Every finding on record at Baywood Crossing Rehabilitation & Healthcare Cente

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the status for 2 (Resident #29 and Resident #85) of 21 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #85's admission MDS assessment accurately reflected his lack of natural teeth in his oral cavity. The facility failed to ensure Resident #29's annual MDS assessment accurately reflected her lack of natural teeth in her oral cavity.These failures could place residents at risk of receiving inadequate care and services due to inaccurate assessments. The findings included: 1 Resident #29Record review of Resident #29's face sheet dated 07/01/26 revealed a [AGE] year-old female admitted to the facility on [DATE], 12/23/22 and re-admitted [DATE]. Her diagnoses included Essential hypertension (primary), chronic obstructive pulmonary disease, unspecified, major depressive disorder, anxiety disorder, presence of urogenital implants overactive bladder, mood disorder, muscle weakness, lack of coordination, cognitive communication deficit (difficulty in communication) dysphagia, other speech and language deficits following cerebral infarction, epileptic seizures.Record review of Resident #29's annual MDS, dated [DATE], revealed her BIMS score was 99 out of 15 indicating not interviewable severely impairment on cognition. Record review of the MDS section L (Oral/Dental status) was checked 0 none of the above no concern on oral cavity. Record review of Resident #29's care plan dated 01/13/26 revealed she was care planned for oral/dental health problems r/t Poor oral hygiene Goal: Resident #29 will be free of infection, pain or bleeding in the oral cavity by review date.Revision on: 05/05/2026, Target Date: 08/22/2026 Intervention - Monitor/document/report PRN any s/sx of oral/dental problems needing attention:Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Record review of Resident #29's dental visit dated 02/25/26 revealed Resident # 29 had no teeth on her oral cavity. Report indicated Resident had inflamed /swollen, bleeding gums and periodontal condition was poor. Observation and interview on 07/01/26 at 10:00AM revealed Resident # 29 was awake, alert and oriented. In an attempted interview, Resident reached out for her mask. Resident's RP stated Resident #29 likes to cover her mouth because she had no teeth in her oral cavity. Lunch observation and interview on 07/01/26 at 1:00PM indicated Resident was served puree diet and was assisted by RP. The RP stated Resident #29 was on puree diet because Resident #29 had no teeth in her oral cavity. He said Resident had multiple problems in her oral cavity and all her teeth were pulled out some time ago and since then she likes to cover her mouth when speaks. He said Resident #29 had dentures at a point but lost them during multiple in and out of hospitals. 2 Resident #85Record review of Resident #85's face sheet dated 7/1/2026 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included: diabetes (is a condition where your body cannot properly manage blood sugar, leading to high glucose levels that can affect your health over time), hypertension (high blood pressure), Oropharyngeal dysphagia (trouble starting a swallow because the muscles in the mouth and throat are weak), gastritis (when the lining of your stomach gets irritated or inflamed, causing discomfort, nausea, or pain), and gastric ulcer (an open sore in the lining of your stomach). Record review of Resident #85's admission MDS, dated [DATE], revealed his BIMS score was 11 out of 15 indicating moderately cognition impairment. Record review of the MDS section L (Oral/Dental status) was checked unable to examine. Record review of the Care plan dated 7/1/2026 revealed Resident #85 was care planned for having missing teeth and has teeth implant. Intervention included to monitor/document/report PRN any signs/symptoms of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. On 7/2/2026 at 9:51 a.m., interview with the MDS coordinator, she stated that the MDS assessment was completed using information generated from the nursing assessment. She stated that she made an error by failing to review the completed assessment for accuracy and finalize (lock) the assessment as required. She stated that this omission resulted in the dental section of the MDS documenting the resident as unable to examine. The MDS Coordinator further stated that she was aware Resident #85 had missing teeth and dental implants, and this information should have been accurately reflected in the MDS. The MDS Coordinator said Resident # 29 had some teeth and not sure when she had all pulled out. She explained that her normal practice was to perform her own assessment of the resident and verify the nursing assessment before completing and locking the MDS. However, in this instance, she failed to return to the assessment to verify the information and make the necessary corrections. She stated that the inaccurate documentation was the result of her error. She stated that inaccurate information could result in staff not knowing the residents' actual care needs, potentially affecting the care and services provided. On 7/2/2026 at 11:18 a.m., interview with Resident #85, the resident stated that he has missing teeth and dental implants. He stated that he removes and reinserts his dental implant as needed. The resident stated that he receives dental care on an as-needed basis and reported that his last dental appointment occurred prior to his admission to the facility. He stated that the visit was for routine dental cleaning. He stated that his dentist continues to monitor his oral health through routine cleanings to help prevent infection and dental cavities. On 7/2/2026 at 1:05 p.m., interview with the DON, he stated that the MDS Coordinator was responsible for ensuring that resident assessments were completed accurately and documented correctly in the MDS. He further stated that the MDS assessment should accurately reflect the resident's condition and be consistent with the resident's comprehensive assessment and plan of care. Regarding Resident #29 and #85, the DON stated that the MDS assessment did not accurately reflect the resident's dental status. He stated that the MDS Coordinator should have reviewed the assessment in the electronic medical record to verify that the information was accurate and consistent with the nursing assessment and care plan before finalizing the MDS. The DON also stated that it was an oversight on his part that he did not monitor and ensure the accuracy and consistency of the resident's assessment and care plan. He stated that inaccurate assessments could result in the resident's actual needs not being accurately identified or communicated, which could lead to care and services that do not fully meet the resident's assessed needs. He stated that accurate assessments are essential to ensure residents receive appropriate, individualized care in accordance with their needs. On 7/2/2026 at 1:09 p.m., interview with Administrator, she stated that the MDS Coordinator was responsible for completing resident MDS assessments. She explained that the comprehensive care plan was developed by the interdisciplinary team, with each department responsible for completing the portions applicable to its discipline. She further stated that the DON oversees the MDS process, reviews the completed assessment, and attests to its accuracy and completion before it is finalized. She stated that she relies on the MDS Coordinator to complete accurate assessments and on the DON to verify their accuracy and completeness. She stated that she was not directly involved in completing or reviewing MDS assessments. The Administrator was unable to identify any potential risks to the residents that could result from an inaccurate MDS assessment. Facility's policy on accuracy of resident's assessment was requested on 07/01/26 at 10:20AM. MDS coordinator and Facility DON said the facility followed the RAI manual.

Based on observation, record review and interview, the facility failed to ensure that each resident received adequate supervision and assistance device to prevent accidents for 1 of 18 residents (Resident #73) reviewed for accidents and supervision.Resident # 73's physician orders for wander guard were not followed.This failure could place residents at risk of falls and injuries that may lead to hospitalization. Record review of Resident # 73's face sheet dated 07/01/26 revealed 83 -year -old male resident who was admitted to the facility on [DATE]. His diagnoses included, Essential hypertension(primary) (High blood pressure) anxiety disorder, parkinsonism (progressive neurodegenerative disorder is characterized by tremors, rigidity, bradykinesia, and postural instability), major depressive disorder, syncope (temporary loss of consciousness, followed by a drop of blood flow the brain), dementia (Memory loss, Forgetfulness), psychotic disturbance, mood disturbance, depression), anxiety, shortness of breath muscle wasting and atrophy, not right lower leg, muscle wasting and atrophy. Record review of Physician orders dated 06/30/26 revealed Resident #73 had an order for wander guard bracelet device to wheelchair. Inspected for placement every shift. Started 03/28/25. Record review of Resident #73's care plan with a revision date of 06/17/26 revealed Resident #73 was care planned for at risk for fall related to deconditioning, Gait/balance problems, unaware of safety needs. Resident #73 has had an actual fall on 11/3/2025 UW, 11/29/25 UW, 12/1/25 UW, 12/5/25 UW, 12/22/25 UW, 12/26/25 UW, 1/1/26 UW, 1/12/26 UW, 1/18/26 UW, 2/27/26 UW, 2/6/26 UW, 3/1/26 UW, 4/6/26 UW, 4/10/26 UW, 5/12/26 W, 5/26/26 ,6/8/26, Revision on: 06/17/20. Goal: Resident #73 will resume usual activities without further incident through the review date. Revision on: 06/17/2026, Target Date: 08/17/2026. Interventions: Immediately after fall, assess Resident #73, for injury, obtain vital signs and initiate neuro-checks. If unwitnessed or head involved, continue neuro-checks & vital signs. every 15 min X 1 hr, every 30 min X 2 hr, every hr X 2 hrs & every shift X 72 hrs. Assess/Document/Report pain, bruises, change in mental status, new onset:confusion, sleepiness, inability to maintain posture, agitation, abnormalities in neuro evaluation, vital signs outside of baseline or normal parameters, any changes in condition. Investigate to determine and address causative factors of the fall. Obtain statements for witnessed falls. The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach, appropriate footwear when ambulating or mobilizing in w/c, and the appropriate adaptive equipment is available and in use. Attempt to anticipate the residents' needs and promptly respond to all requests for assistance Observation on 07/01/26 at 9:20 revealed Hospice staff A was with Resident #73. She said she was present to give Resident #73 his daily bath. She said she sees Resident #73 Monday through Friday. Observation on 07/01/26 at 12:20PM, revealed Resident #73 was in the dining room on his wheelchair. He was alert and oriented but did not answer any questions. Observation revealed no evidence of wheelchair bracelet on his wheelchair. Observation on 07/02/26 at 8:40AM, revealed hospice staff A was with Resident #73. She said she was taking Resident #73 out for therapy. Observation revealed no evidence of wander guard bracelet on his wheelchair. During an interview with CNA' J on 01/07/26 at 9:00AM, she said Resident #73 was on hospice and hospice aide was always present at the facility. She said she had not seen any wander guard on Resident #73's wheelchair. She said Resident #73 had good and bad days. She said Resident #73 was more alert and oriented in some days than others. During an interview with LVN G on 07/02/26 at 12:15PM, she said she would look at Resident #73's wheelchair. She looked and said the wheelchair was from Hospice and she did not see any wander guard on resident wheelchair. During an interview with the MDS coordinator on 07/02/26 at 12:30PM, she said Resident #73 used to wheel himself around the facility and was at risk for fall, but he had declined and now on hospice care. She said Resident #73 can cannot wheel himself as he used to due to health care condition. She said the wander guard was on Resident #73's wheelchair. She said not having the wander guard on his wheelchair may lead to avoidable accidents and delay in providing care In an interview with hospice Aide A on 07/02/26 at 12:45PM, she said she had been working with Resident #73 for about a month, and she has not seen any wander guard bracelet on Resident #73 or on his wheelchair. She said she had no idea when the wheelchair was brought to Resident #73. During an interview with the DON on 07/02/26 at 1:00PM, he said Resident # 73 used to wander all over the facility but he his health had had declined. He said Resident #73 was now on hospice and the wheelchair was provided by the hospice company and not sure when the wheelchair was brought to Resident #73.He said the order for wheelchair wander guard had just been discontinued this afternoon 07/02/26. He said Resident #73 had the potential to wheel himself away or had a fall without having the wander guard in place. In a phone conversation with Hospice Nurse RN K on 07/02/26 at 1:00PM she said Resident #73's wheelchair was delivered to him on 05/08/2026 the same time that Resident #73's hospice service started but was not aware that he was to have wander guard bracelet on his wheelchair. Facility's policy on following physician orders was requested from DON and Administrator on 07/02/26 at 2:00pm and at 3:00pm. Provided policy dated 2001 revised 07/2016 did not address nonbiological orders.

Based on observation, interview, and record review, the facility failed to ensure residents received the appropriate treatment and services to prevent complications of enteral feedings for 2 of 6 residents (Resident #5 and Resident #110) reviewed for assisted nutrition. The facility failed to ensure Resident #5, and Resident #110 wore an abdominal binder (a soft flat device that helps hold a feeding tube in place) to prevent complications as ordered by the physician. This failure could place residents at risk of pain, injury, or unnecessary hospitalizations.Record review of Resident #5's face sheet dated 7/1/2026 revealed a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE]. His diagnoses included unspecified dementia (specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss), cerebral infarction (commonly called a stroke), aphasia following cerebral infarction (stroke-related speech and language difficulty), dysphagia (difficulty swallowing), and gastrostomy status (medical device used to provide nutrition directly to the stomach when oral intake is not possible often referred to as a G-tube). Record review of Resident #5's order summary dated 7/2/2026 revealed an active physician order:1.Please apply abdominal binder on patient at all times while in bed to prevent PEG (G-tube) pulled or displaced. OK to remove abdominal binder for shower, hygiene, or any other necessary tasks. Order start date: 6/29/2026.Record review of Resident #5's current comprehensive care plan with a review date of 5/13/2026 listed the following intervention: Resident may wear a Gastrostomy Tube Holder Belt at all times to aide in maintaining the optimal position of the gastrostomy tube, reduction of accidental removal of gastrostomy tube and/or irritation from excessive movement of the tube. Ensure the belt fits correctly and is in the proper position on the resident abdomen each shift. Record review of Resident #5 tasks included Resident is to wear a G-tube holder belt at all times. Belt should be applied and removed by nurse only. Ensure resident safety and promptly notify nurse if belt is not in place. Start date 7/1/2026.Record review of Resident #110's face sheet dated 7/1/2026 revealed a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE]. His diagnoses included nontraumatic intracranial hemorrhage (bleeding inside the brain that happens without a head injury), dysphagia (difficulty swallowing), cognitive communication deficit (where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes, rather than a primary problem with language or speech), and gastrostomy status (a medical device used to provide nutrition directly to the stomach when oral intake is not possible often referred to as a G-tube).Record review of Resident #110's order summary dated 7/1/2026 revealed an active physician order:1.Abdominal binder to prevent G-tube pulling, every shift. Order start date 6/22/2026.Record review of Resident #110's current comprehensive care plan with a revision date of 7/1/2026 listed the following intervention: Resident may wear a Gastrostomy Tube Holder Belt at all times to aide in maintaining the optimal position of the gastrostomy tube, reduction of accidental removal of gastrostomy tube and/or irritation from excessive movement of the tube. Ensure the belt fits correctly and is in the proper position on the resident abdomen each shift. The nurse will observeresident every two hours to ensure proper fit, placement, and resident comfort during the shift.Record review of Resident #110 tasks included Resident is to wear a G-tube holder belt at all times. Belt should be applied and removed by nurse only. Ensure resident safety and promptly notify nurse if belt is not in place. Start date 7/1/2026.During an observation on 6/30/2026 at 10:11 a.m., Resident #5 was observed as he laidy in bed. Resident #5's G-tube site had a dressing on it dated 6/30/2026. Resident #5 did not have an abdominal binder on. During a wound care observation on 7/1/2026 at 9:32 a.m., Resident #5 did not have an abdominal binder on prior to wound care. After wound care concluded, an abdominal binder was not placed on Resident #5. During an observation on 7/1/2026 at 1:20 p.m., Hospice Aide J was in Resident #110's room and was in the process of wiping down Resident #110's hands with a washcloth. Resident #110 did not have a binder on, nor was an abdominal binder visible in Resident #110's room. During an observation on 7/1/2026 at 2:59 p.m., the DON inspected the site of Resident #110's G-tube site. Resident #110 did not have an abdominal binder on. During an interview on 7/1/2026 at 3:56 p.m., the DON was notified of the absence of an abdominal order for both Resident #5 and Resident #110. The DON stated he would look into this and address both issues. During an interview on 7/2/2026 at 9:41 a.m., the DON stated the facility no longer utilized abdominal binders. The DON stated the nursing department used G-tube retention belts which were less restrictive than an abdominal binder. The DON stated the change was made yesterday. The DON stated that both Resident #5 and Resident #110 now had a G-tube retention belt order placed. The DON stated Resident #5 and Resident #110 were the only two residents in the facility that had an order for an abdominal binder. The DON stated he did not know what led to Resident #5 and Resident #110 to not have an abdominal binder in place during observations. The DON stated nurses were responsible for ensuring physician orders were implemented. The DON stated yesterday he entered into PCC (software platform the facility utilized) a task for CNA's to complete for Resident #5 and Resident #110 on each shift which specifically addressed the need for a G-tube holder belt. The DON stated that prior to this task on PCC, CNA's would have only known if a resident required an abdominal binder through receiving report from another CNA or nurse. The DON stated that the risk to residents who were supposed to wear an abdominal binder and do not include dislodgement and hospitalization.During an interview on 7/2/2026 at 11:24 a.m., CNA K stated she had worked at the facility since April 2026. CNA K stated she was familiar with Resident #5 and Resident #110. CNA K stated that Resident #5 has had an abdominal binder placed on him before but can't remember exactly when. CNA K stated that Resident #5 now has an abdominal belt that was different than an abdominal binder. CNA stated that she had never seen an abdominal binder on Resident #110 before until today, 7/2/2026. CNA K stated that the nurse in charge would tell her if a resident was supposed to be wearing an abdominal binder. CNA K stated that no one had her told in that either Resident #5 or Resident #110 needed an abdominal binder on. CNA K stated that all residents with G-tubes were supposed to have an abdominal binder or belt on. CNA K stated she had been trained on the application and purpose of an abdominal binder. CNA K stated that the risk to residents who are supposed to wear an abdominal binder and do not were dislodgement of the G-tube and hospitalization.During an interview on 7/2/2026 at 12:08 p.m., RN L stated she has worked at the facility since July 2025. RN L stated she was familiar with both Resident #5 and Resident #110. RN L stated Resident #5 had an abdominal binder. RN L stated if Resident #5 did not have it on, most likely the binder was being washed. RN stated it was the CNA's responsibility to put the abdominal back on a resident. RN L stated that Resident #110 was supposed to have an abdominal binder on. RN L stated that she did not see the abdominal binder on Resident #110 yesterday when she administered his medication. RN L stated she did not place one on Resident #110 because it slipped her mind. RN L stated she didn't know where extra abdominal binders were located. RN L stated she ensured the abdominal binder was in place only once during her shift. RN L stated the CNA's all know which residents were required to have abdominal binders in place. RN L stated she did not instruct any of the CNA's yesterday about Resident #5 or Resident #110 required abdominal binders. RN L stated the CNA's know which residents require an abdominal but did not elaborate how the CNA's knew. RN L stated the risk to residents who were supposed to wear an abdominal binder and do not include dislodgement of the G-tube and hospitalization.During an interview on 7/2/2026 at 1:00 p.m., Hospice Aide J stated that she had given Resident #110 a bed bath on 6/29/2026 and 7/1/2026. Hospice aide J stated Resident #110 did not have an abdominal binder on either 6/29/2026 or 7/1/2026. Hospice aide J stated she has never seen Resident #110 with an abdominal binder on. Hospice aide J stated that no one at the facility had notified her that Resident #110 should have an abdominal binder on. During an interview on 7/2/2026 at 1:20 p.m., CNA N stated she had worked at the facility for one month. CNA N stated that Resident #5 had an abdominal binder on yesterday. CNA N stated that she had not worked with Resident #110. CNA N stated RN L told her that Resident #5 required an abdominal binder. CNA N stated that the abdominal binders were kept in the resident's room. CNA N stated the risk to residents who were supposed to wear an abdominal binder and do not include dislodgement of G-tube and hospitalization.During an interview on 7/2/2026 at 1:32 p.m., CNA M stated that she worked at the facility for 5 years. CNA M stated she had seen Resident #5 with an abdominal binder on before. CNA M stated RN L told her yesterday Resident #5 required one. CNA M stated that abdominal binders were kept in the laundry area. CNA M stated there were times that Resident #5 had taken it off or it was not on correctly. CNA M stated she always applied an abdominal binder to Resident #5 after giving him a bath. CNA M stated that Resident #110 did not always have a binder in place. CNA M stated that she was not told if Resident #110 needed to wear an abdominal binder consistently. CNA M stated the risks to residents who were supposed to wear an abdominal binder and do not include dislodgement of G-tube and hospitalization. During an interview on 7/2/2026 at 1:50 p.m., the ADON stated she had worked at the facility for 5 years. The ADON stated nurses were ultimately responsible for ensuring abdominal binders were in place as ordered. The ADON stated the DON was responsible for oversight of G-tubes, anticoagulants, and falls. The ADON stated that CNA's were able to view required resident care by looking at the Kardex on PCC. The ADON stated that abdominal binders were kept in her office. The ADON stated residents who were ordered to wear one should always have an extra one in their room. The ADON stated that risks to residents who were supposed to wear an abdominal binder and do not include trauma, injury, altered nutrition, and hospitalization. During an interview on 7/2/2026 at 2:30 p.m., the Administrator stated she was not involved in the implementation of abdominal binder orders. The Administrator stated nurses were responsible for carrying out orders. The Administrator stated that nurses and CNA should be communicating about it. The Administrator stated that CNA's can also refer to the Kardex for required resident care. The Administrator stated the risk to residents who were supposed to wear an abdominal binder and do not include dislodgement of G-tube and hospitalization.During an interview on 7/2/2026 at 2:40 p.m., the MDS nurse stated that she was responsible for creating care plans. The MDS nurse stated that systems were split between managers, and G-tube related matters were under the DON. The MDS nurse stated that when she created both Resident #5 and Resident #110's care plan, there were intervention options to pick for each goal. For both Resident #5 and Resident #110, the verbiage was automatically populated as may wear a gastrostomy tube belt. The MDS nurse stated she did not want to put each resident was required in case the family wanted to remove it. The MDS nurse stated she should have used a custom verbiage that reflected the physician orders for both Resident #5 and Resident #110. The MDS nurse stated the risk to residents who were supposed to wear an abdominal binder and do not include dislodgement of G-tube and hospitalization.Record review of facility policy titled Enteral Feedings- Safety Precautions dated 2001 and revised March 2024 reads in part, .3. To ensure resident comfort is maintained and prevention of dislocation/dislodgement is observed: a. If necessary, the resident may have a Non-Adhesive Belt Style Enteral Feeding Tube Securement Device for Gastrostomy Tubes as a restraint free, least restrictive medical safety device.c. A resident who requires the use of this device will be monitored frequently by nursing staff to ensure proper fit, comfort and safety. Only a licensed or registered nurse will apply/remove the device.

