Every finding on record at Benedictine Care Community

Based on observation, interview and document review, the facility failed to provide adequate supervision and appropriately secure an exit door to prevent an elopement for 1 of 3 resident (R1) reviewed for elopement. This resulted in immediate jeopardy (IJ) when R1 left the facility without staff knowledge and was not located for approximately three hours.The immediate jeopardy began on [DATE] at 10:41 p.m., when R1 exited the facility through the north assisted living door. At 1:40 a.m., R1 was located laying in a row of trees across the road approximately 288 yards away from the facility. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 5:10 p.m. The facility implemented corrective action prior to start of survey so is being issued at past noncompliance. The IJ was removed on [DATE], prior to survey and was issued at past noncompliance.Findings include: R1's comprehensive Minimum Data Set, dated [DATE], identified R1 was admitted to facility on [DATE], from a hospital with moderately impaired cognition. R1 had physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others) one to three days out of seven. R1 wandered daily, which placed him at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of facility). R1 required partial/moderate assistance with personal hygiene, sit to stand, all transfers, walking up to 150 feet and/or 10 feet on uneven or sloping surfaces with a walker. R1 had an indwelling urinary catheter and was always continent of bowel. R1 had diagnoses of congestive heart failure (CHF), coronary artery disease (CAD), and required the daily use of a wander guard.R1's Fall Risk assessment dated [DATE], identified impaired mobility, R1 required the use of assistive device (walker), had intermittent confusion, poor recall, judgement, and safety awareness. Fall risk score was 14 (score of 10 or higher represented a high risk for falls).R1's elopement risk assessment dated [DATE], identified displayed behaviors and body language indicating possible elopement and was recently admitted to facility. R1 was identified as an elopement risk due to being forgetful and short-term memory impairment. Preventive action taken care plan was developed.On [DATE], Occupational therapy (OT) completed R1's Montreal Cognitive Assessment (MoCA) blind score (a modified version of the standard MoCA test designed for individuals with visual impairments to assess cognitive function) and identified a total score of 11out of 22 (scores below 18 indicated significant cognitive impairment including moderate cognitive impairment) indicating moderate cognitive impairment. R1 was also identified with significantly reduced processing speed and attention skills. These deficits represent a significant decline from R1's prior level of functioning and adverse impact on his ability to independently manage complex daily tasks, medication management, scheduling, safety awareness, decision-making, and community participation.R1's Physical therapy discharge therapy (PT) dated [DATE], identified he responded well to therapies and continued to demonstrate increased instability and difficulty with tight quarter navigation and ambulation on uneven surfaces. Therapy was discontinued due to insurance coverage. Discharge recommendations: Functional outcome: transfers: supervised, Level surfaces: standby assist (SBA). Plan continue using assistive device (AD) (walker) to maintain safety and independence with functional mobility and transfers.R1's elopement risk assessment dated [DATE], identified frustration regarding facility placement, repeatedly opening doors/setting off secured door alarms, making statements about leaving or seeking to find someone/something, questioned the need to be in the facility, displayed behaviors and body language indicating possible elopement. R1 had a recent change in medications, admission to facility, history (last 6 months) of wandering in facility or elsewhere, and alteration in mental status. Based on assessment R1 presented an elopement risk. Preventive actions taken care plan developed, wander guard applied and order set added to check for function and placement every shift.R1's care plan dated [DATE], identified:Vulnerable adult: needed assistance to remain safe within the community. Vulnerabilities included requiring assistance with mobility and cognitive impairment.Cognitive impairment: alert and oriented three times (person, place, time), independent in making decisions but had intermittent confusion and poor judgement.Self-care deficit: activities of daily living (ADLs). Staff were directed to provide front wheeled walker (FWW), limited assistance from one staff for all transfers and walking,Fall Risk due to balance deficit: staff were directed to provide assistance from one staff for all transfers and ambulation with FWW and gait belt.High risk for elopement due to poor judgement, short term memory impairment: staff were directed to place R1 in a secure environment. When he began to wander, provide comfort measure, basic needs, approach from front, walk in step first (walk with R1) before redirecting, 1:1 support (start date [DATE]), wander guard on right ankle, check for placement and functionality every shift (start date [DATE]), 1:1 supervision until interdisciplinary team (IDT) discontinues (start date [DATE] - discontinued date [DATE]), frequent checks for safety, check every one hour from 6:00 a.m.- 4:00 p.m. and every 30 minutes from 4:00 p.m.-6:00 a.m. (start date [DATE]),R1's treatment administration record (TAR) order: check on placement and functionality of wander guard every shift on right ankle start date [DATE], identified from [DATE] through [DATE], R1's wander guard was signed off as being checked every shift except on [DATE], day shift noted: R1 not available.R1's progress notes from [DATE] through [DATE], identified:[DATE] at 11:56 p.m.: notified by another resident R1 was on the floor. Found him on his knees by room [ROOM NUMBER] with his head on the floor. Assisted off the floor with gait belt and back to his room. R1 has been pacing back and forth looking for walletXXX[DATE] at 2:42 a.m.: entered R1's room to complete neuro checks and he was awake and had gotten himself fully dressed. Reminded R1 of the time and explained that he should be sleeping since he had an appointment early tomorrowXXX[DATE] at 5:43 a.m.: R1 continued to pace the hallway. Upset staff will not open doorXXX[DATE] at 10:32 p.m.: R1 paced the facility non-stop since approximately 7:00 p.m., he exhausted himself and became unsteady. Will sit down for approximately five minutes at a time and then back to pacing and exit seekingXXX[DATE] at 2:31 a.m.: at 12:02 a.m., upon checking on R1 unable to locate. Search of facility done without success. Ada police department (PD) notified by hospital staff of R1's unknown whereabouts. At 12:42 a.m., DON notified of his unknown whereabouts, directions to recheck all rooms locked and unlocked. Family notified via DON. At 1:45 a.m. notified R1 had been found and was going to be evaluated in the ER and then return to facilityXXX[DATE] at 3:34 a.m.: R1 returned to facility from ER. New order for Cipro (antibiotic) 250 milligrams (mg) times four days for urinary tract infection (UTI)XXX[DATE] at 5:01 a.m.: R1 resting in bed with eyes closed. Neuro check initiated at this timeXXX[DATE] at 6:02 a.m.: Timeline of elopement: [On [DATE]] At approximately 10:30 p.m. R1 exited the unit through the connecting doors into the hospital area. Brought back by hospital staff and informed nursing staff connecting door did not consistently latch when closing and required verification that it was fully secured after use. At approximately 11:00 p.m. R1 observed by nurse's station during shift report. Nursing staff reported increased pacing and restlessness over the several preceding days. At approximately 12:20 a.m., staff identified R1 was not present in his expected location and unable to locate him on the unit. Staff search initiated of facility and surrounding areas. Called 911 for additional assistance and DON. At approximately 1:50 a.m., R1 was located outside awake and responsive when touched. Located in the tree break between the facility and the school east of the facility. Stated was taking a nap and looking for his wife. Assisted to stand and ambulate up the ditch to a wheelchair and taken directly to ER for medical evaluation. At approximately 3:00 a.m. R1 returned to facility from ER evaluation no injury identified. UTI was identified and antibiotic treatment ordered. Supervision was increased upon return for resident safety. Staff instructed on R1's current exit-seeking risk, need for close observation, and verification that the connecting door was fully closed and secured after each use. R1 remained 1:1 supervision until discontinued by interdisciplinary team (IDT). Confirmed wander guard was functioning, and issue was isolated to door.A Minnesota Adult Abuse Report (MAARC) dated [DATE] at 7:00 p.m., identified on [DATE] at 8:00 p.m. R1 arrived unescorted to hospital nurse's station. R1 carried a handful of notebooks and some business cards and stated, someone sent these to me and I need some help. It was apparent he was confused. He introduced himself but was unable to provide any details of where he came from or what assistance he was requesting. R1 was walked over to the nursing home. A staff licensed practical nurse (LPN) confirmed R1 lived on the other wing at the nursing home. R1 was escorted to his assigned wing. The situation was explained to the registered nurse (RN) and R1 was left in her care. Neither of the nursing home staff seemed aware R1 had been outside the nursing home. Reporter was assured, the doors between the facilities were secure. A MAARC dated [DATE] at 9:30 p.m., identified incident occurred on [DATE] at 11:00 p.m. At around 12:00 a.m. the nursing home staff came over to the hospital and reported R1 was last seen at approximately 11:00 p.m. A search of the hospital and the nursing home was completed around 12:30 a.m. Nursing home staff nurse (NHN) indicated she had not called the administrator or sheriff to report a missing person. Hospital staff (HS) called sheriff's office and reported the missing person at 12:43 a.m. HS checked with NHN periodically, asking if more assistance was needed. Hospital information technology (IT) was contacted and were unable to see R1 on camera. At 1:15 a.m., police officer (PO) arrived, was taken to the nursing home, and suggested senior living area be searched. PO called in back up sheriff and fire department personnel. R1's cell phone was in his room per son R1's son. At roughly 1:45 a.m., R1 was found lying down comfortably in the tree row east of the hospital, he wanted to sit up and go see his wife. R1 was identified as a confused dementia patient who can carry on a conversation. The DON and administrator arrived when R1 was found and transferred to ER to be assessed. The DON was informed by HS, R1 had gotten out earlier from nursing home through the hospital door and ushered back to nursing home staff around 10:00 p.m. DON stated she was not told R1 had already escaped that night. HS informed DON, R1 was at risk to get out again and was able to talk his way out as could hold a short conversation.Facility Vulnerable Adult Maltreatment Report dated [DATE] at 9:33 p.m., identified R1 had dementia and acute encephalopathy (brain disfunction). At approximately 10:30 p.m. R1 entered the adjoining hospital area through the connecting doors between the skilled nursing facility (SNF) and hospital and was brought back to the SNF by hospital staff. Hospital staff updated nurse that door was not latching right. Signs had been placed on door to identify not to let residents through without staff notification and ensure door was latched. At approximately 11:00 p.m., R1 was observed near nurse's station during shift report, ambulating and pacing in the area. At approximately 12:20 a.m., staff noted R1 was not in his anticipated location. Staff immediately initiated efforts to locate him and began a search of the facility and surrounding areas. The facility's elopement response procedures were initiated, emergency room (ER) staff contacted 9-1-1 to provide additional assistance with the search. The DON was notified at approximately 12:41 a.m. At approximately 1:50 a.m., R1 was located outdoors in the tree break east of the facility between the facility and the school approximately 100 yards from the hospital entrance. R1 was awake, responsive, and no apparent injury was observed. R1 stated he had been taking a nap and was looking for his wife. R1 was dressed in a long-sleeved plaid shirt, pants, socks, and shoes. Staff assisted R1 to a standing position, ambulated up the ditch with assistance to a wheelchair, and was transported to ER for further medical evaluation. At approximately 3:00 a.m., R1 returned to the facility with no injury related to the event and an identified urinary tract infection.Emergency department (ED) visit note dated [DATE], at 1:52 a.m., identified R1 was a new admission to our nursing home. Earlier in the evening he had been observed walking by the hospital desk at approximately 10:00 p.m., which he had somehow been able to get through the doors from the nursing home. Hospital staff walked R1 back to the nursing home, from the discussion had with the staff nurse was informed he was supposed to stay on the nursing home side. At approximately midnight the nursing home staff had informed the hospital staff and ED physician assistant (PA) R1 had gotten out, uncertain as to where he would have gone, and requested assistance to help look for him. The police were notified, staff continued to search inside through the building and outside. R1 was located on the east side of the building in the tree line across the street laying in the grass. R1 alluded to the fact he had laid down next to his wife and was resting or taking a nap, denied he had fallen, and denied pain. R1 was assessed from head down to lower legs and able to move upper and lower extremities and neck without difficulty or pain. R1 wanted us to be sure we checked out his wife as well, focused on his deceased wife per staff member, most likely related to dementia, and did not want to go back to the nursing home. R1was brought to ED, examined, and clinical impression identified: confused, tended to wander, did not appear to have any injuries and diagnosed with a urinary tract infection (UTI). R1 was started on an oral antibiotic and discharged back to the nursing home at 3:18 a.m.Local Police Department Incident Report dated [DATE], identified on [DATE] at 12:46 a.m. Ada police officer (PO) was dispatched to the facility for a reported missing adult patient. Upon arrival, he contacted the hospital staff to obtain more information. R1 was reported missing with a request to check the hospital before he contacted law enforcement. PO then located the nursing home registered nurse (RN)-A and advised R1 had not been seen from 11:00 p.m. to 11:30 p.m., and unable to locate him. RN-A explained how R1 had made comments earlier about wanting to leave and may have exited through a door known to not latch and close properly. PO recommended nursing home staff continued to search the interior building while his investigation continued. Based on the totality of circumstances related to R1's vulnerability, he requested a multi-agency and emergency service response in locating him. PO began checking the exterior of the building on foot while additional resources responded and viewed the hospital security closed circuit television (CCTV) (surveillance camera) footage and checked available phone information for a location ping. The Ada Fire Department personnel located R1 laying along some trees just east of 8th [sic] Street [NAME] across from the local hospital. R1 made comments about making sure his wife was warm next to him, losing luggage at the hotel, and other unrelated matters indicating potential cognitive decline. Additional hospital staff soon arrived to assist and were able to convince R1 to return inside the building without incident. Facility Investigation Report - Timeline Review, Facility Actions Report undated identified timeline review through camera footage once obtained to verify:[DATE] at 7:40 a.m., R1 exited the facility through the connecting hospital doors and entered the ER/hospital area. ER staff located R1 and returned him back to the facility. Facility staff saw R1 in Pioneer NA station while getting report around 10:30 p.m. R1 paced around but redirectableXXX[DATE] at 10:39 p.m., Camera footage showed the resident in the kitchen/service hallway traveling in the direction of the Assisted Living (AL) portion of the building. [DATE] at 10:41 p.m. Camera footage showed R1 exit through the AL door and entering outside gazebo area. [DATE] at 12:30 a.m., Staff identified R1 could not be located and immediately initiated search of the facility and surrounding area in accordance with the facility elopement response procedures. [DATE] at 1:13 a.m., law enforcement arrived and assisted with search. [DATE] at 1:40 a.m., R1 was located in a tree row across from the facility, approximately 100 yards from the building. R1 was transported to ER for medical evaluation and returned to facility at approximately 3:00 a.m. and placed on 1:1 for monitoring and safety. No injury attributed to the elopement event. R1 was diagnosed with UTI and treated with oral antibiotics.During observation and interview on [DATE] at 1:00 p.m., with the DON and the regional director of clinical services/registered nurse (RN)-B, surveyor was guided through the facility, the same route R1 took when he eloped from the facility. The DON stated R1 was seen on video footage in the service area/hallway on the other side of the nursing home kitchen. R1 would have gone through the kitchen and a set of double doors to reach the service area/hallway. R1 walked through another set of double doors, these leading to the assisted living facility (ALF). RN-B stated all kitchen doors should have been locked when staff were working in the kitchen, except the fire doors. Surveyor was guided past the ALF main entrance, turned left and then down a long hallway, turned right then walked to the exit door at the end of the hallway. RN-B stated this was the door R1 exited when he left the facility. The exit door locked from the outside, not the inside. There was no wander guard sensor on the exit door. The DON demonstrated how the door opened easily. RN-B used the measurement application on her watch to measure the distance from the exit door to the area R1 was located, 228.8 yards from the AL exit door. DON stated, following R1's elopement, all wander guard door sensors had the volume increased and the range sensitivity was increased. Keypads will be added to five additional doors so a code will be required to unlock those doors. A computer system will be set up so staff can easily identify which door is being opened and or alarming. The DON stated, on [DATE] at 6:00 a.m., maintenance evaluated and serviced the door between the nursing home and the hospital to ensure appropriate closure and latching. The DON stated, due to air pressure between the nursing home and the hospital, the door did not close completely and did not latch properly. The RN-B stated, immediately following R1's elopement and lasting until maintenance was able to fix the door, the door between the nursing and the hospital was closely monitored because it was initially thought that door is the door R1 used to exit the facility. The RN-B stated before noon on [DATE], all doors in the facility were checked to ensure there were no alarm issues. Also identified during the door checks, if a door equipped with a wander guard did not latch, it disabled the wander guard system.During interview on [DATE] at 4:00 p.m., the camera footage was viewed with the regional operations manager (ROM) and identified on [DATE] at 10:30 p.m., R1 walked through the service area located outside the north side of the kitchen. R1 was not using his walker. R1 was seen ambulating alone down a hallway in the assisted living area toward an exit door. At 10:41 p.m., R1 pushed the exit door open, walked outside into the dark, and the door closed behind him. R1 was dressed in jeans, shirt and dark shoes. The ROM stated there were no cameras in the kitchen or dining room. The ROM was unsure how R1 got to the service area except by going through the kitchen first.During interview on [DATE] at 9:24 p.m., HN-A stated he was aware there had been latching issues with the double door that went from the nursing home to the hospital and if not latched it disabled the wander guard sensor. Staff were expected to pull the doors closed so they would latch.During interview on [DATE] at 10:00 a.m., hospital staff (HS)-A stated on [DATE] around 8:00 p.m., R1 arrived unescorted to the hospital nurse's station, very pleasant but unable to identify what he needed help with. HS-A stated R1 did not realize he was at the hospital, stated he was on his way home, had a handful of business cards, and wanted someone to explain the three notebooks he carried with him. No one had walked out of that door from the nursing home prior to when R1 arrived. HS-A stated there was a soft sounding alarm that was activated and a light flashing when R1 came through the double door and again when he walked R1 back through the same door to the nursing home. HS-A was unsure if that alarmed in the nursing home as well. HS-A stated the nursing home staff did not seem surprised or aware R1 had been gone. HS-A stated maintenance had fixed the double doors after the incident, so they latched better now.During interview on [DATE] at 12:05 p.m., family member (FM) stated she was informed by her son R1 tried to get out of the building and left the building on [DATE]. FM stated R1 was so confused and forgetful right now. He thinks he's still working. He would not have been safe outside, especially in the dark by himself. He packed his stuff in a box many times and talked about coming home frequently. We remind him this is his home. FM stated she unpacked his box, he said okay, forgot and packed the box again. FM stated she was informed the door latch or something with the door was broken, was unsure if it had been fixed and worried about residents getting out.During interview on [DATE] at 12:46 p.m., nursing assistant (NA)-D stated R1 was frequently confused. R1's wandering behaviors increased, such as exit seeking and verbalizing he wanted to leave to go help his wife, after she left the nursing home. NA-D stated R1 looked for exit doors and attempted to open the door two or three times, when he gets close to the door his wander guard sets off the alarm and alerts staff on their radios they carry. R1 indicated he had a meeting or wanted to go see his wife. NA-D worked on [DATE] on a different unit than R1 resided on. NA-D saw R1 walking around between 7:30 p.m. and 8:30 p.m. R1's family had taken him out that day and brought him back. NA-D was not made aware R1 had left the nursing home through the door to the hospital but would have expected someone to tell him. NA-D stated if he had been made aware he would have increased how frequent he monitored R1 to help avoid him getting out of the nursing home and /or outside in the dark. NA-D stated R1 would not have been able to find his way back in the dark, was unsafe outside by himself and could have gotten hurt. NA-D stated he already completed his shift at 10:30 p.m. and left the building on [DATE].During interview on [DATE] at 2:32 p.m., licensed practical nurse (LPN)-A stated the beginning of [DATE], R1 was fixated on the double doors that went from the nursing home to the hospital. R1 informed LPN-A, his wife was in the hospital, and he had to give her medications. LPN-A stated prior to R1's elopement on [DATE], it was reported to her that R1 kept going to that door and she previously had to sit with him for 1:1 throughout the night, he even went with her when she made rounds. LPN-A stated, on [DATE] at approximately 8:00 p.m., a nurse from the hospital came over to the nursing home, walking with R1, and asked where his room was. Our conversation was short; I had an idea that [R1] may have been lost but did not ask and directed the nurse to Pioneer, where R1 lived. LPN-A stated she did not include this information in the report, she assumed the nurse located on Pioneer already knew about it. LPN-A left the facility at 10:30 p.m.During interview on [DATE] at 11:45 a.m., RN-A stated R1 was confused, forgetful, at risk of elopement and wore a wander guard on his right ankle. R1 showed signs of exit seeking frequently: talked about leaving and tried to open exit doors, especially door #11 located by his room. When a door was triggered by a wander guard, a notification came up on our walkies. All staff are required to carry one, to alert us as which door the resident was at. RN-A stated staff were expected to check on R1 at least every two hours and redirect him from the exit doors to help avoid an elopement. RN-A stated R1 would not have been safe outside in the community alone due to his confusion and declining mental status. RN-A stated on the evening of [DATE], R1 was last seen on the unit around 8:30 p.m. R1 paced and wandered around the unit that evening quite a bit and carried his business cards with nursing home address in his hand. RN-A stated sometime between 8:30 p.m. and 9:00 p.m., R1 was brought back to the nursing home by a hospital staff nurse after going alone through the connecting double doors to the hospital. RN-A stated she was not aware he had left the nursing home and assumed he followed someone out through the double doors. RN-A stated she did not inform other staff working that R1 had left the nursing home and did not initiate 1:1 supervision. RN-A felt it was unnecessary and the normal monitoring of every two hours was adequate. RN-A stated on [DATE] prior to 10:30 p.m., R1 tried to get out exit door #11 located by his room at least twice, the alarm sounded, and he was redirected by staff without resistance to his room. RN-A stated staff should have been more vigilant and knew where he was at all times. RN-A stated she was unsure it was passed on in report that R1 was brought back to the facility by nursing staff earlier that evening or how he got out. It would have been important to know so the next shift would be more diligent about knowing R1's whereabouts to keep him safe and would have avoided an elopement. RN-A stated she could have called the DON after R1 was [NAME] back from the hospital but thought R1 was settling down and hoped he was going to bed. RN-A stated the last time staff saw R1 was 10:30 p.m., during report on Pioneer. It was twelve-fifteen [12:15 a.m.] when we realized staff were unable find [R1], after checking both Wild [NAME] and Pioneer inside of the nursing home. I had a sinking feeling in my stomach when I realized [R1] was missing. The staff searched all rooms and opened all doors, including those that were locked. Staff went outside and searched around the building by the ambulance garage and parking lot, then came back into building and searched all resident rooms, the lab area, and the hospital. RN-A stated during her search for R1 she tried to push open the double doors located between the nursing home and hospital and they were not latched; no code was required to open them. RN-A called the DON at 12:42 a.m., informed her they were unable to locate R1. RN-A stated it was her responsibility on [DATE] from 6:00 p.m. through [DATE] to 6:30 p.m. to keep R1 safe. RN-A stated it was later identified R1 got out through the side kitchen door, walked through the kitchen to the back door, followed the hallway down to the independent living /assisted living, and went out the exit door that did not have an alarm on it. RN-A stated dietary staff were expected to lock the kitchen door prior to leaving at night. If the door had been locked that night, [R1's] elopement would not have happened.During interview on [DATE] at 2:15 p.m., culinary service director (CSD) stated she would have expected the dietary staff to lock the doors to the kitchen nightly prior to leaving. There was no process in place to have anyone check to see if they were locked prior to R1's elopement on [DATE]. On [DATE], a new process was started, staff are expected to document in a log all three doors going into the kitchen were locked when they arrived in the morning at 5:00 a.m. Staff working the evening shift were expected to check all three doors and document in the logbook. Audits were completed to ensure this process was followed. The part of the kitchen door that made it swing closed was leaking hydraulic fluid, did not hold pressure, and was replaced about six months ago. CSD stated she had not been made aware of any concerns or witnessed the door not closing and/or latching prior to the incident. Maintenance adjusted the door arm at the top so that it closed harder and latched. CSD stated it was concerning R1 got out of the building in the dark. R1 was very mobile, went places quicker than anticipated, confused, could have fallen or walked onto a busy highway, and where he ended up was not a safe situation, laying in the bushes in the dark.During interview on [DATE] at 3:22 p.m., NA-F stated R1 was forgetful and had dementia. He exit-seeks mostly after someone visits him; it seemed to trigger him to wanting to leave the facility. R1 was very social, liked being around others, but was not in the right state of mind. R1 had wandering, exit seeking behaviors that required redirection for his safety due to his elopement risk. R1 would not have been safe outside by himself. NA-F stated sometimes it had taken up to 30 minutes, and more than one staff to redirect R1 away from an exit door. Approximately two months ago, NA-F stood in front of the connecting double door from nursing home to hospital, attempted to redirect R1 and he pushed her into the door. The door opened without a code being entered on keypad. That was when she became aware there was an issue with the door not closing/latching properly. NA-F stated she informed the staff nurse and the DON about the door. NA-F worked on [DATE], and during report at 10:30 p.m., [R1] sat behind us at the nurse's station for about two minutes, got up and went into another resident's room. NA-F answered the call light in that resident's room but R1 was no longer in there. When NA-F came back to nurse's station the other staff had left. NA-F had not been informed that R1 left the unit and went over to the hospital on the evening shift. NA-F stated, if she had been aware, she would have kept a closer eye on him or asked the nurse to watch him while they did rounds to help prevent elopement.During interview on [DATE] at 4:46 p.m., the DON stated R1 was at risk for elopement, had a known wandering history, wore a wander guard, had impaired cognition and safety awareness. DON stated on [DATE] at approximately 10:30 p.m., hospital staff assisted R1 back to the nursing home and RN-A became aware R1 had left the nursing home, entered the adjourning hospital area through the connecting double doors. DON stated she would have expected staff to have notified her R1 had left the nursing home the first time and increased his supervision to help prevent elopement. The DON was notified on [DATE] at approximately 12:40 a.m., staff were unable to locate R1 at approximately 12:20 a.m. and a facility search was underway. DON stated she arrived at facility and at 1:50 a.m., R1 was located outdoors across the road between the facility and the school, lying inside the bushes, awake and responsive. R1 was appropriately dressed and was taken to emergency room to be assessed. No injuries were identified and R1 was diagnosed with a urinary tract infection, placed on antibiotics, and returned to facility.Facility policy, Elopement, dated [DATE], identified associates will engage in interventions to prevent wandering and active elopement by providing a safe and least restrictive environment for residents who are at risk f

Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR) accurately reflected the medication administration times and identify the reason for late documentation for 3 of 3 resident (R4, R5, R6) reviewed for accuracy of medication administration record.Findings include:R4R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had intact cognition. R4's medical diagnoses include progressive neurological conditions, Parkinson's, anemia (low iron), thyroid disorder, anxiety, depression, and malnutrition. Review of R4's electronic medication administration record (eMAR) from 6/1/26 through 8/25/26, included the time of medication documentation but did not include the actual time each medication was administered.R5R5's quarterly MDS dated [DATE], identified he had moderately impaired cognition with no behaviors. R5's diagnoses included anemia, stroke, and Parkinson's.Review of R5's eMAR from 6/1/26 through 8/25/26, included the time of medication documentation but did not include the actual time each medication was administered.R6R6's quarterly MDS dated [DATE], identified R6 had intact cognition and no behaviors. R6 required substantial/maximal assistance with transfers and used a walker and wheelchair for mobility. R6's diagnoses include Parkinson's and anxiety. Review of R6's eMAR from 6/1/26 through 8/25/26, included the time of medication documentation but did not include the actual time each medication was administered. Interview on 8/21/26 at 2:32 p.m. licensed practical nurse (LPN-A) stated yesterday she got busy after administering medications and postponed documenting in R4's eMAR, so it appeared she administered the medications late. LPN-A stated, when medication administration is documented late, nurses are supposed to add a comment with the time the medication was administered and a reason for the late documentation. LPN-A stated she did not add comments to R4's eMAR.Interview on 8/25/26 at 1:55 p.m., LPN-B stated staff were expected to document administration of the medications right away so that the next nurse could identify when the last dose was given and to know when to administer the next dose to prevent medication errors. LPN- B stated the eMAR on the computer system did not identify the time the medication was administered but did record the time. When documenting medication administration late, nurses were expected to add comments to clarify the time the medication was administered and the reason it was documented late. LPN-B stated he found it difficult to document all medications right away, sometimes he got busy. LPN-B reviewed documentation for R5's carbidopa-levodopa due at 6:30 a.m. and 11:00 a.m., Late administration: charted late entries on 8/17/26, were both documented at 12:26 p.m. and again on 8/18/26, due at 11:00 a.m. and 4:30 p.m., both documented at 10:03 p.m. LPN-B stated it did not show the time he administered them, he would have never given two doses at the same time, most likely forgot to document them and had a problem with getting caught up with so many other things to do. During interview on 8/26/26 at 2:26 p.m., the director of nursing (DON) stated staff were expected to follow the standards of practice and facility policy to document a medication was given at the time of administration to ensure timely record keeping of administration of medications. Without timely documentation the risk of potential medication errors was increased. The current electronic medical records system used by the facility, documents as needed medications with a time stamp. Medications administered within in the two-hour window (one hour before and one hour after it was scheduled) there was no indication it was given late, especially with those medications that were due within 15 minutes of the scheduled time. This would be a concern with time-specific medications. The facility was actively looking at another option in eMAR system on how to record the exact administration time for time sensitive medications.A facility policy for documentation of medication administration was requested but was not received.

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with prescriber orders, resulting in significant medication errors for 3 of 3 residents (R4, R5, R6) reviewed for medication administration.Findings include: R4R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had intact cognition. R4's medical diagnoses include progressive neurological conditions, Parkinson's, anemia (low iron), thyroid disorder, anxiety, depression, and malnutrition. R4's orders identified:Ensure 6 ounces (oz) once a day. Special instructions: Please ensure resident drinks supplement don't just leave on table in room. May give flavor of choice. Scheduled time: 6:30 a.m. - 10:30 a.m. Start date 6/1/26.Carbidopa-levodopa 50/200 mg ER two tablets once a day as needed (PRN). Special instructions: Do not crush. Administer orally whole two tablets in middle of the night if awake once a day as needed (PRN). Start date: 6/5/26.Carbidopa-levodopa (medication that combines these two medications to treat Parkinson's by replenishing dopamine levels in the brain) 25/100 milligram (mg) tablet 3 tablets four times a day orally. Special instructions: Give medication within 15 minutes of designated time. Take medication without food, taking it no closer to a meal than 60 minutes before or 60 minutes after a meal or source of protein to reduce interference of protein with the absorption of the medication. Administer four times a day: a.m. med pass 8:00 a.m., noon pass 11:00 a.m., p.m. med pass 2:00 p.m., and HS med pass 5:00 p.m. Start date 6/11/26Carbidopa-levodopa 50/200 mg extended-release (ER) tablet 2 tablets. Special instructions: Give within 15 minutes of designated time. Do not crush. Administer orally at bedtime (HS) med pass 8:00 p.m. Start date 6/11/26. The Federal Drug Administration manufacturer's recommendations for Sinemet (carbidopa-levodopa) on record (https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/017555s069lbl.pdf) included: The patient should be informed that SINEMET is an immediate-release formulation of carbidopa-levodopa that is designed to begin release of ingredients within 30 minutes. It is important that SINEMET be taken at regular intervals according to the schedule outlined by the physician. The patient should be cautioned not to change the prescribed dosage regimen .Patients should be advised that sometimes a 'wearing off ' effect may occur at the end of the dosing interval. The physician should be notified if such response poses a problem to lifestyle.Review of R4's electronic medication administration times from 6/1/26 through 8/25/26, identified:Carbidopa-levodopa 25/100 mg tablet, 3 tablets orally four times a day. Special instructions: Give medication 15 minutes of designated time. Take medication without food, taking it no closer to a meal than 60 minutes before or 60 minutes after a meal or source of protein to reduce interference of protein with the absorption of the medication. Administer four times a day: 8:00 a.m.; 11:00 a.m.; 2:00 p.m.; 5:00 p.m. Start date 6/11/26.6/11/26 through 6/30/26, indicated R4's carbidopa-levodopa was administered late and/or documented late 46 times. 7/1/26 through 7/30/26, indicated R4's carbidopa-levodopa was administered late and/or documented late 64 times.8/1/26 through 8/25/26 indicated R4's carbidopa-levodopa was administered late and/or documented late 59 times.Carbidopa-levodopa 50/200 mg ER tablet, 2 tablets. Special instructions: Give within 15 minutes of designated time. Do not crush. Administer orally at HS, 8:00 p.m.Review of 6/11/26 through 8/26/26, indicated R4's carbidopa-levodopa was administered late and/or documented late 19 times. Carbidopa-levodopa 50/200 mg ER tablet, 2 tablets once a day as needed (PRN). Special instructions: Do not crush. Administer orally whole 2 tablets in middle of the night if awake once a day as needed (PRN). Start date: 6/5/26. Review of 6/5/26, through 8/20/26, identified:6/5/26 through 6/30/26, R4 requested PRN doses 2 times: 6/13/26 and 6/19/26.7/1/26 through 7/31/26, R4 requested PRN doses eight (8) times. 7/2/26, 7/3/26, 7/4/26, 7/13/26, 7/19/26, 7/24/26, 7/26/26 (response: medication did not help), 7/30/26 (response: increased Parkinson's symptoms, the worse she has ever had). R4's reasons/comments included: requested for increased Parkison's symptoms and/or shaking8/1/26 through 8/20/26, R4 requested PRN doses six (6) times, 8/1/26, 8/2/26, 8/3/26 (response: somewhat effective for a short time, expressed improvement), 8/14/26, 8/19/26, and 8/20/26. R4's reasons/comments included: requested for increased Parkinson's symptoms stiffness/can't walk/increased stifling gait.R4's care plan dated 6/2/26, identified:R4 had protein-calorie malnutrition with fair oral intakes requiring the use of feeding tube to maintain nutritional health. Staff were directed to encourage to accept feedings vis tube and if she refused offer Ensure (supplement) or snack. Provide water flushes orally between meals. Encourage 4 to 8 ounces (oz) of supplement daily. Serve R4 a regular diet as ordered and provide built-up utensils and cups with lids.Preference for customary routine made known to those who provide care. R4's preference was to wake up at 9:00 a.m. daily.R4 was at risk for falls due to weakness, psychotropic and diuretic medication use balance related to Parkinson's, depression, edema, and anxiety. Staff were directed to observe for signs/symptoms of medication adverse effects: psychotropic, narcotics, and cardiovascular.R4's progress notes from 7/19/26 to 8/2/26, identified:7/19/26 at 9:36 p.m., Nursing assistant (NA) informed writer R4 was on the floor at hallway leading to Wildrose. R4 was noted up walking, had gotten herself up before writer arrived on scene. R4 was wearing regular socks, refused gripper socks when offered and vitals. No injuries noted.7/20/26 at 5:04 a.m., R4 was walking weakly, increased Parkinson's symptoms and had already received PRN dosage. Assisted and then walked back to her room.7/24/26 at 3:01 a.m., Requested PRN Carbidopa-levodopa for increased Parkinson's symptoms. She did have extra swaying and mouth movements given at 3:00 a.m.7/26/26 at 5:40 a.m., R4 had requested PRN Carbidopa-levodopa for increased Parkinson's symptoms it was given but had not helped tonight.8/1/26 at 6:18 a.m., R4's blood pressure lower 88/53.8/2/26 at 12:59 a.m., R4 expressed concerns about her Parkinson's symptoms worsening at night and she frequently had to take her PRN Carbidopa-levodopa. She has had increased swaying and tongue movements two symptoms that are prominently noticed.8/2/26 at 5:01 a.m., Resident concern: R4 reported that PRN Carbidopa helped her chew for a while and she was able to sleep but the symptoms have returned. Prominently the tongue movements and swaying. She thinks her symptoms are getting worse and that the medication was not helping like it once did. She also felt like she was having a harder time standing. R4's occupational (OT) visit dated 6/30/26, identified R4 met with OT and director of nursing (DON) to discuss her concerns regarding medication and getting them at the correct time and how it affected her ability to perform activities of daily living (ADLs) and ambulation.R4's OT visit dated 7/23/26, identified R4 was approached by OT while standing at the sink with water all over the floor. R4 was noted to have significant swaying while at sink to perform grooming and increased instability with all activities of daily living (ADLs). R4 demonstrated difficulty with dynamic balance/weight shifting task due to instability and loss of balance (LOB) twice when she stepped forward/backward. R4 continued to present with instability with functional reach (FR) task (where she had to stand still and stretch her arms out to grab something) and obstacle negotiation (tired to perform everyday functional activities and navigate around physical obstacles) which placed her at increased risk for falls.R4's neurology visit dated 6/11/26, identified in 2018/2019, R4 began to experience a resting tremor in left hand, balance was off, not falling at that time, diagnosed with Parkinson's disease, started on Sinemet (Carbidopa/Levodopa), and improvement was seen in walking, balance, and tremor. R4 started falling three to four years ago and she transitioned to using a walker full time. Today she had concerns about early wearing off her Parkinson's medications, nausea, and weight loss. Each dose taken orally took about 30 to 45 minutes to take effect and lasted up to two hours. R4 was interested in the Vyalev pump (a small, wearable medical device that delivers a continuous 24-hour subcutaneous (under the skin) infusion of foscarbidopa and falsehood to treat advanced Parkinson's disease). R4 only ate half of her meals, weight loss of unknown etiology, feeding tube placed in 2024, and tried to eat three meals a day. Nursing assistants (NA) noted it was hard for R4 to eat because she had tremors that made it challenging to use utensils. She did not like to eat in front of others at the table where staff were assisting others with eating.During observation on 8/21/26 at 2:24 p.m. licensed practical nurse (LPN)-A brought R4's scheduled 2:00 p.m. dose of Carbidopa-levodopa to R4's room. R4 sat on the edge of her bed with a plate of food in front of her. LPN-A administered the carbidopa-levodopa and R4 stated, I need to eat this food, grabbed her fork, started eating. At 2:28 p.m. LPN-A documented administration of the medication on the EMAR.During observation and interview on 8/25/26 at 9:05 a.m., LPN-B stated he had R4's medications prepared which included: R4's scheduled 8:00 a.m. dose of Carbidopa-levodopa 25/100 mg tablet, 3 tablets. At 9:17 a.m., LPN-B handed R4 a container of ensure with a straw in it. R4 held the ensure in her hand and drank part of the supplement. LPN-B administered R4's pills, with R4 taking sips of the ensure between bites. At 9:26 a.m. LPN-B documented the medications he had administered.During interview and observation on 8/20/26 at 4:10 p.m., R4 sat on the edge of her bed fully dressed swaying back and forth. R4 stated she had Parkinson's, took Carbidopa-levodopa, but it was frequently not administered on time. R4 stated the dose she received at bedtime was often given up to one hour late. R4 reported increased bodily movements when her medication was not administered on time. The afternoon dose, due today at 2:00 p.m., was not given until 3:30 p.m. R4 reported increased bodily movements and did not feel safe going into the bathtub for her bath that was scheduled today. R4 stated, this morning, she did not receive the scheduled 8:00 a.m. dose until 11:30 a.m. R4 stated this was a frequent occurrence. Receiving the medication late has affected her more in the past couple of months. R4 found it more difficult to walk safely, became frustrated, and was worried about falling. R4 stated she had no appetite and lost weight from nausea. R4 was aware she was not supposed to consume protein, receive tubing feedings, or ensure close to the time she received the Carbidopa-levodopa, but this was hard to avoid when she was administered the medication late. R4 stated her quality of life has been affected by not receiving Carbidopa-levodopa mediation on time. It was difficult to feed herself as she was unable to get a spoon to her mouth without dropping food because her hands shake. R4 stated staff informed her if she needed help with meals to come to the dining room. R4 stated she ate meals in her room because the uncontrolled body movements made it difficult to eat without making a mess. R4 did not like others watching her eat and she had problems with swallowing. R4 stated she was embarrassed.During interview on 8/20/26 at 7:15 p.m. family member (FM) stated R4 has mentioned several times that the Carbidopa-levodopa medication was not administered on time, especially the 8:00 p.m. dose. FM stated R4's Parkison's had drastically worsened in the last five months. R4 swayed back and forth, and FM noticed this more following the 7/4/26 neurology visit.During interview on 8/25/26 at 12:46 p.m., nursing assistant (NA)-G stated R4's shakiness had gotten worse since March 2026. NA-G noticed a big difference in R4's ability to walk safely, she swayed back and forth more often and required assistance to prevent falls. NA-G stated she thought the increase in R4's symptoms affected her level of independence, she slept more, could do less for herself, and had difficulty getting food to her mouth due to her movements/swaying.During interview on 8/25/26 at 1:22 p.m. neurology nurse practitioner (NP) stated R4 was last seen June 2026. Carbidopa-levodopa administration timing was strict to ensure the best results and minimize symptoms. NP stated staff would be expected to follow the orders and if given after the 15-minute window it was considered late. If staff consistently administered this medication late it would be considered a significant medication error. NP stated stacking (medication doses were administered too close together) was not a good idea and R4's symptoms would have become more severe when stacking the Carbidopa-levodopa. NP stated the type of symptoms seen would be cognitive fluctuations and worsen dyskinesis (involuntary movements such as swaying). Doses administered too far apart would result in symptoms such as balance impairment and falling. When the Carbidopa-levodopa was not administered as ordered signs of wearing off would increase anxiety, R4 may become overwhelmed and wouldn't want anything to do with anyone. R4 had a history of anxiety and therefore late administration would increase her anxiety. NP stated this medication had an extremely short-half life (an estimate of the time it takes for the concentration of amount in the body of the medication to be reduced by one-half), and the timing was specific to management of R4's symptoms. R4's balance had gotten worse, it was possible this was due to administering the carbidopa-levodopa with protein, such as the ensure R4 drinks and the formula for R4's tube feeding. When administered with protein, the medication did not work as well, the protein interfered with absorption. NP stated it was obvious R4's Parkinson's was not responding as it should to the medication, that was the reason for scheduling it the way NP did and ordering the specific parameters for administration.During interview on 8/25/26 at 3:00 p.m., floor manager registered nurse (RN)-C stated R4's special instructions for administration of the Carbidopa-levodopa, given within 15 minutes of designated time, most likely came from pharmacy recommendations and staff would be expected to follow those instructions so the medication was effective. If it was not administered per ordered instructions, it would be considered late and a medication error. When a medication was administered late, RN-C stated the staff nurse would be expected to notify the provider, ask for further orders and may need to update the order to adjust the next time the medication would be administered.R5R5's quarterly MDS dated [DATE], identified he had moderately impaired cognition with no behaviors. R5's diagnoses included anemia, stroke, and Parkinson's.R5's orders identified:Carbidopa-Levodopa 25/100 mg tablet, one half (1/2) of a tablet three times a day, 6:30 a.m.; 11:00 a.m.; and 4:30 p.m. Special instructions: take one hour before food. Start date: 2/17/26.Give nutritional supplement twice day (BID) and per resident request. Twice a day a.m. med pass: 6:30 a.m. - 10:30 a.m. and p.m. med pass: 3:30 p.m. - 7:00 p.m. Start date: 4/7/26.Review of R5's electronic medication administration times 6/1/26 through 8/25/26, identified:Carbidopa-Levodopa 25/100 mg one half of a tablet three times a day, 6:30 a.m., 11:00 a.m., and 4:30 p.m. Special instructions: take one hour before food. Late administration/charted late (more than 60 minutes after designated scheduled time) identified start date: 2/17/26.6/1/26 through 6/30/26, indicated R5's Carbidopa-levodopa was administered late and/or documented late 49 times.7/1/26 through 7/31/26, indicated R5's Carbidopa-levodopa was administered late and/or documented late 41 times:8/1/26 through 8/25/26, indicated R5's Carbidopa-levodopa was administered late and/or documented late 31 times. R5 one missed dose.R5's care plan dated 2/19/26, identified:Nutritional deficit related to Parkinson's. Staff were directed to provide assistance with eating related to disease symptoms of shaking. R5 preferred Chocolate Ensure as an oral nutrition supplement provided twice a day and PRN.During interview on 8/25/26 at 9:31 a.m., R5 stated he sometimes received his Parkinson's medication late but was unsure how often. R6R6's quarterly MDS dated [DATE], identified R6 had intact cognition and no behaviors. R6 required substantial/maximal assistance with transfers and used a walker and wheelchair for mobility. R6's diagnoses include Parkinson's and anxiety. R6's physician's order dated 2/18/26, Carbidopa-Levodopa 25/100 mg ER tablet, one and one-half (1 1/2) tablets orally three times a day: a.m. med pass 6:30 a.m. -10:30 a.m., noon med pass 11:00 a.m. - 2:30 p.m., and HS med pass 6:30 p.m. - 10:30 p.m.R6's care plan dated 6/1/26, identified a potential for altered nutrition related to diagnosis of Parkinson's and failure to thrive. Staff were directed to provide a regular diet with cut-up food for three meals per day, and twice a day and PRN snacks.Review of R6's electronic medication administration times from 6/1/26 through 8/25/26, identified: Carbidopa-Levodopa 25/100 mg ER tablet, 1 1/2 tablets orally three times a day: a.m. med pass 6:30 a.m. -10:30 a.m., noon med pass 11:00 a.m. - 2:30 p.m., and HS med pass 6:30 p.m. - 10:30 p.m., identified:6/12/26 through 6/30/26, indicated R6's Carbidopa-levodopa was administered late and/or documented late 4 times.7/1/26 through 7/31/26, indicated R6's Carbidopa-levodopa was administered late and/or documented late 5 times.8/1/26 through 8/25/26, indicated R6's Carbidopa-levodopa was administered late and/or documented late 4 times. During interview on 8/25/26 at 4:46 p.m., the director of nursing (DON) stated a supplement such as ensure contained protein and should not have been given with Carbidopa-levodopa as protein affects and minimizes how the medication was absorbed. A late dose would be considered one hour after it was to be administered. DON stated if a medication was scheduled or expected to be administered within 15 minutes of when it was due but was given after those 15 minutes, it would be considered late and would be a medication error. The nurse would have been expected to add a comment and/or write a progress note to identify why it was given late and she was unable to identify any notes for the past three months. DON stated if a medication was administered late that's when the provider should have been called to get some direction as to when the next dose should have been given, it was not within nursing judgement to make that decision. DON stated medication error reports should have been completed on all the medications that were given late. The DON was unsure if it was a significant medication error, unless harm was proven. Staff would be expected to contact the provider when medication was administered late. The DON reviewed the facility policy for medication administration with the surveyor. The policy indicated if regularly scheduled medication is withheld, refused, not available, or given at the time other than the scheduled time the space provided on the front of the MAR for that dosage administration is initiated and circled. An explanatory note is entered on the reverse side of the record. If vital medication is withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. (note: this section refers to the use of a MAR system, most likely paper, that was not electronic and the next section referred to if an electronic MAR system was used refer to the system's user manual as procedures will vary between the various electronic systems available). DON stated she had noticed on the night shift R4's movements were noticeable, and worse, R4 did not sleep well during the night due to swaying. R4 requested Carbidoopa-levodopa PRN on the night shift, the DON was unsure if that may have been due to the last dose administered incorrectly. R4 had requested a neurology appointment in June or July 2026, R4 felt her symptoms had increased.During a follow- up interview on 8/26/26 at 2:26 p.m., the DON indicated staff would be expected to follow the standards of practice/facility policy and document a medication was given at the time of administration to ensure timely record keeping of administration of medications and cares. Without timely documentation this could potentially increase the risk of medication errors and medications may be given late or too soon. This would be a concern with time specific medications such as Carbidopa-levodopa. We are actively looking at another option in our system on how to record the exact administration time for the time sensitive medications.During an interview 8/26/26 at 2:47 p.m. the consultant pharmacist (PD) stated staff would be expected to administer Carbidopa-levodopa according to the prescribed dosing schedule because consistent timing helped maintain its intended therapeutic effect. Delayed or missed doses may result in diminished medication effect and recurrence or worsening of Parkinsonian symptoms including rigidity, bradykinesia (slowness of movement and speed), tremor, or impaired mobility. However, the clinical significance of any timing deviation should be evaluated based on the extent of the delay and the resident's individual clinical response. PD stated administration of Carbidopa/levodopa substantially closer together than prescribed may increase levodopa exposure and the risk of dose-related adverse effects including dyskinesia, nausea, orthostatic hypotension, confusion, or hallucinations. PD stated when a dose was given late, the nurse would be expected to follow facility policy and should not independently alter the prescribed dosing schedule or administer doses substantially closer together without appropriate clinical guidance. Provider notification should occur, when necessary, based on the timing of the next dose, the resident's clinical status, facility policy for late administration and follow-up documented. PD stated current Federal Drug Administration (FDA) drug labeling for Sinemet (Carbidopa-levodopa) indicated a high protein diet may affect the absorption of levodopa.Facility policy Medication Error/Occurrence dated 8/31/23, identified definition of medication error was the preparation or administration of drugs or biologicals which is not in accordance with the attending providers' orders, manufacturer's specification or accepted standards and principles of the professional providing the services. Examples of medication errors include omissions, unauthorized drug, wrong dose, wrong route of administration, wrong dosage form, wrong drug, wrong time, failure to follow manufacturer's instructions. When an error is made in the preparation or administration of a drug or biological, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation or treatment is indicated. Action is taken to prevent the medication error from reoccurring.

