the kitchen staff before the tray went up to the floors. The dietary manager said he was not made aware there was an issue or concern with the beverage choices, and he would switch out one of the juices for flavored water or sugar-free fruit drink. The dietary manager said he expected the staff to inform the resident when a requested substitution was not available and to offer an alternative with equivalent nutritional value. 6. During an interview on 7/8/25 at 12:13 P.M., the dietary concierge/CNA said he/she is responsible for assisting the residents in completing the menu tickets and returning the tickets to the kitchen. If the resident and/or the resident's family member are unable to complete the ticket, he/she will assist in filling the ticket out. Each resident has a copy of the Always Available menu that lists out the options available for substitutions. However, he/she also has one in case the resident has lost their copy. If the resident wants a substitution, the concierge makes sure the substitution is marked on the ticket. However, once the ticket is returned into the kitchen, he/she is unaware of the outcome. The concierge said the menu ticket does not address alternatives for breakfast but if a resident informs him/her they want cereal, he/she will write the request on the back of the ticket. The concierge said he/she was not aware of the different types of cereal that are available. 7. During an interview on 7/8/25 at 11:14 A.M., the administrator said she expected staff to follow the preference of the resident and substitutes should be provided with an equivalent nutritional value. The administrator was not aware of any residents who were not getting their substitutions. MO00254148

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities with residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) (Residents #295, #301, #6, #200, #249, and #9). The sample was 17. The census was 69. Review of the facility's Enhanced Barrier Precautions (EBP) policy, revised February 2024, showed: -Purpose: To provide direction for the implementation of precautions to prevent transmission of novel or targeted multidrug-resistant organisms (MDRO) utilizing guidelines from Centers for Disease Control (CDC); -Responsibility: It is the responsibility of each administrator to enforce this procedure for his/her respective residence. It is the responsibility of all employees to understand and comply with the specific procedures in each residence as related to this policy; -Policy: It is the policy of the company to implement EBP to prevent transmission of novel or targeted MDRO as defined by CDC to residents, staff, volunteers, visitors or any other individuals providing services under a contractual agreement; -Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices); -EBP shall be implemented for resident with any of the following: -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -Infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions (precautions that reduce the risk of transmission of infectious materials by direct contact) do not apply; -Implementation of EBP: -Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray; -Disposable or dedicated medical equipment is not required; but any reusable medical equipment should be cleaned and disinfected with an appropriate agent between residents; -High-contact resident care activities are: -Dressing; -Bathing; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; -Wound care: any skin opening requiring a dressing; -EBP should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, or any high-contact activity; -EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical devices is removed. Review of the facility's EBP signage, undated, showed: -Enhanced Barrier Precautions; -Everyone must clean their hands, including before entering and when leaving the room; -Providers and staff must also: -Wear gloves and a gown for the following high-contact resident care activities; -Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), wound care. 1. Review of Resident #295's electronic medical record (EMR), showed: -An entry Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/14/24 showed: -Diagnoses included wound infection, fusion (joining two or more bones) of the cervical spine, and generalized muscle weakness; -An order, dated 5/7/24, for patient isolation, EBP; -An order, dated 5/8/24, for Unasyn (antibiotic) 3 gram (gm), intravenous (IV) every six hours for wound infection. Observation on 5/21/24 at 9:08 A.M., showed an EBP sign on the resident room door. Licensed Practical Nurse (LPN) J entered the resident room without gown or gloves and proceeded to administer the resident IV medication, through double lumen peripherally inserted central catheter (PICC, a device which delivers fluids directly into a much larger vein) inserted into the right arm. 2. Review of Resident #301's EMR, showed: -admitted [DATE]; -Diagnoses included stroke, infection, high blood pressure, and pacemaker (a device to help control the heart rate); -An order, dated 5/16/24, for patient isolation, EBP. Observation on 5/21/24 at 6:44 A.M., showed a laminated placard titled EBP on the resident room door. Registered Nurse (RN) B entered the resident's room without a gown and proceeded to check the residents blood sugar. Observation on 5/22/24 at 7:08 A.M., showed a laminated placard titled EBP on the resident room door. RN B and Certified Nurses Assistant (CNA) C entered the resident room without gowns on, and exposed the resident's heels and buttocks for skin observation. Observation on 5/23/24 at 7:38 A.M., showed a laminated placard titled EBP on the resident room door. CNA L did not wear a gown while he/she provided a bed bath to the resident. 3. Review of Resident #6's medical record, showed: -Diagnoses included heart failure and presence of heart assist device; -An order, dated 2/26/24, for patient isolation, EBP, for left ventricular assist device (LVAD, device implanted in the chest to help the heart pump blood from one of the main pumping chambers to the rest of the body or to the other side of the heart). Observation on 5/20/24 at 11:02 A.M., showed no EBP sign outside the resident's room. Observation on 5/20/24 at 1:00 P.M., showed an EBP sign posted on the front of the door to the resident's room. During an interview, the resident said staff just told him/her that he/she is being quarantined and he/she does not know why. Staff told him/her it had something to do with having an LVAD, but the LVAD is not new and he/she has had it the whole time he/she has been at the facility. Observation on 5/21/24 at 1:29 P.M., showed the resident sat in a recliner chair. CNA A was in the resident's room with no gown or gloves on, moving items throughout the room. He/She lifted and smoothed the blanket on the resident's bed with ungloved hands. As he/she walked through a small space in between the resident's bed and bedside table, his/her clothing caught and moved the blanket on the resident's bed. He/She picked up a blanket from the table at the foot of the resident's bed and placed it over the resident, using ungloved hands, to cover the resident's feet and smooth the blanket on top of the resident's shoulders. During an interview on 5/22/24 at 1:43 P.M., CNA A said the resident has an LVAD. A gown and gloves are required when changing the resident, but not when transferring or touching them. 4. Review of Resident #200's medical record, showed: -Diagnoses included subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it) left posterior cerebral artery aneurysm (bulge in the wall of an artery); -An order, dated 5/13/24, for patient isolation, EBP, for gastrostomy tube (g-tube, a tube surgically inserted into the stomach to provide hydration, nutrition, and medications). Observation on 5/22/24 at 1:28 P.M., showed an EBP sign posted on the front of the door to the resident's room. The resident sat in a recliner chair in front of a bedside table. CNA A was in the resident's room with no gown or gloves on, adjusting items on the bedside table. CNA A asked if the resident was wet and the resident said no. CNA A said, Let me check, and with ungloved hands, he/she lifted the resident's shirt and pulled the waistband of the resident's pants forward and downward to expose the resident's brief. CNA A moved his/her hands along the waistband of the resident's pants and told the resident he/she was wet and CNA A would come back in a few minutes to change him/her. CNA A picked up a plastic bag filled with soiled linens, exited the room, and brought the bag of soiled linens down the hall to the soiled utility room. Upon exiting the soiled utility room, CNA A attempted to sanitize his/her hands using a dispenser on the wall, but the dispenser did not work. CNA A walked down the hall and entered another resident's room. 5. Review of Resident #249's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included below the knee amputation of left leg and moderate calorie malnutrition. Review of the resident's EMR, showed the resident was on EBP for an infected wound on the resident's right upper leg. Observation on 5/22/24 at approximately 10:00 A.M., showed LPN D in the resident's room to transfer him/her to his/her wheelchair. LPN D touched the resident's arm while guiding him/her into the wheelchair for transport. LPN D was not wearing a gown or gloves. 6. Review of Resident #9's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses including atrial fibrillation (a-fib, a heart condition that causes the upper chambers to beat faster than the lower chambers of the heart, reducing oxygenation of the organs), coronary artery disease (a blockage in one of the arteries to the heart), and heart failure. Review of the resident's EMR, showed the resident on EBP for his/her indwelling urinary catheter. Observation on 5/22/24 at 8:19 A.M., showed a member of the physical therapy staff providing care to the resident, including transferring the resident from his/her bed to the chair, and moving the resident's urinary catheter bag from the bed frame to the chair frame. The physical therapy staff member then wheeled the resident out into the hallway to conduct the resident's scheduled therapy session. For the duration of the observation, the physical therapy staff member wore gloves, but no gown or mask was donned or doffed by the staff member. 7. Observation on 5/21/24 at 7:32 A.M., showed CNA M walked down the 300 hall with a blood pressure monitor on a rolling stand. He/She entered room [ROOM NUMBER], which had an EBP sign posted on the front of the door. CNA M did not sanitize his/her hands upon entry and placed the blood pressure cuff around the resident's right arm. He/She removed the blood pressure cuff, placed the cuff on the rolling stand, and exited the room. CNA M did not sanitize his/her hands upon exiting the room. He/She rolled the stand down the hall and entered room [ROOM NUMBER]. 