Based on interview and record review, the facility failed to ensure each resident had the right to be informed, in advance, of the care to be furnished for 1 (Resident #1) of 10 residents reviewed for pharmacy services. The facility failed to ensure that a consent was signed by Resident #1 for Mirtazapine (an antidepressant medication). The failure could place residents at risk of not having an opportunity to refuse medications, ask questions regarding medications and/or be knowledgeable regarding side effects.Findings included: Record review of Resident #1's face sheet dated 4/2/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of left femur. Resident #1's face sheet also revealed that she was her own responsible party. Record review of Resident #1's admission MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 15 that indicated cognition was intact (13-15).Record review of Resident #1's discharge MDS dated [DATE], section N (Medications) revealed Resident #1 was taking an antidepressant in the last 7 days. Record review of Resident #1's physician orders as of 2/18/26 revealed order for Mirtazapine oral tablet 7.5 mg with instructions to give 1 tablet by mouth at bedtime related to adjustment disorder with mixed anxiety and depressed mood with order and start date of 2/11/2026. Record review of Resident #1's February 2026 MAR revealed administration of Mirtazapine oral tablet 7.5 mg with instructions to give 1 tablet by mouth at bedtime on 2/12/26, 2/13/26, 2/14/26, 2/15/26, 2/16/26 and 2/17/26. Administration on 2/12/26 was signed by MA A. Record review on 4/1/26 at 1:55 p.m. of Resident #1's electronic medical record did not reveal a consent for Mirtazapine.Record review of the Intake Investigation Worksheet created 3/31/2026 revealed Resident #1 had passed away after being discharged from the facility. During interview on 4/3/26 at 9:29 a.m., the ADON said she was filling in for the DON since he was out on medical leave during the investigation. The ADON said Mirtazapine was a medication that should have had a consent. The ADON confirmed that Mirtazapine was given per Resident #1's February 2026 MAR and there was not a consent in the electronic medical record and there should have been. The ADON said when the nurse gets the order, before they proceed, the nurse was supposed to get the consent from the responsible party or the resident if they were their own responsible party. The ADON said she was over psychotropics and this included checking the order for psychotropics, appropriate diagnosis, monitoring order, consent and care plan were completed. The ADON said if a consent was not obtained for a psychotropic medication the resident would not know the warning signs to be aware of. The ADON said the consent was obtained so the resident or responsible party understood the risk and benefits. The ADON said that was why the nurses were told that the medication had to go on hold until the consent could be obtained. On 4/3/26 at 11:52 a.m., the surveyor attempted to contact MA A but was unable to reach MA A via phone. Record review of the facility's policy Psychotropic Medication Use revised January 2025 revealed Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated/effective and after informed consent is obtained and Antidepressant, antianxiety, sedative, hypnotic, and mood stabilizing medications consents will be obtained and will be recorded in the electronic health record.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) of 10 residents reviewed for resident records.1. The facility failed to ensure that antidepressant monitoring documentation was accurate and/or complete for Resident #1. 2. The facility failed to ensure that wound care documentation was accurate and/or completed for Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5.3. The facility failed to ensure that Resident #1 was seen by a physician during her admission at the facility from 1/13/2026 through 2/18/2026. This failure could place residents at risk of an inaccurate medical record and could place the residents at risk of harm and health decline and/or possible missed diagnosis. Findings included: Record review of Resident #1's face sheet dated 4/2/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of left femur. Face sheet also revealed Resident #1 was discharged on 2/18/26. Under care providers on Resident #1's face sheet MD A was listed as primary physician; PA A was listed as physician assistant and NP A was listed as nurse practitioner. Record review of Resident #1's admission MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 15 that indicated cognition was intact (13-15). Record review of Resident #1's discontinued/completed physician orders revealed admitted to BWC under the care of MD A with revision date of 1/13/26 and end date of 2/22/26. Record review of Resident #1's physician progress notes revealed a progress notes written by NP A on 1/15/26, 1/20/26 1/22/26, 1/27/26, 2/3/26, 2/4/26, 2/6/26, 2/9/26, 2/10/26, 2/18/26 and progress notes written by PA A on 1/21/26, 1/24/26, 1/29/26, 2/10/26. Record review on 4/1/26 at 12:21 p.m. of the miscellaneous documents in the electronic medical record revealed physician notes for surgical, pain and psychology/psychiatry. Record review of the Intake Investigation Worksheet created 3/31/2026 revealed Resident #1 had passed away after being discharged from the facility. During interview on 4/1/26 at 2:32 p.m., the Administrator provided a progress note for Resident #1 dated 1/16/26 at 12:05 p.m. written by PA A and said the progress note said, discussed with MD A and also showed the surveyor in the note it was written Discussed with MD A. The Administrator denied having any progress notes for Resident #1 written by MD A. During interview on 4/3/26 at 8:21 a.m., the ADON said the DON was out on medical leave during the investigation. During interview on 4/3/26 at 9:29 a.m., the ADON said she was filling in for the DON since he was out on medical leave during the investigation. The ADON said either the attending or the PA or NP did the admission visits for residents. The ADON said usually for skilled residents it had to be a physician unless the physician was the physician of record at the hospital as it would be continuation of care. On 4/3/26 at 11:02 a.m., surveyor attempted to contact PA A via phone and left message with request to call surveyor. During interview on 4/3/26 at 11:03 a.m., MD A said PA A will see skilled nursing residents three times a week and the long term residents as needed. MD A said that he and PA A would both see residents. MD A said he and PA A both saw residents during the first 72 hours and would discuss the residents. MD A said he saw Resident #1 during her stay at the facility and never saw her in the hospital and was not one of his hospital patients. MD A said he did not have a way to attest the notes so there would not be notes written by him. MD A said PA A wrote in his notes that he discussed with MD A, and he had seen that when reviewing PA A's notes. MD A said, I don't have a way to edit and say I agree with PA A's note. MD A said I have been having him write the notes referring to PA A. During interview on 4/3/26 at 12:58 p.m., the Administrator said she knew the policy that the physician had to do the initial visit. The Administrator said if the physician did not do the initial visit the effect on the resident was that a diagnosis could be missed . Record review of facility's policy Physician Visits revised April 2013 revealed The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. Findings included: Resident #1Record review of Resident #1's face sheet dated 4/2/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of left femur and adjustment disorder with mixed anxiety and depressed mood. Face sheet also revealed Resident #1 was discharged on 2/18/26. Under care providers on Resident #1's face sheet MD A was listed as primary physician; PA A was listed as physician assistant and NP A was listed as nurse practitioner. Record review of Resident #1's admission MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 15 that indicated cognition was intact. Record review of Resident #1's discharge MDS dated [DATE], section N (Medications) revealed Resident #1 was taking an antidepressant in the last 7 days. Section M revealed two unstageable pressure ulcers. Record review of Resident #1's physician orders as of 2/18/26 revealed order for antidepressant medication monitoring every shift with instructions to document N if none were observed and document Y and complete a progress note if side effects were observed with start date of 1/26/26. Physician orders also included orders for Mirtazapine (antidepressant medication) oral tablet 7.5 mg with instructions to give 1 tablet by mouth at bedtime with start date 2/11/26 and Sertraline (antidepressant medication) 25 mg with instructions to give 3 tablets by mouth one time a day with start date of 2/4/26. Record review of Resident #1's discharged and completed physician orders revealed orders for wound location of left buttock with instructions to apply Santyl, calcium alginate and covered with 4x4 bordered gauze one time a day with start date of 1/14/26 and end date of 2/13/26, wound location of coccyx with instructions to apply Santyl, calcium alginate and covered with 4x4 bordered gauze one time a day with start date of 1/14/26 and end date of 2/22/26. Record review also revealed admitted to BWC under the care of MD A with revision date of 1/13/26 and end date of 2/22/26. Record review of Resident #1's January 2026 TAR revealed no documentation on 1/24/26, 1/25/26 and 1/31/26 for treatment of wound locations of left buttock and coccyx with instructions to apply Santyl, calcium alginate and cover with 4x4 bordered gauze. Record review of Resident #1's February 2026 MAR revealed Y was documented for antidepressant medication monitoring for day shift and evening on 2/15/26 by LVN D, night shift on 2/15/26 by LVN E and day shift on 2/16/26 by LVN F. Instructions included Document Y and complete a progress note if side effects are observed. Record Review of Resident #1's February 2026 TAR revealed no documentation on 2/9/26 and 2/18/26 for treatment of wound location of coccyx with instructions to apply Santyl, calcium alginate and cover with 4x4 bordered gauze. No documented revealed on 2/9/26 for treatment of wound location of left buttock with instructions to apply Santyl, calcium alginate and cover with 4x4 bordered gauze Record review of Resident #1's physician progress notes revealed a progress notes written by NP A on 1/15/26, 1/20/26 1/22/26, 1/27/26, 2/3/26, 2/4/26, 2/6/26, 2/9/26, 2/10/26, 2/18/26 and progress notes written by PA A on 1/21/26, 1/24/26, 1/29/26, 2/10/26. Record review of Resident #1's progress notes from 2/15-2/16/26 did not reveal any progress notes regarding side effects related to antidepressant monitoring. Record review of Resident #1's care plan with last care plan review completed 1/21/26 revealed focus of use of antidepressant medication with intervention to monitor and document side effects and adverse reactions to antidepressant therapy. Record review of the Intake Investigation Worksheet created 3/31/2026 revealed Resident #1 had passed away after being discharged from the facility. Record review of Resident #1's N Adv – Skin Check progress note dated 1/16/26 revealed wounds to left gluteus with measurements of 1 centimeter length, 0.7 centimeter width and 0.1 centimeter depth and to coccyx with measurements of 1.6 centimeter length, 3.6 centimeter width and 0.1 centimeter depth. Record Review of Resident #1's surgical note on 1/29/26 by MD B revealed wound progress of the wounds to her coccyx and left ischium had decreased in size. Note also revealed that healing of these wounds can not be guaranteed considering the patient diagnoses and risk factors that impact the healing process of these wounds. Record review of Resident #1's N Adv – Skin Check progress note dated 1/30/26 revealed wounds to left gluteus with measurements of 0.6 centimeter length, 0.5 centimeter width and 0.2 centimeter depth and to coccyx with measurements of 1.1 centimeter length, 2.1 centimeter width and 0.2 centimeter depth. Record review of the Intake Investigation Worksheet created 3/31/2026 revealed Resident #1 had passed away after being discharged from the facility. Record review on 4/1/26 at 12:21 p.m. of the miscellaneous documents in the electronic medical record revealed physician notes for surgical, pain and psychology/psychiatry. Resident #2Record review of Resident #2's face sheet dated 4/3/26, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including senile degeneration (progress decline in cognitive function) of the brain. Record review of Resident #2's significant change MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 6 that indicated severe cognitive impairment (0-7). Record review of Resident #2's N Adv – Skin Check progress note dated 2/2/26 revealed wounds to buttocks with measurements of 0.8 centimeter length, 1.3 centimeter width and 0.2 centimeter depth. Record review of Resident #2's N Adv – Skin Check progress note dated 2/23/26 revealed wounds to right heel with measurements of 4.2 centimeter length, 3 centimeter width and 0 centimeter depth, buttocks with measurements of 0.1 centimeter length, 0.1 centimeter width and 0.1 centimeter depth and possible deep tissue injury to right lateral calf. Record Review of Resident #2's surgical note on 3/26/26 by MD B revealed wound progress of the left buttock wound had decreased in size and right heel wound was undetermined as it was the first visit. Note also revealed that Resident #2 has a chronic wound which may or may worsen as a result of chronic comorbidities, restricted mobility, and thinning skin. Record review of Resident #2's physician orders with active orders as of 4/3/26 revealed order for wound location to left buttock (shear injury) with instructions to apply zinc oxide and nystatin powder and leave open to air one time a day with start date of 3/26/26. Record review of Resident #2's March 2026 TAR revealed no documentation on 3/1/26 and 3/2/26 for treatment of wound location of left buttock (MASD with opening) with instructions to apply collagen to wound, zinc oxide to peri wound and cover with 4x4 bordered gauze one time a day with order date of 1/29/26 and discontinue date of 3/2/26. No documentation on 3/28/26 and 3/31/26 for treatment of wound location of left buttock (shear injury) with instructions to apply zinc oxide, nystatin power and leave open to air one time a day with order date of 3/26/26. No documentation on 3/8/26 for treatment of wound location of left lateral mid foot with instructions to apply betadine and cover with 4x4 bordered gauze one time a day with order date of 3/6/26 and discontinue date of 3/12/26. No documentation on 3/1/26 and 3/8/25 for treatment for wound location of right heel with instructions to apply betadine and cover with 6x6 bordered gauze one time a day with order date of 2/23/26 and discontinue date of 3/12/26. No documentation on 3/1/26 and 3/2/26 for treatment of right lateral leg possible deep tissue injury with instructions to apply betadine and leave open to air one time a day with order date of 2/23/26 and discontinue date of 3/2/26. Observation on 4/1/26 at 10:42 a.m. revealed Resident #2 was clean and dressed covered with blankets lying in bed with her eyes closed and no foul odors noted. During interview on 4/1/26 at 10:42 a.m., Resident #2's family said the majority of Resident #2's care was pretty good and denied any concerns regarding neglect. Resident #2's family said Resident #2 had a sore on her butt and the staff putting salve or cream on the area when they change her. Resident #3Record review of Resident #3's face sheet dated 4/3/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including cerebral infarction (stroke). Record review of Resident #3's quarterly MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 9 that indicated moderate cognitive impairment. Section M revealed one stage 4 pressure ulcer and one unstageable pressure injury presenting as deep tissue injury. Record Review of Resident #3's surgical note on 2/19/26 by MD B revealed wound progress of the left 5th toe wound as being unchanged in size and right lateral foot wound. Record review of Resident #3's N Adv – Skin Check progress note dated 3/30/26 revealed wounds to right lateral foot of non-blanchable erythema, left lateral foot of deep tissue injury, other skin issues to the left dorsum 4th and 5th digits and right lateral foot. Record review of Resident #3's physician orders with active orders as of 4/3/26 revealed orders for would location of left and right lateral foot with instructions to apply betadine and cover with dry dressing one time a day with start date of 4/3/26. Record review of Resident #3's March 2026 TAR revealed no documentation on 3/1/26 and 3/8/26 for treatment of wound location to left 5th toe with instructions to apply collagen power and cover with 4x4 bordered gauze one time a day and to right lateral foot with instructions to apply betadine and cover with 4x4 bordered gauze with order date of 1/23/26 and discontinue date of 3/12/26. No documentation on 3/23/26, 3/27/26, 3/28/26, 3/29/26 and 3/30/26 for treatment of wound to right lateral food with instructions to apply calcium alginate with honey and cover with 4x4 bordered gauze one time a day with order date of 3/19/26 and discontinue date of 3/30/26. Observation on 4/2/26 at 9:42 a.m. revealed Resident #3 was clean and dressed lying in bed. Dressings to both of Resident #3's feet were visible and were clean, dry and intact with no foul odors noted. Observation on 4/3/26 at 2:28 p.m. revealed Resident #3 was clean and dressed lying in bed. Dressings to both of Resident #3's feet were visible and were clean, dry and intact with no foul odors noted. During interview on 4/3/26 at 2:28 p.m., Hospice Nurse B denied any concerns with Resident #3's care and said they take really good care of her. Hospice Nurse B answered yes when asked if Resident #3's wound dressings were clean when she saw her at the facility. During interview on 4/3/26 at 2:29 p.m., LVN B said the wound of Resident #3's left foot was acquired during her last hospitalization. Resident #4Record review of Resident #4's face sheet dated 4/3/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (decreased oxygen levels). Record review of Resident #4's quarterly MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 3 that indicated severe cognitive impairment. Section M revealed one stage 4 pressure ulcer. Record review of Resident #4's N Adv – Skin Check progress note dated 2/27/26 revealed wounds to sacrum with measurements of 5 centimeter length, 2 centimeter width and 0.3 centimeter depth, right heel with measurements of 4.5 centimeter length, 5.2 centimeter width and 0.3 centimeter depth and buttocks with measurements of 1 centimeter length, 0.7 centimeter width and 0.2 centimeter depth. Record Review of Resident #4's surgical note on 3/26/26 by MD B revealed wound progress of the sacrum wound that the wound had increased in size but debridement was performed and had decreased in size to right heel wound. Record review of Resident #4's N Adv – Skin Check progress note dated 3/27/26 revealed wounds to sacrum with measurements of 6 centimeter length, 2.5 centimeter width and 0.3 centimeter depth, right heel with measurements of 3.5 centimeter length, 4.2 centimeter width and 0.2 centimeter depth and skin issue to buttocks was resolved. Record review of Resident #4's physician orders with active orders as of 4/3/26 revealed orders for right heel wound with instructions to apply collagen to wound, betadine to peri wound and cover with dry dressing once time a day with start date of 4/3/26 and for sacrum with instructions to apply calcium alginate with honey to wound, zinc oxide and nystatin power to peri wound and cover with 6x6 bordered gauze one time a day with start date of 4/3/26. Record review of Resident #4's March 2026 TAR revealed no documentation on 3/13/26, 3/14/26, 3/15/26, 3/16/26, 3/17/26, 3/23/26 and 3/28/26 for treatment of gentamicin ointment to be applied to the sacrum topically one time a day with order date of 3/12/26. No documentation on 3/23/26 and 3/28/26 for treatment to right heel with instructions to apply calcium alginate with honey and gentamicin to wound, betadine to peri wound and cover with dry dressing one time a day with order date 3/12/26. No documentation on 3/1/26 and 3/7/26 for treatment of right heel with instructions of calcium alginate with honey, betadine to peri wound and cover with dry dressing one time a day with order date of 2/19/26 and discontinue date of 3/12/26. No documentation on 3/1/26 for treatment to right buttock with instructions to apply calcium alginate with honey and cover with 4x4 bordered gauze one time a day with order date of 2/12/26 and discontinue date of 3/5/26. No documentation on 3/7/26, 3/8/26 for treatment to right buttock with instructions to apply collagen and cover with 4x4 bordered gauze one time a day with order date of 3/5/26 and discontinue date 3/19/26. No documentation on 3/1/26, 3/7/26, 3/8/26 and 3/23/26 for treatment to sacrum with instructions to apply calcium alginate with honey to wound, zinc oxide, antifungal power to peri wound and cover with 6x6 bordered gauze with order date of 1/23/26 and discontinue date of 3/26/26. No documentation on 3/28/26 for treatment of sacrum with instructions to apply calcium alginate with honey, triple antibiotic ointment to wound and cover with 6x6 bordered gauze one time a day with order date of 3/26/26. Observation on 4/1/26 at 12:19 p.m. revealed Resident #4 clean and dressed lying in bed covered with blankets with no foul odors noted. During interview on 4/1/26 at 12:54 p.m., Resident #4's family said her care was good. During interview of 4/1/26 at 3:01 p.m., Hospice Nurse A said Resident #4 was usually clean and felt like the facility did an adequate job of taking care of Resident #4. Hospice Nurse A denied any concerns regarding neglect. Resident #5Record review of Resident #5's face sheet dated 4/3/26, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including unspecified dementia (group of symptoms affecting memory, thinking and social abilities). Record review of Resident #5's quarterly MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 3 that indicated severe cognitive impairment. Section M revealed no pressure ulcers. Record review of Resident #4's N Adv – Skin Check progress note dated 3/24/26 revealed wounds to left with measurements of 2.5 centimeter length, 1.2 centimeter width and 0.2 centimeter depth and left eyes due to a laceration. Record Review of Resident #5's surgical note on 4/2/26 by MD B revealed wound progress of the left lateral heel to have increased in size but had been debrided and left medial heel had decreased in size. Record review of Resident #5's March 2026 physician orders revealed orders for left lateral heel with instructions to apply Santyl and calcium alginate to wound and betadine to peri wound and cover with 4x4 bordered gauze one time a day with start date of 3/27/26 and left medial heel with instructions to apply Santyl and calcium alginate and cover with 4x4 bordered gauze one time a day with start date of 4/3/26. Record review of Resident #5's March 2026 TAR revealed no documentation on 3/28/26 and 3/31/26 for treatment of Santyl ointment to left lateral heel topically one time a day. No documentation on 3/1/26 and 3/8/26 for treatment of left lateral heel with instructions to apply betadine and cover with 4x4 bordered gauze one time a day. No documentation on 3/23/26 and 3/26/26 for treatment of left lateral heel with instructions to apply calcium alginate and cover with 4x4 bordered gauze one time a day. No documentation on 3/28/26 and 3/31/26 for treatment to left lateral heel with instructions to apply Santyl and calcium alginate to wound and betadine to peri wound and cover with 4x4 bordered gauze. No documentation on 3/1/26 and 3/8/26 for treatment to left medial heel with instructions to apply betadine and cover with 4x4 bordered gauze. No documentation on 3/28/26 and 3/31/26 for treatment to left median heel with instructions to apply xeroform and cover with 4x4 bordered gauze one time a day with order date of 2/26/26 and discontinue date of 3/12/26. Observation on 4/1/26 at 1:42 p.m. revealed Resident #5 was clean and lying in bed covered with blankets and no foul odors noted. Record review of Daily Nursing Assignment staffing sheets revealed the following persons were responsible for wound care: on 2/9/26 - charge nurse that included LVN A and LVN C, 2/18/26 – Wound Care Nurse, 2/20/26 – Wound Care Nurse, 3/2/26 – Wound Care Nurse, 3/13/26 – Wound Care Nurse, 3/16/26 – Wound Care Nurse, 3/17/26 – Wound Care Nurse, 3/23/26 – charge nurse that included LVN C, 3/26/26 – Wound Care Nurse, 3/27/26 – Wound Care Nurse, 3/30/26 – Wound Care Nurse, and 3/31/26 – charge nurse that included LVN A and LVN B. Record review of list of residents with pressure ulcers as of 4/1/26 included Resident #2, Resident #3, Resident #4 and Resident #5. During interview on 4/1/26 at 2:32 p.m., the Administrator provided a progress note for Resident #1 dated 1/16/26 at 12:05 p.m. written by PA A and said the progress note said, discussed with MD A and also showed the surveyor in the note it was written Discussed with MD A. The Administrator denied having any progress notes for Resident #1 written by MD A. During interview on 4/3/26 at 8:35 a.m., the Wound Care Nurse said she did all the dressing changes for residents in the facility Monday through Friday unless she was off work. The Wound Care Nurse said Resident #1's dressing changes were every day. The Wound Care Nurse said dressing changes were done daily for Resident #4, Resident #2, Resident #3 and Resident #5 through March 2026. The Wound Care Nurse said on the weekends, the Weekend Supervisor was responsible for dressing changes. The Wound Care Nurse said if she was off work during the week then the staffing scheduler would schedule someone to cover her shift or the hall nurse was responsible for the dressing changes. The Wound Care Nurse said if wound care was ordered daily and not completed daily then the wound could worsen in some cases. The Wound Care Nurse said she was not able to explain the weekends not being checked off regarding wound care. The Wound Care Nurse said she was out sick 2/4/26-2/9/26 and 3/31/26, out for an injury from 3/18/26-3/22/26 and was on vacation from 3/20/26-3/23/26. The Wound Care Nurse said she believed she was also off on 3/27/26 and 3/30/26. Regarding blanks for Resident #4's TAR for Gentamicin the Wound Care Nurse said she was not sure what happened but knew wound care was being provided . The Wound Care Nurse said if she was not available to get to the resident, she would notify the resident's nurse to provide wound care. The Wound Care Nurse said they had healed the wound to Resident #3's left foot before she had went to the hospital. During interview on 4/3/26 at 9:29 a.m., the ADON said she was filling in for the DON since he was out on medical leave during the investigation. The ADON said regarding Y being documented on Resident #1's MAR for February 2026 from 2/15-2/16/26 for antidepressant medication monitoring there should be a note in the progress notes that says Orders – Administration Note and confirmed looking at the February 2026 MAR and progress notes from 2/15-2/16/26 that there were not any progress notes. The ADON said what behavior that was observed and what intervention was performed should be in the progress note. The ADON said it was the nurse who documented on the MAR's responsibility to complete the progress note. The ADON the effect it could have on the resident if progress notes were not completed related to the antidepressant medication monitoring on the MAR was the resident could have repeat behavior because they would not know what caused behavior or if it was a physical or mental cause and so the behavior doesn't occur again or could decrease the occurrence of the behavior. The ADON said she knew if there were blanks on a Monday in March 2026 on the TARS regarding wound care not being completed it was because the wound nurse was not present. The ADON said if the wound care nurse was not present during the week the nurses do their own wound care or the staffing coordinator would call and see if a nurse was off and could come and do wound care. The ADON said the Weekend Supervisor was responsible for wound care. The ADON said if wound care was not completed as ordered there could be a delay in healing but it would depend on the wound or the wound could become macerated or infected. The ADON said she did not feel like it would have an effect on the resident if the wound care was completed but not documented but the doctor or anybody, the NP, PA or the next nurse coming on could assume the wound care was not done. The ADON said if it was not documented then it was not done. The ADON said she would not know if the wound care was completed or not unless she interviewed that nurse. The ADON said to monitor documentation they run a report that was called a Missing Documentation Report. The ADON said they would do an investigation to see if missing documentation was a pattern. The ADON said if there was a pattern they would see what was the reason, and if interventions were needed. She said the MD and family would be notified as well. The ADON said either the attending or the PA or NP did the admission visits for residents. The ADON said usually for skilled residents it had to be a physician unless the physician was the physician of record at the hospital as it would be continuation of care. During interview on 4/3/26 at 10:31 a.m., LVN A said typically Monday through Friday the wound care nurse performs the wound care on residents. LVN A said she was not working on 3/13/26. LVN A said she did not remember anything regarding Resident #4's wound care on 3/17/26. LVN A said Resident #4 would refuse wound care and if Resident #4 refused wound care they would mark it was refused. LVN A said if the Wound Care Nurse was off then the charge nurse would do the wound care unless the facility brought someone in to do the wound care. LVN A said regarding the missing documentation on the TAR for Resident #1 from 2/18/26-2/22/26 she believed she was off. During interview on 4/3/26 at 10:39 a.m., LVN B said typically Monday through Friday the Wound Care Nurse performs the wound care on residents. LVN B said the Wound Care Nurse rounds with the doctor on Thursdays. LVN B said on 3/31/26 she had left LVN C, who was the 2-10 p.m. nurse, wound care for some residents that could have included Resident #2 and Resident #5 and believed he may not have done the click off for the wound care. LVN B said she always rounds on her residents and makes sure their wound care was completed. LVN B said she did not remember anything regarding wound care for Resident #5 on 3/26/26 but believed the Wound Care Nurse was present that day. LVN B said regarding the gap for Resident #3 from 3/27-3/30/26 she had gone out to the hospital. LVN B said that if a resident was in the hospital or unavailable the nurse could document using a drop down box to choose hospital or out on pass or discharged or whatever the reason. LVN B said on the weekends the Weekend Supervisor was responsible for the wound care. On 4/3/26 at 11:02 a.m., surveyor attempted to contact PA A via phone and left message with request to call surveyor. During interview on 4/3/26 at 11:03 a.m., MD A said PA A will see skilled nursing residents three times a week and the long term residents as needed. MD A said that he and PA A would both see residents. MD A said he and PA A both saw residents during the first 72 hours and would discuss the residents. MD A said he saw Resident #1 during her stay at the facility and never saw her in the hospital and was not one of his hospital patients. MD A said he did not have a way to attest the notes so there would not be notes written by him. MD A said PA A wrote in his notes that he discussed with MD A, and he had seen that when reviewing PA A's notes. MD A said, I don't have a way to edit and say I agree with PA A's note. MD A said I have been having him write the notes referring to PA A. During interview on 4/3/26 at 11:17 a.m., MD B, who was the wound care doctor, said dressings were getting changed regularly at the facility and the wound healing rate was relatively high compared to other buildings. MD B said, I am very happy with how things are going from a wound care standpoint. During interview on 4/3/26 at 11:27 a.m.,