Based on observation, interview, and document review, the facility failed to follow provider orders for medication and failed to ensure medication administration was correctly documented for 3 of 3 residents (R4, R5, and R6) reviewed for medication administration.Findings include: R4 R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had intact cognition. R4's medical diagnoses include progressive neurological conditions, Parkinson's, anemia (low iron), thyroid disorder, anxiety, depression, and malnutrition. R4's orders identified:Nutren 1.5 (nutritional supplements) liquid; 0.07 gram (gr) - 1.5 kilocalorie (kcal) /milliliters (ml); 250 ml bolus; feeding tube. Special instructions: please give at specific time ordered with scheduled Zofran at start of administration, 250 ml bolus/bag/tubing via pump to be administered over an hour every shift: morning, day, evening. Start date 2/12/26.Ensure 6 ounces (oz) once a day. Special instructions: Please ensure resident drinks supplement don't just leave on table in room. May give flavor of choice. Scheduled time: 6:30 a.m. - 10:30 a.m. Start date 6/1/26.Carbidopa-levodopa (treat Parkinson's by replenishing dopamine levels in the brain) 50/200 mg (milligrams) extended release (ER) tablet, two (2) tablets once a day as needed (PRN). Special instructions: Do not crush. Administer orally whole, 2 tablets in middle of the night if awake. Start date: 6/5/26.Carbidopa-levodopa 25/100 mg tablet, three (3) tablets four times a day orally. Special instructions: Give medication within 15 minutes of designated time. Take medication without food, taking it no closer to a meal than 60 minutes before or 60 minutes after a meal or source of protein to reduce interference of protein with the absorption of the medication. Administer four times a day: 8:00 a.m.; 11:00 a.m.; 2:00 p.m.; and 5:00 p.m. Start date 6/11/26Carbidopa-levodopa 50/200 mg ER tablet, 2 tablets. Special instructions: Give within 15 minutes of designated time. Do not crush. Administer orally at bedtime (HS), 8:00 p.m. Start date 6/11/26.Review of R4's electronic medication administration times from 6/1/26 through 8/25/26, identified:Carbidopa-levodopa 25/100 mg tablet, 3 tablets orally four times a day. Special instructions: Give medication 15 minutes of designated time. Take medication without food, taking it no closer to a meal than 60 minutes before or 60 minutes after a meal or source of protein to reduce interference of protein with the absorption of the medication. Administer four times a day: 8:00 a.m.; 11:00 a.m.; 2:00 p.m.; 5:00 p.m. Start date 6/11/26.6/11/26 through 6/30/26, indicated R4's carbidopa-levodopa was administered late and/or documented late 46 times. 7/1/26 through 7/30/26, indicated R4's carbidopa-levodopa was administered late and/or documented late 64 times.8/1/26 through 8/25/26 indicated R4's carbidopa-levodopa was administered late and/or documented late 59 times.Carbidopa-levodopa 50/200 mg ER tablet, 2 tablets. Special instructions: Give within 15 minutes of designated time. Do not crush. Administer orally at HS, 8:00 p.m.Review of 6/11/26 through 8/26/26, indicated R4's carbidopa-levodopa was administered late and/or documented late 19 times.Carbidopa-levodopa 50/200 mg ER tablet, 2 tablets once a day as needed (PRN). Special instructions: Do not crush. Administer orally whole 2 tablets in middle of the night if awake once a day as needed (PRN). Start date: 6/5/26. Review of 6/5/26, through 8/20/26, identified:6/5/26 through 6/30/26, R4 requested PRN doses 2 times: 6/13/26 and 6/19/26.7/1/26 through 7/31/26, R4 requested PRN doses eight (8) times. 7/2/26, 7/3/26, 7/4/26, 7/13/26, 7/19/26, 7/24/26, 7/26/26 (response: medication did not help), 7/30/26 (response: increased Parkinson's symptoms, the worse she has ever had). R4's reasons/comments included: requested for increased Parkison's symptoms and/or shaking8/1/26 through 8/20/26, R4 requested PRN doses six (6) times, 8/1/26, 8/2/26, 8/3/26 (response: somewhat effective for a short time, expressed improvement), 8/14/26, 8/19/26, and 8/20/26. R4's reasons/comments included: requested for increased Parkinson's symptoms stiffness/can't walk/increased stifling gait. R4's care plan dated 6/2/26, identified:R4 had protein-calorie malnutrition with fair oral intakes requiring the use of feeding tube to maintain nutritional health. Staff were directed to encourage to accept feedings vis tube and if she refused offer Ensure (supplement) or snack. Provide water flushes orally between meals. Encourage 4 to 8 ounces (oz) of supplement daily. Serve R4 a regular diet as ordered and provide built-up utensils and cups with lids. -Preference for customary routine made known to those who provide care. R4's preference was to wake up at 9:00 a.m. daily. -R4 was at risk for falls due to weakness, psychotropic and diuretic medication use balance related to Parkinson's, depression, edema, and anxiety. Staff were directed to observe for signs/symptoms of medication adverse effects: psychotropic, narcotics, and cardiovascular.R4's progress notes from 7/19/26 to 8/2/26, identified:7/20/26 at 5:04 a.m., R4 was walking weakly, increased Parkinson's symptoms and had already received PRN dosage. Assisted and then walked back to her room.8/2/26 at 12:59 a.m., R4 expressed concerns about her Parkinson's symptoms worsening at night and she frequently had to take her PRN Carbidopa-levodopa. She has had increased swaying and tongue movements two symptoms that are prominently noticed. During observation on 8/21/26 at 2:24 p.m. licensed practical nurse (LPN)-A brought R4's scheduled 2:00 p.m. dose of Carbidopa-levodopa to R4's room. R4 sat on the edge of her bed with a plate of food in front of her. LPN-A administered the carbidopa-levodopa and R4 stated, I need to eat this food, grabbed her fork, started eating. At 2:28 p.m. LPN-A documented administration of the medication on the EMAR.During observation and interview on 8/25/26 at 9:05 a.m., LPN-B stated he had R4's medications prepared which included: R4's scheduled 8:00 a.m. dose of Carbidopa-levodopa 25/100 mg tablet, 3 tablets. At 9:17 a.m., LPN-B handed R4 a container of ensure with a straw in it. R4 held the ensure in her hand and drank part of the supplement. LPN-B administered R4's pills, with R4 taking sips of the ensure between bites. At 9:26 a.m. LPN-B documented the medications he had administered.During interview and observation on 8/20/26 at 4:10 p.m., R4 sat on the edge of her bed fully dressed swaying back and forth. R4 stated she had Parkinson's, took Carbidopa-levodopa, but it was frequently not administered on time. R4 stated the dose she received at bedtime was often given up to one hour late. R4 reported increased bodily movements when her medication was not administered on time. The afternoon dose, due today at 2:00 p.m., was not given until 3:30 p.m. R4 reported increased bodily movements and did not feel safe going into the bathtub for her bath that was scheduled today. R4 stated, this morning, she did not receive the scheduled 8:00 a.m. dose until 11:30 a.m. R4 stated this was a frequent occurrence. Receiving the medication late has affected her more in the past couple of months. R4 found it more difficult to walk safely, became frustrated, and was worried about falling. R4 stated she had no appetite and lost weight from nausea. R4 was aware she was not supposed to consume protein, receive tubing feedings, or ensure close to the time she received the Carbidopa-levodopa, but this was hard to avoid when she was administered the medication late. R4 stated her quality of life has been affected by not receiving Carbidopa-levodopa mediation on time. It was difficult to feed herself as she was unable to get a spoon to her mouth without dropping food because her hands shake. R4 stated staff informed her if she needed help with meals to come to the dining room. R4 stated she ate meals in her room because the uncontrolled body movements made it difficult to eat without making a mess. R4 did not like others watching her eat and she had problems with swallowing. R4 stated she was embarrassed. R5R5's quarterly MDS dated [DATE], identified he had moderately impaired cognition with no behaviors. R5's diagnoses included anemia, stroke, and Parkinson's.R5's orders identified:Carbidopa-Levodopa 25/100 mg tablet, one half (1/2) of a tablet three times a day, 6:30 a.m.; 11:00 a.m.; and 4:30 p.m. Special instructions: take one hour before food. Start date: 2/17/26.Give nutritional supplement twice day (BID) and per resident request. Twice a day a.m. med pass: 6:30 a.m. - 10:30 a.m. and p.m. med pass: 3:30 p.m. - 7:00 p.m. Start date: 4/7/26.Review of R5's electronic medication administration times 6/1/26 through 8/25/26, identified:Carbidopa-Levodopa 25/100 mg one half of a tablet three times a day, 6:30 a.m., 11:00 a.m., and 4:30 p.m. Special instructions: take one hour before food. Late administration/charted late (more than 60 minutes after designated scheduled time) identified start date: 2/17/26.6/1/26 through 6/30/26, indicated R5's Carbidopa-levodopa was administered late and/or documented late 49 times.7/1/26 through 7/31/26, indicated R5's Carbidopa-levodopa was administered late and/or documented late 41 times:8/1/26 through 8/25/26, indicated R5's Carbidopa-levodopa was administered late and/or documented late 31 times. R5 one missed dose.During interview on 8/25/26 at 9:31 a.m., R5 stated he sometimes received his Parkinson's medication late but was unsure how often.R6R6's quarterly MDS dated [DATE], identified R6 had intact cognition and no behaviors. R6 required substantial/maximal assistance with transfers and used a walker and wheelchair for mobility. R6's diagnoses include Parkinson's and anxiety. R6's physician's order dated 2/18/26, Carbidopa-Levodopa 25/100 mg ER tablet, one and one-half (1 1/2) tablets orally three times a day: a.m. med pass 6:30 a.m. -10:30 a.m., noon med pass 11:00 a.m. - 2:30 p.m., and HS med pass 6:30 p.m. - 10:30 p.m.Review of R6's electronic medication administration times from 6/1/26 through 8/25/26, identified: Carbidopa-Levodopa 25/100 mg ER tablet, 1 1/2 tablets orally three times a day: a.m. med pass 6:30 a.m. -10:30 a.m., noon med pass 11:00 a.m. - 2:30 p.m., and HS med pass 6:30 p.m. - 10:30 p.m., identified:6/12/26 through 6/30/26, indicated R6's Carbidopa-levodopa was administered late and/or documented late 4 times.7/1/26 through 7/31/26, indicated R6's Carbidopa-levodopa was administered late and/or documented late 5 times.8/1/26 through 8/25/26, indicated R6's Carbidopa-levodopa was administered late and/or documented late 4 times.During interview on 8/25/26 at 4:46 p.m., the director of nursing (DON) stated a supplement such as ensure contained protein and should not have been given with Carbidopa-levodopa as protein affects and minimizes how the medication was absorbed. A late dose would be considered one hour after it was to be administered. DON stated if a medication was scheduled or expected to be administered within 15 minutes of when it was due but was given after those 15 minutes, it would be considered late and would be a medication error. The nurse would have been expected to add a comment and/or write a progress note to identify why it was given late and she was unable to identify any notes for the past three months. DON stated if a medication was administered late that's when the provider should have been called to get some direction as to when the next dose should have been given, it was not within nursing judgement to make that decision. DON stated medication error reports should have been completed on all the medications that were given late. The DON was unsure if it was a significant medication error, unless harm was proven. Staff would be expected to contact the provider when medication was administered late. The DON reviewed the facility policy for medication administration with the surveyor. The policy indicated if regularly scheduled medication is withheld, refused, not available, or given at the time other than the scheduled time the space provided on the front of the MAR for that dosage administration is initiated and circled. An explanatory note is entered on the reverse side of the record. If vital medication is withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. (note: this section refers to the use of a MAR system, most likely paper, that was not electronic and the next section referred to if an electronic MAR system was used refer to the system's user manual as procedures will vary between the various electronic systems available). DON stated she had noticed on the night shift R4's movements were noticeable, and worse, R4 did not sleep well during the night due to swaying. R4 requested Carbidoopa-levodopa PRN on the night shift, the DON was unsure if that may have been due to the last dose administered incorrectly. R4 had requested a neurology appointment in June or July 2026, R4 felt her symptoms had increased.During a follow- up interview on 8/26/26 at 2:26 p.m., the DON indicated staff would be expected to follow the standards of practice/facility policy and document a medication was given at the time of administration to ensure timely record keeping of administration of medications and cares. Without timely documentation this could potentially increase the risk of medication errors and medications may be given late or too soon. This would be a concern with time specific medications such as Carbidopa-levodopa. We are actively looking at another option in our system on how to record the exact administration time for the time sensitive medications. During an interview 8/26/26 at 2:47 p.m. the consultant pharmacist (PD) stated staff would be expected to administer Carbidopa-levodopa according to the prescribed dosing schedule because consistent timing helped maintain its intended therapeutic effect. Delayed or missed doses may result in diminished medication effect and recurrence or worsening of Parkinsonian symptoms including rigidity, bradykinesia (slowness of movement and speed), tremor, or impaired mobility. However, the clinical significance of any timing deviation should be evaluated based on the extent of the delay and the resident's individual clinical response. PD stated administration of Carbidopa-levodopa substantially closer together than prescribed may increase levodopa exposure and the risk of dose-related adverse effects including dyskinesia, nausea, orthostatic hypotension, confusion, or hallucinations. PD stated when a dose was given late, the nurse would be expected to follow facility policy and should not independently alter the prescribed dosing schedule or administer doses substantially closer together without appropriate clinical guidance. Provider notification should occur, when necessary, based on the timing of the next dose, the resident's clinical status, facility policy for late administration and follow-up documented. PD stated current Federal Drug Administration (FDA) drug labeling for Sinemet (Carbidopa-levodopa) indicated a high protein diet may affect the absorption of levodopa. The EHR system used by the facility did not allow PD to view the actual time of administration, only the time of documentation. PD stated their responsibilities included reviewing resident progress notes, provider orders and documented medication administration times to ensure facility staff are following ordered parameters and administering medications within those parameters. PD was responsible for identifying possible drug interactions, this included interaction with other medications, and supplements. PD would alert the facility of noted concerns and expected the facility to share concerns with the providers to get clarification on the orders. Pharmacy Services Policies and Procedures for Nursing Facilities dated August 2014, identified only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aids) permitted to access medications. Medication rooms, carts, and mediation supplies are locked when not attended by people with authorized access. Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. Medication Administration-Preparation and General Guidelines, medication are administered in accordance with written orders of the prescriber. A schedule of routine dose administration times is established by the facility and utilized on the administration records. Medications are administered at the time they are prepared and are not prepared in advance of the med pass for more than one resident at a time. Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication schedule for the facility. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The individual who administered the medication does records the administration on the resident's medication administration record (MAR). At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time the spaced provided on the front of the MAR for that dosage administration is initiated/circled. An explanatory note is entered on the reverse side of the record. If a vital medication is withheld, refused or not available the physician is notified and documented by nursing along with the physician response. Chart medications administration on MAR immediately following resident's medication administration.Facility policy Monitoring of Medication Administration dated August 2014, identified the consultant pharmacist evaluates medication administration to verify that the resident has received medications in accordance with the prescriber's order and facility policy.