8. During an interview on 5/22/24 at 1:43 P.M., CNA A said EBP signs are posted outside of the room of residents who have wounds, catheters, colostomies or tube feedings. Those residents require extra precautions to make sure urine or colostomy (fecal matter) doesn't get on staff. Gloves and yellow gowns are required when providing personal care to these residents. Gowns and gloves are not required when transferring or touching the residents. Staff should sanitize their hands when they enter the resident's room and when they exit. 9. During an interview on 5/23/24 at 10:15 A.M., CNA H said if a resident is on EBP, staff should wash their hands every time they go in and out of the room. Staff should wear whatever PPE the sign says. Staff should always wear gloves in the room of a resident who is on EBP. CNA H also prefers to wear a gown because he/she never knows if the resident might have something contagious. Gowns are usually in a container outside of the resident's room, but if not, gowns can be found in the supply closet on the hall. 10. During an interview on 5/23/24 at 10:32 A.M., LPN I said if a resident has a medical device, such as an LVAD, a particular infection, or anything that makes them more susceptible, they are placed on EBP. Nurse Managers are responsible for placing the EBP signs outside of the resident rooms. EBP requires staff to wear gloves and gown while providing any type of direct care. Gowns can be located in the closet of the resident's room or in the supply closet on the hall. It would not be appropriate for staff to touch a resident on EBP with ungloved hands. When taking vitals with the machine on the rolling stand, staff should sanitize the equipment after each use. 11. During an interview on 5/23/24 at 10:50 A.M., LPN E said if a resident is on EBP, it means extra precautions must be taken because the resident has wounds or a medical device, such as a g-tube, LVAD, or catheter. Staff should wear a gown and gloves every time they provide any type of direct care to a resident on EBP. Staff should try and make sure gowns are available right outside of the resident's room, but they are also found in the closets on each hall. When taking vitals with the machine on the rolling stand, staff should sanitize the equipment after each use. 12. During an interview on 5/23/24 at 10:16 A.M., RN B said that if he/she had to perform any care related to wounds, he/she should wear gown and gloves. He/She said the yellow gowns are located in storage and also in the residents' rooms. 13. During an interview on 5/20/24 at 12:26 P.M., the Director of Nurses (DON) said rooms with an EBP sign posted on them require staff to wear gloves and gowns in the room if they are providing direct care. On 5/23/24 at 12:35 P.M., the DON said she is currently the facility's Infection Preventionist. The DON and Administrator said residents are placed on EBP if they have a wound, indwelling medical device, or MDRO. Staff should have a heightened sense of awareness when working with these residents. For residents on EBP, staff should wear gowns and gloves in any high-touch situations, including when checking a resident's brief, handling linens, performing transfers, and using a blood pressure cuff. Therapy staff should also wear gowns and gloves while working with the residents on EBP. All staff have been educated on using gowns and gloves during all high touch activities with residents on EBP. Gowns can be located in the closets of each resident's room and in the supply closets on the halls. 46888 49992

Based on observation, interview and record review, the facility failed to ensure each resident's care plan accurately reflected the residents' needs and medical conditions upon admission. This failure was noted in 5 of 17 sampled residents, including Resident #199, whose gastrostomy tube (g-tube, a surgical opening made in the stomach to feed nutrition directly into the stomach) was not included on the care plan, Resident #299 whose continuous positive airway pressure (CPAP, used to treat sleep apnea) was not included on the care plan, Resident #298 whose urinary catheter was not included and Resident #301, whose intravenous (IV) line was not included on the care plan, and for Resident #248 when a foot wound was not included on the care plan. The census was 69. Review of the facility's Care Planning policy, revised 11/22 showed: -It is the responsibility of all members of the interdisciplinary team to know and comply with this policy; -Initial/Baseline care plans must be completed within 48 hours of the resident's admission, and should include pain levels, fall risks, skin conditions, assistance with Activities of Daily Living (ADLs), and the risk for hospitalization no later than eight hours after admission; -The initial care plan is based on several areas, such as physician orders, pertinent diagnoses that would impact the resident's care, dietary orders, therapy services, social services, and utilization of the assessment tool to identify needs, risks, preferences, and services or treatment to be administered by facility staff. 1. Review of Resident #199's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/24, showed: -Cognitively intact; -Diagnoses included malignant neoplasm (a cancerous tumor) of the larynx; -Independence with ADLs including bathing, dressing, and personal hygiene; -An admitted [DATE]. Review of the resident's baseline care plan, entered on 5/17/24, made no mention of the resident's g-tube site or the resident's necessity to receive medications through his/her g-tube site. Observation on 5/20/24 at 11:46 A.M., showed the resident resting in bed with an enteral tube feeding (nutrition infused through a surgical opening in the intestine to meet a resident's caloric intake needs) infusing. The resident said he/she received scheduled enteral feedings and all medications through his/her g-tube and provided care for the g-tube site himself/herself. Observation on 5/21/24 at 9:46 A.M., showed the resident resting in bed with an enteral tube feeding infusing. The resident said he/she got evening meds as ordered by the physician, administered through his/her g-tube. Observation on 5/22/24 at 10:41 A.M., showed the resident resting in bed with an enteral feeding infusing. The resident said his/her g-tube was functioning properly and the dressing had been recently changed. During an interview on 5/23/24 at 10:28 A.M., Certified Medication Technician (CMT) F said the Social Services Designee is responsible for completing baseline and comprehensive care plans at the facility, and the development of care plans begins at admission. CMT F said he/she expected a resident admitted with a g-tube and administered medications through a g-tube to be included on the care plan. CMT F said care plans are important so that each resident's specific needs can be met by facility nursing staff. During an interview on 5/23/24 at 10:11 A.M. Licensed Practical Nurse (LPN) E said the Social Services Designee and floor nurses are responsible for completing baseline and comprehensive care plans at the facility, and the development of care plans begins at admission. LPN E said he/she expected a resident admitted with a g-tube and being administered medications through a g-tube to be included on the care plan. LPN E said care plans are important so that each resident's specific needs can be met by facility nursing staff. During an interview on 5/23/24 at 12:35 P.M., the Administrator and Director of Nursing (DON) said Nurse Managers in conjunction with the facility MDS Coordinator, are responsible for developing care plans, and care planning starts upon admission. The DON said baseline care plans should include fall risks, whether residents are at risk for skin breakdown, active wounds and surgical lines, and other immediate needs. The DON said the resident's g-tube status should be included on the care plan. 2. Review of Resident #299's electronic medical record (EMR) and resident information card, showed: -An entry MDS, dated [DATE], showed an admitted [DATE]; -A baseline care plan showed general information that included a diagnosis of obstructive sleep apnea (OSA, breathing interrupted during sleep); -Diagnoses included cancer, high blood pressure, depression, high cholesterol and sleep apnea; -CPAP device was not listed on the resident's baseline care plan and information card. Observation on 5/20/24 at 11:21 A.M., showed the resident's CPAP rested on top of the headboard. During an interview on 5/23/24 at 10:16 A.M., Registered Nurse (RN) B said the CPAP should be listed on the care plan. During an interview on 5/23/24 at 12:35 A.M., the DON said she expected the CPAP to be on the resident's care plan. 3. Review of Resident #298's EMR and resident information card, showed: -An entry MDS, dated [DATE], showed an admitted [DATE]; -A baseline care plan, dated 5/10/24, showed the resident as incontinent of bowel and bladder; -Indwelling urinary catheter (a tube inserted into the bladder through the urinary tract to drain urine) not indicated on resident information card; -Diagnoses include sleeplessness, seizure, bipolar disorder (a mood disorder characterized with manic highs and depressed lows) and neurogenic bladder (difficulty emptying the bladder due to neurological conditions). Observation on 5/21/24 at 6:54 A.M., showed the resident's indwelling urinary catheter in use and attached to the resident's bedrail. Observation and interview on 5/22/24 at 6:58 A.M., showed RN B and Certified Nursing Assistant (CNA) C performed a skin assessment while the resident lay in bed. CNA C said that he/she drains the indwelling urinary catheter gravity bag at the end of the shift. RN B said nurses should change the indwelling urinary catheter every thirty days or as needed. During an interview on 5/23/24 at 10:16 A.M., RN B said he/she expected to see the indwelling urinary catheter on the care plan and any nurse can update the care plan. During an interview on 5/23/24 at 12:35 P.M., the DON said if a resident has an indwelling urinary catheter, she expected it to be on the care plan. 4. Review of Resident #301's EMR, showed: -admitted [DATE]; -Diagnoses included stroke, infection, high blood pressure, and pacemaker (a device to help control the heart rate); -The resident's baseline care plan did not identify the use of any intravenous (IV) devices. Observation on 5/21/24 at 6:41 A.M., showed the resident had an IV pole with tubing at the bedside, and a double lumen peripherally inserted central catheter (PICC, a device which delivers fluids directly into a much larger vein) inserted into the right side of the resident's neck. During an interview on 5/23/24 at 10:16 A.M., RN B said he/she expected to see a PICC line on a care plan and any nurse can update the care plan. During an interview on 5/23/24 at 12:35 P.M., the DON said if a resident has a PICC line, she expected it to be on the care plan. 5. Review of Resident #248's EMR, showed: -admitted [DATE]; -Diagnoses included cellulitis, altered mental status, wound on coccyx, wound on right heel, right foot toes are amputated; -The resident's baseline care plan, in use at the time of the survey, did not identify wound care of the resident's right foot surgical incisions. During an interview on 5/20/24 at 11:48 A.M., the resident said he/she was at the facility for rehab and to heal the surgery incisions on his/her foot. During an interview on 5/23/24 at 11:36 A.M., LPN K said he/she was aware of the resident's wounds being treated on the resident's right foot. He/She expected for wound care to be on the care plan. During an interview on 5/23/24 at 12:38 P.M., the DON said she expected wounds and surgical incisions to be on the care plan to ensure staff know how to care for the resident properly. 46888 49992