Based on observation, interview and record review the facility failed to assist residents in obtaining routine and 24- hour emergency dental care for 1 of 11 residents (Resident #1) reviewed for dental services in that: The facility failed to assist Resident #1 with obtaining dental services between 7/6/25 when dental pain was noted in Resident #1's electronic medical record and on 8/12/25 when Resident #1's family member made a grievance with the facility regarding Resident #1 wanting to see a dentist. This failure could place residents at risk of not having their oral health care needs met or dental pain.The findings include:Record review of Resident 1's face sheet, dated 10/15/25, revealed a 59- year-old male who was admitted to the facility on [DATE]. Resident #1 had a diagnosis which included Hemiplegia and Hemiparesis (one sided weakness) following Cerebral Infarction (Stroke)Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 13, which indicated the resident's cognition was intact. Record review of Resident 1's Health Drive record, revealed treatment notes that prophylaxis was performed and varnish applied. Resident #1's tooth #19 (tooth in left lower side of mouth) broke four days ago and was hurting. Record review of Resident #1's progress notes did not reveal any notes made by the social worker related to dental care during June or July of 2025. Record review of Resident #1's progress note, by LVN A, dated 7/6/25 at 5:10 p.m., revealed Resident complain of dental pain. Roommate explained that resident has had recent dental pain, avoiding eating due to dental pain. This nurse left message with RP, requesting a return call to see if any dental appointment has been set up. Awaiting return call. This nurse to note to Social Services. Noted in MD A communication book. Record review of Resident #1's progress note, dated 8/12/25, by the Social Worker, revealed Resident #1's family member expressed concern regarding Resident #1's dental care and stated a dental appointment was needed. The note revealed Resident #1's family member was informed the facility dentist visited quarterly and was unable to provide unscheduled visits for individual residents. Resident #1's family member was advised they may take Resident #1 to an outside dentist of their choice prior to the next scheduled on-site dental visit on 8/19/25. The Social Worker plan included to invite Resident #1's family to a care plan meeting to provide a list of local dental providers accepting Resident #1's insurance; offer assistance in scheduling and arranging transportation for an earlier appointment, if desired; and follow up with Resident #1's family after scheduled 8/19/25 dental visit to assess satisfaction and address any remaining concerns. Record review of Resident #1's progress note, dated 8/14/25, by the Social Worker, revealed the Social Worker interviewed Resident #1 following his dental appointment on 8/14/25. The progress note revealed Resident #1 said he may be receiving a dental bridge, and his tooth no longer caused him pain, and two teeth were to be extracted at the next visit. Record review of Resident #1's Dental- Clinical History, dated 8/18/25, revealed pain/discomfort to upper left side. Note also revealed plan for extraction of tooth #14 (tooth in left upper side of mouth) and bridge for teeth #19, #20, and #21 (teeth in left lower side of mouth). Record review of Resident #1's electronic medical record did not reveal any other dental notes from June to August 2025. Record review of Resident #1's Order Summary Report with active orders as of 10/15/25 revealed appointment with local dentist on 8/14/25 at 10:30 a.m. Record review of Resident #1's August 2025 MAR/TAR revealed appointment on 8/18/25 at 11 a.m. with a local dentist and appointment with oral surgeon on 8/22/25 at 1 p.m. Record review of Grievance/Complaint Report, dated 8/11/25, revealed grievance for Resident #1 by Resident #1's family member due to Resident #1 wanting to see a dentist. Grievance revealed Resident #1 was approved for a filling and was scheduled for 8/19/25. Record review of Resident #1's weights did not reveal any weight loss from June to August of 2025. Record review of Resident 2's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated cognition was intact. During interview on 10/14/25 at 12:56 p.m. with Resident #1's family member revealed he believed the tooth infection was taken care of at the time of the interview and was a huge ordeal. Resident #1's family member said Resident #1 had the infection for probably two months and there was no sense of urgency from the facility. Resident #1's family member said Resident #1 had a tooth extraction and something else. Resident #1's family member said Resident #1's other family member had to schedule those appointments. Resident #1's family member said the facility told them they had to take Resident #1 to the dentist and pay for the services. Resident #1's family member said Resident #1's tooth issues started during the summer of 2025 and was resolved in August of 2025. Resident #1's family member said Resident #1 had got to the point he did not want to tell anybody anything because the facility would not do anything, so he would just deal with it. Resident #1's family member said Resident #1 was not eating as much because of the pain and was not eating solid things. During interview and observation on 10/15/25 at 9:14 a.m., Resident #1 denied any current pain in his teeth and last went to the dentist about two weeks ago. Resident #1 said he had a tooth pulled about a month ago because it was chipped and started hurting and possibly decayed. Resident #1 said it was about a month from when his tooth started hurting to when it was pulled out. Resident #1 said he did not know why it took about a month from when the tooth started hurting to when it was pulled out, just that it took too long. No signs of distress were noted of Resident #1 during the interview. During interview on 10/15/25 at 11:15 a.m., the Social Worker said they started at the facility in the middle or end of June 2025. The Social Worker said the facility provided dental services via a contracted dentist or the resident could choose to see an outside dentist. The Social Worker said if a resident had a complaint before the facility's contracted dentist came then they would get residents an outside appointment and they would not make them wait. The Social Worker said if it was an emergency, and the resident could not eat the facility would have to get the resident out for an appointment. The Social Worker said they considered tooth pain an emergency because that could stop residents from eating. Regarding Resident #1, the Social Worker said she remembered Resident #1's family member had written a letter, and they did not remember any dental problems related to Resident #1 before the letter. The Social Worker said once Resident #1's family member wrote the letter we got on it. The Social Worker said she did not remember the nurse, Resident #1 or Resident #1's family notifying her regarding Resident #1 having dental pain. The Social Worker said if a nurse had a dental concern, the nurse would either come tell the Social Worker verbally or leave a note under the door and then they would add the resident to the list. Attempted phone interview with LVN A was unsuccessful and a call back from LVN A prior to the exit date was not received. During interview on 10/15/25 at 2:15 p.m., Resident #2, who was also roommates with Resident #1, said Resident #1's tooth pain started about 6-7 months ago. Resident #2 said it was a long time before Resident #1 was able to get the tooth fixed or pulled out and Resident #1 was in really bad pain . Resident #2 said Resident #1's tooth had chipped and hurt when he bit down. During interview on 10/15/25 at 2:35 p.m., the DON said referrals for dental services went through the social worker. During interview on 10/15/25 at 3:57 p.m., Resident #1 said the tooth that had hurt him was on the left upper side. During interview on 10/15/25 at 4:24 p.m., the Administrator said when they were made aware of dental issues on 8/12/25 with Resident #1, they were figuring out if he was seen and they called the facility's contacted dentist on 8/11/25 and Resident #1 was scheduled for a filing on 8/19/25. The Administrator said the facility's contracted dentist said Resident #1 did not want the tooth extracted so they had to take it back to get authorization for the filling and that was scheduled for when they were to come back out on 8/19/25. Record review of the facility's policy Dental Services, revised December 2016, revealed routine and 24 hour emergency dental services are provided to residents.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objective and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 2 (Resident #69 and Resident #302) of 7 residents reviewed for care plans. 1. The facility failed to ensure Resident #69's care plan included information regarding assist rails. 2. The facility failed to ensure Resident #302's care plan included information regarding her use of CPAP and advance directives information. The failure could place residents at risk of not receiving appropriate care and interventions to meet their needs. Findings included: Record review of Resident #69's face sheet dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Displaced Intertrochanteric Fracture of Right Femur (right hip fracture), Muscle Weakness and Difficulty in Walking. Record review of Resident #69's quarterly MDS dated [DATE] revealed a BIMS score of 6 that indicated severe cognitive impairment. MDS also revealed admission performance for functional abilities in Section GG of partial/moderate assistance for sit to stand and char/bed-to-chair transfers. Record review of Resident #69's Order Summary Report dated [DATE] revealed no physician's orders regarding bed or assist rails. Record review of Resident #69's Order Summary Report dated [DATE] revealed physician's order Resident may have an assist rail(s) as an assistive device to maximize independence in bed mobility and/or transfer ability with order date of [DATE]. Record review of Resident #69's care plan printed [DATE] revealed no mention regarding side or assist rails. Record review of Resident #69's care plan printed [DATE] revealed The resident may use an assist rail(s) to aid in turning/repositioning. Observation on [DATE] at 9:33 a.m. revealed bed rails near the head to both sides of Resident #69's bed in the up position. Record review of Resident #302's face sheet dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Acute on Chronic Diastolic (Congestive) Heart Failure (disorder when the heart does not pump blood as well as it should) and Obstructive Sleep Apnea (disorder where people repeatedly stop and start breathing while they sleep). Record review of Resident #302's admission MDS dated [DATE] revealed a BIMS score of 14 that indicated cognition was intact. Record review of Resident #302's Order Summary Report as of [DATE] revealed physician's order for Full Code: Perform CPR with order date of [DATE] and Place CPAP machine on Resident at bedtime with order date of [DATE]. Record review of Resident #302's May MAR/TAR printed [DATE] revealed Place CPAP machine on Resident at bedtime Settings 35BPM with order date of [DATE] at 8:32 a.m. and for documentation to have started on [DATE]. Record review of Resident #302's care plan as of [DATE] revealed focus of Resident #302 had exercised their right to maintain a full code status with revision date of [DATE]. Record review also revealed focus of uses a CPAP machine brought from home with revision date of [DATE]. Record review of Resident #302's Nurse Progress Notes revealed Oxygen via CPAP under N Adv Skilled Evaluation dated [DATE] at 1:06 p.m. Record review also revealed CPAP was documented under Admission Details dated [DATE] at 5:04 p.m. under respiratory section. Observation on [DATE] at 10:13 a.m. revealed CPAP machine on nightstand in Resident #302's room. During interview on [DATE] at 2:33 p.m., the DON said there should be an order for grab bars and should be documented on residents' care plan. The DON said Resident #302 should have of had an order for her CPAP on admission. During interview on [DATE] at 11:30 a.m., Resident #302 said she had worn her CPAP every night since arriving to the facility. During interview on [DATE] at 8:37 a.m., the DON said the nursing management team was responsible for placing information like advance directives, bed/assist rails or CPAPs on the residents' care plans. The DON said the nursing management team consisted of the DON, MDS nurse, ADON and wound care nurse. During interview on [DATE] at 8:54 a.m., LVN G said they assumed the MDS Coordinator put information regarding advance directives, CPAP, and bed rails on the care plan. LVN G said nurses did not add information to the care plans. During interview on [DATE] at 9:18 a.m., the ADON said the MDS Coordinator put information for bed rails and CPAPs on the care plans. The ADON said effects residents could experience if the CPAP was not documented on the care plan was the resident could have low O2 sats or not be able to sleep well. During interview on [DATE] at 9:32 a.m., the MDS Coordinator said she care plans everything that was triggered on the resident's MDS. The MDS Coordinator said all the managers had a hallway and check for new orders that need to be added to residents' care plans otherwise she would catch at the resident's next assessment. The MDS Coordinator said the managers did chart checks to ensure the orders were entered and were on the care plan and this typically occurs the next day. The MDS Coordinator said any of the administrative nurses can add information to the residents' care plans. The MDS Coordinator said she had meetings and in-services regarding ongoing training for care plans. The MDS Coordinator said if information like CPAP was not on the care plan, then the resident may not get the CPAP. During interview on [DATE] at 9:43 a.m., the Administrator said nursing put information for bed rails, advance directives, and CPAPs on the care plans. The Administrator said the effect on residents if there was not information entered into the care plan for bed rails, advance directives, and CPAPs was there would be lack of communication to the nursing staff. Record review of facility's policy Care Plans, Comprehensive Person-Centered revised [DATE] revealed The comprehensive, person-centered care plan will: describe the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Record review also revealed The comprehensive, person-centered care plan will: reflect the resident's expressed wishes regarding care and treatment goals.