Based on observation, interview, and document review, the facility failed to establish and maintain an infection prevention and control program that included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Specifically, the facility failed to timely initiate and consistently implement transmission-based precautions for 2 of 2 residents (R12. R24) reviewed who exhibited signs and symptoms of potentially infectious diarrhea; failed to consistently identify and monitor residents exhibiting signs and symptoms of potential infection through the facility's surveillance system for 2 of 2 residents (R7, R24) reviewed for infection surveillance; failed to ensure staff adhered to infection prevention practices related to hand hygiene for 1 of 3 residents (R24) reviewed for activities of daily living; and failed to implement enhanced barrier precautions for 2 of 5 residents (R6, R7) reviewed who met criteria for enhanced barrier precautions. These deficient practices had the potential to affect all 36 residents residing in the facility. Findings include: TRANSMISSION BASED PRECAUTIONS R12 R12's annual Minimum Data Set (MDS) dated [DATE], identified R12 had severe cognitive impairment, and included a diagnosis of chronic kidney disease. R12 required partial/moderate assistance with toileting and was always incontinent with bowel and bladder. R12's care plan revised 5/28/26, identified R12 had acute gastroenteritis (inflammation that spreads from your stomach into your intestines, causing pain, vomiting and diarrhea) as evidenced by diarrhea and/or vomiting. Placing R12 at risk for dehydration, electrolyte imbalance, impaired skin integrity, and infection transmission. Staff were directed to: Administer antiemetics, antidiarrheals, or antibiotics as ordered by provider. Monitor for medication effectiveness and side effects. Assess for abdominal pain, cramping, nausea, fever, or discomfort; report concerns to the resident's provider and treat as ordered. Assist with toileting as needed, provide perineal care after diarrhea, and apply barrier cream/protective ointments as indicated. Initiate appropriate isolation precautions per facility policy, minimize resident movement outside of room, and clean and disinfect high-touch surfaces and shared equipment. Monitor frequency, consistency, and volume of stools and/or emesis. R12's Clostridium difficile (C. diff) by Molecular Detection dated 5/27/26, identified R12 was was positive for C. diff (a highly contagious bacterium that causes diarrhea and colitis. It often infects people who've recently taken antibiotics. Antibiotics that kill other bacteria in your gut but don't kill C. diff allow it to quickly grow out of control, (Cleveland Clinic dated 11/19/24)). R12's Enteric Pathogens by Molecular Detection dated 5/27/26, identified R12 was positive for norovirus. (Norovirus is a highly contagious virus that causes acute gastroenteritis (inflammation of the stomach and intestines). Often mistaken for the stomach flu or food poisoning, it results in explosive vomiting, watery diarrhea, and stomach cramps. It is notoriously difficult to kill and spreads rapidly through contaminated food, surfaces, or close contact, Cleveland Clinic dated 2/3/23) R12's nurse progress notes identified the following: 5/18/25 at 5:05 p.m., social work designee (SWD) met with resident on 5/18/26 and completed PHQ-9 Assessments (a screening tool for depression). PHQ-9 score was 3/27 indicating minimal depression. R12 answered yes to feeling down, depressed, and hopeless. R12 stated he doesn't know why he feels this way at times, but stated he was glad that his legs were getting better and was working with therapy. R12 also stated yes for poor appetite, he stated he wasn't eating much when he was feeling sick and stated he had been having loose stools these last couple of days. R12 stated he ate better today. Case manager notified about loose stools, no other concerns for R12 at this time. 5/19/26 at 9:15 a.m., Discussed at Interdisciplinary Team (IDT): weight variance. Will be followed up with provider today during rounds. 5/19/26 at 4:52 p.m., PROVIDER UPDATE: Regarding concerns with loose stools. Reviewed by provider with orders received as follows: comprehensive metabolic panel (CMP) (measures 14 different substances in your blood and is primarily used to evaluate organ function and metabolism), magnesium (Magnesium is a vital electrolyte that your nerves, muscles, and heart need to function properly), complete blood count (CBC), C-reactive protein (CRP) (CRP is a protein made by your liver that increases when there is inflammation in your body). Orders updated. However, the nursing progress note failed to identify if R12 was placed into contact precautions. 5/20/26 at 5:15 a.m., R12 at baseline. No complaints. Incontinent of stool one time. 5/20/26 at 10:30 a.m., LAB RESULTSCRP: 2.6RBC: 3.82HGB: 12.2MCV: 102.1MCHC: 31.3RDW: 16.3BUN: 37Creatinine: 1.58GFR: 40Glucose: 128Albumin: 3.0Alkaline Phosphatase: 224Alanine Aminotransferase: 7Provider updated. No further orders at this time. 5/20/26 at 12:30 p.m., per provider, CRP was elevated but substantially improved compared to a few weeks ago in the hospital. Electrolytes and kidney functions look okay for R12. Alkaline Phosphatase was elevated but had been elevated over the last year. Add a Gamma-glutamyl transferase (GGT) to see if the Alkaline Phosphatase elevation was likely from the liver or bone. GGT lab order added. Writer called lab to inform of add-on lab. However, the nursing progress note failed to identify if R12 was placed into contact precautions. 5/21/26 at 7:15 a.m., staff interviewed for Assessment Reference Date (ARD) ending 05/22/2026: Staff reported continence level for bladder as incontinent and bowel as incontinent. R12 was incontinent in briefs at this time and required check and change in bed or on toilet. Staff reported R12 had frequent loose stools daily since hospital stay. Provider aware. Imodium (anti-diarrhea medication) is in use as needed. 5/26/26 at 5:12 a.m., loose stools twice. Imodium given. However, the nursing progress note failed to identify if R12 was placed into contact precautions. 5/26/26 at 9:06 a.m., some difficulty with therapies due to loose stools per therapy. Will see about stool sample today. 5/27/26 at 11:12 a.m., spoke to R12's doctor about ongoing problems with loose stools and incontinence since hospitalization. Received order for stool culture and C-diff labs. [NAME] 5/27/26 5:53 p.m., R12 at baseline. No concerns noted. Obtained stool specimen and dropped off to lab as ordered for occult parasite and C-diff. However, the nursing progress note failed to identify if R12 was placed into contact precautions. 5/28/26 at 6:20 a.m., writer received lab results this morning indicating R12 was positive for C-Difficile - Norovirus strain. Staff were updated immediately and isolation precautions implemented. Writer spoke to R12 and strongly encouraged him to stay in his room today so as not to spread the illness. Provider was updated. Communication sent out to facility staff. However, the nursing progress note failed to identify R12 cohorting with a roommate. 5/28/26 at 6:27 a.m., LAB RESULTSClostridium Difficile: PositiveNorovirus GI/GII: Detected 5/28/26 at 8:48 a.m., writer contacted R12's doctor regarding positive stool results. Orders received as follows:1. Oral Vancomycin (an antibiotic that kills C. diff) 125 milligrams (mg) 4 times a day for 10 days. 5/28/26 10:02 a.m., discussed at IDT: R12 was diagnosed with C-Diff and norovirus. Isolation precautions in place. Notifications made. However, the nursing progress note failed to identify R12 cohorting with a roommate. 5/28/26 at 10:05 a.m., Antibiotic(s) prescribed:: VancomycinStart Date:: 05/29/2026Dose:: 125 mgRoute:: OralDuration:: 10 daysStop Date:: 06/07/2026Reason Antibiotic(s) Prescribed:: Other (List) C-Diff/NorovirusReview Event: Did resident meet McGeer's Criteria to treat?: YesReview Event: Did culture or imaging tests confirm infection?: YesRisk Factors/Concerns:: No Risk Factors/ConcernsDoes resident still have symptoms?: YesAre signs and symptoms improving?: YesRed Flags:: Antibiotic is ordered for more than 7 daysActions to Take:: Notify nurse manager or facility supervisor, Update providerHas attending provider been updated?: Yes 5/28/26 at 6:32 p.m., no concerns or complaints noted. R12 was on contact precautions due to c-diff. 5/29/26 at 11:30 a.m., Annual Nutrition Review: R12 had just been diagnosed with norovirus and C diff. R12 may benefit from the addition of a probiotic. Nutritional care plan reviewed. Goal for weight maintenance is 230-250 pounds (lbs). Nutritional needs were being met by weight trend. No changes were needed. Encourage fluids related to kidney disease. 5/30/26 at 6:02 p.m., No concerns or complaints noted. Continued to be in contact isolation due to C-diff, no loose stools noted, antibiotic continued with no adverse effect noted. 6/3/26 at 12:26 p.m., regarding active Loperamide prescription (PRN), writer received orders as follows:1. Hold Loperamide for duration of C-Diff infection 6/7/26 at 5:42 a.m., R12 at baseline, no concerns. Continued with contact precautions. R12 stated was ready to come out of that. 6/7/26 at 7:09 p.m., continued contact precautions for C-diff. R12 was noncompliant. R12 came from his room to dining room at times, staff continued to redirect. 6/8/26 at 3:47 a.m., R12 self-transferred to bathroom twice during the night. R12 was reeducated on the need to use his call light for assistance. During a continuous observation on 6/8/26 at 7:46 a.m., R12 had a 3-drawer plastic cart outside his room. A Contact Precautions sign, bleach disposable wipes and red biohazard bags were sitting on top. The top drawer contained gloves and surgical masks, the second drawer had eye and face protection, and the bottom drawer was empty. Inside the doorway, there was a 13-gallon trash bin. R12 was sitting on the edge of his bed. R12's roommate, R7, was in bed with the privacy curtain pulled. At 8:26 a.m., R12 continued sitting on the side of his bed. R12 was dressed and had his wheelchair and overbed table in front of him in reach. 8:41 a.m., LPN-A stated she did know who the facility's infection prevention nurse was. There have been too many changes. R12 began hollering at LPN-A. LPN-A asked dietary aide (DA)-A if R12 had eaten breakfast. DA-A stated no, half the residents in the unit had not eaten breakfast and stated after 9:00 a.m., you have to deliver it. DA-A continued to the dining room. At 8:48 a.m., R12 continued to sit on the side of his bed. R12 did not have his breakfast. At 9:04 a.m., the health unit coordinator (HUC) delivered gowns and placed them in R12's cart in the bottom drawer. At 9:14 a.m., NA-B entered R12's without any personal protective equipment (PPE). R12 began yelling what the hell is going on? I haven't had my breakfast yet. NA-B stated she would go check. Left room and went to the dining room. NA-B did not use hand sanitizer. At 9:19 a.m., NA-B returned with R12's breakfast tray. NA-B put on a gown, gloves and a surgical mask then brought the tray to R12. NA-B placed R12's tray on the overbed table and set up R12's meal, touching items on his overbed table. NA-B removed her gloves and made to leave the room when R12 stopped her and stated, no coffee? NA-B stated R12 had already had some coffee that morning. R12 stated yes, he had, but that was a while ago. Ok, that's fine. I'll get some later. NA-B removed her washable gown and placed it into the trash can at the door, then used hand sanitizer. At 9:24 a.m., NA-B stated staff only needed to wear a gown and gloves when doing anything with R12 and did not need to wear anything if they were caring for R7. NA-B then reentered the room to care for R7 without a gown or gloves. At 10:42 a.m., the wellness activity director (WAD)-A and culinary manager (CM)-A entered R12's room without gown or gloves. WAD-A and CM-A are touching R12's personal items such as his overbed table, wheelchair, closet and bedding. The bedding was brushing WAD-A's clothing. WAD-A told R12 they were going to help R12 with his bath. CM-A removed clothing from R12's closet for R12 to pick out. WAD-A put a gait belt on R12 and assisted R12 to transfer to his wheelchair. At 10:47 a.m., CM-A stated R12 had been removed from contact precautions that morning. They knew this because it was discussed in the IDT that morning and staff just had not gotten around to removing the cart. However, CM-A did not know if R12's room had been cleaned. At 11:10 a.m., housekeeping manager (HM)-A was in R12's room wearing gloves but without a gown. HM-A was pulling linens from R12's bed and cleaning his room. At 12:11 p.m., the cart was removed from R12's doorway. During an interview on 6/8/26 at 12:15 p.m., trained medication aide (TMA)-A stated when a resident needed contact precautions, the charge nurse came around and told all the staff. The cart was placed outside the room, and a trash container was put inside the doorway to remove your gown and gloves. Staff were expected to put on a gown and gloves every time you entered the room. When the contact precautions were done, the charge nurse came around again to tell all the staff. The room needs to be broken down and everything needed to be cleaned. Housekeeping had to sanitize the room as well as the cart. The cart was then stocked and put back in the supply closet for another use. When a resident had 3 or more loose stools, TMA-A brought it to the attention of the charge nurse; especially if the stool was foul smelling. When that happens, I put the cart out because it's like lice, nobody wants it. During an interview on 6/8/26 at 12:25 p.m., HM-A stated R12 had come off of contact that morning so HM-A sanitized R12's room and bathroom with a bleach disposable wipe and then waited 30 minutes before R12 could go back into his room to make sure everything was dry. HM-A stated she wore gloves when she used the disposable wipe. Well, everybody was in there without a gown, so I didn't think I needed to do that if I was cleaning it. That's just standard precautions. R7 R7's annual Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment and diagnosis included obesity, diabetes, and dementia. R7's care plan dated 5/22/26, identified the care plan lacked any guidance regarding a possible exposure to C. diff. R24 R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had a mild cognitive impairment and had diagnoses that included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24 was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder. R24's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 5/11/26, identified R24 was a recent admit from another care center and had diagnoses of dementia, depression, heart failure and asthma. R24 had clear speech and was understood and usually understood. R24 denied shortness of breath. R24 stated she had pain per medication administration record (MAR) review. R24 had a history of refusing medications per staff. R24 was frequently incontinent of bowel and bladder and had some moisture-associated skin damage (MASD) noted with ointment/cream to apply. R24 required assistance for transfers. Care area was triggered due to ADL review. R24 would be assisted per need and per request. R24 was to be encouraged to be as independent as able and observed for changes in her abilities. Peri care completed with incontinence episodes. R24's Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE], identified R24 required assistance for transfers. Care area was triggered due to prescribed medication, impaired mobility, health history and ADL review. She was to be observed for changes in her elimination pattern and peri care to be completed with incontinent episodes. R24's care plan revised 5/27/26, identified the following: R24 was frequently incontinent of urine. Staff were directed to document incontinent episodes. Bladder assessment at least quarterly. Monthly 24-hour (hr) bladder/bowel record. Provide with appropriate incontinence products. R24 required an extensive partial assistance of one (PAO1) using a gait belt (GB) and a wheeled walker to transfer, wipe, adjust clothing and manage incontinence. R24 was to receive peri cares twice daily and as needed after any incontinent episode. Protective ointment to skin as needed. Observe for signs/symptoms of urinary tract infection (UTI): pain or burning with urination, fever, increased incontinence, cloudy/odorous urine in small amounts, increased confusion/lethargy. Encourage adequate fluids. However, the care plan failed to direct staff regarding precautions related to R24's loose stools. R24's nursing progress notes identified the following: On 5/13/26 at 8:30 p.m., R24 was complaining of pain. As needed (PRN) Ibuprofen given per orders and effective. R24 was given Imodium (an anti-diarrhea medication) per order after 2 loose stools. So far effective. On 5/15/26 at 1:33 p.m., R24 complained of some pain especially during transfers. R24 some diarrhea. Ibuprofen and Imodium given per orders. On 5/17/26 at 12:48 p.m., R24 had loose stools. PRN Imodium given per order. R24 verbalizing pain but refuses all interventions. On 5/24/25 at 1:49 p.m., R24 refused some of her medications this morning. Loperamide given at 1015 for loose stools, medication was effective. On 5/27/26 at 1:20 p.m., R24 had a loose stool before lunch and was given 4 mg of PRN loperamide at 11:09 a.m. No further loose stools noted. On 5/28/26 at 1:33 p.m., R24 has loose stools. PRN Imodium given and effective. R24 also complaining of pain. Scheduled Tylenol was given a little early due to condition. No other concerns. On 5/29/26 at 9:31 a.m., IDT review: R24 having loose stools, will contact provider for stool sample. On 5/29/26 at 1:33 p.m., R24 had PRN Imodium per order. No other concerns. On 5/29/26 at 2:26 p.m., writer contacted R24's doctor regarding concerns of loose stools. Received order as follows: 1. Stool C-diff 2. Stool culture. On 6/2/26 at 10:43 a.m., stool sample was collected. On 6/3/26 at 11:25 p.m., stool tests were negative, and results were sent to R24's doctor. R24's medical record failed to identify if R24's loose stools required contact precautions. R24 R4's Enteric Pathogens by Molecular Detection resulted 6/2/26, identified R24 as negative. R24's Clostridium difficile by Molecular Detection resulted 6/2/26, identified R24 was negative. During an observation on 6/7/26 at 11:30 a.m., R24's doorway had no signage and/or cart. R24 was lying in bed with her head of bed (HOB) at 30 degrees. R24 was wearing a dusky purple sweatshirt and no pants. There was a fleece blanket across the foot of R24's bed but it was not covering R24. R24 was wearing an incontinent brief with no pants and had her knees bent with her feet resting on the bed. R24 had been incontinent of bowel and bladder. At 12:10 p.m., NA-B entered R24's room and told R24 she was wet, so she needed to be cleaned up. NA-B put on gloves but no gown, then told R24 she didn't need to cry because she was there. R24 stated I want to get up. At 12:11 p.m. NA-B unfastened R24's incontinent brief and used disposable wipes to clean R24's skin of feces and urine. R24 had a loose, watery stool. R24 stated that her skin was itchy, NA-B told R24 that R24 had pooped and NA-B would clean R24's skin well. At 12:22 p.m., NA-A and NA-B entered the room and used the ceiling lift to transfer R24 from her bed to her wheelchair. NA-B then brought R24 to the dining room for her noon meal. NA-B did not offer to wash R24's hands in the sink and NA-B used hand sanitizer when leaving the room. During an interview on 6/7/26 at 12:28 p.m., NA-B stated she had removed her gloves and did not clean her soiled gloves with a disposable wipe. No. I removed my gloves. NA-B then stated staff had to remove their gloves after cleaning feces to prevent the spread of germs everywhere. NA-B stated hand sanitizer was ok. During an observation on 6/8/26 at 1:09 p.m., TMA-A entered R24's room without gown or gloves. TMA-A used hand sanitizer when exiting R24's room. During an interview on 6/9/26 at 2:49 p.m., the DON stated whenever staff are requesting a stool panel for a resident that has loose stools, precautions should be started. Even if the provider did not believe a stool panel was warranted and the loose stools were ongoing, precautions should be started to ensure a stool panel was needed in the future and became positive. This should continue until the loose stools resolve. Staff were expected to follow precautions and precautions should be care planned to direct staff to do so. The facility policy Contact Precautions revised 9/2023, identified Contact Precautions are used when diseases are transmitted by contact with the resident or the resident's environment. Residents with disease caused by organisms that have been demonstrated to cause heavy environmental contamination will be placed on Contact Precautions. The policy included the following: A. Resident Placement: Decisions regarding resident placement during an acute infection will be made on a case-by-case basis. Consideration will be given to risk of transmission to roommate, presence of any factors that will increase the likelihood of transmission, and the psychological impact on the infected resident. B. Procedure for Contact Precautions: 1. Hand Hygiene is done prior to donning PPE. 2. PPE is donned prior to entering room. A gown and gloves are needed upon entering room. 3. Change gown and gloves between residents even if only one resident is on Contact Precautions. 4. Use of masks, eye protection and face shields is not routinely a part of contact precautions, however, just as with Standard Precautions, these items are worn during resident care activities that are likely to create splashes or sprays of blood, body fluid, secretions, and excretions. 5. Hand hygiene is perfom1ed between glove changes and when removing gloves. The facility policy Standing House Orders for Symptoms Management revised February 2025, identified the following: Bowel and Bladder Management Bowel: Diarrhea (Perform steps sequentially) Perform rectal check to determine if impaction is present; If impacted, follow guidelines for constipation; If not impacted, hold all cathartic-related (constipation) meds and observe for 24 hours. If diarrhea is resolved, resume cathartic-related (constipation) med. If diarrhea continues: Notify Provider of the change in condition to determine if sending a stool specimen for C. difficile toxin A and [NAME] indicated; If testing for C. difficile toxin is ordered, collect only diarrheal (unformed) stool; and Encourage fluids to help maintain hydration. However, the policy failed to direct staff to place the resident into precautions until testing and/or loose stools were resolved. The Center for Disease Control and Prevention (CDC) About C. diff dated 5/13/26, identified Clostridioides difficile [klos–TRID–e–OY-[NAME] dif–uh–SEEL], also known as Clostridium difficile and often called C. difficile or C. diff, is a bacterium (germ) that causes diarrhea and inflammation of the colon. Symptoms include: Diarrhea, Fever, Stomach tenderness or pain, Loss of appetite, and Nausea.C. diff infection (CDI) is more common among patients in healthcare settings, such as hospitals and nursing homes. This is because many people who have C. diff stay or get treated in those facilities. Other risk factors include: Older age (65 or older); A weakened immune system, such as people with cancer or organ transplants taking drugs that suppress the immune system; and Previous infection with C. diff or known exposure to the germs When C. diff germs are outside the body, they become spores. These spores are an inactive form of the germ and have a protective coating allowing them to live for months or years on surfaces and in the soil. Spores become active again after being swallowed and reaching the intestines. Once there, they can cause infection if your immune system is weak or you've recently taken antibiotics. However, most healthy people don't get infected even if spores reach their intestines. If a patient has had three or more stools in 24 hours; Isolate patients with possible C. diff immediately, even if you only suspect CDI; Order a C. diff test if other etiologies of diarrhea such as stool softener or laxative were not used; Wear gloves and a gown when treating patients with potential infectious diarrhea, including C. diff infection, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. In addition, handwashing alone may not be sufficient to eliminate all C. diff spores; and Reassess appropriateness of antibiotics in C. diff patients. SURVEILLANCE The facility surveillance log dated 2/25/26 through 6/2/26, identified resident name, room number and unit, admit date , event closed date, infection type, body system of infection, origin of infection, onset date, resolved date, was surveillance met, was there a hospital admission, was the infection reportable, signs and symptoms, was it a device related infection, risk factors, laboratory results, type of tests, test dates, culture source/radiology site, test results, treatment, medication class, dose, route, frequency, treatment start date, treatment end date, total days of therapy, did the infection meet criteria and was transmission-based precautions implemented. The log identified the following infections: 12 Urinary tract infection (UTI) 4 cellulitis (skin infection) 3 other 1 lower respiratory tract infection 1 norovirus (a highly contagious virus that causes acute gastroenteritis - inflammation of the stomach and intestines. Commonly referred to as the stomach flu or food poisoning, it is completely unrelated to the influenza virus. It triggers sudden, severe vomiting, diarrhea, and stomach cramps) 1 Clostridioides difficile (C. diff) (a highly contagious bacterium that infects the large intestine (colon), causing severe inflammation (colitis) and watery diarrhea. It primarily affects individuals whose normal gut bacteria have been disrupted by recent antibiotic use, making it a common healthcare-associated infection) However, the log did not identify any resident with a sign and/or symptom of an infection that was not treated. During an interview on 6/9/26 at 3:13 p.m., the director of nursing (DON) stated there was an infection tracker built into the electronic medical record. Whenever a resident exhibited signs or symptoms of an infection, staff opened an infection tracker for that resident. The tracker helped identify trends and addressed antibiotic stewardship, room grouping, history of organisms, and a deeper dive into the infections. Outbreak management required an action plan depending on the organism. Also, it helped determine who needed precautions, testing, etc. The surveillance tracking log then pulled data from the electronic medical record system. The facility used the McGreer criteria (standardized definitions used to detect and track infections (such as UTIs, pneumonia, and respiratory illnesses) in long-term care and nursing facilities.) The resident infections were monitored daily to determine if there were trends then, at the end of the month, percentages were calculated, and all the data was brought to the quality improvement meeting for discussion. The DON stated all infections should be documented and put on the surveillance log for tracking. For R24, an event should have started to track R24's diarrhea. It was important to track bowels in general, but diarrhea lets the staff know when intervention was needed. At 3:21 p.m., the DON stated an event tracker should have started for R7 as well. The DON had noticed R7 was rooming with R12 who had tested positive for C. diff and norovirus when she began her role at the facility the week prior. At that point, R12 was fully into treatment, experiencing symptoms and R7 was already exposed. The DON felt to roomR7, at that time, was just going to spread the infection more so R7 continued rooming with R12. The DON stated she was going to have a meeting with the unit managers to discuss the resident care plans and Kardex because that was what instructed the staff on how to provide care for the residents. If the staff were unaware, the staff would not follow precautions as expected. Hand Hygiene R24's admission MDS dated [DATE], identified R24 had mild cognitive impairment and was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder. Diagnoses included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 5/11/26, identified R24 was a recent admit from another care center and had diagnoses of dementia, depression, heart failure and asthma. R24 had clear speech and was understood and usually understood. R24 denied shortness of breath. R24 stated she had pain per medication administration record (MAR) review. R24 had a history of refusing medications per staff. R24 was frequently incontinent of bowel and bladder and had some moisture-associated skin damage (MASD) noted with ointment/cream to apply. R24 required assistance for transfers. Care area was triggered due to ADL review. R24 would be assisted per need and per request. R24 was to be encouraged to be as independent as able and observed for changes in her abilities. Peri care completed with incontinence episodes. R24's Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE], identified R24 required assistance for transfers. Care area was triggered due to prescribed medication, impaired mobility, health history and ADL review. She was to be observed for changes in her elimination pattern and peri care to be completed with incontinent episodes. R24's care plan revised 5/27/26, identified the following: R24 was frequently incontinent of urine. Staff were directed to document incontinent episodes. R24 was to receive peri cares twice daily and as needed after any incontinent episode. Protective ointment to skin as needed. During an observation on 6/7/26 at 12:11 p.m., NA-B unfastened R24's incontinent brief and used disposable wipes to clean R24's skin of feces and urine. R24 stated that her skin was itchy, NA-B told R24 that R24 had pooped and NA-B would clean R24's skin well. At 12:13 p.m., NA-B rolled R24 to the right and R24 began crying and stated, I can't do this. NA-B told R24 that they were almost done. R24's skin on her upper thighs and buttocks was reddened but had no open areas. NA-B applied barrier cream then a clean brief. NA-B used disposable wipes to clean her gloves. NA-B did not remove her gloves nor use hand sanitizer. During an interview on 6/7/26 at 12:28 p.m., NA-B stated she had removed her gloves an