Base on observation, interview and record review, the facility failed to ensure two residents' Activities of Daily Living (ADL) needs were met by failing to ensure both residents received at least two showers/bed baths weekly (Residents #248 and #249) . The sample was 17. The census was 69. Review of the facility's AM and PM Care policy, revised 10/2022, showed: -Purpose: to provide grooming and hygiene for each resident, assisting with bathing, dressing and elimination as needed; -Policy: it shall be the policy of Bethesda that each resident receives assistance with ADLs as needed throughout each day. Consideration will be given to making the experience as home-like and individual as possible; -Procedure: on the designated day, assist the resident with their bath or shower. 1. Review of Resident #248's electronic medical record (EMR), showed: -admitted [DATE]; -Cognitively intact; -Diagnoses included cellulitis, altered mental status, wound on coccyx, wound on right heel, right foot toes are amputated. Observation on 5/20/24 at 12:00 P.M., showed the resident had greasy hair. During an interview on 5/23/24 at 8:30 A.M., the resident said he/she has not had a shower or bed bath since his/her arrival to the facility. He/She felt dirty and uncomfortable and would like a shower. During an interview on 5/23/24 at 11:42 A.M., Licensed Practical Nurse (LPN) G said the resident had received a bed bath on 5/21/24 but the nursing staff who gave him/her the bath forgot to document. He/She expected for staff to document anytime they give a resident a shower or bed bath. 2. Review of Resident #249's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/20/24, showed: -admitted [DATE]; -Cognitively intact; -Diagnoses included below the knee amputation of the left leg. During an interview on 5/20/24 at 1:55 P.M., the resident said he/she had only received one bed bath since he/she arrived at the facility. He/She said he/she would like a shower and feels dirty. He/She said he/she had not refused any bed baths or showers since arriving to the facility. Review of the facility's shower documentation on 5/23/24 at 9:59 A.M., showed the only shower the resident received was on 5/17/24. During an interview on 5/23/24 at 12:41 P.M., the Director of Nursing (DON) said the resident has a history of refusing ADL care. 3. During an interview on 5/23/24 at 12:08 P.M., Certified Nursing Assistant (CNA) M said staff should document showers and refusal of showers in the resident's chart. 4. During an interview on 5/23/24 at 12:41 P.M., the DON said she expected all residents to receive at least two showers or bed baths weekly. She expected nursing staff to document when showers are given and when a resident refused a shower.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one resident (Resident #301). The resident admitted from the hospital on 5/16/24. The facility admission nursing assessment identified an open area on the buttock and a double lumen peripherally inserted central catheter (PICC, a device which delivers fluids directly into a much larger vein) inserted into the right side of the resident's neck. There was no order for the PICC line dressing change, flushing, or care. In addition, facility staff failed to complete treatment orders and apply dressing changes as ordered to the buttocks. The sample was 17. The census was 69. Review of the facility's Central Vascular Access Device (CVAD) Flushing and Locking policy, dated 1/15/2004 and last revision 6/1/21, showed: -Licensed nurses providing infusion therapy in the post-acute setting; -To be performed by licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy with his/her scope of practice; -A prescriber's order is required to access/flush/lock a catheter. Review of the facility's Prescribing and Ordering of Medication/Products policy, dated effective date 4/2002 and last revision 1/24, showed: -To establish guideline for properly obtaining physician orders and processing these orders; -To obtain admission orders from the physician, check the transfer sheet from the discharging facility as a reference; -Enter orders into the resident's medical record. Review of Resident #301's electronic medical record (EMR), reviewed on 5/21/24 at 11:45 A.M., showed: -admitted [DATE]; -Diagnoses included stroke, infection, high blood pressure, and pacemaker (a device to help control the heart rate); -An admission wound assessment, dated 5/16/24, showed a wound to the buttocks; unstageable (the actual base and condition of the ulcer cannot be determined), clear drainage, peri wound (the skin surrounding the wound bed) excoriated (reddened), measured 3.7 x 4.6 x 0.0 centimeter (cm). Review of the resident's electronic physician order sheet (ePOS), showed: -A order dated 5/16/24, for intravenous (IV) medication, Cefazolin (antibiotic) 2 gram (G) every 8 hours; -An order dated 5/17/24, for Calvida (barrier cream). Cleanse wound on buttocks with cleanser and apply Calvida; -An order dated 5/20/24, for Medi honey (ointment to assist in wound healing and prevent infection). Cleanse wound on buttocks with cleanser, protect peri wound with skin prep (barrier wipe), apply to wound bed Medi honey gel, cover wound with bordered foam, change as needed for soiling and/or saturation; -An order dated 5/22/24 at 5:23 P.M., to add foam to the buttocks pressure ulcer (wound caused by pressure or friction) and change every three days; -No order for the PICC line, dressing change, care, or flushing. Observation on 5/21/24 at 6:41 A.M., showed the resident had an IV pole with tubing at the bedside, and a double lumen PICC line inserted into the right side of the resident's neck. The dressing over the PICC line was dated 5/14/24 8:00 P.M. Observation on 5/22/24 at 7:08 A.M., showed Registered Nurse (RN) B and Certified Nursing Assist (CNA) C performed care on the resident. Upon turning the resident over, no dressing was present on the resident's buttocks wound. The wound had an oval shape, approximately the size of a half dollar, with no drainage. The wound bed appeared beefy read with approximately a nickel size area of yellow stringy tissue. RN B applied Calvida cream to the resident buttocks. The ordered treatment to cleanse wound on buttocks with cleanser, protect peri wound with skin prep, apply to wound bed Medi honey gel, and cover wound with bordered foam dressing was not completed as ordered. Dressing to the PICC line was dated as changed on 5/21/24 at 9:00 P.M. Observation on 5/23/24 at 7:38 A.M., showed CNA L provided a bed bath to the resident. The resident's buttocks wound was open to air with no treatment in place. RN B instructed CNA L to apply Calvida to the resident buttocks. CNA L applied the Calvida cream. The ordered foam dressing was not applied. During an interview on 5/23/24 at 10:16 A.M., RN B said that a resident should have an order for a PICC line, included with the order is the type of access, dressing change, and flush. Nurses should follow physician's orders for wound treatments. During an interview with the Director of Nursing (DON) on 5/23/24 at 12:35 P.M., she said that a resident with a PICC line should have orders and the orders should include flushing, dressing change, and monitoring. On 5/24/24 at 11:04 A.M., she said that nurses should perform wound treatments per physician's orders.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #298) who was admitted with a indwelling urinary catheter (thin tube inserted into the bladder to drain urine) had a physicians order to provide care for the catheter. The sample size was 17. The census was 69. Review of the facility's Prescribing and Ordering of Medication/Products policy, dated effective date 4/2002 and last revision 1/24, showed: -To establish guideline for properly obtaining physician orders and processing these orders; -To obtain admission orders from the physician, check the transfer sheet from the discharging facility as a reference; -Enter orders into the resident's medical record. Review of Resident #298's electronic medical record (EMR) and resident information card, reviewed on 5/21/24 at 10:40 A.M., showed: -An entry Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff, dated 5/10/24, showed an admitted [DATE]; -A baseline care plan showed the resident as incontinent of bowel and bladder; -Indwelling urinary catheter not indicated on resident information card; -No order for an indwelling urinary catheter; -Diagnoses include sleeplessness, seizure, bipolar disorder (a mood disorder characterized with manic highs and depressed lows), and neurogenic bladder (difficulty emptying the bladder due to neurological conditions). Observation on 5/21/24 at 6:54 A.M., showed the resident's indwelling urinary catheter in use and attached to the resident's bedrail. During an interview on 5/23/24 at 10:16 A.M., Registered Nurse (RN) B said that he/she would expect to see a physician order for the indwelling urinary catheter, included with the order would be the size of the catheter, diagnosis for the catheter, balloon size, routine for changing, and monitoring output. During an interview with the Director of Nursing (DON) on 5/23/24 at 12:35 P.M., she said would expect to see a physician order for the indwelling catheter, included with order would be the size, monitoring, and cleaning.