Based on observation, interview and record review, the facility failed to attempt to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails prior to installation and obtain informed consent prior to installation for 2 (Resident #69 and Resident #5) of 8 residents reviewed for use of side rails. The facility failed to ensure Residents #69 and #5 had documentation and orders prior to installation of bed rails. This failure could place residents at risk of injury, not have adequate education regarding bed rails and/or staff not have adequate communication regarding residents' use of bed rails. Findings included: Record review of Resident #69's face sheet dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Displaced Intertrochanteric Fracture of Right Femur (right hip fracture), Muscle Weakness and Difficulty in Walking. Record review of Resident #69's quarterly MDS dated [DATE] revealed a BIMS score of 6 that indicated severe cognitive impairment. MDS also revealed admission performance for functional abilities in Section GG of partial/moderate assistance for sit to stand and char/bed-to-chair transfers. Record review of Resident #69's Order Summary Report dated [DATE] revealed no physician's orders regarding bed or assist rails. Record review of Resident #69's Order Summary Report dated [DATE] revealed physician's order Resident may have an assist rail(s) as an assistive device to maximize independence in bed mobility and/or transfer ability. Record review of Resident #69's assessments did not reveal an assessment being conducted for rail usage. Record review of Resident #69's MAR/TAR printed [DATE] revealed resident may have an assist rail(s) as an assistive device to maximize independence in bed mobility and/or transfer ability with order date of [DATE]. Record review of Resident #69's care plan printed [DATE] revealed no mention regarding side or assist rails. Record review of Resident #69's care plan printed [DATE] revealed The resident may use an assist rail(s) to aid in turning/repositioning. Record review of Resident #69's Progress Notes from ,d+[DATE]-[DATE] revealed on [DATE] at 12:35 p.m. that telephone consent was obtained from Resident #69's family member and the risks and benefits of assist rails were explained. On [DATE] at 12:21 p.m. Resident #69 was assessed for the use of assist rails. Observation on [DATE] at 9:33 a.m. revealed bed rails near the head to both sides of Resident #69's bed in the up position. During interview on [DATE] at 1:35 p.m., the DON said the rails on Resident #69's bed were grab handles but did not know if that was the technical term. The DON said they did not need orders for grab handles. The DON said he did not know if the grab handles needed to be on the care plan, but he would find out. Record review of Resident #5's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility admission [DATE] with a re-admission of [DATE] with diagnoses Alzheimer's, High Blood Pressure and COPD (lung disease). Record review of Resident #5's Annual MDS dated [DATE] revealed a Staff Assessment of Mental Status completed. This revealed resident's cognition was severely impaired. Record review of Resident #5's Order Summary Report dated [DATE] revealed no physician's orders regarding bed or assist rails. Record review of Resident #5's assessments did not reveal an assessment being conducted for rail usage. Record review of Resident #5's care plan printed [DATE] revealed no mention regarding side or assist rails. Record review of facility incident report dated [DATE] revealed after bruising on the right side of chest that they covered the rails with foam. Observation of Resident #5's room on [DATE] at 3:30 PM revealed rails in up position covered with foam. Resident was not in her room. Resident #5 was observed in near nurses' station in her wheelchair waiting for her family member. She was unable to answer any questions. During interview on [DATE] at 3:45 PM, MA A said the Resident #5's rails have been there since her family member died . She said that was about 3 months ago. She said when the rails were first placed, she used them for help, but not now. She did not assist any longer with ADL's. During interview on [DATE] at 3:48 PM, CNA O said they do not leave rails up when residents were in bed. They put one up and one down. They then can still use for mobility but get out of bed. During interview on [DATE] at 3:55 PM, the DON said Resident #5 used the rails for mobility. If she did not need them, he would take them down. He said there were no orders or care plans for rails. He said these should be completed. During interview on [DATE] at 2:33 p.m., the DON said there should have been an order for grab bars and should have been on residents' care plan. The DON said that when the grab bars were in the up position, they were not considered a restraint. During interview on [DATE] at 8:37 a.m., the DON said the effect on residents of not having an order or documentation on the care plan regarding bed rails was a potential hazard to the resident like entanglement or the resident trying to get over the bed rail. The DON said they should assess the residents' ability to use the bed rails. The DON said they had in-services and online trainings but was not aware of trainings specific to bed/assist rails. The DON said they constantly educate staff and family regarding what could be a restraint and regarding possible restraint education. The DON said they put in orders and care planned all residents yesterday regarding assist rails. During interview on [DATE] at 8:54 a.m., LVN G said they did not know they needed an order for bed rails but bed rails needed to be care planned. LVN G said they had training about bed rails that was given verbally and by in-service. During interview on [DATE] at 9:06 a.m., LVN H said they needed an order for bed rails and usually got orders for bed rails on admission. LVN H said we usually did not use bed rails and said she had in-services regarding bed rails. During interview on [DATE] at 9:15 a.m., CNA M said most of the time they keep both bed rails up unless there was a reason to put one side down. During interview on [DATE] at 9:18 a.m., the ADON said there needed to be an order for bed rails and the nurse was responsible for obtaining orders for bed rails on admission. The ADON said if there was not an order or documentation on the care plan for bed rails then residents could receive a skin tear, bruising, and could hinder bed mobility, transfers, or positioning. The ADON said staff had training regarding bed rails in their yearly check offs. During interview on [DATE] at 9:43 a.m., the Administrator said they should have orders for bed rails and nursing put information for bed rails on the care plans. The Administrator said the effect on residents if there were not orders or information entered into the care plan for bed rails then there would be lack of communication to the nursing staff. During interview on [DATE] at 11:36 p.m., CNA N said residents would use the assist rails if they needed help sitting up, assistance returning to bed or turning side to side. CNA N said if both assist rails were in the down position it would be considered a restraint but that the nurse would let them know. Record review of facility's policy Bed Safety revised [DATE] revealed The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. Record review also revealed Assist rails may be used if assessment and consultation with the attending physician has determined that they are needed. Record review also revealed Before using assist rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails.

Based on interviews and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #302) of 7 residents reviewed for advance directives. The facility failed to ensure that Resident #302's advance directives was clearly identified and documented in the resident's electronic medical record and was not care planned until [DATE] when the resident was admitted [DATE]. The failure could place residents at risk of not having their end of life wishes honored and having incomplete records. Findings included: Record review of Resident #302's face sheet dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Acute on Chronic Diastolic (Congestive) Heart Failure (disorder when the heart does not pump blood as well as it should). Record review of Resident #302's admission MDS dated [DATE] revealed a BIMS score of 14 that indicated cognition was intact. Record review of Resident #302's electronic medical record on [DATE] at 2:14 p.m. revealed no advance directive information in Code Status section. Record review of Resident #302's electronic medical record on [DATE] at 12:32 p.m. revealed no advance directive information in Code Status section. Record review of Resident #302's electronic medical record on [DATE] at 11:13 p.m. revealed information of full code: perform CPR in the advance directive information in Code Status section. Record review of Resident #302's Order Summary Report as of [DATE] revealed physician's order for Full Code: Perform CPR with order date of [DATE]. Record review of Resident #302's care plan as of [DATE] revealed focus of Resident #302 had exercised their right to maintain a full code status with revision date of [DATE]. Record review of Resident #302's Progress Notes with date range of ,d+[DATE]-[DATE] revealed progress note written by the Social Worker dated [DATE] at 8:45 a.m. Progress note stated resident was a full code status and status had been entered into the record. Progress note also revealed advanced care planning material was provided and discussed with the resident. During interview on [DATE] at 1:35 p.m., the DON said Resident #302 was a full code. The DON said the advance directive section on the electronic medical record should be updated on admission and should go on the care plan within 24 hours of admission. The DON said the order for advance directives generated the information in the electronic medical record. The DON said the social worked updated the resident's care plan for information regarding advance directives. The DON said the nurses were instructed that residents who did not have a DNR were automatically a full code. The DON said the admitting charge nurse was responsible to generate the advance directive order as part of the resident's admission orders. The DON said if advance directives were not updated then it could cause miscommunication of their wishes and might not be handled per the resident's wishes. During interview on [DATE] at 8:50 a.m., the Social Worker said the residents were always a full code unless they had a DNR. The Social Worker said the charge nurse put in the order for residents who were full code. The Social Worker said she entered information into the residents' care plan if they were full code or DNR. The social worker said she completed the paperwork if a resident wished to be a DNR but would notify the nurse to obtain the order. During interview on [DATE] at 8:54 a.m., LVN G said the admitting nurse can update advance directive order if changed. LVN G said she was trained all the time regarding advance directives and training was part of admission training. During interview on [DATE] at 9:06 a.m., LVN H said the admitting nurse would put the order for advance directives on admission. LVN H said all residents were a full code unless they came to the facility with a DNR or until the social worker saw the resident and they wanted to be a DNR. LVN H said she had in-services regarding advance directives. During interview on [DATE] at 9:18 a.m., the ADON said the nurse that did the admission should enter the order for advance directives. The ADON said advance directive information should be completed dur the admission process and usually was entered on the care plan within 24 hours of admission. The ADON said nurses have training regarding advance directives in orientation and in their yearly review. The ADON said if an order for advance directives was not entered then care could go against the resident's wishes. During interview on [DATE] at 9:32 a.m., the MDS Coordinator said the nurses put in orders for advance directives on admission. During interview on [DATE] at 9:43 a.m., the Administrator said they should have orders for advance directives and nursing put information for advance directives on the care plans. The Administrator said the effect on residents if there were not orders or information entered into the care plan for advance directives then there would be lack of communication to the nursing staff. Record review of facility's policy Advance Directives revised [DATE] revealed Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 medication fridges reviewed for storage of drugs. The facility failed to ensure that food items were not stored in the medication fridge per facility policy. This failure could place residents at risk of medications being cross contaminated with food items. Findings included: Observation on 5/19/25 at 2:50 p.m. revealed a 12 ounce can of Dr. Shasta cola in the door of the medication fridge in the facility's medication room. During interview on 5/19/25 at 2:50 p.m., the ADON said the drink probably belonged to a resident that does not like water and will only take their medications with soda. The ADON said the soda should have been in the nutrition room. During interview on 5/19/25 at 3:04 p.m. the DON said a soda can should not have been in the medication refrigerator and could result in cross contamination with the food contaminating the medications or the medications contaminating the food. Record review of facility's policy Storage of Medications revised November 2020 revealed Medications are stored separately from food and are labeled accordingly.

Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Quetiapine fumarate (Seroquel) that was administered to Resident #3. The failure could affect residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Findings include: Record review of Resident #3's face sheet dated 04/10/24 revealed he was an [AGE] year-old male who admitted to the facility on [DATE] with an initial admitted [DATE], with diagnoses of unspecified dementia, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (group of symptoms that affects memory, thinking and interferes with daily life), anxiety disorder (group of mental illnesses characterized by intense anxiety and fear), and encephalopathy (a group of conditions that cause brain dysfunction), and major depressive disorder (a persistent feeling of sadness and loss of interest). Record review of the comprehensive MDS assessment, dated 02/07/2024, revealed Resident #3 was unable to complete the BIMS and a staff assessment was conducted. Resident #3's BIMS was 99, indicating resident was unable to complete the interview. The MDS staff assessment for mental status revealed Resident #3 had short-term and long-term memory problems; memory/recall problems; and severely impaired daily decision-making skills (never/rarely made decisions). The MDS assessment revealed no behavior problems during the look-back period. The MDS assessment for Resident #3 revealed he had received an antipsychotic 7 days in the 7-day -look -back -period. Record review of Resident #3's care plan dated 01/12/2024 revealed that Focus: Resident# 3 uses antipsychotic medication Quetiapine (Seroquel) related to yelling out. Goal: Resident# 3 will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Record review of Resident #3's physician's order summary report revealed the following order: Quetiapine fumarate (Seroquel) tablet 25 mg give 0.5 mg by mouth two times a day for agitation with dementia related to unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety with a start date of 11/06/2023 and stop date of 03/27/2024. Quetiapine fumarate (Seroquel) tablet 25 mg give 0.5 mg by mouth at bedtime for antipsychotic/antimanic agent related to Mood Disorder due to known physiological condition, unspecified with a start date of 03/27/2024. Record review of Resident #3's MAR revealed that Resident #3 was actively taking the medication, Quetiapine fumarate (Seroquel). Interview on 04/09/24 at 10:43 AM, the DON stated [NAME] a nurse received an order for a psychotropic, they should make sure they have consents. If a resident does not have consent the nurse should contact the management nurse and the management nurse would let the doctor know. The DON was asked why it is important to inform a resident of the risk and benefits of the medication. The DON stated that it is every resident's right to be informed about the treatment and medication they received. Interview on 04/09/24 at 11:05 AM, the ADON stated that she was aware that Resident #3 was diagnosed with dementia and had been order the medication, Seroquel related to yelling out, mood disturbance, and agitation. The ADON stated Resident #3 was initially admitted on [DATE] with the diagnosis of dementia. The ADON stated that Resident #3 was initially ordered Quetiapine fumarate (Seroquel) tablet 25 mg give 0.5 mg by mouth at bedtime with a started date of 07/18/2023 related to Resident #3 behavior of yelling out. The ADON stated that Resident #3 had frequency changes to the medication on 11/06/2023 and an additional change to the medication frequency on 03/27/2023. The surveyor requested the documented consent for antipsychotic medication treatment for Resident #3. The ADON stated that the facility did not have a current consent for treatment. The ADON stated that she was working on obtaining consent from Resident #3's POA. She stated that she reached out to the Resident #3 's POA last week Wednesday, 04/03/2024 but had not followed up to obtain consent. The ADON stated she was waiting to receive the new form from the hospital as the facility no longer used Form 3713 (consent for antipsychotic medication treatment) prior to following up with the POA. The ADON was asked why it is important to inform a resident of the risk and benefits of the medication. The ADON stated that it is every resident's right to be informed about the treatment and medication they received. Record review of the facility's policy last revised January 2023, titled Psychotropic medication use, revealed the following: o Prior to administration of or with a change in the dosage of an antipsychotic medication, the facility shall obtain informed consent from the resident/resident representative. This will be documented on form 3713 in conjunction with the resident/resident representative, attending physician and/or psychiatrist and the facility staff.

Based on observation, interview, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 4 of 20 (Resident # 8, #26, #76 and & #97) residents review for accuracy of assessment. Resident # 8, #26, #76 and resident #97 were not accurately assessed for their oral dental needs on their MDS assessments. Resident # 76 was not accurately assessed for his vision on his annual MDS assessment. These failures could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being. Findings included: Resident #8 Record review of Resident #8's electronic face sheet dated 04/09/24 indicated Resident #8 was [AGE] year-old, female, admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder, anxiety disorder, depressive disorders, lack of coordination, muscle weakness, muscle wasting and atrophy, difficulty in walking, iron deficiency anemia, cognitive communication deficit, chronic obstructive pulmonary disease, hypertensive heart, and chronic kidney disease. Record review of Resident #8's Significant change assessment dated [DATE] indicated Resident #8 had a BIMS score of 3 which indicated severe cognitive impairment. Review of the section on oral dental indicated she had no oral dental concerns. All sections were left blank, indicating Resident #8 had no broken or loosely fitting full or partial dentures, no natural teeth or tooth fragments, no abnormal mouth tissue, no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums or loose natural teeth, and no mouth or facial pain, discomfort, or difficulty with chewing. Record review of Resident #8's care plan dated 06/02/21 with a revision date of 03/25/24 indicated Resident #8 had potential for oral dental health problems r/t missing teeth/Dentures: Goals- Resident # 8 will be free of infection, pain or bleeding in the oral cavity by review date of 03/25/24. Interventions- Monitor/document/report PRN any signs and symptoms of oral/dental problems needing attention, Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue . Observation on 04/08/24 at 8:00AM, revealed Resident #8 in bed sleeping. Observation on 04/10/24 at 9:00Am revealed Resident #8 was in the activity room. She was alert and oriented. Attempt was made to have an interview, but she was not interviewable. Observation and interview on 04/09/24 at 12:15PM, revealed she was on a mechanical diet assisted with her meal. During an interview at the time, CNA' Q said Resident #8 had no teeth and no dentures. Resident #26 Record review of Resident #26's face electronic face sheet dated 04/09/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included anxiety disorder, depression, dysfunction of bladder, multiple sclerosis, essential (primary) hypertension, other seizures, chronic obstructive pulmonary disease, acute kidney failure, quadriplegia, and lack of coordination. Record review of Resident #26's admission MDS assessment dated [DATE] revealed a BIMS score of 12 indicated she was moderately impaired on cognition. Review of the section on oral dental indicated she had no oral dental concerns. All sections were left blank, indicating Resident #26 had no broken or loosely fitting full or partial dentures, no natural teeth or tooth fragments, no abnormal mouth tissue, no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums or loose natural teeth, and no mouth or facial pain, discomfort, or difficulty with chewing Record review of Resident #26's care plan dated 08/08/23 read in part - Resident #26 is edentulous (few or no teeth) and wears upper and lower dentures. Goals: Resident # 26 will be free of infection, pain or bleeding in the oral cavity by review date. Revision on: 02/08/2024 Interventions Monitor/document/report PRN any signs and symptoms of oral/dental problems needing attention ., Observation on 04/08/24 at 7:30AM revealed Resident #26 was in bed alert and oriented. She attempts to communicate but her speech was unclear. Observation revealed she had a mechanically altered diet. She was assisted with her meal. Resident # 76 Record review of Resident #76's face sheet dated 04/09/24 indicated Resident #76 admitted on [DATE] and was [AGE] years old. His diagnoses included muscle wasting, unspecific chest pain, communicative deficit, cellulitis of left toe (inflammation of right toe), and prostatic cancer. Record review of MDS annual assessment dated [DATE] indicated Resident #76 had a BIMS score of 10, which indicated he was moderately impaired with cognition, had clear speech, and clear vision. He was assessed as having no problem in his oral cavity (section L oral dental) Record review of Resident # 76 care plan with a revision date of 11/09/23 read in part the resident has missing teeth and chooses not to wear his dentures. Dentures are at home'. Goal-The resident will be free of infection, pain, or bleeding in the oral cavity by review date. Revision on: 03/20/2024 Target Date: 02/09/2023. The resident will comply with mouth care at least daily through review date. Revision on: 03/20/2024 Intervention: Coordinate arrangements for dental care, transportation as needed/as ordered. Diet as Ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Provide mouth care as per ADL personal hygiene. During observation and interview on 04/08/24 at 8:50 AM, Resident #76 placed his hand over his mouth during communication. He said he needed to see a dentist but was told that he had to pay for a dental visit. He said he eats what he can. He said all his teeth on his upper oral cavity are almost gone. He said he had two teeth on each side. He said he had none on his lower oral cavity. He said he can see large things but not in print. He pointed to his reading glasses and said he had his eyes examined few weeks ago and was told that he needed a bifocal eyeglass. Resident # 97 Record review of Resident #97's admission record indicated an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus, osteoarthritis (a chronic degenerative joint disease), chronic obstructive pulmonary disease, chronic pain, muscle weakness, communication deficit, generalized anxiety disorder, dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #97's admission MDS assessment dated [DATE] indicated Resident #97 had a BIMS score of 13 out of 15 which indicated her cognition was intact. Review of the section on oral dental indicated she was assessed as having no problem in her oral cavity (section L oral dental) Record review of Resident # 97's care plan dated 12/12/23 read in part Resident #97 is edentulous and wears upper and lower dentures. Revision on: 12/12/2023 target date of 03/23/24 Goal; The resident will be free of infection, pain or bleeding in the oral cavity by review date.03/28/24 Interventiono Coordinate arrangements for dental care, transportation as needed/as ordered . During an interview with the MDS coordinator on 04/10/24 at 1:20PM, she looked at all identified areas and said she was new to the MDS position and was not sure what to code on residents' oral dental assessment. She said she would correct all identified MDS to reflect each resident's condition. During an interview with facility social worker on 04/09/24 at 2:00PM, she said Resident # 76 was a full vendor and he had to pay for his dental care service and his eyeglasses out of pocket. She said she would check on his insurance provider if he was covered for dental care and eyeglasses but had not heard anything from anyone. During a follow up interview on 04/10/24 at 1:50PM, the Social Worker said she had spoken with Resident # 76's insurance provider and resident was covered for routine dental care, and one pair of glasses per year. She said she did not follow up with the eye Dr. and she would. She said she would find a local company that would accept Resident #76's insurance. Record review of Facility's policy on resident assessment dated 2001 and updated 2019 read in part: A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS Requirements 2 comprehensive assessment includes: a. completion of the Minimum Data Set (MDS); b. completion of the care area assessment (CAA) process; and c. development of the comprehensive care plan. Admission Assessment and Follow Up: Role of the Nurse Level III Purpose The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS.