Based on observation, interview, and document review, the facility failed to provide sufficient nursing staff to meet residents' assessed needs and provide required care and services. The facility's staffing shortages resulted in delayed toileting assistance, delayed eating assistance, loss of dignity, and transfers performed contrary to assessed needs and facility policy for 2 of 6 residents (R23, R24) reviewed in the sample requiring staff assistance with quality-of-care needs. The facility's ongoing staffing shortages had the potential to affect all 36 residents residing in the facility. Findings include:The Centers for Medicare and Medicaid Services (CMS) PBJ Staffing Data Report CASPER Report 1705 D identified the following:FY [fiscal year] Quarter 3 2025 (April 1 - June 30) identified the metric for excessively low weekend staffing was triggered. The trigger is defined as submitted staffing data that was excessively low.FY Quarter 4 2025 (July1 -September 30) identified the metric for excessively low weekend staffing was triggered. The trigger is defined as submitted staffing data that was excessively low.FY Quarter 1 2026 (October 1 - December 31) identified the metric for excessively low weekend staffing was triggered. The trigger is defined as submitted staffing data that was excessively low.On 6/7/26 at 11:40 a.m., the survey team approached the facility at the entrance door, and it was locked. The phone on the wall was used to call to gain entry into the building. The call was answered and then immediately hung up. the survey team knocked on the glass door and licensed practical nurse (LPN)-A could be seen standing at the medication cart. LPN-A looked at the team but did not respond. The team attempted to call again and was immediately given an entry code for the lock, and the call was disconnected. The team attempted several times to enter the code, but eventually nursing assistant (NA)-A let the team in. At that time, LPN-A stated the facility was working short, as a day shift nurse did not show up that morning to work. The night nurse stayed until 10:30 a.m. but then left the facility. LPN-A stated she attempted to call staff in to work but had been answering call lights, assisting the nursing assistants (NA) as much as possible and trying to complete her own duties as well. LPN-A stated she had two nursing assistants in the facility. LPN-A showed a binder that contained a phone tree but stated she just hadn't had time to call anyone. LPN-A was visibly frustrated with facial grimacing, and she was rubbing her forehead. The nursing assistants were busy in rooms. Many resident room doors were shut.FACILITY ASSESSMENT and SCHEUDLE REVIEW:The Facility Assessment updated 1/22/26, identified the following staffing needs with an average daily census of 42: Licensed nurses providing direct care, every day of the week for AM and evening shift had two staff and night shift had one staff. Unlicensed staff (nursing assistant/trained medication assistant), every day of the week for AM and evening shift had four staff and night shift had 2 staff.The facility provided a working schedule for the week of survey and identified the Sunday 6/7/26, AM shift 6:00 a.m. to 2:30 p.m., had one nurse working and two nursing assistants (NA) working. The nurse staff posting dated 6/7/26 identified the resident census was 36. The working nursing schedules from FY Quarter 1 2026 (October 1 - December 31) were reviewed for weekend staffing patterns and identified the following:Saturday 10/4/25, AM shift 6:00 a.m. to 10:00 a.m. and PM shift 2:00 p.m. to 10:30 p.m., only 3 NAs scheduled on each of the identified shifts.Sunday 10/5/25, AM shift 6:00 a.m. to 10:00 a.m. and PM shift 2:00 p.m. to 11:30 p.m., only 3 NAs scheduled on each of the identified shifts.Saturday 10/11/25, AM shift 6:00 a.m. to 10:00 a.m. and PM shift 2:00 p.m. to 10:30 p.m., only 3 NAs working on each of the identified shifts.Sunday 10/12/25, AM shift 6:00 a.m. to 2:30 p.m., only 2 NAs were scheduled. On PM shift 2:00 p.m. to 10:30 p.m., only 3 NAs were scheduled on the identified shifts.Saturday 10/18/25, AM shift 6:00 a.m. to 2:30 p.m., only 3 NAs were scheduled on the identified shift.Sunday 10/19/25, AM shifts from 11:00 a.m. to 2:30 p.m., and PM shift 2:00 p.m. to 6:00 p.m., only 3 NAs were scheduled on the identified shifts.Saturday 10/25/25, PM shift 2:00 p.m. to 10:30 p.m., only 3 NAs were scheduled on the identified shift.Sunday 10/26/25, AM shift 6:00 a.m. to 10:00 a.m., only 2 NAs were scheduled . At 11:00 a.m. to 2:30 p.m. and PM shift 2:00 p.m. to 10:30 p.m., only 3 NAs were scheduled on the identified shifts.Saturday 11/1/25, AM shift 11:00 a.m. to 2:30 p.m. and 2:00 p.m. to 6:00 p.m., only 3 NAs were scheduled on the identified shifts.Sunday 11/2/25, AM shift 6:00 a.m. to 10:00 a.m. and PM shift 2:00 p.m. to 6:00 p.m., only 3 NAs were scheduled on the identified shifts.Saturday 12/6/25, AM shift 10:00 a.m. to 2:30 p.m. and PM shift 2:00 p.m. to 10:30 p.m., only 3 NAs were scheduled on the identified shifts.Sunday 12/7/25, AM shift 6:00 a.m. to 10:00 a.m. and PM shift 2:00 p.m. to 10:30 p.m., only 3 NAs were scheduled on the identified shifts.Saturday 12/13/25, AM shift 6:00 a.m. to 10:00 a.m., only 3 NAs were scheduled on the identified shift.Sunday 12/14/25, AM shift 6:00 a.m. to 10:00 a.m., only 3 NAs were scheduled on the identified shift.Saturday 12/20/25, AM shift 6:00 a.m. to 2:30 p.m., only 3 NAs were scheduled on the identified shift.Sunday 12/21/25, AM shift 6:00 a.m. to 2:30 p.m., only 2 NAs were scheduled and PM shift 6:00 p.m. to 10:30 p.m., only 3 NAs were scheduled on the identified shifts.See also F677: Based on observation, interview, and document review, the facility failed to provide activities of daily living (ADL) care and services necessary to maintain residents' abilities by failing to provide timely toileting assistance for 1 of 6 residents (R24) reviewed who required staff assistance with toileting and transfers; and failed to provide timely supervision and assistance with eating for 1 of 6 residents (R23) reviewed who required staff assistance during meals.R24:R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had mild cognitive impairment and was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder. Diagnoses included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24's care plan revised 5/27/26, R24's care plan dated 5/27/26 identified she was dependent on staff for transfers and toileting, required a full-body mechanical lift with assistance of two staff for transfers, and was to be offered toileting every three hours and upon request to maintain skin integrity and dignity.During an observation on 6/7/26 at 11:30 a.m., R24 was lying in bed with her head of bed (HOB) at 30 degrees. R24 was wearing a dusky purple sweatshirt and no pants. There was a fleece blanket across the foot of R24's bed but it was not covering R24. R24 was wearing an incontinent brief with no pants and had her knees bent with her feet resting on the bed. R24 was crying and stated staff told R24 she had to stay in bed and couldn't get up. I don't know why. R24 then stated, they told me to pee my pants, and they'd clean me up here. R24 stated this happened all the time. At that time, nursing assistant (NA)-B stepped into the room and told R24 NA-B needed to help another resident and would be back. NA-B turned off R24's call light and left the room. R24 continued to cry and stated nursing assistants said that and shut off R24's call light just about every day and they say they're short. R24 sobbed and stated I hate it here. It's awful. I hate peeing in my pants.At 12:10 p.m., NA-B entered R24's room and told R24 she was wet, so she needed to be cleaned up. NA-B put on gloves then told R24 she didn't need to cry because she was there. R24 stated I want to get up.At 12:11 p.m. NA-B unfastened R24's incontinent brief and used disposable wipes to clean R24's skin of feces and urine. R24 stated that her skin was itchy, NA-B told R24 that R24 had pooped and NA-B would clean R24's skin well.At 12:13 p.m., NA-B rolled R24 to the right and R24 began crying and stated, I can't do this. NA-B told R24 that they were almost done. R24's skin on her upper thighs and buttocks was reddened but had no open areas. NA-B applied barrier cream then a clean brief. At 12:16 p.m., NA-B put on R24's pants. NA-B then removed her gloves and removed the trash from the trash containers and asked for assistance with R24's transfer over the walkie. NA-B exited the room.At 12:19 p.m., NA-B returned with a full body mechanical lift sling and placed it under R24. NA-B told R24 that she needed another staff person to assist with the transfer and left the room. At 12:22 p.m., NA-A and NA-B entered the room and used the ceiling lift to transfer R24 from her bed to her wheelchair. NA-B then brought R24 to the dining room for her noon meal. During an interview on 6/7/26 at 12:28 p.m., NA-B stated the facility was working short that day. You just do the best you can. NA-B stated R24 did get up into her chair for breakfast that morning, but staff laid R24 down to do incontinent care after breakfast. NA-B stated R24 was encouraged to stay in bed because NA-B had other residents to care for. R24 did turn on her call light and asked to get up, but R24 was assistance of two and NA-B was providing care to another resident. R23:R23's quarterly MDS dated [DATE], identified R23 was cognitively intact and independent with eating. R23 had diagnoses of obesity and mass/lump on abdomen. R23's care plan dated 5/26/26 identified R23 was independent with eating. However, R23's mini nutritional assessment dated [DATE], identified R23 normally ate 51-75% of most meals. R23 was assisted with meals for optimal intake. During observations on 6/7/26 at 1:04 p.m., there were not enough staff in the dining room to assist residents with eating. At 1:05 p.m., there were at least two residents who were sitting there with food in front of them and were not eating nor were staff helping them. At 1:09 p.m., R23 was identified as one of the residents sitting at the table where staff are supposed to assist residents with eating. At 1:12 p.m., R23 still had her plate of food in front of her, and she had not attempted to eat. R23's potatoes and meat had formed a crust on them. R23 waited 45 minutes before staff assisted her to eat. At 1:15 p.m., R23 ate well with staff assistance. During an interview on 6/9/26 at 2:02 p.m., NA-A stated R23 had changed over the weekend, previously she just required supervision with eating. R23 had seemed to decline and had started to pocket food and had moved to a different table to assist with eating because R23 needed more help with meals. During lunch on Sunday 6/7/26, the facility was short staffed and the residents in the dining room had to wait for assistance to eat and some had to wait an extended period of time before they received help. See also F550: Based on observation, interview, and record review, the facility failed to ensure dignified care was provided for 1 of 1 resident (R24) reviewed for dignity. Staff encouraged R24 to remain incontinent rather than assisting her to the toilet when requested, resulting in embarrassment, and loss of dignity. R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had mild cognitive impairment and was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder. Diagnoses included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24's care plan revised 5/27/26, R24's care plan dated 5/27/26 identified she was dependent on staff for transfers and toileting, required a full-body mechanical lift with assistance of two staff for transfers, and was to be offered toileting every three hours and upon request to maintain skin integrity and dignity.During an observation on 6/7/26 at 11:30 a.m., R24 was lying in bed with her head of bed (HOB) at 30 degrees. R24 was wearing a dusky purple sweatshirt and no pants. There was a fleece blanket across the foot of R24's bed but it was not covering R24. R24 was wearing an incontinent brief with no pants and had her knees bent with her feet resting on the bed. R24 was crying and stated staff told R24 she had to stay in bed and couldn't get up. I don't know why. R24 then stated, they told me to pee my pants, and they'd clean me up here. R24 stated this happened all the time. At that time, nursing assistant (NA)-B stepped into the room and told R24 NA-B needed to help another resident and would be back. NA-B turned off R24's call light and left the room. R24 continued to cry and stated nursing assistants said that and shut off R24's call light just about every day and they say they're short. R24 sobbed and stated I hate it here. It's awful. I hate peeing in my pants.During an interview on 6/7/26 at 12:28 p.m., NA-B stated the facility was working short that day. You just do the best you can. NA-B stated R24 did get up into her chair for breakfast that morning, but staff laid R24 down to do incontinent care after breakfast. NA-B stated R24 was encouraged to stay in bed because NA-B had other residents to care for. R24 did turn on her call light and asked to get up, but R24 was assistance of two, and NA-B was providing care to another resident. See also F689: Based on interview and document review, the facility failed to ensure transfers were performed in accordance with assessed needs, care plan interventions, and facility policy for 1 of 3 residents (R24) reviewed for accidents. Staff performed transfers using a full-body mechanical lift with one staff member rather than the required two staff members, creating the potential for falls, entrapment, and transfer-related injury. R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had a mild cognitive impairment and had diagnoses that included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24 was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder. R24's care plan revised 5/27/26, identified R24 had self-deficit with transferring. Staff were directed to provide assistance with two staff with all transfers to and from bed, wheelchair and toilet. R24 used a full body mechanical lift. During an interview on 6/9/26 at 11:29 a.m., trained medication aide (TMA)-A stated staffing was awful. The facility used a lot of agency staff and the schedule frequently got messed up which added to the problem. Staff did the best they could with what they had. TMA-A tried her hardest when they had to work short to prioritize work and to help the nursing assistants as much as she was able. R24 could not wait when R24 asked to use the bathroom because she would be incontinent. TMA-A stated she wasn't going to lie and transferred R24 using the full body mechanical lift by herself. TMA-A did this because R24 had a right to get up and use the bathroom. It was also harmful to R24 skin to void in her pants. TMA-A stated she felt the transfer was safe doing that.During an interview on 6/9/26 at 11:57 a.m., R24 stated sometimes there was not enough staff at the facility, and they transfer her with the lift with only one staff member. R24 stated they say there's not enough staff and it was against the rules, but they do it. R24 never felt unsafe but knew she was not supposed to tell anyone to get anybody in trouble. I'm just thankful to get to the toilet. STAFF INTERVIEWS:During an interview on 6/8/26 at 4:44 a.m., RN-A stated she was the unit manager and was covering night shift because the facility was short on staff. During an interview on 6/9/26 at 11:29 a.m., TMA-A stated staffing was awful. The facility used a lot of agency staffing and the schedule would get screwed up. On 6/9/26, TMA-A had to work a double shift because her relief was scheduled on the electronic module but not on the printed schedule. The Pioneer unit needed at least 2 aides because the cares were heavier over there. There should be a float that goes between the Pioneer unit and the Wild [NAME] unit, but they don't like to do it and refuse to help on Wild Rose. They just don't do it. The agency staff don't know what to do when a staff member calls in for their shift. The agency staff don't have access to the texting app but they have the staff list and the have the phone tree. TMA-A was not called to work on Sunday. TMA-A had heard nothing about the staff being short staffed on 6/7/26. Staff working the medication cart were expected to assist the nursing assistants with answering call lights and resident care, but some of the agency staff would not do it.During an interview on 6/9/26 at 11:42 a.m., NA-C stated she worked as needed, but didn't work much. Stated the facility did call her at approximately 1:00 p.m. on 6/7/26 but NA-C could not work that day. NA-C worked 6/8/26, 6/9/26 and was scheduled to work 6/10/26 because state was there. Usually when I'm working, we have everybody here because I'm the one who picked up.During an interview on 6/9/26 at 1:36 p.m., LPN-A stated she was an agency staff person so that right there should tell you what staffing is like. Stated the facility worked short like they were on 6/7/26 a lot. Every week. LPN-A stated the nurse who was supposed to work on 6/7/26 comes to work late often. The night nurse stayed to cover, but the nurse never arrived. That's when LPN-A realized she wasn't coming. LPN-A was trying to call staff to come in to work but was getting pulled in every direction because the nursing assistants needed help, plus she had nursing duties she had to attend to.During an interview on 6/9/26 at 1:49 p.m., NA-A stated the facility worked short staffed all the time and even if NA-A had a float, the float wasn't much help, so she was working alone anyway. Some of the floats just didn't want to work. They liked the social aspect of the role, but they didn't want to listen to direction, or they were slow in their tasks. Some didn't answer call lights. For example, one float wanted to sit with the residents and drink coffee and visit. The float routinely didn't look at the bath list and didn't want to answer call light. When NA-A would tell this person what to do, NA-A would get ignored. NA-A stated she had reported this to administration many times and not had a response.During an interview on 6/9/26 at 2:06 p.m., RN-A stated she had been told there were float staff ho were resistant to working on the Wild [NAME] unit. The floats had worked at the facility for years and believed they didn't have to. RN-A had spoken to the float staff individually and informed administration but had never documented this. During an interview on 6/9/26 at 2:49 p.m., the DON stated she expected staff to answer call lights when they can safely leave the person they are caring for to check on the call light to ensure it's not a safety concern. The DON also stated she had recognized the float staff didn't have accountability because the float didn't have an assigned resident group. The DON planned to change assignments so each nursing assistant, including the float, would have an assigned group of residents. This would include the float assigned residents from each unit. That way, the float would be assisting on each unit and there would be a way to hold the float accountable for their work.