Based on observation, interview and record review, the facility failed to ensure one resident maintained acceptable parameters of nutritional status to the extent possible, for one resident (Resident #34) who experienced a significant weight loss (weight loss of 5% or more in the last month, loss of 7.5% or more in the last three months, or loss of 10% or more in the last six months) of -10.35% from July 2023 to January 2024. During this timeframe, the facility's Registered Dietician (RD) completed two nutritional assessments, noted a decline in the resident's meal intake, and did not recommend additional nutritional interventions. The resident was not served fortified cheesy eggs as recommended by the RD, and the RD's recommendation for fortified pudding did not get added to the resident's meal ticket. Nursing staff failed to consistently chart the resident's meal intake, which is reviewed during the RD's nutrition assessments, and the resident was not served preferred foods at meals. The sample was 17. The census was 69. Review of the facility's Nutritional Intervention Program policy, revised November 2023, showed: -Purpose: To provide guidelines for assessing the need for medical nutritional products and administering nutritional supplements to residents. To ensure that residents are receiving medical nutritional products per physician's orders and consumption is monitored and documented; -Responsibility: It is the responsibility of the nursing and clinical nutrition staff to initiate the program in collaboration with physicians when a resident exhibits the need for a nutritional supplement. The Nurse Manager or Charge Nurse is responsible for the oversight of all nutritional supplements; -Policy: There will be a program to provide a palatable nutritional supplement pass program to enhance the nutritional status of residents as recommended by clinical staff. It will be the policy of the company to administer nutritional supplements to residents in agreement with physician's orders; -Nursing and clinical staff will assess residents for the following indicators of the need for Nutritional Interventions: --An un-planned weight loss; --Resident exhibits a decline in usual meal consumption; -RD/doctor will make recommendations for interventions based on resident preferences and nutritional needs; -All efforts to use regular food and beverage will be made. Use of medical nutritional products/ formulas will be used as a last resort and only when other attempted interventions are unsuccessful; -Offer high calorie/fortified foods/beverage options. A variety of items can be offered to prevent taste fatigue and better acceptance by residents. No physician order is required for fortified foods; -The RD/doctor will document the assessment/progress note the number of fortified/enhanced foods needed per day for the resident. This information is included on the care plan and noted on the resident's meal ticket. Review of the Resident #34's medical record, showed: -Diagnoses included Multiple Sclerosis (MS, disease of the central nervous system), autoimmune hepatitis (when the body's immune system attacks the liver), hypothyroidism (underactive thyroid), high blood pressure, gastroesophageal reflux disease (GERD, stomach contents leak backwards into the esophagus) and depression; -A physician order, dated 3/3/22, for fortified foods: fortified cheesy eggs and fortified oatmeal; -A physician order, dated 4/19/22, for Boost Plus (nutritional shake) once daily; -A physician order, dated 12/13/22, for Boost Breeze (nutritional shake) 237 milliliters (mL) twice daily; -On 7/24/23, weighed 163.3 pounds (lb.). Review of the resident's quarterly nutrition assessment, completed by the facility's previous RD, dated 8/17/23, showed: -Current weight: 161 lb.; -Diet: Regular with average meal intake reported approximately (~) 70 percent (%) in the past 30 days; -Nutrition interventions: Boost Plus once daily (360 kilocalories (kcal, a unit of energy), 14 grams (g.) protein), fortified eggs (435 kcal, 20 g. protein), fortified oatmeal (430 kcal, 14 g. protein) with breakfast; -Resident is historically alert and oriented to person and place. Able to feed self after set-up assistance with supervision; -Estimated energy needs based on current body weight: 1772 to 2127 kcal per day, 70 g. protein per day. Resident needs to consume approximately 75% of meals to meet calculated needs without in place interventions, suggesting continued need for in place interventions; -No change to nutrition plan at this time. Review of the resident's weights, showed: -On 9/5/23: 163.3 lb.; -On 10/19/23: 154 lb.; -On 10/23/23: 152.6 lb. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/1/23, showed: -Resident unable to complete Brief Interview for Mental Status (BIMS); -Substantial/maximal assistance required for eating; -Weight: 153 lb. Review of the resident's annual nutrition assessment, completed by the facility's previous RD, dated 11/14/23, showed: -Current weight: 153 lb. -5% weight loss in three months. 0.65% weight loss in 6 six months. No significant weight changes noted; -Diet: Regular with average meal intake reported ~55% in the past 30 days; -Nutrition interventions: Boost Plus once daily (360 kcal, 14 g. protein), fortified eggs (435 kcal, 20 g. protein), fortified oatmeal (430 kcal, 14 g. protein) with breakfast; -Resident is historically alert and oriented to person and place. Able to feed self after set-up assistance with supervision; -Estimated energy needs based on current body weight: 1772 to 2127 kcal per day, 70 g. protein per day. Resident needs to consume approximately 75% of meals to meet calculated needs without in place interventions, suggesting continued need for in place interventions; -No change to nutrition plan at this time. Review of the resident's weights, showed: -On 11/16/23: 149.2 lb.; -On 11/20/23 and 11/29/23: 150.3 lb.; -On 12/7/23: 149.9 lb.; -On 12/18/23: 149.4 lb.; -On 1/24/24: 146.4 lb.; -Significant weight loss of -10.35% in six months, from 7/24/23 to 1/24/24. Review of the resident's quarterly MDS, dated [DATE], showed: -Resident rarely/never understood; -Substantial/maximal assistance required for eating; -Weight: 146 lb.; -No weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of the resident's quarterly nutrition assessment, completed by the facility's current RD, dated 2/6/24, showed: -Diet: Regular; -Nutrition interventions: Boost Plus once daily (360 kcal, 14 g. protein), fortified eggs (435 kcal, 20 g protein), fortified oatmeal (430 kcal, 14 g. protein) with breakfast; -Weight: 146.4 lb. No significant weight changes noted. -Estimated energy needs based on current body weight: -Energy needs: 1848 to 1980 kcal; -Protein needs: ~66 g. per day; -Resident needs to consume ~80 to 85% of meals to meet their daily energy needs. Current intake per nursing staff documentation is ~58% of meals; -Resident appears to not be meeting their nutritional needs as evidenced by reported intake less than estimated needs. Will continue current nutrition interventions. Will add fortified pudding daily (340 kcal, 15 g protein) to promote kcal intake. Review of the resident's electronic Physician Order Sheet (ePOS), showed no order for fortified pudding. Review of the resident's weights, showed: -On 2/22/24: 148.2 lb.; -On 2/28/24: 143.3 lb.; -On 3/4/24: 144 lb.; -On 3/11/24: 145.6 lb.; -On 3/19/24: 142.7 lb.; -On 3/26/24: 142.4 lb. Review of the resident's March 2024 meal intake, showed: -93 meals total; -30 meals missing documentation of meal intake; -Six meals documented with 0% of meal consumed; -Average of total average meal consumption: 44%. Review of the resident's weights, showed: -On 4/17/24: 140 lb.; -On 4/22/24: 139.9 lb. Review of the resident's quarterly MDS, dated [DATE], showed: -Substantial/maximal assistance required for eating; -Weight: 140 lb.; -Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, not on physician-prescribed weight-loss regimen. Review of the resident's quarterly nutrition assessment, completed by the facility's current RD, dated 4/29/24, showed: -Diet: Regular diet with regular texture; -Nutrition interventions: Boost Plus once daily (360 kcal, 14 g. protein), fortified oatmeal (430 kcal, 14 g. protein) with breakfast, fortified pudding daily (340 kcal, 15 g. protein); -Weight: 139.9 lb. Patient with 11% weight loss in six months (significant for timeframe); -Estimated energy needs based on current body weight: -Energy needs: 1848 to 1980 kcal; -Protein needs: ~66 g. per day; -Resident needs to consume ~80 to 85% of meals to meet their daily energy needs. Current intake per nursing staff documentation is ~61% of meals; -Resident appears to not be meeting their nutritional needs as evidenced by reported intake less than estimated needs. Will continue current nutrition interventions. Review of the resident's April 2024 meal intake, showed: -90 meals total; -46 meals missing documentation of meal intake; -Five meals documented with 0% of meal consumed; -Average of total average meal consumption: 60%. Review of the resident's RD note, dated 5/3/24, showed the nurse reported to the RD that the resident is having difficulty chewing regular texture food and that resident would benefit from mechanical soft diet for chewing. Downgraded diet to regular diet with mechanical soft texture. Diet order modified to promote by mouth (PO) intake, reduce risk of weight loss, and preserve quality of life. Review of the resident's ePOS, showed an order, dated 5/13/24, for mechanical soft diet. Review of the resident's care plan, in use at the time of survey, showed: -Resident is alert and oriented to self and not able to express his/her needs; -Usual body weight is ~155 lb.; -Meals/snacks/fluids: -Resident is offered a regular diet with mechanical soft texture; -Resident is able to feed self after set-up assistance with supervision; -Resident is at nutrition/hydration risk because of advanced age and diagnosis of depression; -Please offer fortified oatmeal and cheesy eggs, which provide an additional 430 kcal each and 13 g./21 g. protein, respectively; -Resident will maintain his/her weight +/-6% through next 90 day review; -No documentation regarding