Based on observation, interview and record review, the facility failed to create a comprehensive resident-centered care plan with measurable objectives for person-centered care for 3 of 21 residents reviewed for care plan development (Residents # 17, 52, 158). --- Resident # 17 did not have a care plan for ADL assistance --- Resident # 52 did not have a care plan for ADL assistance --- Resident # 158 did not have a care plan for ADL assistance These failures placed residents at risk of not receiving accurate care and services according to their individual needs. Findings include: Resident # 17 Record review of the undated face sheet for resident # 17 revealed an 82- year- old female, admitted [DATE] with diagnoses including dementia, psychosis (mental condition causing loss of contact with reality), chronic kidney disease (longstanding kidney disease leading to kidney failure), dysfunction of bladder (lack of bladder control), cerebral infarction (disruption of blood flow to the brain), seizures (abnormal electrical activity in the brain). Record review of Resident # 17's Significant Change MDS dated [DATE] revealed a BIMS score of 99, indicating severely impaired cognitive ability, was sometimes understood by others and sometimes understands others, always incontinent of bladder and bowel, and was dependent on staff assistance for toileting, bath/shower, dressing, and required maximum assistance for hygiene. Record review of Resident # 17's comprehensive care plan (undated) revealed there was no care plan for ADL assistance, including goals and interventions for completion of tasks needing staff assistance. Observation and interview with Resident # 17 at 8:30 am revealed she was in bed, awake, dressed in a clean gown, and looking out her window. Attempted interview at that time revealed she was not able to answer any questions, was confused, and kept repeating that a man was outside her window, and he was run over by a car. Interview with LVN M on 4/9/24 at 2:30 pm revealed Resident # 17 does require staff assistance for ADLs, and she occasionally hallucinated, for which she was re-directed. Resident # 52 Record review of the undated face sheet for Resident # 52 revealed a 77- year- old female, admitted [DATE] with diagnoses including osteoarthritis (degeneration of joint cartilage and bone), major depressive disorder (persistently depressed mood or loss of interest in activities), hypertension (high blood pressure), dementia (progressive loss of intellectual functioning), speech disturbance (inability to form speech sounds), dysphagia (difficulty swallowing food). Record review Resident #52's Significant Change MDS dated [DATE] revealed Resident # 52 had unclear speech, sometimes understood by others, and usually understands, a BIMS score of 03 indicating severely impaired cognitive skills, always incontinent of bladder and bowel, and required extensive staff assistance for transfers, dressing, toileting, hygiene, and supervision for bath/shower. Record review of Resident #52's comprehensive care plan (undated) revealed there was no care plan for ADL assistance, to include goals and interventions for completion of tasks needing staff assistance. Observation and attempted interview with Resident #52 on 4/8/24 at 10:10 am revealed she was sitting up in bed, awake, dressed, with clean clothes and clean linen on the bed, but not responding verbally. Interview with LVN M on 4/8/24 at 10:40 am revealed Resident # 52 usually did not talk, but if she did her speech would not be clear. She said they do help her with transfers, bathing, toileting, and hygiene. Resident # 158 Record review of the undated face sheet of Resident # 158 revealed a [AGE] year-old female, admitted [DATE] with diagnoses including Metabolic Encephalopathy (chemical imbalance in the blood), enterocolitis (inflammation throughout the intestines), dementia (progressive loss of intellectual functioning), dysphagia (difficulty swallowing), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Record review of Resident #158's Significant Change MDS dated [DATE] revealed she, sometimes understood others and was sometimes understood, BIMS score was 01 indicating severely impaired cognitive skills, and required moderate staff assistance with hygiene and maximum assistance with transfers, showers, toileting, and dressing. Record review of Resident #158's comprehensive care plan (undated) revealed there was no care plan for ADL's, including goals and interventions for completion of tasks needing staff assistance. Observation and attempted interview with Resident #158 on 4/8/24 at 9:20 am revealed she was in bed, awake, with clean linens on the bed. Resident was speaking but was not understandable, unable to answer any questions, and was reaching for the covers on the bed. Interview with LVN M on 4/8/24 at 9:30 am revealed Resident #158 wan not easy to understand when she talked, and they helped her with all her ADL's. Interview with MDS nurse on 4/10/24 at 2:10 pm revealed she does the care plans, with input from nurses and other staff and the MDS. She said the ADL care plans for Residents # 17, #52, #158 were missed and the risk of not having accurate care plans would be the resident not receiving proper care. Interview with the DON on 4/10/24 at 2:40 pm revealed the expectation is for all care plans to be accurate for the resident's condition, and the risk if it's not accurate would be improper resident care. Record review of the facility policy Care Plans- Comprehensive Person Centered, revised September, 2013, revealed in part: .assessments of residents are ongoing and revised as information about residents and resident conditions change . 26867

Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Quetiapine fumarate (Seroquel) that was administered to Resident #3. The failure could affect residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Findings include: Record review of Resident #3's face sheet dated 04/10/24 revealed he was an [AGE] year-old male who admitted to the facility on [DATE] with an initial admitted [DATE], with diagnoses of unspecified dementia, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (group of symptoms that affects memory, thinking and interferes with daily life), anxiety disorder (group of mental illnesses characterized by intense anxiety and fear), and encephalopathy (a group of conditions that cause brain dysfunction), and major depressive disorder (a persistent feeling of sadness and loss of interest). Record review of the comprehensive MDS assessment, dated 02/07/2024, revealed Resident #3 was unable to complete the BIMS and a staff assessment was conducted. Resident #3's BIMS was 99, indicating resident was unable to complete the interview. The MDS staff assessment for mental status revealed Resident #3 had short-term and long-term memory problems; memory/recall problems; and severely impaired daily decision-making skills (never/rarely made decisions). The MDS assessment revealed no behavior problems during the look-back period. The MDS assessment for Resident #3 revealed he had received an antipsychotic 7 days in the 7-day -look -back -period. Record review of Resident #3's care plan dated 01/12/2024 revealed that Focus: Resident# 3 uses antipsychotic medication Quetiapine (Seroquel) related to yelling out. Goal: Resident# 3 will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Record review of Resident #3's physician's order summary report revealed the following order: Quetiapine fumarate (Seroquel) tablet 25 mg give 0.5 mg by mouth two times a day for agitation with dementia related to unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety with a start date of 11/06/2023 and stop date of 03/27/2024. Quetiapine fumarate (Seroquel) tablet 25 mg give 0.5 mg by mouth at bedtime for antipsychotic/antimanic agent related to Mood Disorder due to known physiological condition, unspecified with a start date of 03/27/2024. Record review of Resident #3's MAR revealed that Resident #3 was actively taking the medication, Quetiapine fumarate (Seroquel). Interview on 04/09/24 at 10:43 AM, the DON stated [NAME] a nurse received an order for a psychotropic, they should make sure they have consents. If a resident does not have consent the nurse should contact the management nurse and the management nurse would let the doctor know. The DON was asked why it is important to inform a resident of the risk and benefits of the medication. The DON stated that it is every resident's right to be informed about the treatment and medication they received. Interview on 04/09/24 at 11:05 AM, the ADON stated that she was aware that Resident #3 was diagnosed with dementia and had been order the medication, Seroquel related to yelling out, mood disturbance, and agitation. The ADON stated Resident #3 was initially admitted on [DATE] with the diagnosis of dementia. The ADON stated that Resident #3 was initially ordered Quetiapine fumarate (Seroquel) tablet 25 mg give 0.5 mg by mouth at bedtime with a started date of 07/18/2023 related to Resident #3 behavior of yelling out. The ADON stated that Resident #3 had frequency changes to the medication on 11/06/2023 and an additional change to the medication frequency on 03/27/2023. The surveyor requested the documented consent for antipsychotic medication treatment for Resident #3. The ADON stated that the facility did not have a current consent for treatment. The ADON stated that she was working on obtaining consent from Resident #3's POA. She stated that she reached out to the Resident #3 's POA last week Wednesday, 04/03/2024 but had not followed up to obtain consent. The ADON stated she was waiting to receive the new form from the hospital as the facility no longer used Form 3713 (consent for antipsychotic medication treatment) prior to following up with the POA. The ADON was asked why it is important to inform a resident of the risk and benefits of the medication. The ADON stated that it is every resident's right to be informed about the treatment and medication they received. Record review of the facility's policy last revised January 2023, titled Psychotropic medication use, revealed the following: o Prior to administration of or with a change in the dosage of an antipsychotic medication, the facility shall obtain informed consent from the resident/resident representative. This will be documented on form 3713 in conjunction with the resident/resident representative, attending physician and/or psychiatrist and the facility staff.

Based on interviews and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR ) Screening for 1 of 3 residents (Resident #8) reviewed for resident assessments. The facility failed to review Resident #8's PASRR level 1 assessment for accuracy and refer Resident #8 for further assessment for services. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #8's face sheet printed 04/09/24 indicated Resident #8 was an [AGE] year-old, female, admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis including other bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder, anxiety disorder, depressive disorders, lack of coordination, muscle weakness, muscle wasting and atrophy, difficulty in walking, iron deficiency anemia, cognitive communication deficit, chronic obstructive pulmonary disease, hypertensive heart, and chronic kidney disease. Record review of Resident #8's MDS Significant change assessment dated [DATE] indicated Resident #8 had a BIMS score of 3 which indicated severe cognitive impairment. Review of the section on PASRR-section on Mental illness and other related condition were not checked. Review of the section on active diagnoses was checked for Bipolar, anxiety and depression. Record review of Resident #8's medical diagnoses dated 07/16/18 indicated Resident #8 had a diagnosis of Bipolar. Record review of Resident #8's PASRR Level 1 Screening dated 07/15/21 indicated .Mental illness .Is there evidence or an indicator this is an individual that has a Mental Illness .No . During an interview on 04/10/24 at 1:45 PM, the MDS Coordinator said she was responsible for completing the PASRRs and ensuring that all resident with mental illness diagnoses are referred for PASRR evaluation for services as needed. She said Resident # 8 should have been referred for PASRR evaluation on admission but was overlooked. She said she would request PASRR evaluation for Resident #8.

Based on observation, interview, and record review, the facility failed to provide or obtain from an outside source dental services to meet the needs of 1 of 21 residents reviewed for dental services. (Resident #76) The facility did not assist Resident #76, who had missing teeth and dental decay, with a dental service consult. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being. Findings included: Record review of Resident #76's face sheet dated 04/09/24 indicated Resident #76 admitted on [DATE] and was [AGE] years old. His diagnoses included muscle wasting, unspecific chest pain, communicative deficit, cellulitis of left toe (inflammation of right toe), and prostatic cancer. Record review of MDS annual assessment dated [DATE] indicated Resident #76 was moderately impaired with cognition, (BIMS score 10), had clear speech, and clear vision. He was assessed as having no problem in his oral cavity (section L oral dental) Record review of Resident # 76 care plan with a revision date of 11/09/23 read in part the resident has missing teeth and chooses not to wear his dentures. Dentures are at home'. Goal-The resident will be free of infection, pain, or bleeding in the oral cavity by review date. Revision on: 03/20/2024 Target Date: 02/09/2023. The resident will comply with mouth care daily through review date. Revision on: 03/20/2024. Intervention: Coordinate arrangements for dental care, transportation as needed/as ordered. Diet as Ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Provide mouth care as per ADL personal hygiene. During observation and interview on 04/08/24 at 8:50 AM, Resident #76 placed his hand over his mouth during communication. He said he needed to see a dentist but was told that he had to pay for a dental visit. He said he eats what he can. He said all his teeth on his upper oral cavity are almost gone. He said he had two teeth on each side of his mouth. He said he had none on his lower oral cavity but eat what he can. During an interview with facility social worker on 04/09/24 at 2:00PM, she said Resident # 76 was a full vendor and he had to pay for his dental care service out of pocket. She said she would check on Resident #8's insurance provider if he was covered for dental care. During a follow up interview on 04/10/24 at 1:50PM, the Social Worker said she had spoken with Resident #76's insurance provider and resident was covered for routine dental care, and she would refer Resident #76 to a dentist. Record review of facility's policy on referral dated 2001 revised 2008 read in part- Policy Statement. Social services personnel shall coordinate most resident referrals with outside agencies. Social services will document the referral in the resident's medical record. Social services and administration will maintain a listing of referral agencies that may provide assistance or therapy to residents with special problems and/or needs. Social services will help arrange transportation to outside agencies, clinic appointments, etc., as appropriate.

Based on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 6 residents (Resident #15), 1 of 1 medication storage rooms, and 1 of 3 medication carts, reviewed for pharmacy services in that: 1. The facility failed to order medications timely for Resident #15 which resulted in missed administration observed on 2/22/23. 2. The facility failed to ensure that expired medications were not stored with current medications in the medication storage room and the medication cart. This failure could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns. Findings included: 1. Record review of Resident # 15's face sheet dated 02/23/23 revealed a [AGE] year-old female with an admitted [DATE], diagnoses included dehydration (abnormal water loss from the body), malignant neoplasm of liver (cancer of the liver), diabetes mellitus due to underlying condition with diabetic polyneuropathy (inability of the pancreas to produce insulin to bring blood sugar levels down due to another condition, with nerve pain), disease of biliary tract (problems with tubes that drain bile from the liver), pressure ulcer of sacral region, unstageable (pressure ulcer near the buttocks that is not known how deep it is), muscle wasting and atrophy (loss of muscle making them smaller and weaker), muscle weakness, cognitive communication deficit (difficulty with thinking or how someone uses language). Record review of Resident # 15's physician order summary report with start date 1/19/23 had the following medication to be given by mouth. Zinc Sulfate Tablet Give 1 tablet PO QD for supplement, to aid in wound healing. The physician order summary report also revealed an order with a start date of 2/7/23 for Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. Record review of Resident # 15's Comprehensive MDS dated [DATE] revealed a BIMS score of 06 out of 15, indicating severe impairment with her cognition. Resident #15 required limited to extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. She did not have any functional limitations with her upper or lower extremities. Resident #15 was unable to walk and used a wheelchair to get around the facility. She was always incontinent of bowel and bladder and was not on a toileting program. Resident #15 did not have trouble swallowing and was on a therapeutic diet. According to the MDS, Resident #15 had 4 unstageable pressure ulcers present on admission. Record review of Resident #15's baseline care plan with date 1/17/23, revealed she had unstageable pressure ulcer/pressure injury to her sacrum (tailbone) with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer/pressure injury r/t disease process cholangiocarcinoma (cancer of the bile ducts) with biliary obstruction s/p biliary stent and biliary drainage (a device to open the bile ducts to allow for drainage). Stage III to left buttocks, stage III to right buttocks and DTI to right heel. The resident's pressure ulcer/pressure injury will show signs of healing and remain free from infection by/through review date: Administer medications, supplements and/or treatments as ordered. Resident #15 had unplanned/unexpected weight loss r/t acute illness: Give the resident supplements as ordered. Alert nurse/dietician if not consuming on a routine basis. Observation and interview on 2/22/23 at 8:58 am Med Tech A revealed the medications (Zinc Sulfate and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate) were not on the medication cart and were not available to give to Resident #15 on 2/22/23. Med Tech A stated the physician ordered medications were not available to give to Resident #15 on 2/22/23 because they were back ordered from the pharmacy. Record review of Resident #15's MAR for February 2023 revealed an order Zinc Sulfate Tablet Give 1 tablet PO QD for supplement, to aid in wound healing and Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. According to February MAR, Zinc Sulfate was not administered 1 time, on 2/22/23. Pro-Stat, according to the February MAR, was not administered 5 times: 2/17/23 in the AM, 2/19/23 in the AM and PM, 2/20/23 in the AM, and 2/22/23 in the AM. Record review of clinical nurse's progress notes dated 2/17/23 at 11:08am, 2/19/23 at 11:57am, 2/19/23 at 9:13pm, 2/20/23 at 12:33pm, and 2/22/23 at 9:31am for Resident #15 revealed medication was back ordered for Pro-Stat Oral Liquid. The clinical nurses progress note dated 2/22/23 at 9:31am revealed medication was also back ordered for Zinc Sulfate. Record review of Resident #15's clinical record revealed no documentation or fax indicating the doctor was notified of the medications missed by the resident. Interview on 2/23/23 at 9:56am with LVN A stated the staff called the MD if the resident had not received the missed medication for at least 3 days, unless it was a significant medication like seizure medication then they called right away. She said the documentation of the call was in the medication administration note. LVN A stated the MD would then decide to discontinue the medication or change it depending on what the medication was and what the reason was for not having it, like insurance approval or being back ordered. LVN stated a lot of the time the reason they did not have the medication was due to insurance reasons. Interview on 2/23/23 at 10:50am with LVN B, the nurse for another hall, revealed they notified the MD the same day a medication was not available or was back ordered and not available to give to a resident. She also stated they documented the conversation in the progress note. LVN B stated they also notified pharmacy to see if it was insurance related so pharmacy could help get it resolved. Interview on 2/23/23 at 10:55am with LVN A again revealed she was aware Zinc Sulfate and Pro Stat were back ordered; however, she was not aware the Pro Stat had been back ordered for so long, and that so many doses were missed. She stated the Pro Stat should be here any day and she would check with pharmacy to find out when. LVN A stated the MD was aware the medications were back ordered; however, she was unable to find any documentation stating this. She stated she must have told the MD verbally and forgot to document it. Interview on 02/23/23 at 1:45pm with the ADON revealed she had not been made aware of Resident #15's Zinc Sulfate and Pro-Stat not being available for administration. She stated the nursing staff should have notified the physician if the medications were not available because the risk is that Resident #15's wound could get worse or stop healing. Record review of facility's Medication and Treatment Orders policy (revised July 2016) read in part: Policy Interpretation and Implementation: 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy (revised May 2022) read in part: Assessment and Recognition: 6.Staff will identify significant factors that may affect medication effectiveness and medication-related problems . Cause Identification: 2.staff will evaluate the effectiveness and effects of the medications in a resident's regimen. Treatment/Management: 4. The staff .will identify and address unexpected, unintended, undesirable . responses to medication based on the severity of underlying conditions .risks of worsening medical conditions, and other factors. Record review of the facility's Administering Medications policy (Revised April 2019)) read in part: .Policy: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 8. If a .medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss concerns 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . 2. Observation on 2/23/23 at 10:41am, with ADON present, revealed the following expired medications/biologicals in the medication storage room: -1 full medium sized plastic bag of purple top vacutainers (blood collection tubes), expired on 3/31/22; -1 full medium sized plastic bag of gold top vacutainers (blood collection tubes), expired on 11/30/21; -1 box of blue top vacutainers (95 out of 100 count blood collection tubes), expired 4/30/21; -15 single use containers of Vial2Bag Advanced 20mm (single use fluid transfer device) for IV (intravenous) containers, expired 8/1/22; and -3 bottles of Amoxicillin and Clavulanate Potassium for Oral Suspension, USP 400mg/57mg expired 2/11/23 in the refrigerator. Further observation on 2/23/23 at 10:41am revealed a sign posted on the cabinet door under the handwashing sink that read, There is to be NO!!! Items in the cabinet underneath the sink. Inside the cabinet the surveyor observed 3 boxes of medications: 2 boxes of Budesonide inhalation suspension 0.5mg/2ml and 1 box of Ipratropium Bromide Albuterol Sulfate inhalation solution 0.5mg/3mg per 3ml. These medications were placed underneath the sink, below the water drainpipe. Interview on 02/23/23 at 10:53 am the ADON stated, expired medications should not be in the medication storage room because they would not be good. The ADON stated medications should not be placed underneath the sink because water could leak on the medications and that could be harmful to the resident. The ADON stated it is each nurses' responsibility to ensure that any medications they administer is not expired, removed for patient safety and all nurses had to follow the 5 rights of medication administration. Observation on 2/23/23 at 12:20pm, with LVN C present, revealed the following opened and expired medications in the nurse's medication cart: 2 blister packs of Hyoscyamine Sublingual 0.125mg tablets expired 2/8/23, with 1 opened. 3 blister packs of Promethazine 25mg tablets expired 2/8/23, with 1 opened. Interview on 2/23/23 at 12:25pm with LVN C stated there was not a policy or protocol on who or when to check for expired medications in the medication carts. She stated that she checked the medication carts every now and then for expired medications. LVN C stated that if expired medications are given, they could be less effective. Record review of the facility's Storage of Medications policy (Revised 2020) read in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary matter. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of the facility's Administering Medication policy (Revised April 2019) read in part: Policy Interpretation and Implementation: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 4 days reviewed for RN hours, in that: Facility failed to make sure there was RN coverage for 4 days in the facility. This failure could place residents at risk of not receiving related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. Findings include: Record review of facility payroll- based journal for the month of February 2023 showed there was no RN coverage for the following 4 days: - February 4th 2023. - February 5th 2023. - February 11th 2023. - February 12th 2023. During an interview on 02/23/2023 at 1:15 p.m., the Administrator stated she usually tried to stretch the RN time to cover every day, but she was not able to cover all days as she would love to. She stated she did not know how this would affect the residents because she was not a clinical person. She stated they do it because the regulation required it. During an interview on 02/23/2023 at 1:15 p.m., the ADON stated it was important for the facility to have RN coverage because the RN would be available to do what was not in the scope of an LVN and this failure could affect residents not to receive the adequate care/intervention they needed. Record review of facility staffing policy dated October 2017, line number 2 reads A Registered nurse shall be available for 8 consecutive hours per day, 7 days per week.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities, which involved 1 of 6 residents (Resident #15), and 1 of 5 staff (Med Tech A) reviewed for medication errors. Med Tech A failed to administer 2 medications (Zinc Sulfate Tablet and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate) to Resident #15 on 02/22/2023. This failure could place residents at risk for not receiving therapeutic effects of their prescribed medications and possible adverse reactions. Finding included: Record review of Resident #15's face sheet dated 02/23/23 revealed a [AGE] year-old female with an admitted [DATE], diagnoses included dehydration (abnormal water loss from the body), malignant neoplasm of liver (cancer of the liver), diabetes mellitus due to underlying condition with diabetic polyneuropathy (inability of the pancreas to produce insulin to bring blood sugar levels down due to another condition, with nerve pain), disease of biliary tract (problems with tubes that drain bile from the liver), pressure ulcer of sacral region, unstageable (pressure ulcer near the buttocks that is not known how deep it is), muscle wasting and atrophy (loss of muscle making them smaller and weaker), muscle weakness, cognitive communication deficit (difficulty with thinking or how someone uses language). Record review of Resident # 15's physician order summary report with start date 1/19/23 had the following medication to be given by mouth. Zinc Sulfate Tablet Give 1 tablet PO QD for supplement, to aid in wound healing. The physician order summary report also revealed an order with a start date of 2/7/23 for Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. Record review of Resident # 15's Comprehensive MDS dated [DATE] revealed a BIMS score of 06 out of 15, indicating severe impairment with her cognition. Resident #15 required limited to extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. She did not have any functional limitations with her upper or lower extremities. Resident #15 was unable to walk and used a wheelchair to get around the facility. She was always incontinent of bowel and bladder and was not on a toileting program. Resident #15 did not have trouble swallowing and was on a therapeutic diet. According to the MDS, Resident #15 had 4 unstageable pressure ulcers present on admission. Record review of Resident #15's baseline care plan with date 1/17/23, revealed she had unstageable pressure ulcer/pressure injury to her sacrum (tailbone) with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer/pressure injury r/t disease process cholangiocarcinoma (cancer of the bile ducts) with biliary obstruction s/p biliary stent and biliary drainage (a device to open the bile ducts to allow for drainage). Stage III to left buttocks, stage III to right buttocks and DTI to right heel. The resident's pressure ulcer/pressure injury will show signs of healing and remain free from infection by/through review date: Administer medications, supplements and/or treatments as ordered. Resident #15 had unplanned/unexpected weight loss r/t acute illness: Give the resident supplements as ordered. Alert nurse/dietician if not consuming on a routine basis. Observation on 2/22/2023 beginning at 8:58 a.m. during med pass revealed, Med Tech A prepared, dispensed, and administered 5 medications to Resident #15. The medications observed were: 1. Senna-S 8.6-50mgmg Give 1 tablet PO BID for constipation. 2. Vitamin C 500mg Give 1 PO QD to aid in wound healing. 3. Norco 10/325mg Give 1 tablet PO BID for pain. 4. Coreg 6.25 Give 1 PO BID for high blood pressure. 5. Neurontin 300mg Give 1 PO TID for neuropathy (nerve pain). Further observation revealed Med Tech A failed to administer 2 prescribed medications. 1) Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. 2) Zinc Sulfate Tablet Give 1 PO QD for supplement, to aid in would healing. Observation and interview on 2/22/23 at 8:58 am Med Tech A revealed the medications (Zinc Sulfate Tablet and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate) were not on the medication cart and were not available to give to Resident #15. Med Tech A stated the physician ordered medications were not available to give to Resident #15 on 2/22/23 because they were back ordered from the pharmacy. Record review of Resident #15's MAR for February 2023 revealed an order Zinc Sulfate Tablet Give 1 tablet PO QD for supplement, to aid in wound healing and Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. According to February MAR, Zinc Sulfate was not administered 1 time, on 2/22/23. Pro-Stat, according to the February MAR, was not administered 5 times: 2/17/23 in the AM, 2/19/23 in the AM and PM, 2/20/23 in the AM, and 2/22/23 in the AM. Record review of nurse's progress notes dated 2/17/23 at 11:08am, 2/19/23 at 11:57am, 2/19/23 at 9:13pm, 2/20/23 at 12:33pm, and 2/22/23 at 9:31am for Resident #15 revealed medication was back ordered for Pro-Stat Oral Liquid. The nurse's progress note dated 2/22/23 at 9:31am revealed medication was also back ordered for Zinc Sulfate. Record review of Resident #15's nurse's notes for February 2023, revealed no documented evidence found that the doctor was notified of the missed doses on February 22, 2023, or any of the other dates in February, for the medications prescribed (Zinc Sulfate Tablet and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate). Interview on 2/23/23 at 9:56am with LVN A stated the staff called the MD if the resident had not received the missed medication for at least 3 days, unless it was a significant medication like seizure medication then they called right away. She said the documentation of the call was in the medication administration note. LVN A stated the MD would then decide to discontinue the medication or change it depending on what the medication was and what the reason was for not having it, like insurance approval or being back ordered. LVN stated a lot of the time the reason they did not have the medication was due to insurance reasons. Interview on 2/23/23 at 10:50am with LVN B, the nurse for another hall, revealed they notified the MD the same day a medication was not available or was back ordered and not available to give to a resident. She also stated they documented the conversation in the progress note. LVN B stated they also notified pharmacy to see if it was insurance related so pharmacy could help get it resolved. Interview on 2/23/23 at 10:55am with LVN A again revealed she was aware Zinc Sulfate and Pro Stat were back ordered; however, she was not aware the Pro Stat had been back ordered for so long, and that so many doses were missed. She stated the Pro Stat should be here any day and she would check with pharmacy to find out when. LVN A stated the MD was aware the medications were back ordered; however, she was unable to find any documentation stating this. She stated she must have told the MD verbally and forgot to document it. Interview on 02/23/23 at 1:45pm with the ADON revealed she had not been made aware of Resident #15's Zinc Sulfate and Pro-Stat not being available for administration. She stated the nursing staff should have notified the physician if the medications were not available because the risk is that Resident #15's wound could get worse or stop healing. Record review of facility's Medication and Treatment Orders policy (revised July 2016) read in part: Policy Interpretation and Implementation: 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy (revised May 2022) read in part: Assessment and Recognition: 6.Staff will identify significant factors that may affect medication effectiveness and medication-related problems . Cause Identification: 2.staff will evaluate the effectiveness and effects of the medications in a resident's regimen. Treatment/Management: 4. The staff .will identify and address unexpected, unintended, undesirable . responses to medication based on the severity of underlying conditions .risks of worsening medical conditions, and other factors. Record review of the facility's Administering Medications policy (Revised April 2019) read in part: .Policy: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 8. If a .medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss concerns 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug .

Based on record review, and interview, the facility failed include the resident and the resident's representative in the development of their comprehensive care plan for 1 of 10 sampled residents (Resident#16). The facility failed to notify Resident #16's Representative Party of the care plan meeting date This failure could place the residents at risk for improper care for the resident, and not being informed of potential life-threatening conditions. Findings included: Record review of R#16's face sheet dated 06/10/22 indicated a [AGE] year-old-female who was admitted to the facility on [DATE] and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of R#16's face sheet dated 06/10/22 revealed that she had a Responsible Party listed as one of her contacts. In an interview on 08/19/22 at 12:20pm with the R#16 Responsible Party she stated that she did not receive any notification from the facility that R#16 had a scheduled meeting to discuss her care plan. In an interview on 08/19/22 at 1:25pm with the facility's Administrator, she stated that she could not find a copy of a letter notifying the R#16 or the resident's representative. The Administrator stated that it was obvious that a letter was not sent to the resident or the resident's representative. In an interview on 08/19/22 at 1:35 pm, the Director of Nurses stated that they held R #16's care plan dated 06/10/22, since she was readmitted to the facility. She further stated that she was not the one that sends out the notification to the resident and the resident's representative. It is the Social Workers responsibility to notify the Resident and their responsible party if the Resident has one. In an interview on 08/30/22 at 11:30am with the Social Worker, she stated that she just started her position on 08/01/22. She was asked what the process was for notifying a Resident or a Resident representative to their care plan meeting. The Social Worker said that a letter should be sent to the resident and if the Resident has a representative then a letter should be sent to the representative.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 1 of 5 residents (CR #1) reviewed for quality of care. -The facility failed to transfer CR#1 to the hospital for wound care once informed the Wound MD was unable to enter the facility and after the residents' wound and lab results continued to rapidly deteriorate. -The facility failed to transfer CR#1 to the hospital after three sets of critical labs on three consecutive days indicating the resident had a severe infection resulting [MEDICAL CONDITION], acute [MEDICAL CONDITION]/injury, and death. -The facility failed to properly inform CR#1's RP of the severity of the critical lab results and wound infection. These failures resulted in an immediate jeopardy on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures placed residents with critical lab values at risk of inadequate care, wound deterioration, decline in health, or hospitalization . Findings include: Record review of CR#1's face sheet revealed an [AGE] year-old-female admitted on [DATE] with [DIAGNOSES REDACTED]. She was discharged on [DATE] to an acute care hospital. Record review of CR #1's Care plan dated [DATE] read in part, The resident has shearing injury to right buttocks with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer/pressure injury r/t disease process, Hx of pressure ulcers or pressure injury, Immobility, Incontinent of Bladder, Incontinent of Bowel, Non-compliance with turning/repositioning, Weight loss/weight gain/evidence of inadequate nutrition and/or hydration. The resident will show signs of healing and remain free from infection. The resident will have intact skin, free of redness, blisters or discoloration, administer medications, supplements and/or treatments as ordered. Encourage adequate intake of hydration and nourishment to aid in wound healing. Monitor/document for side effects and effectiveness. Refer to/consult with RD. Conduct a complete head-to-toe skin assessment on a weekly basis. Further record review of CR #1's Care plan dated [DATE] read in part, If new skin breakdown occurs, promptly inform the resident/resident representative, Physician, Director of Nursing, Treatment Nurse and Registered Dietician of any new area of skin breakdown. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Encourage and provide education to the resident/resident representative and staff to keep the bed as flat as possible to reduce shear and avoid positioning resident in a manner that allows additional pressure to affected area. Ensure a pressure reduction cushion is in the resident wheelchair. Further record review of CR #1's Care plan dated [DATE] read in part, Evaluate/record/monitor wound healing with each dressing change. Measure length, width and depth (where possible) at least one time per week. Evaluate and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Request consult with wound care specialist when necessary . Inform MD of efforts and outcomes. Keep skin clean and dry. Provide incontinent care as quickly as possible following episodes of voiding or bowel movement, dry gently and thoroughly after bathing, and/or if perspiration is prevalent ensure prompt changing of clothing/linen. Further record review of CR #1's Care plan dated [DATE] read in part, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . Record review of CR#1's nursing progress notes dated [DATE] at 07:18am writer Treatment nurse read in part, Sacral excoriation has exacerbated; unstageable wound incorporated into right buttocks blister. Measurement 6.2x5.8x? Depth undeterminable due to 100% non-viable tissue. Minimal/serous drainage, no odor, light [DIAGNOSES REDACTED]. Will consult with NP upon arrival. Site dressed as ordered. Further record of CR#1's nursing progress notes dated [DATE] at 11:23am writer Treatment nurse read in part, Call placed to NP, for MD. Informed her of resident's current wound condition, interstitial fluid in right arm, decreased appetite and lower abdominal pain. Consulting with MD, at this time. Call placed to RP informed her of resident's current condition, same as reported to NP. Consent given for resident to be seen by wound care MD in the a.m.; consent also given for bedside debridement, if necessary. Record review of nursing progress notes dated [DATE] at 6:52 pm, [DATE] at 5:09 pm, [DATE] at 3:57 am revealed, critical labs showed CR#1 had an elevated WBC count, BUN level, and BUN/Creatinine ratio indicating acute [MEDICAL CONDITION]/injury, dehydration, and infection. Record review of CR #1's lab results dated [DATE] revealed, a critical elevated BUN level of 96, an elevated BUN/Creatinine level of 48, and an elevated WBC count of 20.8. Further record review of CR #1's lab results revealed, a decreased [MEDICATION NAME] level of 7.5. Record review of CR #1's lab results dated [DATE] revealed, a critical elevated BUN level of 104, a critical elevated BUN/Creatinine level of 52, and an elevated WBC of 25.6. Further record review of CR #1's labs revealed, a decreased total protein level of 4.6. Record review of CR #1's lab results dated [DATE] revealed, an elevated WBC count of 29.3. Record review of CR #1 lab results dated [DATE] revealed, a critical elevated BUN level of 103, and a critical elevated WBC count of 36.2. Record review of Gamma Healthcare Lab normal reference ranges revealed, a BUN range of ,[DATE]mg/dl, BUN/Creatinine ratio range of ,[DATE] mg/dl, WBC count range of 4XXX,[DATE].0 k/ul, Protein, total range of 6XXX,[DATE].9 g/dl, and a [MEDICATION NAME] range of ,[DATE] mg/dl. Record review of Medscape's BUN interpretation dated [DATE] read in part, Possible critical value: >100 mg/dl indicates seriously impaired renal function. Record review of ABC's of Interpretive Laboratory Data dated 2002 revealed, a BUN/Creatinine ratio of 15 to ,[DATE] indicative of dehydration, a ratio of >,[DATE] indicative of Prerenal/Postrenal azotemia (a condition that that is characterized by abnormally high levels of nitrogen waste products in the blood). Record review of Medscape's Leukocyte Count (WBC) interpretation dated [DATE] read in part, An elevated WBC count is seen in response to infection, stress, [MEDICAL CONDITION] disorders. Record review of Gamma Healthcare Lab [MEDICATION NAME] interpretation read in part, ,[DATE] mg/dl Severe protein depletion, ,[DATE] mg/dl Moderate protein depletion, ,[DATE] mg/dl Mild protein depletion. Record review of ABC's of Interpretive Laboratory Data dated 2002 read in part, The main clinical use of [MEDICATION NAME] levels is for monitoring nutritional status. Record review of ABC's of Interpretive Laboratory Data dated 2002 revealed, causes of decreased total protein levels include; [MEDICAL CONDITION], nephroti[DIAGNOSES REDACTED], malnutrition, malabsorption, chronic debilitating disease. Record review of nursing progress notes dated [DATE] at 7:29 am writer LVN A revealed, a new order from the NP to send CR#1 to the ER due to elevated WBC count of 29.3 Further record review of nursing progress notes dated [DATE] at 8:19 am writer LVN A revealed, the NP called the facility and stated the MD did not want CR #1 to go to the ER since she was just started on IV antibiotics, and to closely monitor and start IV [MEDICATION NAME] for 7 days. A CBC and BMP was ordered. Record review of CR #1's physician orders [REDACTED]. Further record review of CR #1's physician orders [REDACTED]. Further record review of nursing progress notes dated [DATE] at 7:25 am writer Treatment nurse read in part, Wound has changed: appearance is gray/yellow. Moderate/serous drainage, strong odor detected, light [DIAGNOSES REDACTED] noted to peri-wound. Size has increased to 7.2x8.0; unable to determine depth due to 100% non-viable tissue. Cleaned and dressed as ordered. Floor nurse made aware; NP has been called about other conditions. Awaiting return call back. Further record review of nursing progress notes dated [DATE] at 7:41 am read in part, Nurse informed about a critical lab for resident, BUN 103, WBC 36.2. Informed on call for MD, new order given for BLOOD CULTURE X1, 0.9NS AT 70ML/HR, REPEAT CBC, BMP 24HRS AFTER LAST DRAW. Further record review of nursing progress notes dated [DATE] at 8:30 am revealed, CR #1 was sent to the ER after a change in condition and after the fourth set of critical lab results showed an elevated WBC count and BUN level. Record review of CR#1's SBAR Communication Form and progress note dated [DATE] writer LVN A revealed, the change in condition, symptoms, or signs included elevated WBC 36.2, Vital Signs Pulse: 115, Mental Status Changes 1d. Decreased consciousness (sleepy, lethargic) was checked. Further record review of CR#1's SBAR Communication Form and progress note dated [DATE] writer LVN A read in part, Nursing Notes (for additional information on the Change in Condition): resident noted decreased consciousness and elevated WBC 36.2, NP notified new order send to hospital, RP notified, arranged transportation . Interview on [DATE] at 9:21 am with LVN A, when asked if CR#1 had wounds that were being treated, she stated she was not working between [DATE] to approximately [DATE], she said when she came back, she had a wound on her sacrum stating she thought it was a St III or IV PU. She said the Treatment nurse was doing daily wound treatments. When asked if the Wound MD assessed and/or was treating the residents wound, she stated the wound MD had not seen the resident. She stated the wound MD was supposed to assess and complete wound debridement on ,[DATE] but he never entered the facility due to COVID exposure at a previous facility. She further stated he could not enter the facility for 14 days per CDC guidelines. Further interview on [DATE] at 9:21 am with LVN A, when asked if another Wound MD was contacted to treat CR#1's sacral wound, she stated, no the resident was not seen by another Wound MD. When asked if she noticed any changes to the residents' behavior or condition, she stated the resident wasn't eating much further stating she also had abnormal lab results. She said the treatment nurse called the MD and RP because the wound was deteriorating. She said the resident was started on [MEDICATION NAME] then [MEDICATION NAME] for a wound and UTI infection. She stated the resident was sent out because her renal function was declining, and she was not eating. Interview on [DATE] at 11:28 am with the Administrator, when the surveyor informed the Administrator there was no documentation in the progress notes showing wound care was completed on CR#1's right buttock blister ,[DATE]-,[DATE]. Then on ,[DATE] the Treatment nurse documented in a progress note a sacral excoriation which exacerbated measuring 6.2 x 5.8. When asked why CR#1 was not transferred out for wound care if the Wound MD could not treat/manage the infected wound when wound care was ordered and consent obtained for debridement? The Administrator stated she was under the impression the NP and MD were doing telemedicine visits and were aware of the residents wound. When asked if the resident had s/s of infection, malnutrition, critical labs, and a declining renal function, should she have been sent out for higher level of care if the facility was unable to manage the wound and infection, she said regardless of COVID if a resident has to be sent out then they would, but she thought the NP and MD knew the severity of the wound. She said the wound MD had a back log and just doesn't come to this facility. She then asked if a debridement would have made a difference. Telephone interview on [DATE] at 1:23 pm with the NP, she stated she did not remember how long the wound was present but stated she would ask how CR#1 was doing for several weeks. She said she knew the resident was battling poor appetite and depression for months stating her weight had stabilized and she was hanging in there and after speaking to the psychiatrist it was recommended to increase the residents [MEDICATION NAME] to better manage her depression. She stated when she spoke to the Treatment nurse, she said the resident had what she described as a blister that ruptured and stated there was no changes. She stated the resident did not like to turn, and was always flat on her back, stating staff would try to turn her and position her on pillows, but she would just turn back onto her back. She said on ,[DATE] the Treatment nurse informed her the wound had deteriorated and spread to her sacrum. She said she came into the facility on Monday after being informed, and she was told the resident was not eating even when the staff tried to feed her. She stated she ordered labs, a Wound MD consult, and consent for bedside debridement if necessary. Further telephone interview on [DATE] at 1:23 pm with the NP, she stated when the labs came back the next day, the resident had elevated WBCs and she still was not feeling great and not eating. She stated the resident also had a UTI and was dehydrated so she ordered IV fluids and [MEDICATION NAME] to treat the UTI and to recheck labs in the morning. She stated when those labs came back, more fluids were ordered because of her elevated BUN and she was still dehydrated, she stated she and the MD discussed transferring the resident but with the COVID risk they felt it was best to keep her at the facility. She further stated LVN A had informed her the resident was doing better and eating, so she felt clinically, the IV antibiotics may be kicking in so she did not think at that time the resident needed to be transferred. She said the Treatment nurse contacted her on ,[DATE] in the morning stating the wound wasn't looking good, so she and the MD decided to repeat labs in the morning and monitor the resident for another 24 hours. Further telephone interview on [DATE] at 1:23 pm with the NP, when asked if the RP was fully aware of the severity of the wound infection and the critical labs, she stated the RP was contacted to let her know they did not want to transfer the resident because of the COVID and she agreed to keep the resident at the facility. She stated the next day she received a call stating the resident had critical labs and her WBC count was in the 30s, so she and the MD had a discussion and they wanted to continue to monitor closely and repeat labs in the morning the following day. She stated the resident was transferred because of an elevated WBC count and change in mental status. When asked if the resident should have been transferred considering the resident had a severe infection, multiple critical labs, lab results showing possible malnutrition, and the wound MD could not treat or debride the infected wound, she stated the resident was in bad shape and at the time, because of the COVID they did the best they could and they kept her at the facility as long as they could given the situation. Telephone interview on [DATE] at 2:04 pm with CR #1's family member, when asked if the facility contacted her and informed her of the severity of the wound infection and critical lab results, she stated the Treatment nurse called her on [DATE] and told her they had found a wound two weeks prior and it was small. She said she was told over the weekend it blew up further stating she was trying to figure out how did it just, blow up. She stated she called them back the next day because she wanted to know why it took two weeks to notify her about the wound stating the Treatment nurse did tell her the wound was infected. She said she was not aware of the size of the wound until the resident went to the hospice center stating the wound was a size of a dinner plate. Further telephone interview on [DATE] at 2:04 pm with CR #1's family member. She stated she was not aware of the severity of the labs, stating she was told the labs came back and with an elevated WBC count and it was probably from the infection. She stated they were more interested in telling her (CR #1) was refusing to eat. Said she did not know about any other critical labs other than the WBC count. She said she was told they would try to get the Wound MD in, but he could not enter due to CDC guidelines. She stated the only time she had a sense of urgency was on Thursday morning when they told her they were going to take her to the hospital. She stated that same day, they called back and then said they weren't going to take her because they were going to see if the antibiotics were going to manage the infection and said she didn't know who made that decision. When asked if she was aware of the severity of the problems with the residents' kidneys, she said she was told she did have some changes to her kidneys. When asked if she spoke to the NP or MD regarding the residents' condition, she stated she spoke to the NP after multiple attempts of trying to contact her, but it was about something else. She said she never spoke to the NP or MD about the wound or infection. She stated she did not know the severity of the WBC count and infection until she looked it up herself. She stated CR#1 expired on ,[DATE] shortly after being placed on hospice. Interview on [DATE] at 8:54 am with the DON and Treatment nurse, when asked once notified the Wound MD was unable to enter the facility, was another Wound MD contacted to determine if he/she could assess and/or treat the resident, the DON stated the Wound MD works in a group and another Wound MD could have come out, but the Medical Director wanted to wait two weeks to see if the wound would heal first before sending someone out to assess and or treat the wound. Further interview on [DATE] at 8:54 am with the DON, when asked if any nursing staff responsible for the care of CR#1 requested the NP and/or MD transfer the resident when they were aware multiple labs results showed her WBC count and renal function were critical and not improving after interventions and her wound was deteriorating quickly, the DON said No, we did call the MD and he said to do this, & this, & this and if it doesn't' work, then we will take the next steps. The DON further stated, she did not ask the MD or NP ask why she was not being sent out. She further stated when the WBC count continued to increase, and the labs were not looking good the resident was sent out. Telephone interview on [DATE] at 9:57 am with the Wound MD, when asked if he ever saw and/or treated CR#1's wounds after an order for [REDACTED].#1 should have been transferred out of the facility for wound care and to manage the infection considering she had a series of critical labs, poor appetite with weight loss, diabetes, and a wound that was deteriorating rapidly, he stated based an educated case, if she was unstable, further stating he did not know what her vital signs were, but if her WBCs were rapidly elevating she would be transferred. He stated usually if a wound was significant and deteriorating quickly, sometimes he would refer for treatment at a higher level of care if there were concerns [MEDICAL CONDITION]. He stated he thinks she was a candidate to transfer earlier because of the critical labs and co-morbid conditions, further stating if the wound was rapidly progressing he would have recommended she be sent out for more acute care. Record review of CR#1's Hospital Surgical Consultation Note dated [DATE] read in part, [AGE] year old lady with a medical history significant for diabetes, hypertension, [MEDICAL CONDITION], gastroparesis, dementia with Lewy bodies, previous [MEDICAL CONDITION], presents to hospital from nursing home for worsening sacral decubitus pressure ulcers. Apparently, there is been deterioration of the sacral decubitus pressure ulcers associated with fouls smell, necrotic tissue, as well as purulent drainage that has progressed and not improved despite medical management. Due to the frank infected nature of the wound, she was brought in here for further evaluation and work-up. Indeed, confirmed a necrotic purulent devitalized wound with foul smell prompting surgical intervention . Further record review of CR#'1s Hospital Surgical Consultation Note dated [DATE] read in part, Musculoskeletal: Necrotic foul-smelling sacral decubitus pressure ulcer measuring at least 15 x 20 cm with purulent discharge and drainage . Assessment: [AGE] year-old lady with: 1. Sacral decubitus pressure ulcer, 2.[MEDICAL CONDITION] 3. Urinary tract infection 4. Acute kidney injury . Record review of CR#1's Hospital Discharge Summary dated [DATE] read in part, Date of discharge [DATE]. Discharge Diagnosis: [REDACTED].Patient seen examined [DATE]. [MEDICATION NAME] in blood along with Proteus and E. Coli and [MEDICATION NAME] in the wound of the sacrum .Worsening leukocytosis noted, continue with current antibiotic regimen. Poor prognosis overall, bedridden status .Patient seen on [DATE] Patient with [MEDICATION NAME] bacteremia, sacral decubitus ulcer status [REDACTED]. Bedridden, not clinically improving. Worsening metabolic acidosis. Lactic acidosis seen today also. [MEDICATION NAME] drip started. [DIAGNOSES REDACTED]: Noted, replace now. Worsening renal function. Poor prognosis, overall not improving. [MEDICAL CONDITION]ly due to DIC [MEDICAL CONDITION]. Detailed in-depth conversation with (family member) today .Family expect patient to not suffer anymore and therefore will be aiming for hospice placement at this time . The facility Administrator, DON, and ADON were notified on [DATE] at 10:12 AM that an IJ situation had been identified due to the above failures. The IJ template was provided. A Plan of Removal was submitted by the Administrator on [DATE]. After several revisions, the final Plan of Removal was accepted on [DATE] at 9:06 AM. The plan of removal included the following: Facility Notified of the Immediate Jeopardy - [DATE] Date Removal Plan Developed - [DATE] Date All Tasks of the Removal Plan initiated - [DATE] Date Removal Plan planned to be fully implemented - [DATE] PLAN FOR REMOVAL OF IMMEDIATE JEOPARDY - [DATE] Task 1 - The facility shall conduct full skin assessments of the entire resident population. Any identified areas of pressure injury are identified and documented appropriately. Date of Task #1 initiated [DATE]. Task #1 completed [DATE]. Task 2 - Facility RN to complete head to toe assessment of all identified residents with Stage III and Stage IV wounds to assure that the resident is not experiencing immediate care needs. Date of Task #2 initiated [DATE]. Task #2 completed [DATE]. Task 3 - Facility RN to complete head to toe assessment of all other residents requiring wound care to assure that the resident is not experiencing immediate care needs. Date of Task #3 initiated [DATE]. Task #3 completed [DATE]. Task 4 - Upon completion of the assessment any identified immediate care needs, including but not limited to new or worsening skin conditions, abnormal lab values, changes in condition, changes in orders shall be presented to the attending physician by the facility RN for further guidance, direction, and orders. Date of Task #4 initiated [DATE]. Task #4 to be completed [DATE]. Task 5 - The facility shall assure that any identified wounds are appropriately documented in the Skin and Wound module by the facility. This module includes a photograph and measurements of the wound that the attending physician or the wound care physician can review remotely and provide further guidance, direction and, orders. Date of Task #5 initiated [DATE]. Task #5 to be completed [DATE]. Task 6 - Upon completion of the assessments any identified care needs, including but not limited to new or worsening skin conditions, abnormal lab values, changes in condition, changes in orders shall be presented to the Resident Representative. Date of Task #6 initiated [DATE]. Task #6 completed [DATE]. Task 7 - Communication to Wound Care physician group regarding onsite visitation during COVID. An alternate physician shall be available to evaluate residents in the event the assigned physician has been exposed to COVID. The facility and physician also have Telemedicine and Skin and Wound module of the electronic health record to communicate. Date of Task #7 initiated [DATE]. Task #7 completed [DATE]. Task 8 - Communication to the attending physicians that the facility shall accommodate the Wound Care physician group regarding onsite visitation during COVID. An alternate physician shall be available to evaluate residents in the event the assigned physician has been exposed to COVID. The facility and physician also have Telemedicine and Skin and Wound module of the electronic health record. Date of Task #8 initiated [DATE]. Task #8 completed [DATE]. Task 9 - Licensed nursing staff shall be immediately inserviced regarding use of clinical judgement regarding concerns to transfer a resident to a higher level of care. Licensed nursing staff shall be trained before returning to work or assuming job responsibilities. Concerns may be presented to a member of nursing management, the facility Administrator, the Corporate Compliance line, and/or one of the facility Medical Directors. This inservice shall begin immediately and continue until all licensed nursing staff have been properly inserviced. Date of Task #9 initiated [DATE]. Task #9 to be completed [DATE]. Task 10 - Wound care nurse RN, WOCN, consultant to review Skin and Wound Module in the electronic medical record compared to Weekly Skin Report for accuracy. Any identified areas of concerns shall be addressed with the Director of Nurses, or Assistant Director of Nurses for further communication to the attending physician and/or wound care physician. Date of Task #10 initiated [DATE]. Task #10 to be completed [DATE]. Task 11 - Licensed nursing staff shall be inserviced the wound care nurse, RN, WCON, regarding identification and treatment to residents with pressure injuries [DATE]. Licensed nursing staff shall be trained before returning to work or assuming job responsibilities. This inservice shall begin immediately and continue until all licensed nursing staff have been properly inserviced. Date of Task #11 to be scheduled. Task 12 - Licensed nursing staff shall be immediately inserviced regarding communicating to the physician, and the family or Resident Representative regarding new or worsening skin conditions, abnormal lab values, changes in condition, and/or changes in orders. This inservice shall begin immediately and continue until all licensed nursing staff have been properly inserviced. Licensed nursing staff shall be trained before returning to work or assuming job responsibilities. Date of Task #12 initiated [DATE]. Task #12 to be completed [DATE]. Task 13 - Licensed nursing staff shall be immediately inserviced regarding the facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol. This inservice shall begin immediately and continue until all licensed nursing staff have been properly inserviced. Licensed nursing staff shall be trained before returning to work or assuming job responsibilities. Date of Task #13 initiated [DATE]. Task #13 to be completed [DATE]. Task 14 - Certified Medication Aides and Certified Nurse Aides were trained regarding reporting skin observation and reporting skin conditions to the charge nurse immediately. This inservice shall begin immediately and continue until all Certified Medication Aides and Certified Nurse Aides have been properly inserviced. Certified Medication Aides and Certified Nurse Aides shall be trained before returning to work or assuming job responsibilities. Date of Task #14 initiated [DATE]. Task #14 to be completed [DATE]. Task 15 - The Director of Nurses, or designee shall review lab values on a daily basis and will ensure that the attending physician is notified. Date of Task #15 initiated [DATE]. Task #15 to be ongoing. Task 16 - The Director of Nurses, or designee shall complete wound rounds with the Treatment nurse. This shall begin immediately and on a weekly basis. Date of Task #16 initiated [DATE]. Task #16 to be ongoing. The surveyor monitored the POR and included the following: Record review of Task #1 resident full skin assessments dated [DATE] revealed, skin assessments completed on all residents along with documentation of new and/or old PU wounds or skin concerns. Record review of Task #2 head-to-toe assessments dated [DATE] of residents with St III and IV PU revealed, head-to-toe assessments completed by the DON on 11 residents with no immediate needs identified in the residents assessed. Record review of Task #3 head-to-toe assessments of remaining residents requiring wound care dated [DATE] revealed, the remaining residents assessed by the DON did not have any immediate care needs identified. Record review of Task #4 resident RP and physician notification for further guidance for all residents assessed with [REDACTED]. Record review of Task #5, documentation of the Treatment nurses notes for identifiable wounds revealed, wound appropriately documented in the Skin and Wound Module, including pictures and measurements completed on [DATE]. Record review of Task #6, RP notified of resident immediate care needs (new or worsening skin conditions, abnormal lab values, changes in condition, changes in orders) revealed, documentation stating assessments were completed and there were no immediate care needs identified, RP were not notified since there were no immediate needs identified. Record review of Task #7 Communication to Wound Care physician group MD regarding onsite visitation during COVID, and Telemedicine and Skin and Wound module of the EHR for the facility physician revealed, on ,[DATE] the Wound MD, the facility Medial Director and facilities physicians were all notified of onsite visitation during COVID and the need for an alternate physician will be assigned in the event the assigned wound MD is exposed to COVID. Further record review of the communication revealed, all facility physicians notified of Telemedicine and the Skin and Wound module of the EHR to communicate with. Record review of Task #8 Communication to the attending physicians that they shall accommodate the Wound MD group if the assigned MD is unable to visit the facility due to COVID exposure revealed on ,[DATE] the facility Medial Director and attending physicians were all notified o (TRUNCATED)