Based on observation, interview and document review the facility failed to develop comprehensive, person-centered care plan to include enhanced barrier precautions (EBP) for 3 of 5 residents (R6, R7, R1) reviewed who were identified to be on EBP.Findings include: R6 R6's annual Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and required moderate assistance with bathing. R6 had an abdominal feeding tube (G-tube). Diagnoses included Parkinson's disease, narcolepsy, anxiety, and dysphagia (difficulty swallowing). R6's care plan with review date 6/1/26, identified R8 was frequently incontinent of bladder. Approaches included for staff to provide peri care two times per day and as needed (PRN) when incontinent. R8's care plan also identified R8 has special treatment/procedures related to the presence of a G-tube. Approaches included to provide daily care and observance of R8's G-tube to ensure patency and usefulness. The care plan failed to include instructions for EBP related to when staff provided G-tube and/or personal cares. R6's undated Active Order Report reviewed 6/9/26, identified numerous medication orders, all with instruction to crush and administer the medication through her feeding tube. On 6/8/26, at 6:34 a.m. a plastic cart was observed outside of R6's room. The cart contained disposable gloves and masks. A sign on top of the cart identified R6 was on enhanced barrier precautions and directed staff to wear a gown and gloves when performing direct care, including G-tube care. During interview on 6/8/26, at 10:38 a.m. the director of nursing (DON) stated providing G-tube care would be one instance when EBP should be used. EBP should be on resident's plan of care when it was required to be used. The DON stated it was important for staff to put on a gown when indicated for direct care to prevent transmission of multidrug-resistant organisms (MDRO), protect other residents and to keep the staff uniform clean from splashes. The required use of EBP's should be care planned on the resident's plan of care because it did affect the resident's care. The DON thought it used to be on the resident's care plan as well as in the physician orders, but she had not gotten all resident's charts audited and so it may not be on every resident's chart as needed. R7 R7's annual Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment and diagnosis included obesity. R7 had an unstageable pressure ulcer and moisture associated skin damage (MASD). R7's wound assessment dated [DATE], identified the coccyx ulcer was stable and measured 1.5 centimeters (cm) x 0.3 cm x 0.3 cm deep. R7's care plan dated 5/22/26, lacked any guidance of use for EBP. During observations on 6/8/26 at 7:46 a.m., there was an isolation cart outside of R7's room with a contact precaution sign for R7's roommate and did not address if R7 was on EBP. The cart had gloves and masks in the first drawer, eye/face protection in second drawer, and the third drawer was empty. There were no gowns on the cart. During an interview and observation on 6/8/26 at 9:19 a.m., nursing assistant (NA)-A stated they did not need to wear a gown or gloves when caring for R7, we only needed to wear that for R7's roommate. NA-A then entered R7's room and proceeded to get R7 ready for the day. NA-A was not wearing a gown or gloves. R1 R1's quarterly MDS dated [DATE], identified R1 had moderate cognition and had an indwelling catheter. Diagnoses included renal insufficiency, urinary retention. R1's care plan dated 5/22/26, included instructions to change catheter monthly, complete catheter care daily, and monitor for signs and symptoms of infection. The care plan failed to include instructions for EBP related to catheter. During observation on 6/9/26 at 7:23 a.m., a plastic cart was outside R1's room. The cart contained disposable gowns and gloves, and a sign identifying R1 was on enhanced barrier precautions. The sign included instructions for staff to wear gowns and gloves when performing direct care, including catheter care. During interview on 6/10/26 at 5:16 p.m., DON stated EBP was used to prevent the spread of infections between staff/residents and helped to reduce the spread of multidrug-resistant organisms (MDRO's) whether they are known, suspected or potential. The DON stated staff were expected to follow resident care plans and the facility policy regarding wearing PPE for EBP. The Enhanced Barrier Precautions policy, revised 3/28/24, identified the purpose was to decrease transmission of CDC-targeted and other epidemiologically important MDRO's, and EBP would be used for residents actively infected or colonized with CDC-targeted and other epidemiologically important MDRO's. Additionally, residents at risk for MDRO's, specifically those with an indwelling medical device and/or chronic wounds requiring a dressing would be required to use EBP. The Comprehensive Assessments and Care Planning policy revised 2/26/26, identified a comprehensive person-centered care assessment of the resident's condition was completed in order to develop consistent quality care that would attain or maintain the highest practicable physical, mental and psychological functioning possible.

Based on interview and document review, the facility failed to ensure consultant pharmacist recommendations regarding an irregularity in psychotropic medication use were addressed and resolved for 1 of 5 residents (R8) reviewed for unnecessary medications. The facility failed to ensure a required face-to-face practitioner evaluation occurred and allowed a PRN antipsychotic medication order to remain active and be administered despite repeated consultant pharmacist recommendations for review and discontinuation.Findings include: R8's quarterly Minimum Data Set, dated [DATE], identified R8 had moderate cognitive deficit and required moderate assistance with most activities of daily living (ADLs). R8 had not exhibited any behavior during the observation period and did not have hallucinations or delusions. R8 consumed antianxiety and antidepressant medications during the observation period. Diagnoses included congestive heart failure, dementia, diabetes, and depression. R8's care plan dated 3/23/26, identified R8 was under hospice care for end-of-life status due to heart failure. Approaches included to follow the hospice plan of care, communicate with hospice physician and nurses to discuss medication concerns and what was effective. Hospice services with standing orders, scheduled and as needed (PRN) medications for pain, shortness of breath, restlessness and secretions. The care plan identified R8 received psychotropic medications for depression and anxiety with a goal to not experience any adverse reactions. Approaches listed included to administer medications as ordered. Administer the antianxiety medication for increased anxiety and restless. Staff were to document three interventions trialed before administering the PRN medication. MD review per guidelines for a gradual dose reduction and monthly pharmacist review. R8's undated Active Physician Orders identified numerous medication orders for R8, which included haloperidol 1 milligram (MG) for agitation and restlessness every four hours PRN with start date 3/1/26 and end date was listed as open ended. R8's PRN Medication Administration Record (MAR) dated 5/1/26 to 5/31/26, identified an order for Haldol 1 mg every four hours PRN for agitation and restless. start date of 3/1/26 and open-ended end date. The MAR documented the medication had been administered to R8 on 5/19/26 and 5/26/26. Consultant Pharmacist Recommendation to Physician forms identified the following:3/9/26, identified the pharmacist recommended to discontinue the PRN use of Haldol 1 mg every four hours PRN for anxiety/agitation on or before 3/14/26, following federal guidelines that PNR orders for anti-psychotic drugs were limited to fourteen days and could not be renewed unless the attending physician evaluated the resident for the appropriateness of the renewal. R8's physician commented that R8 was a hospice patient and signed the recommendation with no further response or action on 3/24/26. 4/3/26, identified the pharmacist recommended to discontinue the PRN use of Haldol 1 mg every four hours PRN for anxiety/agitation on or before 3/14/26, following federal guidelines that PNR orders for anti-psychotic drugs were limited to fourteen days and could not be renewed unless the attending physician evaluated the resident for the appropriateness of the renewal. No physician response was documented. R8's medical record lacked a face-to-face assessment by the medical provider to justify continued use of the Haldol. During interview on 6/9/26, at 10:27 a.m. the director of nursing (DON) stated all PRN psychotropic medications should have a fourteen-day review. She had thought the regulation had changed for hospice patients, and it could go longer than fourteen days, but she always had them reviewed every fourteen days. The facility's process was to have hospice follow their patient's medications and notify the facility if there was any need for review or update. The facility's consultant's pharmacist was telephoned on 6/9/26, at 5:56 p.m. and message left to return call. During telephone interview on 6/10/26, at 9:29 a.m. the facility's consultant pharmacist (CP)-G stated he only reviewed medications for the facility for new admissions or hospital returns and was not the pharmacist that had done the monthly medication reviews for R8. CP-G stated it was his understanding the Center for Medicaid and Medicare (CMS) guidelines were that any PRN antipsychotic medication needed to be addressed by the physician The medication needed to be limited to fourteen days and re-evaluated by the provider. If the provider chose to continue the PRN antipsychotic medication, it would need to be evaluated with a face-to-face visit from the provider. CP-G stated hospice was not an exception. In an electronic mail (email) response received on 6/10/26, at 4:30 p.m. CP-H wrote she had made recommendations to R8's primary provider both in March and April of 2026. R8's physician had signed each recommendation, acknowledging he had reviewed them. In addition, CP-H had emailed the DON and the facility's medical director to reiterate that all PRN antipsychotic medications were subject to an initial 14 day stop date requirement unless a documented face to face evaluation was completed. The order for the PNR haloperidol was discontinued on 6/9/26, However, the discontinuation of the medication was after interviews were completed regarding the continued use of the PRN medication. The facility's policy Psychotropic Medication Use with review date 9/7/23, identified PRN orders for psychotropic drugs were limited to fourteen days and could not be renewed unless the attending provider evaluated the resident for the appropriateness of the medication.

Based on interview and document review, the facility failed to ensure a reported medication error was investigated, documented, and addressed in accordance with facility policy for 1 of 5 residents (R37) reviewed for unnecessary medications. This deficient practice resulted in the facility's inability to determine the circumstances surrounding a reported Zepbound medication error, assess resident impact, and implement interventions to prevent recurrence.Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had a moderate cognitive impairment and had diagnoses that included morbid obesity, cerebral palsy and obstructive sleep apnea. R37's Event Report dated 4/23/26 at 9:37 a.m., identified Zepbound (an FDA-approved, once-weekly injectable medication containing tripeptide. It is prescribed alongside a reduced-calorie diet and increased exercise for chronic weight management in adults with obesity or those who are overweight with weight-related conditions) wrong dose on 4/22/26. The report failed to identify any investigation into the event or actions taken to prevent further events. R37's medical record failed to identify any further information regarding the 4/22/26 Zepbound wrong dose. During an interview on 6/8/26 at 10:44 a.m., the director of nursing (DON) stated she had reviewed R37's medical record and R37's medication error investigation. The DON stated there was a lapse in the process and an investigation was not completed. The DON spoke with facility staff who explained the medication did not come from the pharmacy and R37 did not receive his dose of medication. However, the event report stated wrong dose. The DON stated investigation needed to be done to ensure what had occurred. The staff were expected to complete an event report, then complete an investigation into what had happened. This needed to be documented as well as interventions to prevent further medication errors. During an interview on 6/9/26 at 2:15 p.m., registered nurse (RN)-A stated she vaguely remembered the event and attempted to review R37's medical record for further information. RN-A stated there was no documentation to explain what had occurred or actions taken. RN-A stated there should be a progress note, an event report, and a documented investigation into what happened. Afterwards, it would be brought to IDT to discuss what had occurred and/or if further actions needed to be taken. An emailed response from the consultant pharmacist dated 6/10/26, identified the pharmacist expected facility staff to complete a thorough root cause investigation and analysis, appropriate follow-up, and detailed documentation for any medication error identified. This should include assessment of the resident, physician notification when indicated, monitoring for adverse effects, and implementation of measures to help prevent recurrence. In the case of a resident receiving a one-time higher dose of tirzepatide (Zepbound), potential adverse effects may include gastrointestinal intolerance such as nausea, vomiting, diarrhea, abdominal discomfort, and decreased appetite. Conversely, if a resident receives a lower-than-ordered dose, potential concerns may include less effective appetite suppression, and possible elevations in blood glucose for residents using the medication for glycemic control. The facility policy Medication Error/Occurrence dated 2021, identified When an error is made in the preparation or administration of a drug or biological, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation or treatment is indicated. Medication errors are tracked and trended for quality improvement purposes.

Based on observation, interview, and document review, the facility failed to provide activities of daily living (ADL) care and services necessary to maintain residents' abilities by failing to provide timely toileting assistance for 1 of 6 residents (R24) reviewed who required staff assistance with toileting and transfers; and failed to provide timely supervision and assistance with eating for 1 of 6 residents (R23) reviewed who required staff assistance during meals. Findings include: R24: R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had mild cognitive impairment and was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder. Diagnoses included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 5/11/26, identified R24 was a recent admit from another care center and had diagnoses of dementia, depression, heart failure and asthma. R24 had clear speech and was understood and usually understood. R24 denied shortness of breath. R24 stated she had pain per medication administration record (MAR) review. R24 had a history of refusing medications per staff. R24 was frequently incontinent of bowel and bladder and had some moisture-associated skin damage (MASD) noted with ointment/cream to apply. R24 required assistance for transfers. Care area was triggered due to ADL review. R24 would be assisted per need and per request. R24 was to be encouraged to be as independent as able and observed for changes in her abilities. Peri care completed with incontinence episodes. R24's Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE], identified R24 required assistance for transfers. Care area was triggered due to prescribed medication, impaired mobility, health history and ADL review. She was to be observed for changes in her elimination pattern and peri care to be completed with incontinent episodes. R24's care plan revised 5/27/26, identified the following: R24 was frequently incontinent of urine. Staff were directed to document incontinent episodes. Bladder assessment at least quarterly. Monthly 24-hour (hr) bladder/bowel record. Provide with appropriate incontinence products. R24 required an extensive partial assistance of one (PAO1) using a gait belt (GB) and a wheeled walker to transfer, wipe, adjust clothing and manage incontinence. R24 was to receive peri cares twice daily and as needed after any incontinent episode. Protective ointment to skin as needed. Observe for signs/symptoms of urinary tract infection (UTI): pain or burning with urination, fever, increased incontinence, cloudy/odorous urine in small amounts, increased confusion/lethargy. Encourage adequate fluids. R24 had self-deficit with the following activities of daily living: bathing, personal hygiene, ambulation, transferring, toileting, dressing, bed mobility, eating, ambulating and medication administration. Staff were directed R24 required assist of two (AO2) assistance with all transfers to and from bed, wheelchair and toilet. R24 used a full body mechanical lift. R24 could verbally ask for assistance with toileting. R24 required assistance from two to get R24's toileting needs addressed. R24 used the toilet for my current toileting needs and was both continent/incontinent. R24 was to be offered toileting every three hours to help R24 to remain free of skin breakdown and respect R24's dignity. During an observation on 6/7/26 at 11:30 a.m., R24 was lying in bed with her head of bed (HOB) at 30 degrees. R24 was wearing a dusky purple sweatshirt and no pants. There was a fleece blanket across the foot of R24's bed but it was not covering R24. R24 was wearing an incontinent brief with no pants and had her knees bent with her feet resting on the bed. R24 was crying and stated staff told R24 she had to stay in bed and couldn't get up. I don't know why. R24 then stated, they told me to pee my pants, and they'd clean me up here. R24 stated this happened all the time. At that time, nursing assistant (NA)-B stepped into the room and told R24 NA-B needed to help another resident and would be back. NA-B turned off R24's call light and left the room. R24 continued to cry and stated nursing assistants said that and shut off R24's call light just about every day and they say they're short. R24 sobbed and stated I hate it here. It's awful. I hate peeing in my pants. At 12:10 p.m., NA-B entered R24's room and told R24 she was wet, so she needed to be cleaned up. NA-B put on gloves then told R24 she didn't need to cry because she was there. R24 stated I want to get up. At 12:11 p.m. NA-B unfastened R24's incontinent brief and used disposable wipes to clean R24's skin of feces and urine. R24 stated that her skin was itchy, NA-B told R24 that R24 had pooped and NA-B would clean R24's skin well. At 12:13 p.m., NA-B rolled R24 to the right and R24 began crying and stated, I can't do this. NA-B told R24 that they were almost done. R24's skin on her upper thighs and buttocks was reddened but had no open areas. NA-B applied barrier cream then a clean brief. At 12:16 p.m., NA-B put on R24's pants. NA-B then removed her gloves and removed the trash from the trash containers and asked for assistance with R24's transfer over the walkie. NA-B exited the room. At 12:19 p.m., NA-B returned with a full body mechanical lift sling and placed it under R24. NA-B told R24 that she needed another staff person to assist with the transfer and left the room. At 12:22 p.m., NA-A and NA-B entered the room and used the ceiling lift to transfer R24 from her bed to her wheelchair. NA-B then brought R24 to the dining room for her noon meal. During an interview on 6/7/26 at 12:28 p.m., NA-B stated the facility was working short that day. You just do the best you can. NA-B stated R24 did get up into her chair for breakfast that morning, but staff laid R24 down to do incontinent care after breakfast. NA-B stated R24 was encouraged to stay in bed because NA-B had other residents to care for. R24 did turn on her call light and asked to get up, but R24 was assistance of 2 and NA-B was providing care to another resident. During an interview on 6/9/26 at 11:29 a.m., trained medication aide (TMA)-A stated R24 should never wait when she had to go to the bathroom because R24 would then be incontinent and R24 deserved to receive the care she needed. Staff were expected to either request help from another staff member or to prioritize work to the best of their ability. During an interview on 6/9/26 at 11:42 a.m., NA-C stated R24 cannot wait when R24 asked to use the bathroom. When R24 turned on her call light, NA-C tried to get her to the bathroom right away because R24 would have an accident. During an interview on 6/9/26 at 1:36 p.m., licensed practical nurse (LPN)-A stated staff were expected to provide timely toileting assistance to prevent incontinence and skin breakdown. During an interview on 6/9/26 at 2:06 p.m., registered nurse (RN)-A stated a resident should be provided with timely toileting assistance to prevent incontinence and skin breakdown. During an interview on 6/9/26 at 2:49 p.m., the director of nursing (DON) stated staff were expected to provide care when requested and to ensure all residents were safe. R23: R23's quarterly MDS dated [DATE], identified R23 was cognitively intact and independent with eating. R23 had diagnoses of obesity and mass/lump on abdomen. The MDS did not identify any a significant weight loss or gain. R23's mini nutritional assessment dated [DATE], identified R23 normally ate 51-75% of most meals. R23 was assisted with meals for optimal intake. R23's care plan dated 5/26/26 identified R23 was independent with eating. During observations on 6/7/26 at 1:04 p.m., there was not enough staff in the dining room to assist residents with eating. A t 1:05 p.m., there were at least 2 residents who were sitting there with food in front of them and were not eating nor was staff helping them. A t 1:09 p.m., R23 was identified as one of the residents sitting at the table where staff are supposed to assist residents with eating. At 1:12 p.m., R23 still had her plate of food in front of her, and she had not attempted to eat. R23's potatoes and meat had formed a crust on them. R23 waited 45 minutes before staff assisted her to eat. At 1:15 p.m., R23 ate well with staff assistance. During an interview on 6/9/26 at 7:36 a.m., nursing assistant (NA)-D stated R23 needed to be supervised while eating. R23 ate slowly and it would take her a while to eat, and we encourage her at that time. When R23 stopped using the silverware while eating, staff assisted R23. During an interview on 6/9/26 at 2:02 p.m., NA-A stated R23 had changed over the weekend, previously she just required supervision with eating. R23 had seemed to decline and had started to pocket food and had moved to a different table to assist with eating because R23 needed more help with meals. During lunch on Sunday 6/7/26, the facility was short staffed and the residents in the dining room had to wait for assistance to eat and some had to wait an extended period of time before they received help. During an interview on 6/9/26 at 4:43 p.m., the director of nursing (DON) stated residents who required supervision with eating would be watched and if the residents had stopped eating or had not started for about five minutes staff are expected to cue residents to continue to eat. If after ten minutes staff should approach resident and assist with eating. I would be expected if R23 was not eating it would be realized quickly and assisted in a timely fashion. It is not dignified to sit there with a plate of food in front of you and not being able to eat it. Staff should wait until someone is available to assist with eating before bringing out the plate. The facility policy Activities of Daily Living (ADL) dated 2021, identified staff were directed to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

During observation, interview, and document review, the facility failed to perform hand hygiene between glove changes during pressure ulcer wound care for 1 of 2 residents (R5) reviewed for pressure ulcers, creating the potential for contamination of pressure ulcer wounds and development of infection. Findings include:R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively intact. R5 was substantial/maximal assist with transfers, and supervision with bed mobility. R5's diagnosis includes fracture of thoracic (mid back) vertebrae, muscle weakness, and amputation of right lower leg. It identified the resident was at risk for pressure ulcers but did not have one. R5's pressure ulcer/injury Care Area Assessment (CAA) dated 5/8/26, identified R5 was at risk for pressure ulcers due to recent injury with a fracture of thoracic vertebra. Plan of care updated for prevention of pressure related skin impairments. R5's provider's orders identified the following:6/1/26, identified for left heel, cleanse heel gently with saline wipe. Pat dry. place a Mepilex (a specialized silicone foam dressing). over the area. 6/8/26, identified to cleanse the right buttock with saline wipes and pat dry, then pack with Aquacel AG (an advanced antimicrobial primary wound dressing) and cover with a sacral Mepilex. In gluteal crease (between the buttocks) cleanse wound with saline wipes and cover with a 4-inch by 4-inch Mepilex.R5's wound assessment dated [DATE], identified they had a pressure ulcer on right upper buttock. The wound measured 5 centimeters (cm) wide x 6.5 cm long x 2 cm deep. The wound was odorous, and heavy drainage of purulent dark brown drainage which saturated the dressings. R5 also had an unstageable pressure ulcer on their coccyx measuring 2.2 cm x 2.8 and identified scab was completely attached. R5 also had a deep tissue injury on his left heel with drained blister and intact epidermal (skin) layer in place which measured 4 cm x 5 cm. The resident was seen the previous week and had wound debrided and had not much change and ordered a follow up appt for wound debridement. During observation on 6/9/26 at 8:08 a.m., licensed practical nurse (LPN)-A gathered the supplies she would need and asked nursing assistant (NA)-A to help position R5. LPN-A and NA-A both sanitized hands and then put on personal protective equipment (PPE) for wound dressing change. Once in the room they positioned R5, and NA-A helped to stabilize him. LPN-A placed a barrier down and then proceeded to remove the old dressing. The dressing was saturated with purulent dark brown drainage and was very odorous. The wound bed was full of slough (dead, non-viable tissue that accumulated on the surface of the wound bed). The gluteal fold dressing was also removed due to starting to come off. Once the dressings were removed, LPN-A removed the dirty gloves and did not do hand hygiene and then placed another pair of gloves on. LPN-A then proceeded to clean both wounds using saline spray and wipes. LPN-A then removed her dirty gloves and did not perform hand hygiene before putting a pair of new gloves on. LPN-A opened the Aquacel AG and placed it in the wound bed then opened the sacral Mepilex on the wound on the right buttock and then placed a 4-inch x 4-inch Mepilex in gluteal crease. LPN-A then started to clean up and when completed she removed her gloves then seen the left heel dressing was coming off. Without doing hand hygiene LPN-A placed a pair of gloves on and then removed the old dressing. There was no drainage or odor coming from wound and it was covered with a layer of old skin. LPN-A removed gloves and put a different pair on without doing hand hygiene and then, then proceeded to clean the heel with saline wipes. Then changed gloves again without doing hand hygiene and placed the 4-inch x 4-inch Mepilex dressing on R5's heel. Upon completing the dressing changes, she washed her hands with soap and water and then removed her gown and sanitized her hands on exiting the room. During an interview on 6/9/26 at 8:51 a.m., LPN-A stated she washed her hands prior to starting and once the dressing change was done. She did not think to do hand hygiene when changing gloves. During an interview on 6/9/26 at 8:51 a.m., the director of nursing (DON) stated nurses were to follow wound procedures when doing dressing changes. That would include hand hygiene each time gloves were changed. Hand hygiene was done to ensure the wound does not become decontaminated when placing clean dressings. The facility's Contact Precautions policy dated 9/2023, identified hand hygiene is performed between glove changes and when removing gloves. A policy regarding pressure ulcers was requested, but one was not received.