the resident's significant weight loss, average meal intake, substantial/maximal assistance from staff required for eating, preferred foods, or RD's recommendation on 2/6/24 for addition of fortified pudding. Review of the resident's meal intake from 5/1/24 through 5/21/24, reviewed 5/22/24, showed: -63 meals total; -22 meals missing documentation of meal intake; -Five meals documented with 0% of meal consumed; -Average of total average meal consumption: 35%. Review of the resident's meal tickets, showed: -Breakfast: fortified eggs, fortified oatmeal; -No documentation of fortified pudding. Observation on 5/20/24 at 1:04 P.M., showed the resident sat upright in a reclining chair with Certified Nurse Aide (CNA) A seated next to the resident, attempting to provide feeding assistance. Lunch was served on a divided plate and included raw baby carrots. No fortified pudding was observed. Review of the dietary slip, showed the mechanical soft diet. CNA A held bites of food to the resident's mouth and the resident did not eat. CNA A held a container of Boost Breeze to the resident's mouth and the resident drank the shake. During an attempted interview, the resident did not respond. During an interview, CNA A said the resident used to eat independently, but now requires feeding assistance from staff. The resident does not eat much, but will drink nutritional shakes. It is unknown why the resident is no longer eating much and he/she does not have a new health condition. He/She should receive a mechanical soft diet but today was served raw carrots. Observation on 5/21/24 at 8:08 A.M., showed the resident sat upright in bed with a plate of breakfast on his/her bedside table. Breakfast consisted of scrambled eggs with no cheese, a biscuit, and a bowl of oatmeal. No fortified cheesy eggs were served. No banana or frosted flake cereal was served. CNA A attempted to feed the resident and the resident did not eat. Observation on 5/21/24 at 1:27 P.M., showed the resident's lunch tray on a cart of trays on the hall. CNA M removed the resident's lunch tray and showed the plate consisted of full portions of spaghetti and large steamed broccoli florets. A small plate contained a piece of cake with one bite missing. A carton of Boost Breeze was empty. No fortified pudding was observed. Observation of breakfast preparation on 5/22/24 at 7:01 A.M., showed Cook O made regular texture scrambled eggs and pureed eggs. He/She did not make fortified cheesy eggs. Observation on 5/22/24 at 8:24 A.M., showed the resident sat upright in bed with CNA A seated next to the bed, attempting to provide feeding assistance. Breakfast served consisted of scrambled eggs, a muffin, mechanical soft sausage with gravy, a cup of yogurt and a bowl of oatmeal. No fortified cheesy eggs were served. No banana or frosted flake cereal were served. CNA A held bites of food to the resident's mouth and the resident did not eat. CNA A held a carton of Boost Breeze to the resident's mouth and the resident drank the shake. During an interview, CNA A said the resident used to eat independently and consumed 100% of his/her meals. Then the resident declined a little and staff had to start feeding him/her, but the resident still ate 100% of his/her meals. A couple months ago, the resident moved to his/her current room and completely declined. He/She no longer feeds him/herself at all and consumes less than 25% of each meal served. He/She likes the nutritional shakes and loves bananas and pancakes at breakfast, but doesn't really eat anything else. CNA A told the RD about the resident's food preferences and the RD said the kitchen seldom has bananas. Observations on 5/23/24, showed: -At 8:20 A.M., the resident seated at a table in the dining room while CNA N provided feeding assistance. Breakfast served consisted of scrambled eggs, pancakes, and a bowl of oatmeal. No fortified cheesy eggs were served. No banana or frosted flake cereal were served; -At 8:30 A.M., 75% of the resident's pancakes and eggs consumed. During an interview, CNA N said the resident is still eating his/her breakfast. He/She likes pancakes. It is hit and miss how much food the resident will eat because it depends on if the resident likes the food served. During an interview on 5/23/24 at 10:06 A.M., Cook O said he/she did not make fortified cheesy eggs on 5/22/24. He/She expected nursing staff to communicate a resident's dietary preferences with dietary staff. Dietary slips that go out with resident trays are generated by the RD. During an interview on 5/23/24 at 10:09 A.M., the Dining Services Director said the RD generates the dietary slips that show what residents are served at each meal. If a resident with weight loss is only willing to eat certain foods, like bananas, it should be communicated to dietary so they can add it to the food order. During an interview on 5/23/24 at 10:14 A.M., CNA H said the resident receives a regular diet, not mechanical soft or puree. He/She has no issues with chewing or swallowing. He/She requires total assistance from staff, including while eating. His/her appetite is alright. He/She closes his/her mouth and shakes his/her head no when he/she doesn't want to eat. He/She really likes drinking Boost shakes and will drink 100% of them. If he/she is not eating the meal served, staff should offer him/her a Boost or a different supplement. CNAs are responsible for charting a resident's intake of each meal served during the shift. During an interview on 5/23/24 at 10:32 A.M., Licensed Practical Nurse (LPN) I said the resident is alert and oriented to self. He/She requires feeding assistance from staff. He/She has not been eating well, generally consuming 25% of each meal. He/She loves to drink Boost shakes. If the resident doesn't eat his/her meal, it should be reported to the nurse and the resident should be given an extra Boost shake. This should also be documented in the resident's record. It is expected that CNAs chart a resident's meal intake during each shift, especially if a resident has had weight loss. During an interview on 5/23/24 at 10:50 A.M., LPN E said it is expected that CNAs chart meal intake at each shift. If a resident is not eating, it should be reported to the nurse. During an interview on 5/23/24 at 11:00 A.M., the facility's current RD said she completes admission, quarterly, and annual nutrition assessments on all long-term care residents. Some residents may be seen more frequently based on clinical judgement. He/She just identified the resident's weight loss during the resident's quarterly assessment in April 2024, and now the resident is on the high-risk caseload. Prior to this, the resident was having weight loss, but it was not significant. Before the RD started working at the facility in November 2023, the resident was feeding him/herself and now requires feeding assistance. His/Her decline in health has been a natural progression, and there has not been any new disease process. During her nutrition assessments, the RD reviews the resident's chart, including labs, weights, and meal intake. She expected nursing staff to chart routinely so she can assess the resident. Recently, it was reported the resident had difficulty chewing so the RD changed his/her diet to mechanical soft. Raw carrots and large steamed broccoli would not be considered mechanical. The resident's meal intake has remained the same since being changed to mechanical. When meal intake decreases, the RD will ask residents if there is anything in particular they will eat. Resident #34 is not interviewable. The RD knows the resident like bananas, frosted flake cereal, potatoes, peas, corn, and no cheese on his/her sandwiches. The facility does not have frosted flake cereal and bananas were on order, but did not arrive with the food order. The RD enters the resident's diet orders, including fortified foods, and preferences into a computer system shared with dietary. Dietary can adjust their food orders to add the foods preferred by residents. The RD can also add a resident's dislikes, which would prompt dietary staff to provide a substitution. The facility stopped doing fortified cheesy eggs a while ago. Residents didn't seem to like them, so the facility started using fortified milk (regular whole milk with added dry milk flavoring) instead. Residents didn't seem to like that, either. The facility is in the process of trying to identify other options. The order for fortified cheesy eggs should be removed from the resident's ePOS. The order for fortified pudding should be added to the ePOS. While the resident likes pancakes, the kitchen may not be able to make pancakes every morning for one particular resident. The resident's food preferences should be provided. Review of the resident's dietary profile, provided 5/23/24, showed at breakfast, the resident likes bananas and frosted flakes. During an interview on 5/23/24 at 12:25 P.M., the Dining Services Director said it was not a problem for dietary staff to make pancakes daily for one resident who is not eating other foods. Dietary can provide substitutions for items based on what the resident's preferences are, which should be communicated to dietary by the RD via the shared computer system. The facility does not have bananas or frosted flakes right now. During an interview on 5/23/24 at 12:35 P.M., the Director of Nurses and Administrator said the resident has had significant weight loss. When he/she does not eat, it is expected that staff offer the resident a shake. If fortified cheesy eggs are not made anymore, it is expected the RD and dietary staff come together to identify an alternate fortified food or nutritional supplement. Any nutritional intervention identified and recommended by the RD should be added to the resident's ePOS, meal ticket, or care plan, and should served to the resident. It is expected that nursing staff communicate a resident's food preferences to dietary and the RD. It is expected that CNAs chart meal intake during every shift to assist the RD during her nutritional assessments. It is expected that residents receive diets per orders, and raw carrots should not be served to a resident with difficulty chewing who should receive a mechanical soft diet.