Based on interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to prevent development and worsening of pressure ulcers to 1 of 5 residents (CR#1) reviewed for pressure ulcers. -The facility failed to ensure CR#1 received appropriate and timely wound care once an unstageable infected sacral wound was identified on [DATE] resulting in [MEDICAL CONDITIONS], and subsequent death. -The facility failed to transfer CR#1 to the hospital for wound care once informed the Wound MD was unable to enter the facility due to COVID exposure and after the residents' wound and lab results continued to rapidly deteriorate. -The Treatment nurse failed to appropriately monitor and document CR#1's wound progression on the weekly Skilled Nurse Assessment, nurses progress notes, and Weekly Pressure Ulcer Reports. -The facility failed to transfer CR#1 to the hospital after three sets of critical labs were received on [DATE], [DATE], and [DATE] indicating the resident had a severe infection resulting [MEDICAL CONDITION], acute [MEDICAL CONDITION]/injury, and death. -The facility failed to properly inform CR#1's RP of the wound onset date and size and the severity of the critical lab results and wound infection. -The facility failed to ensure CNAs and/or Shower techs appropriately documented old and/or new skin changes on the Skin Monitoring: Comprehensive CNA Shower Review sheets. -The Treatment nurse failed to document completion of CR #1's wound care on the TAR on 6 dates between February and [DATE]. These failures resulted in an immediate jeopardy on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures placed residents with wounds and/or pressure ulcers at risk of wound deterioration, a decline in health, possible hospitalization , and death. Findings include: Record review of CR#1's face sheet revealed an [AGE] year-old-female admitted on [DATE] with [DIAGNOSES REDACTED]. She discharged on [DATE] to a local hospital. Record review of CR#1's physician orders [REDACTED]. One time a day. Order date [DATE]-D/C Date-[DATE]. Record review of facility's Weekly Non-Pressure Ulcer Report week ending [DATE] revealed, documentation of a new facility acquired right buttock, open blister with an onset date of [DATE] measuring 1.4 x 1.1 X .1, moist, no odor, red wound bed, no slough, peri-wound normal. Record review of CR#1's February 2020 TAR revealed, no documentation showing wound care to the right buttock blister was completed on ,[DATE] and ,[DATE]. Record review of CR#1's nursing progress notes dated [DATE], writer Treatment nurse read in part, .Open blister to right buttock measures 1.0 x 1.0 x .2 (cm); 90% granulating tissue, 10% white non-viable tissue. Moist, no odor, no [DIAGNOSES REDACTED]. No change to treatment. Record review of CR #1's Care plan dated [DATE] read in part, The resident has shearing injury to right buttocks with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer/pressure injury r/t disease process, Hx of pressure ulcers or pressure injury, Immobility, Incontinent of Bladder, Incontinent of Bowel, Non-compliance with turning/repositioning, Weight loss/weight gain/evidence of inadequate nutrition and/or hydration. The resident will show signs of healing and remain free from infection. The resident will have intact skin, free of redness, blisters or discoloration, administer medications, supplements and/or treatments as ordered. Encourage adequate intake of hydration and nourishment to aid in wound healing. Monitor/document for side effects and effectiveness. Refer to/consult with RD. Conduct a complete head-to-toe skin assessment on a weekly basis. Further record review of CR #1's Care plan dated [DATE] read in part, If new skin breakdown occurs, promptly inform the resident/resident representative, Physician, Director of Nursing, Treatment Nurse and Registered Dietician of any new area of skin breakdown. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Encourage and provide education to the resident/resident representative and staff to keep the bed as flat as possible to reduce shear and avoid positioning resident in a manner that allows additional pressure to affected area. Ensure a pressure reduction cushion is in the resident wheelchair. Further record review of CR #1's Care plan dated [DATE] read in part, Evaluate/record/monitor wound healing with each dressing change. Measure length, width and depth (where possible) at least one time per week. Evaluate and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Request consult with wound care specialist when necessary . Inform MD of efforts and outcomes. Keep skin clean and dry. Provide incontinent care as quickly as possible following episodes of voiding or bowel movement, dry gently and thoroughly after bathing, and/or if perspiration is prevalent ensure prompt changing of clothing/linen. Further record review of CR #1's Care plan dated [DATE] read in part, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . Record review of CR#1's [DATE] TAR revealed, no documentation showing wound care to the right buttock blister was completed on ,[DATE] and ,[DATE]. Record review of CR#1's nursing progress notes dated [DATE] through [DATE] writer Treatment nurse revealed, no documentation showing progression of the right buttock blister and/or wound care completion. There was no documentation showing development of an excoriation or sacral wound until [DATE]. Record review of CR#1's Skin Monitoring: Comprehensive C.N.A. Shower Review sheets dated [DATE], [DATE], [DATE], [DATE] revealed, no documentation showing any changes new or old to the residents' skin. Further record review of CR#1's Skin Monitoring: Comprehensive C.N.A. Shower Sheet dated [DATE] revealed, an X marked on the groin area of the anatomical figure with Bed sore documented. Further record review of CR#1's Skin Monitoring: Comprehensive C.N.A Shower Review sheets dated [DATE], [DATE], [DATE], [DATE] revealed, documentation of refusal. Interview on [DATE] at 9:06 am with CNA B, when asked if she completed the showers and/or bed baths on CR#1, she stated yes, further stating CR#1's shower days were scheduled on Tuesday, Thursday, and Saturday. When asked if she noticed any changes to CR#1's skin, she stated she always bruised easily, and had skin tears. When asked if she had any wounds, she said she had one on her left arm and it was covered and she had a bed sore on her butt stating it was red. When asked if there was any dressing on the sacral area, she stated no, she said she applied the pink cream on the red area. Further interview on [DATE] at 9:06 am with CNA B, when asked what the facility's policy is if a wound is identified during a shower or bed bath, she stated she we complete the shower sheets and label where the wound is located and what we see and notify the nurse immediately. She stated every resident has a shower sheet completed by the shower tech and/or CNA and it is given to the nurse to review before the end of shift and the nurse must check the sheets. She stated the shower tech must report changes to a resident's skin immediately. When asked if she noticed any changes to CR#1's behavior within the past month, she stated about 7 months ago, the resident was able to move, talk, and about three months ago, the resident was stiff, we had to turn her every two hours and she was total care. She stated the resident's appetite decreased, stating the past couple of months, she had decreased energy and refused to eat everything and refused her baths. Further record review of the facility's Weekly Non-Pressure Ulcer Report weeks ending [DATE], [DATE], [DATE], [DATE] revealed, documentation of the right buttock open blister as improving. Further record review of the facility's Weekly Non-Pressure Ulcer Report week ending [DATE] revealed, documentation of the right buttock open blister as unchanged. Further record review of the facility's Weekly Non-Pressure Ulcer Report week ending [DATE] revealed, documentation of the right buttock blister as deteriorated. Record review of the facility's Weekly Non-Pressure Ulcer Report week ending [DATE] revealed, documentation stating the right buttock open blister changed. Interview on [DATE] at 9:56 am with the DON and Treatment nurse, when asked where wound care was documented, the Treatment nurse stated she documented on the weekly PU reports and if the wound was not a pressure ulcer, it would be documented on the weekly Non-PU report. She further stated she documented daily wound care treatment in the nursing progress notes. When informed on [DATE] there was documentation in the nursing progress note showing wound care was completed on CR#1's right buttock blister, but there was no further documentation in the progress notes showing daily wound treatments were completed or the progression of the blister into a sacral wound/excoriation until [DATE]. The Treatment nurse could not state why wound care to the right buttock blister was not documented in the nurses' progress notes. Interview on [DATE] at 9:56 am with the Treatment nurse, when informed a St II PU is a defined as blister and asked if the right buttock blister should have been documented on the weekly PU report since a blister is a PU, she stated the resident scratched herself. She said because it was a scratch, not a PU, she documented the wound on the Non-PU report further stating, the wound deteriorated so fast over the weekend. She could not state why it was not documented on the Weekly PU report. Record review of Guidelines for Staging of Pressure Ulcers dated [DATE] read in part, Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister . Record review of CR#1's Skilled Nurses Notes dated between [DATE] and [DATE] revealed, documentation showing no new changes to skin was checked in section G. Skin/Wound: 1. Skin Integrity. Further record review of section G. 2. Wound Care revealed, no documentation of treatable wounds, dressing changes per treatment orders, or notable skin changes documented. Interview on [DATE] at 9:21 am with LVN A, when asked who completes the Skilled Nurses Notes, she stated the nurse assigned to the hall completes them daily. When asked if section G. Skin/Wound should be completed by the nurse, she stated any treatments, new wounds would be entered in this section stating, further stating antibiotics and treatment orders would be documented as well. When asked if a resident has an old wound would this be documented, she said the wound nurse documents the measurements in her progress notes, but whatever is on her documentation would then be entered in section G by the nurse. When asked if the Skin/wound section should be left blank if a resident has a wound and/or skin changes, she stated that section should not be left blank. Interview on [DATE] at 9:56 am with the DON and Treatment nurse, when asked who completed the Skilled Nurses Notes and how often was this note completed, the DON stated the nurse on the skilled hall completed them daily. When asked if section G. Skin/Wound should be completed when a resident has a new and/or old wound, she stated most of the time the treatment nurse documents the wound treatment in her progress notes. When asked if there were no changes to an old wound and/or a new wound should section G be completed, the DON stated the nurse would check the appropriate boxes in that section and would document if the wound is new, old, any changes such as the color, odor, and location. When asked if that section should ever be left blank if a resident has a wound, she stated no, it should be completed by the nurse. Record review of CR#1's [DATE] TAR revealed, no documentation showing wound care to the right buttock blister was completed on [DATE] and [DATE]. Further interview on [DATE] at 8:54 am with the Treatment nurse and DON, when asked why there was no documentation showing wound care was completed on the right buttock blister and/or sacral wound on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] she stated, I have no answer as to why it was not documented. She stated the weekend nurse would be responsible for completing wound care on Saturday and Sunday, so she could not answer for those days. The DON stated they currently do not have a weekend treatment nurse stating the nurse on that hall would be responsible for completing the wound care. She stated the position has been opened for six months and it is hard to fill because its PRN and weekend position. Further interview on [DATE] at 9:49 am with the Treatment nurse, she stated there was no documentation on the TAR for [DATE], [DATE], and [DATE] stating when a new order is entered after 9:00 am, the wound treatment completed skips to the next day and will look like the treatment was not completed. After surveyor intervention, she further stated they have since fixed the problem. She could not account for the missing documentation on [DATE], [DATE], and [DATE]. Record review of CR#1's physician orders [REDACTED]. One time a day. Order Date-[DATE]-D/C Date-[DATE]. Record review of CR#1's nursing progress notes dated [DATE] at 07:18am writer Treatment nurse read in part, Sacral excoriation has exacerbated; unstageable wound incorporated into right buttocks blister. Measurement 6.2x5.8x? Depth undeterminable due to 100% non-viable tissue. Minimal/serous drainage, no odor, light [DIAGNOSES REDACTED]. Will consult with NP upon arrival. Site dressed as ordered. Further record of CR#1's nursing progress notes dated [DATE] at 11:23am writer Treatment nurse read in part, Call placed to NP, for MD. Informed her of resident's current wound condition, interstitial fluid in right arm, decreased appetite and lower abdominal pain. Consulting with MD, at this time. Call placed to RP informed her of resident's current condition, same as reported to NP. Consent given for resident to be seen by wound care MD in the a.m.; consent also given for bedside debridement, if necessary. Record review of CR#1's Braden Scale for Predicting Pressure Sore Risk dated [DATE] revealed, a score of 10 indicating high risk for developing a pressure sore. Record review of nursing progress notes dated [DATE] at 6:52 pm, [DATE] at 5:09 pm, [DATE] at 3:57 am revealed, critical labs showing CR#1 had an elevated WBC count, BUN level, and BUN/Creatinine ratio indicating acute [MEDICAL CONDITION]/injury, dehydration, and infection. Record review of nursing progress notes dated [DATE] at 7:29 am writer LVN A revealed, a new order from the NP to send CR#1 to the ER due to elevated WBC count of 29.3. Further record review of nursing progress notes dated [DATE] at 8:19 am writer LVN A revealed, the NP called facility and stated the MD does not want CR #1 to go to the ER since she was just started on IV antibiotics, and to closely monitor and start IV [MEDICATION NAME] for 7 days. A CBC and BMP was ordered. Record review of CR #1's physician orders [REDACTED]. Further record review of CR #1's physician orders [REDACTED]. Record review of the facility's Weekly Pressure Ulcer Log week ending [DATE] revealed CR #1 had a new facility acquired unstageable sacral wound measuring 6.2 x 5.8cm depth undetermined with minimal serous drainage, no odor, 100% slough present, and peri-wound light red. There was no documentation on the weekly pressure ulcer logs showing documentation of a right buttock blister, or an unstageable wound or excoriation prior to [DATE]. Record review of nursing progress notes dated [DATE] at 7:25 am writer Treatment nurse read in part, Wound has changed: appearance is gray/yellow. Moderate/serous drainage, strong odor detected, light [DIAGNOSES REDACTED] noted to peri-wound. Size has increased to 7.2x8.0; unable to determine depth due to 100% non-viable tissue. Cleaned and dressed as ordered. Floor nurse made aware; NP has been called about other conditions. Awaiting return call back. Further record review of nursing progress notes dated [DATE] at 7:41 am read in part, Nurse informed about a critical lab for resident, BUN 103, WBC 36.2. Informed on call for MD, new order given for BLOOD CULTURE X1, 0.9NS AT 70ML/HR, REPEAT CBC, BMP 24HRS AFTER LAST DRAW. Further record review of nursing progress notes dated [DATE] at 8:30 am revealed, CR #1 was sent to the ER after a change in condition and after the fourth set of critical lab results showed an elevated WBC count and BUN level. Record review of CR#1's SBAR Communication Form and progress note dated [DATE] writer LVN A revealed, the change in condition, symptoms, or signs included elevated WBC 36.2, Vital Signs Pulse: 115, Mental Status Changes 1d. Decreased consciousness (sleepy, lethargic) was checked. Further record review of CR#1's SBAR Communication Form and progress noted dated [DATE] writer LVN A read in part, Nursing Notes (for additional information on the Change in Condition): resident noted decreased consciousness and elevated WBC 36.2, NP notified new order send to hospital, RP notified, arranged transportation . Interview on [DATE] at 9:21 am with LVN A, when asked if CR#1 had wounds that were being treated, she stated she was not working between [DATE] to approximately [DATE], she said when she came back, she had a wound on her sacrum stating she thought it was a St III or IV PU. She said the Treatment nurse was doing daily wound treatments. When asked if the Wound MD assessed and/or was treating the residents wound, she stated the wound MD had not seen the resident. She stated the wound MD was supposed to assess and complete wound debridement on ,[DATE] but he never entered the facility due to COVID exposure at a previous facility. She further stated he could not enter the facility for 14 days per CDC guidelines. Further interview on [DATE] at 9:21 am with LVN A, when asked if another Wound MD was contacted to treat CR#1's sacral wound, she stated, no the resident was not seen by another Wound MD. When asked if she noticed any changes to the residents' behavior or condition, she stated the resident wasn't eating much further stating she also had abnormal lab results. She said the treatment nurse called the MD and RP because the wound was deteriorating. She said the resident was started on [MEDICATION NAME] then [MEDICATION NAME] for a wound and UTI infection. She stated the resident was sent out because her renal function was declining, and she was not eating. Interview on [DATE] at 11:28 am with the Administrator, when asked why CR#1 was not transferred out for wound care if the Wound MD could not treat/manage the infected wound when wound care was ordered and consent obtained for debridement, the Administrator stated she was under the impression the NP and MD were doing telemedicine visits and were aware of the residents wound. When asked if the resident had s/s of infection, malnutrition, critical labs, and a declining renal function, should she have been sent out for higher level of care if the facility was unable to manage the wound and infection, she said regardless of COVID if a resident has to be sent out then they would, but she thought the NP and MD knew the severity of the wound. She said the wound MD has a back log and just doesn't come to this facility. She then asked if a debridement would have made a difference. Interview on [DATE] at 12:01 pm with CNA A, when asked what she would do if a resident refused a shower or bed bath, she said she would report to the nurse, so the nurse can go in and try to get the resident to shower. Further stating if the nurse can't get the resident to bed bath or shower, the RP would be notified. She stated she would keep trying if the resident refused on the scheduled day and would try to ask the next day. She said with CR#1 they could not continue to give her a shower she would vomit if they tried to get her up and sit in the chair. They said she was not eating well, and she wanted to stay in the bed. She said it was rough trying to get her to eat, stating she ate approximately ,[DATE]%. She stated the decrease appetite was going on for a while and the CNAs and nurses all said to try to go into the room and feed her because she could not feed herself. She said sometimes she would throw it up and it would not stay. When asked if she noticed any changes to CR#1's skin she said before she was transferred, her she had generalized discoloration. Said she didn't see any wounds, further stating she said she did see a scrape on her buttock and was told to put a topical barrier cream on the wound. Telephone interview on [DATE] at 1:23 pm with the NP, she stated she did not remember how long the wound was present but stated she would ask how CR#1 was doing for several weeks. She stated when she spoke to the Treatment nurse, she said the resident had what she described as a blister that ruptured and stated there was no changes. She stated the resident did not like to turn, and was always flat on her back, stating staff would try to turn her and position her on pillows, but she would just turn back onto her back. She said on [DATE], the Treatment nurse informed her the wound had deteriorated and spread to her sacrum. She said she came into the facility on Monday after being informed, and she was told the resident was not eating even when the staff tried to feed her. She stated she ordered labs, a Wound MD consult, and consent for bedside debridement if necessary. Further telephone interview on [DATE] at 1:23 pm with the NP, she stated when the labs came back the next day, the resident had elevated WBCs and she still was not feeling great and not eating. She stated the resident also had a UTI and was dehydrated so she ordered IV fluids and [MEDICATION NAME] to treat the UTI and to recheck labs in the morning. She stated when those labs came back, more fluids were ordered because of her elevated BUN and she was still dehydrated, she stated she and the MD discussed transferring the resident but with the COVID risk they felt it was best to keep her at the facility. She further stated LVN A had informed her the resident was doing better and eating, so she felt clinically, the IV antibiotics may be kicking in so she did not think at that time the resident needed to be transferred. She said the Treatment nurse contacted her on ,[DATE] in the morning stating the wound wasn't looking good, so she and the MD decided to repeat labs in the morning and monitor the resident for another 24 hours. Further telephone interview on [DATE] at 1:23 pm with the NP, when asked if the RP was fully aware of the severity of the wound infection and the critical labs, she stated the RP was contacted to let her know they did not want to transfer the resident because of the COVID and she agreed to keep the resident at the facility. She stated the next day she received a call stating the resident had critical labs and her WBC count was in the 30s, so she and the MD had a discussion and they wanted to continue to monitor closely and repeat labs in the morning the following day. She stated the resident was transferred because of an elevated WBC count and change in mental status. When asked if the resident should have been transferred considering the resident had a severe infection, multiple critical labs, lab results showing possible malnutrition, and the wound MD could not treat or debride the infected wound, she stated the resident was in bad shape and at the time, because of the COVID they did the best they could and they kept her at the facility as long as they could given the situation. Telephone interview on [DATE] at 2:04 pm with CR #1's family member, when asked if the facility contacted her and informed her of the severity of the wound infection and critical lab results, she stated the Treatment nurse called her on [DATE] and told her they had found a wound two weeks prior and it was small. She said she was told over the weekend it blew up further stating she was trying to figure out how did it just, blow up. She stated she called them back the next day because she wanted to know why it took two weeks to notify her about the wound stating the Treatment nurse did tell her the wound was infected. She said she was not aware of the size of the wound until the resident went to the hospice center stating the wound was a size of a dinner plate. When asked if she spoke to the NP or MD regarding the residents' condition, she stated she spoke to the NP after multiple attempts of trying to contact her, but it was about something else. She said she never spoke to the NP or MD about the wound or infection. She stated she did not know the severity of the WBC count and infection until she looked it up herself. She stated CR#1 expired on [DATE] shortly after being placed on hospice. Interview on [DATE] at 8:54 am with the DON and Treatment nurse, when asked, once notified the Wound MD was unable to enter the facility, was another Wound MD contacted to determine if he/she could assess and/or treat the residents wound, the DON stated the Wound MD works in a group and another Wound MD could have come out, but the Medical Director wanted to wait two weeks to see if the wound would heal first before sending someone out to assess and or treat the wound. Further interview on [DATE] at 8:54 am with the DON, when asked if any nursing staff responsible for the care of CR#1 requested the NP and/or MD transfer the resident when they were aware multiple labs results showed her WBC count and renal function were critical and not improving after interventions and her wound was deteriorating quickly, and she was showing s/s of malnutrition, the DON said No, we did call the MD and he said to do this, & this, & this and if it doesn't' work, then we will take the next steps. The DON further stated, she did not ask the MD or NP ask why she was not being sent out. She further stated when the WBC count continued to increase, and the labs were not looking good the resident was sent out. Telephone interview on [DATE] at 9:57 am with the Wound MD, when asked if he ever saw and/or treated CR#1's wounds after an order for [REDACTED].#1 should have been transferred out of the facility for wound care and to manage the infection considering she had a series of critical labs, poor appetite with weight loss, diabetes, and a wound that was deteriorating rapidly, he stated based an educated case, if she was unstable, further stating he did not know what her vital signs were, but if her WBCs were rapidly elevating she would be transferred. He stated usually if a wound is significant and deteriorating quickly, sometimes he would refer for treatment at a higher level of care if there are concerns [MEDICAL CONDITION]. He stated he thinks she was a candidate to transfer earlier because of the critical labs and co-morbid conditions, further stating if the wound was rapidly progressing he would have recommended she be sent out for more acute care. Interview on [DATE] at 2:03 pm with the DON, when asked what the facility policy was if a CNA and/or shower tech identifies a new and/or change to a resident's skin during a bath/shower or ADL care, she stated they are supposed to document what they observe on the shower sheet and report it to the resident's nurse immediately. When asked if the CNA and/or shower tech is supposed to document old wounds on the shower sheet, she stated yes, they should always document the old wound that is present and anything that is observed on the residents' skin so other CNAs or shower techs who shower the same resident will know that it is an existing wound and not a change to the residents skin. Record review of CR#1's Hospital Surgical Consultation Note dated [DATE] read in part, [AGE] year old lady with a medical history significant for diabetes, hypertension, [MEDICAL CONDITION], gastroparesis, dementia with Lewy bodies, previous [MEDICAL CONDITION], presents to hospital from nursing home for worsening sacral decubitus pressure ulcers. Apparently, there is been deterioration of the sacral decubitus pressure ulcers associated with fouls smell, necrotic tissue, as well as purulent drainage that has progressed and not improved despite medical management. Due to the frank infected nature of the wound, she was brought in here for further evaluation and work-up. Indeed, confirmed a necrotic purulent devitalized wound with foul smell prompting surgical intervention . Further record review of CR#'1s Hospital Surgical Consultation Note dated [DATE] read in part, Musculoskeletal: Necrotic foul-smelling sacral decubitus pressure ulcer measuring at least 15 x 20 cm with purulent discharge and drainage . Assessment: [AGE] year-old lady with: 1. Sacral decubitus pressure ulcer, 2.[MEDICAL CONDITION] 3. Urinary tract infection 4. Acute kidney injury . Record review of CR#1's Hospital Discharge Summary dated [DATE] read in part, Date of discharge [DATE]. Discharge Diagnosis: [REDACTED].Patient seen examined [DATE]. [MEDICATION NAME] in blood along with Proteus and E. Coli and [MEDICATION NAME] in the wound of the sacrum .Worsening leukocytosis noted, continue with current antibiotic regimen. Poor prognosis overall, bedridden status .Patient seen on [DATE] Patient with [MEDICATION NAME] bacteremia, sacral decubitus ulcer status [REDACTED]. Bedridden, not clinically improving. Worsening metabolic acidosis. Lactic acidosis seen today also. [MEDICATION NAME] drip started. [DIAGNOSES REDACTED]: Noted, replace now. Worsening renal function. Poor prognosis, overall not improving. [MEDICAL CONDITION]ly due to DIC [MEDICAL CONDITION]. Detailed in-depth conversation with (family member) today .Family expect patient to not suffer anymore and therefore will be aiming for hospice placement at this time . Record review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol revised [DATE] read in part, Assessment and Recognition .2 the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active [DIAGNOSES REDACTED].>Further record review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol revised [DATE] read in part, Monitoring 1. During resident visits, the physicians will eva (TRUNCATED)