Based on interview and document review, the facility failed to review and justify continued use of an as needed (PRN) psychotropic medication for 1 of 5 residents (R8) who were reviewed for unnecessary medications. Findings include: R8's quarterly Minimum Data Set, dated [DATE], identified R8 had moderate cognitive deficit and required moderate assistance with most activities of daily living (ADLs). R8 had not exhibited any behavior during the observation period and did not have hallucinations or delusions. R8 received antianxiety and antidepressant medications during the observation period. Diagnoses included congestive heart failure, dementia, diabetes, and depression. R8's undated Active Physician Orders, identified numerous medication orders for R8, which included haloperidol (antipsychotic) 1 milligram (MG) for agitation and restlessness every four hours PRN with start date 3/1/26 and end date was listed as open ended. R8's care plan dated 3/23/26, identified R8 was under hospice care for end-of-life status due to heart failure. Approaches included to follow the hospice plan of care, communicate with hospice physician and nurses to discuss medication concerns and what was effective. Hospice services with standing orders, scheduled and as needed (PRN) medications for pain, shortness of breath, restlessness and secretions. The care plan identified R8 received psychotropic medications for depression and anxiety with a goal to not experience any adverse reactions. Approaches listed included to administer medications as ordered. Administer the antianxiety medication for increased anxiety and restless. Staff were to document three interventions trialed before administering the PRN medication. MD review per guidelines for a gradual dose reduction and monthly pharmacist review. R8's Consultant Pharmacist Recommendation to Physician reports identified the following:3/9/26, identified the pharmacist recommended to discontinue the PRN use of Haldol 1 mg every four hours PRN for anxiety/agitation on or before 3/14/26, following federal guidelines that PNR orders for anti-psychotic drugs were limited to fourteen days and could not be renewed unless the attending physician evaluated the resident for the appropriateness of the renewal. R8's physician commented that R8 was a hospice patient and signed the recommendation with no further response or action on 3/24/26. 4/3/26, identified the pharmacist recommended to discontinue the PRN use of Haldol 1 mg every four hours PRN for anxiety/agitation on or before 3/14/26, following federal guidelines that PNR orders for anti-psychotic drugs were limited to fourteen days and could not be renewed unless the attending physician evaluated the resident for the appropriateness of the renewal. No physician response was documented. R8's PRN Medication Administration Record (MAR) dated 5/1/26 to 5/31/26, identified an order for Haldol 1 mg every four hours PRN for agitation and restless. start date of 3/1/26 and open-ended end date. The MAR documented the medication had been administered to R8 on 5/19/26 and 5/26/26. R8's medical record lacked evidence a face-to-face visit was performed by a medical provider and identified the justification for continued used of the antipsychotic. During observation on 6/7/26, R8 was noted be hollering she had to use the bathroom from her room. An unidentified nursing assistant (NA) assisted the resident to use the bathroom and then assisted her into a recliner in the facility's commons area. R8 closed her eyes and went to sleep. The NA stated R8 was tired as she had been up till 3:00 a.m. the night before. During interview on 6/8/26, at 1:23 p.m. licensed practical nurse (LPN)-A stated R8 had a PRN Haldol ordered that was used once in a while. The medication made R8 sleepy, so LPN-A did not typically give her the medication during the day. R8 was diabetic and LPN-A wanted to be sure R8 was alert enough to eat her meals. If R8 was sleepy she would not eat. The PRN Haldol order came from hospice, so hospice would be the ones to review the order. LPN-A knew a pharmacist also came once in a while and reviewed resident medications. LPN-A did know PRN anti-psychotic medications were limited to a specific time, and she had asked the hospice nurse about that, however, she did not get any results. During interview on 6/9/26, at 10:27 a.m. the director of nursing (DON) stated all PRN psychotropic medications should have a fourteen-day review. She had thought the regulation had changed for hospice patients, and it could go longer than fourteen days, but she always had them reviewed every fourteen days. The facility's process was to have hospice follow their patient's medications and notify the facility if there was any need for review or update. The facility's consultant's pharmacist was telephoned on 6/9/26, at 5:56 p.m. and message left to return call. During telephone interview on 6/10/26, at 9:29 a.m. the facility's consultant pharmacist (CP)-G stated he only reviewed medications for the facility for new admissions or hospital returns and was not the pharmacist that had done the monthly medication reviews for R8. CP-G stated it was his understanding the Center for Medicaid and Medicare (CMS) guidelines were that any PRN antipsychotic medication needed to be addressed by the physician The medication needed to be limited to fourteen days and re-evaluated by the provider. If the provider chose to continue the PRN antipsychotic medication, it would need to be evaluated with a face-to-face visit from the provider. CP-G stated hospice was not an exception. The facility's policy Psychotropic Medication Use with review date 9/7/23, identified PRN orders for psychotropic drugs were limited to fourteen days and could not be renewed unless the attending provider evaluated the resident for the appropriateness of the medication.

Based on interview and document review, the facility failed to ensure transfers were performed in accordance with assessed needs, care plan interventions, and facility policy for 1 of 3 residents (R24) reviewed for accidents. Staff performed transfers using a full-body mechanical lift with one staff member rather than the required two staff members, creating the potential for falls, entrapment, and transfer-related injury. Findings include:R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had a mild cognitive impairment and had diagnoses that included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24 was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder.R24's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 5/11/26, identified R24 was a recent admit from another care center and had diagnoses of dementia, depression, heart failure and asthma. R24 had clear speech and was understood and usually understood. R24 denied shortness of breath. R24 stated she had pain per medication administration record (MAR) review. R24 had a history of refusing medications per staff. R24 was frequently incontinent of bowel and bladder and had some moisture-associated skin damage (MASD) noted with ointment/cream to apply. R24 required assistance for transfers. Care area was triggered due to ADL review. R24 would be assisted per need and per request. R24 was to be encouraged to be as independent as able and observed for changes in her abilities. Peri care completed with incontinence episodes.R24's Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE], identified R24 required assistance for transfers. Care area was triggered due to prescribed medication, impaired mobility, health history and ADL review. She was to be observed for changes in her elimination pattern and peri care to be completed with incontinent episodes.R24's care plan revised 5/27/26, identified R24 had self-deficit with transferring. Staff were directed to provide assistance with two staff with all transfers to and from bed, wheelchair and toilet. R24 used a full body mechanical lift. During an interview on 6/9/26 at 11:29 a.m., trained medication aide (TMA)-A stated staffing was awful. The facility used a lot of agency staff and the schedule frequently got messed up which added to the problem. Staff did the best they could with what they had. TMA-A tried her hardest when they had to work short to prioritize work and to help the nursing assistants as much as she was able. R24 could not wait when R24 asked to use the bathroom because she would be incontinent. TMA-A stated she wasn't going to lie and transferred R24 using the full body mechanical lift by herself. TMA-A did this because R24 had a right to get up and use the bathroom. It was also harmful to R24 skin to void in her pants. TMA-A stated she felt the transfer was safe doing that.During an interview on 6/9/26 at 11:42 a.m., NA-C stated she never transferred R24 with assistance of one and the full body mechanical lift. It was unsafe to do that. During an interview on 6/9/26 at 11:57 a.m., R24 stated sometimes there was not enough staff at the facility, and they transfer her with the lift with only one staff member. R24 stated they say there's not enough staff and it was against the rules, but they do it. R24 never felt unsafe but knew she was not supposed to tell anyone to get anybody in trouble. I'm just thankful to get to the toilet. During an interview on 6/9/26 at 1:36 p.m., licensed practical nurse (LPN)-A stated she had told the nursing assistants to not transfer any resident with the full body mechanical lift with assistance of one and had never witnessed any staff doing that. During an interview on 6/9/26 at 1:49 p.m., nursing assistant (NA)-A didn't know for sure if staff transferred R24 using the full body mechanical lift with only one staff member, but if they're unable to find help NA-A could see them doing it. NA-A stated she has seen staff come out of a room pushing a resident in a wheelchair and NA-A had questioned how the resident was transferred because NA-A had not helped. NA-A stated she had never asked, and the staff member had never said.During an interview on 6/9/26 at 2:06 p.m., registered nurse (RN)-A stated the staff should never be so short staffed they were transferring any resident using the ceiling lift with assistance of one for the safety of the resident. During an interview on 6/9/26 at 2:49 p.m., the director of nursing (DON) stated no resident should be transferred with the full body mechanical lift using assistance of one because it was a safety issue as well as best practice. The facility policy Using a Mechanical Lift dated 2024, identified the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. I. At least two (2) trained associates are needed to safely move a resident with a mechanical full body floor based mechanical lift or a ceiling/overhead full body lift.

Based on interview and document review, the facility failed to ensure a resident grievance regarding a missing hearing aid was fully investigated, documented, resolved, and communicated to the resident representative in accordance with facility policy for 1 of 1 resident (R5) reviewed for grievances. Findings include: R5's Customer Concern/Grievance dated 5/20/26, identified family member (FM)-A reported R5's hearing aid was missing. The facility documented an initial search of the room, bedding, and laundry; however, no further investigation, follow-up, or resolution was documented. R5's progress notes from 5/20/26 through 6/6/26 contained no documentation regarding the missing hearing aid or grievance follow-up. During an interview on 6/9/26 at 2:33 p.m., the social services designee (SSD) acknowledged receiving the grievance but stated it had been assigned to another person and no outcome had been communicated. During an interview on 6/9/26 at 3:48 p.m., FM-A reported she had not received any updates or information regarding the grievance after filing the concern. During an interview on 6/9/26 at 4:43 p.m., the director of nursing (DON) confirmed there was no documented follow-up and stated the expectation was that grievances would be resolved within five days and the complainant updated on progress and outcome. The facility's Concerns and Grievances policy required investigation, resolution, communication with the complainant within five business days, ongoing updates when resolution was delayed, and documentation of actions taken.

Based on observation, interview, and record review, the facility failed to ensure dignified care was provided for 1 of 1 resident (R24) reviewed for dignity. Staff encouraged R24 to remain incontinent rather than assisting her to the toilet when requested, resulting in embarrassment, and loss of dignity. Findings include: R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had a mild cognitive impairment and had diagnoses that included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24 was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder.R24's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 5/11/26, identified R24 was a recent admit from another care center and had diagnoses of dementia, depression, heart failure and asthma. R24 had clear speech and was understood and usually understood. R24 denied shortness of breath. R24 stated she had pain per medication administration record (MAR) review. R24 had a history of refusing medications per staff. R24 was frequently incontinent of bowel and bladder and had some moisture-associated skin damage (MASD) noted with ointment/cream to apply. R24 required assistance for transfers. Care area was triggered due to ADL review. R24 would be assisted per need and per request. R24 was to be encouraged to be as independent as able and observed for changes in her abilities. Peri care completed with incontinence episodes.R24's Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE], identified R24 required assistance for transfers. Care area was triggered due to prescribed medication, impaired mobility, health history and ADL review. She was to be observed for changes in her elimination pattern and peri care to be completed with incontinent episodes.R24's care plan revised 5/27/26, identified the following:R24 was frequently incontinent of urine. Staff were directed to document incontinent episodes. Bladder assessment at least quarterly. Monthly 24-hour (hr) bladder/bowel record. Provide with appropriate incontinence products. R24 required an extensive partial assistance of one (PAO1) using a gait belt (GB) and a wheeled walker to transfer, wipe, adjust clothing and manage incontinence. R24 was to receive peri cares twice daily and as needed after any incontinent episode. Protective ointment to skin as needed. Observe for signs/symptoms of urinary tract infection (UTI): pain or burning with urination, fever, increased incontinence, cloudy/odorous urine in small amounts, increased confusion/lethargy. Encourage adequate fluids.R24 had self-deficit with the following activities of daily living: bathing, personal hygiene, ambulation, transferring, toileting, dressing, bed mobility, eating, ambulating and medication administration. Staff were directed R24 required assist of two (AO2) assistance with all transfers to and from bed, wheelchair and toilet. R24 used a full body mechanical lift.R24 could verbally ask for assistance with toileting. R24 required assistance from two to get R24's toileting needs addressed. R24 used the toilet for my current toileting needs and was both continent/incontinent. R24 was to be offered toileting every 3 hours to help R24 to remain free of skin breakdown and respect R24's dignity. During an observation on 6/7/26 at 11:30 a.m., R24 was lying in bed with her head of bed (HOB) at 30 degrees. R24 was wearing a dusky purple sweatshirt and no pants. There was a fleece blanket across the foot of R24's bed but it was not covering R24. R24 was wearing an incontinent brief with no pants and had her knees bent with her feet resting on the bed. R24 was crying and stated staff told R24 she had to stay in bed and couldn't get up. I don't know why. R24 then stated, they told me to pee my pants, and they'd clean me up here. R24 stated this happened all the time. At that time, nursing assistant (NA)-B stepped into the room and told R24 NA-B needed to help another resident and would be back. NA-B turned off R24's call light and left the room. R24 continued to cry and stated nursing assistants said that and shut off R24's call light just about every day and they say they're short. R24 sobbed and stated I hate it here. It's awful. I hate peeing in my pants.At 12:10 p.m., NA-B entered R24's room and told R24 she was wet and needed to be cleaned up. While putting on gloves, NA-B told R24 she didn't need to cry because NA-B was there. NA-B proceeded to provide incontinent care. Afterwards, NA-A and NA-B transferred R24 into her wheelchair using the full body mechanical lift. During an interview on 6/7/26 at 12:28 p.m., NA-B stated the facility was working short that day. You just do the best you can. NA-B stated R24 did get up into her chair for breakfast that morning, but staff laid R24 down to do incontinent care after breakfast. NA-B stated R24 was encouraged to stay in bed because NA-B had other residents to care for. R24 did turn on her call light and asked to get up, but R24 was assistance of 2 and NA-B was providing care to another resident. During an interview on 6/9/26 at 11:29 a.m., trained medication aide (TMA)-A stated R24 should never wait when she had to go to the bathroom because R24 would then be incontinent. R24 should never be encouraged to go to the bathroom in her pants because that's not what R24 or any resident deserved. Staff are expected to either request help from another staff member or to prioritize work to the best of their ability.During an interview on 6/9/26 at 11:42 a.m., NA-C stated R24 cannot wait when R24 asked to use the bathroom. When R24 turned on her call light, NA-C tried to get her to the bathroom right away because R24 would have an accident. R24 or any other resident should never be told to go in their pants because of dignity.During an interview on 6/9/26 at 1:36 p.m., licensed practical nurse (LPN)-A stated a resident should never be told to just go in their pants because the residents have the right to receive their care.During an interview on 6/9/26 at 2:06 p.m., registered nurse (RN)-A stated a resident should never be told to be incontinent. It was a dignity issue as well as an ADL issue. It's just wrong.During an interview on 6/9/26 at 2:49 p.m., the director of nursing (DON) stated staff were expected to provide care when requested and to ensure all residents are safe. Staff were also expected to never tell a resident to be incontinent because it was a dignity issue for the residents.The facility policy Activities of Daily Living (ADL) dated 2021, identified staff were directed to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Based on observation, interview and document review, the facility failed to identify and act on a change of condition for 1 of 3 residents (R1) who was care planned for potential infections, had a fever and was experiencing hallucinations which was an atypical symptom. This delay in treatment resulted in an immediate Jeopardy (IJ) for R1 when she was diagnosed with sepsis and was hospitalized . The IJ began on 2/21/26, when R1's vital signs indicated a temperature of 101.7 degrees Fahrenheit (F) and she was demonstrating other signs of illness such as vomiting, visible shaking, hallucinations, disruptive behavior, reports of pain, and crying with no nursing assessment conducted and the provider was not contacted. R1's symptoms continued until she was brought to the emergency department (ED), had a temperature of 102.8 degrees F, a physical appearance described as ill and toxic appearing and was diagnosed with septic shock and had to be hospitalized . The administrator was notified of the immediate jeopardy at 4:30 p.m. on 3/4/26. The immediate jeopardy was removed on 3/5/26, but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's annual Minimum Data Set, dated [DATE], identified intact cognition and indicated she did not display hallucinations, delusions or behaviors. R1's care plan identified a self-care deficit and a potential for infection related to urinary incontinence. The care plan directed staff to update the provider as needed. The care plan indicated R1 was alert and oriented and independent in making decisions. R1's Vitals Report identified the following: 2/21/26 -10:32 a.m. temperature (Temp) 101.7 degrees Fahrenheit (F), pulse 140 beats per minute (bpm) -11:37 a.m. Temp 103.2 degrees F. -1:02 p.m. Temp 101.6 degrees F. -5:18 p.m. Temp 100.2 degrees F. 2/22/26 -9:50 a.m.- pulse (P) 109 bpm. -9:50 a.m. Temp 99.4 degrees F. -4:55p.m.- Temp 100.1 degrees F. 2/23/26 -8:50a.m. Temp 99.1 degrees F, P 102 bpm. -3:42 p.m. Temp 100 degrees F. R1's Physician Order Report indicated she was administered scheduled, acetaminophen 1000 milligrams three times daily for pain. R1's Progress Notes indicated the following: -2/19/26, R1 had not slept, was in and out of her room and hollering at her phone about murdering her babies. -2/19/26, R1 suddenly started yelling and crying stating they want to take my babies from me and stated her family member texted her and said she would see her in heaven at which point R1 was sobbing uncontrollably. -2/19/26, Interdisciplinary team (IDT) discussed R1's behavior of throwing a water pitcher, wanted to cancel appointment and was hallucinating. -2/21/26, R1 stated she had been vomiting all night and stated she was in so much pain she could hardly move. -2/21/26, R1 was visibly shaking and cold in the morning. Vitals signs normal except for Temp which was 101 degrees F. Tylenol was given and Temp repeated and remained 101 degrees F. -2/22/26, R1 had episodes of incontinent diarrhea and was running a low-grade fever of 99 degrees F. R1 reported pain everywhere, was tearful and crying and stated she wanted to leave. -2/22/26, R1's had Temp 100.1 degrees F., Tylenol given. -2/23/26, IDT discussed R1's fevers over the weekend, feeling tired, refusing medications and verbal behaviors toward staff. Staff would assess R1 and contact provider if necessary. -2/23/26, R1 was lying in bed and reported not eating dinner and feeling very tired. Writer checked vitals at this time. Temp was 100 degrees F. -2/23/26, R1 did not eat dinner but ate some pudding. R1 did not want any medications. -2/24/26, R1 was shivering at this time stating she was cold. Temperature was 99.2 degrees F, color was pale with a grey hue, dark circles under her eyes. R1 stated she hurt all over and just did not feel well. Ambulance called and R1 was sent to emergency department (ED) for evaluation. -2/25/26, R1 had been transferred to hospital with diagnosis of sepsis. R1's ED Provider Notes dated 2/24/26, indicated R1 had been brought to the ED after becoming drowsier and unresponsive. R1's temp was 102.8 degrees F. R1 had started a fever on Friday (2/20/26). Physical appearance indicated ill-appearing, and toxic-appearing. Cardiovascular indicated tachycardia (a resting heart rate that is too fast, typically over 100 bpm in adults, resulting from an abnormal electrical signal in the heart). ED course indicated intravenous (IV) fluids were started and R1 started to develop hypotension (low blood pressure) and R1 had GFR [glomerular filtration rate] a medical test that measures how well your kidneys filter blood, acting as a key indicator of kidney function) was quite low. R1 received IV antibiotics and had a urinary tract infection. Due to R1 showing signs of sepsis, she needed to be transferred to a higher level of care. Problems addressed included acute kidney injury, ureteral obstruction and sepsis with acute renal failure and septic shock. R1's Hospital discharge paperwork identified the principal problem as sepsis due to E-coli with acute organ dysfunction and septic shock and urinary tract infection secondary to obstructing left ureteral stone. During observation and interview on 3/3/26 at 3:03 p.m., R1 was seated in a recliner chair in her room. R1 stated the Friday before she went to the hospital she had gotten her pills, then started throwing up. R1 stated prior to going to the hospital, she really did not remember anything. R1 said at the hospital they told her she had kidney stone and placed a stent and said she had been really sick. During interview on 3/3/26 at 4:39 p.m., registered nurse (RN)-D stated she had worked with R1 and said she had not identified anything out of the ordinary other than R1 complained of feeling weak and had been running a low-grade fever. RN-D said she contributed her symptoms to R1 possible having influenza. RN-D said one morning when R1's temperature was checked it was 98.2 degrees F, and with the presumption of R1 having influenza it was thought maybe R1 was getting over it. RN-D stated the nurses had conversations between incoming and outgoing shifts about R1's condition and she had been told at the beginning of her shift on Monday, R1 was not feeling better and if it continued she night need to be sent to the ED. RN-D said the morning R1 was sent to the ED, she had checked on R1 and said her color did not look good and she complained of having pain all over so she had called 911. During interview on 3/4/26 at 9:20 a.m., medical doctor (MD)-A said staff had not contacted her when R1 had the change of condition. The MD stated people could have bladder stones for years with urinary tract infections that came and went but said when stone pain started it was important to be seen right away. MD-A stated the facility should have contacted her when R1 developed a fever. Adding, if they had, R1's septic shock would have been avoided. During interview on 3/4/26 at 10:01 a.m., nurse practitioner (NP) stated R1 arrived at the ED early in the morning and had been barely responsive. NP stated the ED staff were about to intubate but R1 perked up with intravenous fluids and vasopressors. NP stated R1 was very sick and said her blood pressure had dropped which indicated the use of vasopressors and R1's kidneys were in bad shape. The NP indicated R1 had a large stone she could not pass on her own with puss behind it that was drained and, while the stone would had not have been avoidable, the sepsis and unnecessary pain could have been prevented if R1 had been sent to the ED sooner. During interview on 3/4/26 at 10:36 a.m., RN-C stated if a resident displayed a change of condition, she would start with checking vital signs and comparing them to the resident's baseline, completing a general assessment and then reporting to the nurse managers. RN-C said prior to R1 going to the hospital, she had come to work in the morning and R1 had reported not sleeping. RN-C stated R1 had been crying and talking about her daughter. RN-C said R1 had been hallucinating, which was not normal. RN-C stated she had spoken to R1's family member (FM) and RN-A about R1 that day. During interview on 3/4/26 at 11:24 a.m. RN-A said R1's change in condition happened over the weekend and said the IDT was not there on the weekend which was part of the problem. RN-A said R1 was discussed during the IDT meeting on Monday but said they did not review the progress notes or R1's vital signs. During interview on 3/4/26 at 11:47 a.m., RN-B said when a change of condition occurred, depending on the change, staff should assess and monitor. RN-B said she had not assessed R1 on 2/23/26, following the IDT discussion and said she had gone to R1's room but she had been asleep and her temp had been down to 99.1 degrees F. RN-B stated she felt the IDT missed R1's change of condition because her diagnosis of Bipolar and previous behaviors had masked the change and said it had interfered with their judgement. RN-B further stated staff should have notified the physician about R1's elevated temperature over the weekend. Facility policy Change in Condition, Resident Examination and Evaluation dated 11/10/25, indicated a thorough resident examination will capture any abnormalities in health status, physical function and acute change of condition. Procedure: Licensed nurses within their scope of practice standards, evaluate for a significant change of condition through direct observation/physical examination that is outside of baseline findings including interview or report from other staff. Obtain vital signs. Notify the provider of change of condition and implement orders for treatment and appropriate monitoring as directed. Notify the provider of any abnormalities such as, but no limited to, abnormal vital signs, change in behavioral of neurological condition, worsening pain reported by the resident. The immediate jeopardy that began on 2/21/26 was removed on 3/5/26, after the facility implemented a systemic plan that included the following actions: Review of Policy and Procedures related to Change in Condition and Physician Notification. Reviewed all residents for a potential change in condition. Education to nursing staff on identification of policies and procedures related to change of condition and resident monitoring, qualifying factors for a change of condition as well as assessment of the resident symptoms (removing bias of resident behaviors/baseline) and timely notification of Physician and treatment of resident symptoms.