Based on observation, interview and record review, the facility failed to ensure physician orders were obtained for the use of a continuous positive airway pressure (CPAP, machine that keeps the airways open during sleep for persons with sleep apnea) for one resident (Resident #299) and to ensure CPAP masks were properly stored while not in use for infection control purposes for two residents (Residents #299 and #146). The sample was 17. The census was 69. Review of the facility's CPAP/Bilateral Positive Airway Pressure (BIPAP, mechanical breathing device)/Average Volume Assured Pressure Support (AVAPS, mode of non-invasive ventilation)/Trilogy Ventilator (device used to provide pressure support, pressure control, or volume control during breathing support) policy, revised November 2021, showed: -Purpose: To provide guidelines for staff to assist the resident in using a CPAP/BIPAP/AVAPS/Trilogy Ventilator device; -Responsibility: It will be the responsibility of all licensed nursing staff to know and follow these guidelines; -Policy: A physician's order is required for CPAP/BIPAP/AVAPS/Trilogy Ventilator. Pressure settings are to be set by the durable medical equipment (DME) company per physician order/direction. If the resident brings equipment from home, the settings used at home can be used if approved by the physician; -Obtain physician's order for device use; -If device is from home, the order should specify home settings; -Add device use and care to resident's care plan/resident profile; -Equipment cleaning: -Wipe mask daily using a damp cloth; -The policy failed to provide guidance for mask storage while not in use. 1. Review of Resident #299's electronic medical record (EMR) and resident information card, reviewed on 5/21/24 at 8:46 A.M., showed: -An entry Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 5/13/24, showed an admitted [DATE]; -A baseline care plan showed a diagnosis of obstructive sleep apnea (OSA, breathing interrupted during sleep); -Diagnoses included cancer, high blood pressure, depression, high cholesterol, and sleep apnea; -CPAP device was not listed on the resident's baseline care plan and information card; -No physicians order for the CPAP on admission. New order obtained 5/23/24 8:00 A.M. Observations on 5/20/24 at 11:21 A.M., showed the resident's CPAP tubing rested over the top of the headboard, mask faced down and rested against the headboard. During an interview on 5/21/24 at 6:46 A.M., the resident said he/she receives supplies every six weeks to his/her home and that he/she takes care of the CPAP machine while at the facility. During an interview on 5/22/24 at 10:32 A.M., Registered Nurse (RN) B said that the resident takes care of the CPAP, the mask should be stored when not being used, and he/she only monitors the machine to see if it is clean. On 5/23/24 at 10:16 A.M., RN B said that there should be on order for the CPAP. During an interview on 5/23/24 at 10:27 A.M., Certified Nursing Assistant (CNA) C said he/she is aware that the resident has a CPAP, the mask should be stored when not being used, and that the resident takes care of it. During an interview with the Director of Nursing (DON) on 5/23/24 at 12:35 A.M., she said she would expect there to be an order for the CPAP. 2. Review of Resident #146's admission MDS, dated [DATE], showed: -Cognitively intact; -Supervision/touch assistance required for sit to stand; -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), obstructive sleep apnea, and acute and chronic respiratory failure. Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 5/13/24, for CPAP application, apply CPAP at bedtime. Check every two hours for mask placement and complications; -An order dated 5/14/24, for CPAP removal every 24 hours, clean mask and rinse humidifier with soap and water. Rinse and let air dry. Review of the resident's care plan, in use at the time of survey, showed: -General: Resident is at facility for physical therapy/occupational therapy for COPD exacerbation. Resident uses a rented CPAP to assist him/her at night with home settings. Please ensure to rinse and fill humidifier each night and monitor him/her throughout the shift for mask placement and/or complications; -Vitals/pain: Resident wears CPAP at night. Observations on 5/20/24 at 11:28 A.M. and 1:06 P.M., showed the resident sat upright in a recliner chair next to his/her bed with oxygen on via nasal cannula (device used to deliver oxygen with two small tubes that fit into the nostrils). A CPAP machine sat on a nightstand next to his/her bed, not in use. The CPAP mask was uncovered and with no barrier, face down on top of miscellaneous items in the open top drawer of the nightstand. Observations on 5/21/24, showed: -At 7:59 A.M., the resident sat upright in bed. His/Her CPAP machine was not in use. The CPAP mask was uncovered and had no barrier on top of the nightstand, behind the CPAP machine, with the base of the mask face down directly on the table and partially touching the base of a table lamp; -At 9:40 A.M., the resident sat upright in bed. His/Her CPAP machine was not in use. The CPAP mask was uncovered with no barrier on top of the nightstand, behind the CPAP machine, with base of the mask face down directly on the table and partially touching the base of a table lamp. Licensed Practical Nurse (LPN) G entered the resident's room and spoke with the resident; -At 11:13 A.M., LPN G and CNA A entered the resident's room; -At 11:31 A.M. and 1:16 P.M., the resident sat upright in his/her recliner. His/Her CPAP machine was not in use. The CPAP mask was uncovered with no barrier on top of the nightstand, behind the CPAP machine, with base of mask face down directly on the table and partially touching the base of a table lamp. During an interview on 5/21/24 at 1:16 P.M., the resident said he/she uses his/her CPAP machine at night. He/She does not clean the CPAP mask. He/She thinks the staff might clean it, but isn't sure. He/She does not have a protective covering to store the CPAP mask while not in use and was not sure if he/she was supposed to cover the mask when not in use. Observations on 5/22/24, showed: -At 8:27 A.M., the resident sat in bed. His/Her CPAP machine was not in use. The CPAP mask was uncovered with no barrier, at the bottom of the open top drawer in his/her nightstand, face down with base of mask touching the bottom of the drawer. During an interview, the resident said he/she used his/her CPAP last night and removed it him/herself at 7:30 A.M.; -At 12:44 P.M., the resident sat in his/her recliner chair. His/Her CPAP machine not in use. The CPAP mask uncovered and with no barrier, at the bottom of the open top drawer in his/her nightstand, face down with base of mask touching the bottom of the drawer. During an interview on 5/22/24 at 1:43 P.M., CNA A said the resident wears a CPAP at night. The resident was wearing his/her CPAP mask when CNA saw the resident earlier that morning. Nurses handle the CPAP machines, not the aides. During an interview on 5/23/24 at 10:32 A.M., LPN I said the resident can use his/her CPAP on his/her own. Nursing staff puts the resident's CPAP mask on him/her at night. 3. During an interview on 5/23/24 at 10:32 A.M., LPN I said nursing staff is responsible for cleaning CPAP masks. CPAP masks should be stored in a plastic bag while not in use. 4. During an interview on 5/23/24 at 10:50 A.M., LPN E said some residents can remove their CPAP masks themselves and some require assistance from the nurse. Nurses are responsible for ensuring CPAP masks are stored in plastic bags while not in use. 5. During an interview on 5/23/24 at 12:35 P.M., the DON and Administrator said residents, nursing and respiratory therapy staff are responsible for ensuring CPAP masks are stored properly. After CPAP mask use, either the resident or nursing staff should rinse off the mask and store it in a bag. Since Resident #146 does not stand or walk, it is expected that nursing staff assist him/her with CPAP mask cleaning and storage. It is expected that CPAP use be indicated on a resident's care plan. Department heads complete their respective portions of a resident's care plan upon admission and comprehensive care plans are overseen by MDS staff. 49992

Based on interview and record review, the facility failed to timely identify a resident's twice daily anti-epileptic (anti-[MEDICAL CONDITION]) medication had not been delivered from the pharmacy over a two day time period. The omission of five consecutive doses resulted in the resident experiencing uncontrolled [MEDICAL CONDITION] activity and prolonged postictal state (abnormal condition occurring at the end of a [MEDICAL CONDITION]; cognitive and sensorimotor impairments, changes in behavior, motor function, and neuropsychological performance) with unresponsiveness. This deficient practice affected one of three sampled residents (Resident #1). The census was 63. Review of Resident #1's face sheet, no date, showed the following Diagnoses: [REDACTED]. -Metabolic [MEDICAL CONDITION] (a problem in the brain, [MEDICAL CONDITION], caused by a chemical imbalance in the blood and not caused by a head injury); -Difficulty in walking and lack of coordination; -Hypertension (high blood pressure); -Stroke affecting left non-dominant side, [MEDICAL CONDITION] and [MEDICAL CONDITION] (muscle weakness or [DIAGNOSES REDACTED] of one side of the body), 03/2017; -Diabetes mellitus; -[MEDICAL CONDITION] of native coronary artery (build up of plaque in the coronary walls). Review of the resident's Profile Report (plan of care), no date, showed the following: -The resident was admitted to the facility for physical and occupational therapy, due to removal of a brain mass, to