Based on interview and record review, the facility failed to provide services in accordance with the plan of care for one of six residents reviewed for physician's orders [REDACTED]. -- CR #1 received her blood thinner after her physician ordered it be held in preparation for a dental procedure. She was discharged to an acute care hospital on [DATE] because of uncontrollable bleeding following a dental procedure (extraction of two teeth) she had on 6/3/15. This failure affected one resident and put 112 residents at risk of not receiving care and services specific to their needs and plan of care. Complaint # 4 Findings include: Review of the CR #1's admission sheet revealed she was [AGE] years old female and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was discharged to an acute care hospital on [DATE] because of uncontrollable bleeding following the dental procedure (extraction of two teeth) she had on 6/3/15. Record review of a physician's orders [REDACTED].#1's Xarelto from May 31, 2015 thru June 3, 2015 for dental work. Record review of CR #1's Medication Review Report for 5/1/15 - 6/30/15 revealed an order to hold Xarelto 15 MG (Rivaroxaban) from 5/31/15 to 6/4/15 for [MEDICAL CONDITION]. Record review of CR #1's Medication Administration Record [REDACTED]. Record review of Progress Notes, dated, 6/4/15, revealed that at 9:30 p.m., LVN A noted some bleeding and applied gauze for CR #1 to bite on. At 9:55, LVN A applied more gauze to CR #1's extracted site and noted small amounts of clots. At an undocumented time, LVN B wrote, Upon getting report from previous nurse, she informed me that this resident had 2 teeth pulled this morning and that she had checked her at 9:50 p.m. and that she was fine but that she would not leave gauze in mouth in place. I checked on her at 10:10 p.m. and saw slight blood trickling out of mouth. CNA came to desk and stated that she was bleeding harder. Upon observing resident had blood seeping on side of mouth and had blood on tongue. Came to nurse's station and called primary physician. Upon giving info, he stated to send her out to ER . Approximately 12 midnight, CNA stated it seemed like resident choking. 2-10 nurse got suction machine and began to suction mouth of resident. Called ambulance back and stated they needed to use lights and siren and get here quick. Record review of physician's orders [REDACTED].#1's doctor ordered to take her to a local hospital emergency room for excessive bleeding due to 2 teeth extracted. Record review of the facility's policy, Administering Medications revealed that it read in part, .3. Medications must be administered in accordance with the orders, including any required timeframe. In an interview with the facility's DON, on 7/8/15, at 3:45 p.m., she stated she did not know why the Medication Administration Record [REDACTED]. She said the order to hold the medication was clearly written on the record and should not have given on that day. According to the facility's roster, the census was 113.

Based on interview and record review, the facility failed to provide services in accordance with the comprehensive assessment and plan of care for one of six residents reviewed for quality of care (CR #1). -- CR #1 received her blood thinner after her physician ordered it be held in preparation for a dental procedure.She was discharged to an acute care hospital on [DATE] because of uncontrollable bleeding following the dental procedure (extraction of two teeth) she had on 6/3/15. This failure affected one resident and put 112 residents at risk of not receiving care and services specific to their needs and plan of care. Complaint # 4 Findings include: Review of the CR #1's admission sheet revealed she was [AGE] years old female and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was discharged to an acute care hospital on [DATE] because of uncontrollable bleeding following a dental procedure (extraction of two teeth) she had on 6/3/15. Record review of a physician's orders [REDACTED].#1's Xarelto from May 31, 2015 thru June 3, 2015 for dental work. Record review of CR #1's Medication Review Report for 5/1/15 - 6/30/15 revealed an order to hold Xarelto 15 MG (Rivaroxaban) from 5/31/15 to 6/4/15 for [MEDICAL CONDITION]. Record review of CR #1's Medication Administration Record [REDACTED]. Record review of Progress Notes, dated, 6/4/15, revealed that at 9:30 p.m., LVN A noted some bleeding and applied gauze for CR #1 to bite on. At 9:55, LVN A applied more gauze to CR #1's extracted site and noted small amounts of clots. At an undocumented time, LVN B wrote, Upon getting report from previous nurse, she informed me that this resident had 2 teeth pulled this morning and that she had checked her at 9:50 p.m. and that she was fine but that she would not leave gauze in mouth in place. I checked on her at 10:10 p.m. and saw slight blood trickling out of mouth. CNA came to desk and stated that she was bleeding harder. Upon observing resident had blood seeping on side of mouth and had blood on tongue. Came to nurse's station and called primary physician. Upon giving info, he stated to send her out to ER . Approximately 12 midnight, CNA stated it seemed like resident choking. 2-10 nurse got suction machine and began to suction mouth of resident. Called ambulance back and stated they needed to use lights and siren and get here quick. Record review of physician's orders [REDACTED].#1's doctor ordered to take her to a local hospital emergency room for excessive bleeding due to 2 teeth extracted. Record review of the facility's policy, Administering Medications revealed that it read in part, .3. Medications must be administered in accordance with the orders, including any required timeframe. In an interview with the facility's DON, on 7/8/15, at 3:45 p.m., she stated she did not know why the Medication Administration Record [REDACTED]. She said the order to hold the medication was clearly written on the record and should not have given on that day. According to the facility's roster, the census was 113.