increase independence; -The resident was able to make needs and wants known, even though he/she refused to speak when spoken to at times; -Staff to ask the resident about wants and needs, monitor for any changes in his/her ability to make wants and needs known, and report any changes to the physician; -One person assistance for transfers and activities of daily living; -May be resistive to medications and care at times; -The resident was alert but unable to verbally express needs; -The resident was on a [MEDICAL CONDITION] medication; -Staff to monitor and report any signs or symptoms of [MEDICAL CONDITION] activity to the nurse; -Staff to crush medications due to poor intake and a slow eater; -The resident's goal was to discharge to home with home health. Review of the resident's admission nurse's note, dated 1/25/21 at 6:54 P.M., showed Nurse B documented the resident arrived at 4:30 P.M., was alert and oriented to self, hand grips were strong, appetite was poor, there was some left-sided weakness, and medication orders were faxed to the pharmacy. Review of the resident's physician order [REDACTED].M., for lacosamide (brand name [MEDICATION NAME], an anti-epileptic, federally controlled Schedule II drug, that requires a signed physician prescription to be either hand delivered to the pharmacy, or faxed to the pharmacy by the physician's agent/facility nurse, or electronically written and sent by the physician, or called in by the physician for a short term emergency supply) 200 milligram (mg) tablet to be given every 12 hours, with the first dose to be given on 1/25/21 at 9:00 P.M., for indication of [MEDICAL CONDITION] disorder. Review of the resident's Medication Administration Record [REDACTED] -All 5:00 P.M. medications were documented by Nurse G as administered at 6:20 P.M.; -6:00 P.M. [MEDICATION NAME] (for hypertension) was documented by Nurse G at 6:21 P.M. as not done, awaiting arrival, unable to complete, provider notified; -9:00 P.M. atorvastatin (for cholesterol control) was documented by Certified Medication Technician (CMT) B at 10:54 P.M. as administered; -9:00 P.M. ramelteon (for [MEDICAL CONDITION]) was documented by CMT B at 10:53 P.M. as not given, medication not available, charge nurse notified; -9:00 P.M. [MEDICATION NAME] was documented by CMT B at 10:54 P.M. as administered. During an interview on 2/23/21 at 12:18 P.M., Nurse G said he/she faxed the resident's medication orders to the pharmacy sometime after 5:00 P.M. on 1/25/21. The pharmacy does not deliver medications received in the afternoons until the next morning. The resident's [MEDICATION NAME] was not due until 9:00 P.M. that night and he/she was off at 7:00 P.M., so there was nothing to be done about the [MEDICATION NAME]. Nurse G said he/she was aware [MEDICATION NAME] was a controlled drug but physician notification was not necessary because the orders were faxed to the pharmacy. If there is a controlled drug ordered, the pharmacy would fax over an authorization to the physician. Additionally, [MEDICATION NAME] is occasionally available in the emergency kit. During an interview on 2/23/21 at 12:00 P.M., Pharmacy Technician (PT) C, with the facility's contracted pharmacy, said they received the resident's admission medication orders, created by the facility nurse, via fax at 5:16 P.M. on 1/25/21. However, because there was no physician-signed paper prescription faxed over for the Schedule II [MEDICATION NAME] , the [MEDICATION NAME] was not dispensed. The resident's other medications were dispensed and sent out at 2:00 A.M. on 1/26/21, which was the next scheduled pharmacy run. The pharmacy sends out fax requests, for authorization of Controlled drugs not dispensed, to facilities the next day. They never call the facility or the physician to request a prescription for the dispensing of controlled drugs. The PT said they do not keep copies of the faxes sent to facilities. During an interview on 2/23/21 at 10:43 A.M., CMT B said he/she must have accidentally touched or hit the computer and it charted the [MEDICATION NAME] was given at 10:54 P.M. on 1/25/21, unbeknownst to him/her. The resident's medications had not yet arrived from the pharmacy and there was no [MEDICATION NAME] to give. New residents never get their medications delivered from the pharmacy the day they arrive. CMT B said some medications were given because he/she always tries to find the medications needed, all over the building, and give them. If a medication cannot be found in the building, he/she goes to see if the nurse can find it. He/she was not aware the [MEDICATION NAME] was accidentally charted as given, which is why he/she did not tell the charge nurse the [MEDICATION NAME] was not there and was not given. During an interview on 2/23/21 at 5:15 P.M., Nurse J said he/she was the resident's nurse from 7:00 P.M. on 1/25/21 to 7:00 A.M. on 1/26/21. CMT B did not notify him/her the resident's [MEDICATION NAME] was not available, however residents' medications faxed over after noon would not arrive until 3:00 A.M. the next day. Medications needed before arrival from pharmacy are pulled from the emergency medication supply kit or automated dispensing system. If a controlled medication, that requires a prescription from the physician, is needed, then they fill out a Situation-Background-Assessment-Recommendation (SBAR-a form completed by nurses, regarding important resident information/condition, to facilitate and increase the communication between health care professionals) and put it in the physician's binder. [MEDICATION NAME] was a stocked medication in their emergency kit. Further review of the nurse's notes, dated 1/25/21, showed no documentation addressing the resident's [MEDICATION NAME] medication was not available, not given, or that staff notified the physician. Further review of the resident's MAR, dated 1/26/21, showed the following: -9:00 A.M., five medications were documented as administered by Nurse G; -9:00 A.M., [MEDICATION NAME] 200 mg was not documented as administered. [MEDICATION NAME] was not printed on the MAR; -11:00 A.M., [MEDICATION NAME] was documented as administered at 3:20 P.M. by Nurse G; -12:30 P.M., medications were documented as administered by CMT H; -4:30 P.M., 5:00 P.M., and 6:00 P.M. medications were documented as administered by Nurse G; -9:00 P.M., [MEDICATION NAME] was documented by Nurse D as not done, rescheduled, supplies unavailable; -9:30 P.M., medications were documented by Nurse D as administered. During an interview on 2/23/21 at 12:37 P.M., Nurse G said he/she was not aware the resident's 9:00 A.M. [MEDICATION NAME] was not given. They get new admissions every day and they all have controlled drugs. It is up to the CMT to notify the nurse if a medication is not available. During an interview on 2/23/21 at 1:34 P.M., Nurse D said during the medication pass on the evening of 1/26/21, he/she realized the [MEDICATION NAME] was not there. He/she told the nurse supervisor and the nurse supervisor went to get it from the emergency kit or the Omnicell (automated dispensing machine). He/she could not recall what the supervisor later said, but Nurse D documented the medication was not available in the electronic MAR. Nurse D was recently told the resident's physician and family should have been immediately notified the medication had not been given since the resident was admitted . Further review of the nurse's notes, dated 1/26/21, showed no documentation addressing the resident's missing [MEDICATION NAME] medication. Review of the nurse practitioner's progress note, dated 1/27/21 at 8:38 A.M., showed the resident had a right sided craniotomy (surgical opening into the skull) for a [DIAGNOSES REDACTED] removal on 12/22/20 in the hospital. He/she was admitted to the intensive care unit (ICU), following the surgery, for close observation and an electroencephalogram (EEG, a test that detects electrical activity in the brain using small, metal discs attached to the scalp) showed the resident was having [MEDICAL CONDITION]. The resident was started on [MEDICATION NAME] in the ICU. The nurse practitioner saw him/her and noted the resident responded with one-word answers but was not consistent with it. There was no documentation acknowledging the resident had not received his/her [MEDICATION NAME] since admission to the facility. Further review of the resident's MAR, dated 1/27/21, showed the following: -8:00 A.M., medications were documented as administered by CMT E; -9:00 A.M., [MEDICATION NAME] 200 mg was documented by CMT E as not done, rescheduled, equipment unavailable; -4:30 P.M., four medications were documented by CMT E as not given, patient declined; -9:00 P.M., ramelteon was documented by Nurse F as patient refused to swallow; -9:00 P.M., [MEDICATION NAME] was documented by Nurse F as not done, medication unavailable. During an interview on 2/25/21 at 11:52 A.M., CMT E said he/she forgot to notify the nurse that the resident's [MEDICATION NAME] was not available on 1/27/21 at 9:00 A.M. CMT E did not know the medication's purpose was to prevent [MEDICAL CONDITION]. Review of the physician history and physical, dated 1/27/21 at 1:22 P.M., showed the resident's principal [DIAGNOSES REDACTED]. The resident's medication list included [MEDICATION NAME], 200 mg, orally, every 12 hours. There was no information documented regarding the resident's recent [MEDICAL CONDITION] activity [DIAGNOSES REDACTED]. During an interview on 2/25/21 at 3:31 P.M., a PT with the facility's contracted pharmacy, said the resident's physician sent the [MEDICATION NAME] prescription to them electronically at 4:23 P.M. on 1/27/21 and the [MEDICATION NAME] left the pharmacy at 2:00 A.M. on 1/28/21. The medication was not requested or called in as stat. During an interview on 2/23/21 at 2:30 P.M., Nurse F said he/she could not find the resident's [MEDICATION NAME] on 1/27/21 around 9:00 P.M. and when he/she went back to see if it had been given, he/she noted it had not been given since the resident was admitted to the facility. The nurse supervisor was called, told about the resident's [MEDICATION NAME] not being given since admission because it was never received from pharmacy, and asked if he/she could use another resident's [MEDICATION NAME], who had discharged from the facility. The supervisor told him/her to call the physician and let him know the [MEDICATION NAME] was not there and the resident had not received it since admission. Nurse F said he/she went to give the resident's other scheduled medications, after crushing and mixing with pudding, but they just sat in the resident's mouth and the water ran out of his/her mouth. Nurse F said there was no point in trying to give the resident another resident's [MEDICATION NAME] because the resident was not swallowing anything. Nurse F said he/she did not call the physician because the charge nurse from the night before had filled out a SBAR and placed it in the physician's binder. Sometimes the physician does not get to them right away, but that is their process, for the night shift (7:00 P.M. to 7:00 A.M.) nurses, for physician notification. Nurse F said the other reason he/she did not call the physician was because the resident was not able to swallow. He/she did not even think about notifying the resident's family. Further review of the nurse's notes, dated 1/27/21, showed no documentation addressing the resident's missing [MEDICATION NAME] medication, the resident's medication refusals that afternoon and evening, or the resident's inability to swallow. During an interview on 3/1/21 at 3:17 P.M., the DON said the SBAR is completed for non-urgent changes in condition. The night shift nurses are expected to call the physician to notify him/her of missing or refused medications. Further review of the resident's MAR, dated 1/28/21, showed the following: -9:00 A.M., all medications, including [MEDICATION NAME], were documented as administered by CMT H; -12:00 P.M., [MEDICATION NAME] was documented by CMT H as not given, unable to give, patient not responding. Further review of the nurse's notes, dated 1/28/21 at 10:09 A.M., showed the resident continued to refuse medications. His/her medications were offered both whole and crushed but the resident refused to take the medications. The physician was made aware of the resident's poor fluid intake, poor food intake, and refusal of medications. A new order was received to start an intravenous (IV) line to begin IV fluids. Review of the nurse practitioner's progress note, dated 1/28/21 at 3:01 P.M., showed the resident was being assessed because the nursing staff reported the resident had not been eating more than a few bites at a time since his/her admission, was intermittently refusing his/her medications, and had one witnessed [MEDICAL CONDITION] that morning which lasted about one minute. Upon assessment, the resident was not responsive to vocal or tactile stimulation, and then seized for 90 seconds. The resident was unresponsive for 15 minutes after the [MEDICAL CONDITION] and had an obstructive breathing pattern throughout the time at his/her bedside. EMS was contacted to transport the resident to the hospital for evaluation of multiple [MEDICAL CONDITION] in the setting of missed antiepileptic doses. Further review of the nurse's notes, dated 1/28/21 at 4:07 P.M., showed the nurse was called to the resident's room by the nurse practitioner because the resident was having another [MEDICAL CONDITION]. The resident required suctioning after several loose, congested coughs and began to seize. The gag reflex was briefly lost after the [MEDICAL CONDITION]. The resident's vital signs were stable and was receiving 2 liters of oxygen. The nurse practitioner gave orders to send the resident to the emergency room . The paramedics arrived in less than five minutes because they were already in the facility parking lot. Further review of the nurse's notes, dated 1/28/21 showed no prior charge nurse documentation regarding the resident's [MEDICAL CONDITION] activity. During an interview on 2/23/21 at 4:00 P.M., the Nurse Practitioner said there was a communication binder, with SBARs in it filled out by the nurses, which she and the physician checked every day upon their arrival. She did not recall seeing an SBAR, or a pharmacy fax, regarding the resident's [MEDICATION NAME]. When she saw the resident on 1/28/21, he/she was having a [MEDICAL CONDITION]. The nurse told her the resident had been refusing medications and the CMT was not very clear about it. She immediately asked CMT H if the resident took his/her [MEDICAL CONDITION] medication that morning and CMT H said, If it was in the cart I gave it. She did not pursue this because the resident was having a rapid increase in [MEDICAL CONDITION] activity and there was an urgent need to get him/her to the hospital. When told the resident had missed five doses of the [MEDICATION NAME], the Nurse Practitioner said, Jesus Christ! Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/28/21, showed the following: -[DIAGNOSES REDACTED]. -Severe cognitive impairment; -No speech; -Always incontinent of bowel and bladder; -Required extensive assistance of two plus staff for transfers, bed mobility and toileting; -Required extensive assistance of one staff for eating; -Loss of liquids/solids from mouth when eating or drinking; -Holding food in mouth/cheeks or residual food in mouth. During an interview on 2/25/21 at 3:31 P.M., a PT with the facility's contracted pharmacy, said they have two scheduled runs per day for all their long-term care facility customers. Medication orders received before 12:00 P.M. leave their building every day at 4:00 P.M. and medication orders received after 12:00 P.M., leave their building every day at 2:00 A.M. the next day. Medications needed before these delivery times must be ordered stat by the facility. The pharmacy never calls the facility or the physician, regarding the need for a controlled medication prescription. If no prescription is received, a fax request is sent the following morning to the facility. Review of the Director of Nursing's (DON) investigation summary, received on 2/10/21, showed the resident's hospital discharge orders, for 1/25/21, included [MEDICATION NAME] 200 mg every 12 hours, however an actual paper prescription for the medication was not included in the resident's discharge packet, as it should have been. Additionally, [MEDICATION NAME] was not a stocked drug available in the facility emergency medication supply kit or automated dispensing system. During an interview on 3/1/21 at 3:17 P.M., the DON said she did not have a copy of a pharmacy fax requesting a script for [MEDICATION NAME] and she did not receive a fax for the [MEDICATION NAME] in her mailbox, as she usually does. The pharmacy faxes go to the fax machine in the front office as well as to the fax machines on the resident floors, which are accessible to the charge nurses. During an interview on 2/24/21 at 1:22 P.M., the resident's physician said he was at the facility all day on 1/27/21 and the nurse on the floor told him about the resident's missing [MEDICATION NAME]. He suggested they borrow the medication from another resident. The facility admits many residents from the hospital who have had [DIAGNOSES REDACTED]s removed, so they are familiar with [MEDICATION NAME]. The residents always come with paper prescriptions for their controlled drugs and if they do not, then either the charge nurse or the pharmacy calls him. He did not get a call from the pharmacy, or the charge nurse, about the resident's [MEDICATION NAME] needing a prescription. He has had meetings with their contracted pharmacy and the decision was made for them to call him directly, or ask the nurse to call him, if a controlled drug needs a prescription. That was the essence of the problem. As soon as a charge nurse recognized [MEDICATION NAME] was a controlled drug, the nurse should have called him. During an interview on 2-2-21 at 6:41 A.M., the resident's family member said the resident had brain surgery on 12/22/20 for [MEDICAL CONDITION] and [MEDICAL CONDITION] activity. The resident was transferred to the facility on [DATE] with hospital orders for staff to administer [MEDICAL CONDITION] medication either by mouth or IV because the resident needed this life sustaining medication. The facility called the family member on 1/29/21, regarding the resident having multiple [MEDICAL CONDITION] and they were sending the resident by ambulance to the hospital. The resident could not have refused the [MEDICAL CONDITION] medications due to his/her altered mental status and incapacitated state. Review of the facility's policy on medication/pharmacy services, provided by the contracted pharmacy, dated 01/01/2013, showed if orders for medications are received from the physician when the pharmacy is closed, facility staff should take the following steps: -Remind physician that pharmacy is closed and that a delay in medication therapy can be prevented by using a medication that is included in the facility's emergency medication supply; -If a medication cannot be substituted, ask physician if the medication can be initiated the next morning, document the conversation with the physician, and include the new start time in the order; -If a medication is considered essential and cannot be substituted or delayed, contact the emergency number provided by pharmacy. MO 167