Based on interview and document review, the facility failed to ensure the infection preventionist (IP) completed the required training for the role of IP.Findings include: RN-B's record of completed training was reviewed and lacked evidence of training related to the role of IP. During interview on 3/5/26 at 2:22 p.m., registered nurse (RN)-B stated she was the facility designated IP. RN-B stated she had started the required training but had not had time to finish.Facility policy Infection Preventionist Role dated 8/2023, indicated the IP or designee is responsible for directing the infection prevention and control program within the facility. The IP should have a background and training appropriate for carrying out these responsibilities, have a primary professional training in nursing, medical technology, microbiology, epidemiology or other related field, be qualified by education, training, certification or experience, and have completed specialized training in infection prevention and control.

Based on interview and document review the facility failed to ensure annual abuse training was completed for 2 of 10 staff reviewed for training.Findings Include:Nursing assistant (NA)-A had a hire date of 11/7/25. NA-A's record of Completed Training printed 3/5/26, indicated she had not completed annual abuse training.Registered nurse (RN)-B had a hire date of 8/28/24. RN-B's record of Completed Training printed 3/5/26, indicated she had not completed annual abuse training since 8/28/24.During interview on 3/5/26 at 1:41 p.m., the human resources manager (HRM) stated the mangers were responsible to ensure their staff completed training. The HRN said the corporate office sent messages quarterly regarding required trainings and she reminded the managers. The HRM said she did not track who had or had not completed required training.Facility policy Regulatory and Compliance Education dated 5/1/24, indicated each community should assign an associate the responsibility of the super registrar role. This person is to manage the tracking of the training system. Assigned hire courses should be completed before an associate works independently on the floor. Annual requirements are established according to licensure, certification and/or role-based requirements and are assigned quarterly.

Based on interview and document review the facility failed to ensure physician notification of a change of condition for 1 of 3 residents (R1) reviewed who subsequently admitted to the hospital for septic shock.Findings include:R1's Annual Minimum Data Set, dated [DATE], identified intact cognition and indicated she did not display hallucinations, delusions or behaviors.R1's care plan identified a self-care deficit and a potential for infection related to urinary incontinence. The care plan directed staff to update the provider as needed. The care plan indicated R1 was alert and oriented and independent in making decisions.R1's Vitals Report identified the following:2/21/26-10:32 a.m. temperature (Temp) 101.7 degrees Fahrenheit (F), pulse 140 beats per minute (bpm)-11:37 a.m. Temp 103.2 degrees F.-1:02 p.m. Temp 101.6 degrees F.-5:18 p.m. Temp 100.2 degrees F.2/22/26-9:50 a.m.- pulse (P) 109 bpm.-9:50 a.m. Temp 99.4 degrees F.-4:55p.m.- Temp 100.1 degrees F.2/23/26-8:50a.m. Temp 99.1 degrees F, P 102 bpm.-3:42 p.m. Temp 100 degrees F.R1's Physician Order Report indicated she was administered acetaminophen 1000 milligrams three times daily.R1's Progress Notes indicated the following:-2/19/26, R1 had not slept, was in and out of her room and hollering at her phone about murdering her babies.-2/19/26, R1 suddenly started yelling and crying stating they want to take my babies from me and stated her family member texted her and said she would see her in heaven at which point R1 was sobbing uncontrollably.-2/19/26, Interdisciplinary (IDT) discussed R1's behavior of throwing a water pitcher, wanted to cancel appointment and was hallucinating.-2/21/26, R1 stated she had been vomiting all night and stated she was in so much pain she could hardly move.-2/21/26, R1 was visibly shaking and cold in the morning. Vitals signs normal except for Temp which was 101 degrees F. Tylenol was given and Temp repeated and remained 101 degrees F.-2/22/26, R1 had episodes of incontinent diarrhea and was running a low-grade fever of 99 degrees F. R1 reported pain everywhere, was tearful and crying and stated she wanted to leave.-2/22/26, R1's had Temp 100.1 degrees F., Tylenol given.-2/23/26, IDT discussed R1's fevers over the weekend, feeling tired, refusing medications and verbal behaviors toward staff. Staff would assess R1 and contact provider if necessary.-2/23/26, R1 was lying in bed and reported not eating dinner and feeling very tired. Writer checked vitals at this time. Temp was 100 degrees F.-2/23/26, R1 did not eat dinner but ate some pudding. R1 did not want any medications.-2/24/26, R1 was shivering at this time stating she was cold. Temperature was 99.2 degrees F, color was pale with a grey hue, dark circles under her eyes. R1 stated she hurt all over and stated just did not feel well. Ambulance called and R1 was sent to emergency department (ED) for evaluation.-2/25/26, R1 had been transferred to hospital with diagnosis of sepsis.R1's ED Provider Notes dated 2/24/26, indicated R1 had been brought to the ED after becoming drowsier and unresponsive. R1's temperature was 102.8 degrees F. R1 had started a fever on Friday (2/20/26). Physical appearance indicated ill-appearing, and toxic-appearing. Cardiovascular indicated tachycardia (a resting heart rate that is too fast, typically over 100 bpm in adults, resulting from an abnormal electrical signal in the heart). ED course indicated intravenous (IV) fluids were started and R1 started to develop hypotension (low blood pressure) and R1 had GFR [glomerular filtration rate] a medical test that measures how well your kidneys filter blood, acting as a key indicator of kidney function) was quite low. R1 received IV antibiotics and had a urinary tract infection. Due to R1 showing signs of sepsis, she needed to be transferred to a higher level of care. Problems addressed included acute kidney injury, ureteral obstruction and sepsis with acute renal failure and septic shock.R1's Hospital discharge paperwork identified the principal problem as sepsis due to E-coli with acute organ dysfunction and septic shock and urinary tract infection secondary to obstructing left ureteral stone.During interview on 3/4/26 at 9:20 p.m., the physician said staff had not contacted her when R1 had the change of condition. The physician said people could have bladder stones for years but said when she developed a fever staff should have contacted her. The physician said the septic shock could have been avoided.During interview on 3/4/26 at 9:20 a.m., medical doctor (MD)-A confirmed staff had not notified her of R1's change of condition. MD-A stated she should have been contacted when R1 developed a fever. MD-A said R1's septic shock would have been avoided.During interview on 3/4/26 at 11:47 a.m., registered nurse (RN)-B stated staff should have notified the provider of R1's change of condition.Facility policy Change in Condition, Resident Examination and Evaluation dated 11/10/25, indicated when a significant change in the resident's physical, mental or psychological status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nurse consults with the attending provider and notifies the resident representative. Notify the provider of change of condition and implement orders for treatment and appropriate monitoring as directed. Notify the provider of any abnormalities such as, but no limited to, abnormal vital signs, change in behavioral of neurological condition, worsening pain reported by the resident.

Based on interview and document review the facility failed to ensure physician ordered medical supplies were available upon admission for 2 of 2 residents (R1, R2) reviewed who admitted to the facility with a catheter. In addition, the facility failed to obtain a physician's order prior to using an alternate catheter size.Findings include:R1's Resident Face Sheet indicated she admitted to the facility on [DATE]. R1's diagnosis included spinal cord injury, neuromuscular dysfunction of bladder and depression.R1's Physician Order Report dated 12/28/25 through 1/28/26, identified and order for catheter change every four weeks and as needed, dated 10/25/25. R1's care plan dated 9/23/25 identified a urinary catheter to manage obstructive uropathy.R1's Resident Progress Notes identified the following:-9/23/25, R1 requested a tub bath instead of a shower. No Foley catheter clamp available. Staff used tape to kink and clamp catheter.-9/25/25, When attempting to flush catheter, noted catheter was plugged. Spoke with director of nursing (DON) as did not have the correct catheter size. R1's catheter was a 20 French 10 cubic centimeters (cc) balloon in place. Catheter replaced with an 18 French 10 cc balloon. Informed R1 that a different sized catheter and R1 was okay with it.R2's Resident Face Sheet indicated she admitted to the facility 1/9/26. R2's diagnosis included urinary tract infection, urine retention and chronic kidney disease. R2's Physician Order Report dated 12/28/25 through 1/28/26, identified an order dated 1/9/26, for an indwelling catheter 14 French with a 5cc balloon, one time. R2's Resident Progress Note dated 1/15/26, indicated staff spoke with family about changing catheter and informed they did not have a 14 French catheter and had to replace with a 16 French 10 cc balloon.During interview on 1/22/26 at 12:25 p.m., registered nurse (RN)-A stated typically the person who entered the admission orders should check to ensure the supplies were available. RN-A said the DON was responsible for ordering supplies but said when she inputs an order, she goes to the supply room to verify if the catheter was in stock and alerts the DON if it was not.During interview on 1/22/26 at 12:40 p.m., The DON stated upon admission, the staff that does the admission puts the orders in. The DON stated she was responsible to ensure the correct catheter size was in stock. The DON said when R1 admitted to the facility they did not have the correct catheter size in stock. The DON said the decision was made to use a different size, adding she was not aware they did not have the correct catheter size for R2. The DON stated if a different size was utilized a physician order should have been obtained. The DON stated use of the incorrect catheter size could result in bladder spasms.Facility Policy Physician Services dated 2019, indicated all physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.Facility policy related to physician notification of change of orders was requested but not received.

Based on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R1) received necessary medical attention following a change in a left hip surgical incision. Additionally, the facility failed to comprehensively assess, monitor, and document skin changes. R1 sustained actual harm and required hospitalization, surgery, and insertion of a peripherally inserted central line catheter (PICC) for intravenous (IV) antibiotic treatment for sepsis. Findings include: R1's hospital Discharge summary dated [DATE], identified mechanical ground level fall after losing her balance and sustained a left subtrochanteric femur fracture. She required surgery that included an surgical open reduction and internal fixation (ORIF) of the left hip and tramedullary nailing of left femur. Surgical incision noted to left hip with dressing. R1's progress notes from 8/25/25 through 9/10/25, identified: -8/25/25 at 2:57 p.m. Weekly Skin Check: R1 continued with stapes to surgical incision on the left hip/thigh. No new skin issues noted. -8/25/25 at 3:06 p.m. Skilled Nursing Documentation: Surgical wound left hip/thigh, no drainage, surrounding tissue intact and no pain. Nursing interventions: surgical wound care. -8/26/25 at 1:42 p.m. Skilled Nursing Documentation: Surgical wound left hip/thigh, no drainage, surrounding tissue intact and no pain. Nursing Interventions: surgical wound care. -8/26/25 at 8:33 p.m. Staples to left hip/thigh removed per order. R1 tolerated well. Cleansed area with saline and applied steri strips. -8/27/25, 8/28/25, 8/29/26, 8/30/25, Skilled Nursing Documentation completed. No documentation in progress notes on left hip/thigh incision (4 days). -9/1/25 at 8:43 a.m. Surgical wound left hip scant amount of purulent (thick and milky discharge from a wound and almost always indicates an infection, should not be ignored, and needs treatment as soon as possible) drainage. Surrounding tissue erythema (redness that occurs when extra blood rushes to an area and often indicates inflammation or infection). Pain was present with tenderness to upper aspect of incision. Nursing interventions: proper positioning and surgical wound care. -9/1/25 at 8:43 a.m. Skin Assessment: Skin check done prior to shower. Surgical incision to left hip is red and warm to upper half of incision. R1 does report some tenderness to area. Scant purulent drainage noted to two areas of upper incision: bottom area measuring 1.3 centimeters (cm) along incision and top area measuring 3 cm along incision. Cleansed with wound wash and patted dry. Waterproof surgical post op bandage applied. -9/1/25 at 11:59 a.m. as needed (PRN) Tylenol given at 12:00 p.m. per her request for pain. -9/1/25 at 2:19 p.m. Surgical wound left hip scant amount of purulent drainage, surrounding tissue erythema, and no pain. Interventions to promote healing and prevent infection: proper positioning and surgical wound care. -9/2/25 at 2:19 p.m. surgical wound left hip scant amount of purulent drainage, surrounding tissue erythema, and no pain. Interventions used to promote healing and prevent infection: positioning and surgical wound care. -9/3/25 at 4:07 p.m. R1 had red and warm to touch right foot/toes. Charge nurse sent picture to primary provider medical doctor (MD) who ordered Bactrim double strength (DS) two times a day (BID) times 7 days. Orders updated. -9/3/25 at 11:18 p.m. Skilled Nursing documentation completed. Skin and/or left hip incision was not included in this entry. -9/4/25 at 6:24 p.m. Nurse was asked to check left hip as was noted to be red and swollen today with pain. Started on Bactrim yesterday. Area or [sic] erythema and edema marked earlier. There was a Mepliex surgical in place with 430% [sic] serous drainage present to foam. The area marked has not spread and is 37 x 34 cm. There is a peau d [sic] orange skin texture. Skin is warm and erythematous. R1 reported it throbs and aches. Temperature 100.0 (F). Report sent to MD. Further vitals checked at within proximity to last check. No response from MD yet. Did report to oncoming nurse no response yet and encouraged to monitor vitals more frequently throughout the evening. Told R1 she may need an evaluation through the hospital and possible increase in antibiotics and she said no. When asked further she stated she did not wish to go to the hospital. She was informed a message was sent to the provider and that they would continue to monitor. Instructed to report feeling of chills or sweats. -9/4/25 at 7:11 p.m. MD responded thinking of a resident transfer to higher level of care. Awaiting orders for transfer to local ER vs another hospital. R1 agreed with transfer stated, if she had to. Nurse on duty was aware of pending transfer. Hand off report had been given. -9/4/25 at 7:28 p.m. R1 was transferred to local hospital via son. Bed holds in place. -9/5/25 at 8:43 a.m. Discussed at interdisciplinary team (IDT): transferred to local hospital due to worsening of infection of left hip. -9/10/25 at 10:55 a.m. R1's planned arrival date back to facility 9/10/25 around 11:30 a.m. to 12:00 p.m. admission diagnoses: sepsis due to post surgical abscess. Cares: peripherally inserted central catheter (PICC) (a long flexible catheter goes into your upper arm vein, through the vein in the arm and into a large vein located by the heart and allowed for long term access to infuse IV fluids, medications, and draw blood) line/antibiotic (Abx) for six weeks and wound vac/Prevena (not to be removed until batteries die) left hip. -9/10/25 at 12:35 p.m. R1 admitted from hospital in stable condition. -9/10/25 at 4:22 p.m. Skin assessment: left hip incision swollen and redness noted with wound vac in place. Left posterior calf open area 4 x 1 cm and 0.5 cm deep with clear drainage. Meplix dressing over Silvadene gauze ordered. R1's treatment administration record (TAR) August 2025, identified:-Change Mepilex dressing daily to left hip, start dated 8/19/25. Dressing change was signed off as being completed on 8/20/25, 8/22/25 through 8/26/25, 8/29/25, through 8/31/25. Dressing was signed off as not completed on 8/21/25 (not administered: due to condition), 8/27/25 (dressing changed at appointment) and 8/28/25 (did not want dressing on). -Complete weekly skin check observation and record vitals once a day on Monday. Documented on 8/4/25, not administered, no bath. Documented completed on 8/11/25, 8/18/25, and 8/25/25. R1's TAR September 2025, identified: -Change Mepilex dressing daily to left hip, start dated 8/19/25. Dressing changed was signed off as being completed on 9/1/25, 9/2/25, and 9/4/25. On 9/3/25, dressing change was documented as not completed. -Complete weekly skin check observation and record vitals once a day on Monday. Documented on 9/1/25 completed. -R1 was being treated for diagnosis abscess of left leg. Document every shift (3 times a day) in progress notes if these signs and symptoms are noted: temperature, pus present at wound skin or soft tissue site, new or increase in heat, redness, swelling, tenderness/pain, serous drainage at the affected site, changes in mental status and/or increase in ADL assistance. Start dated 9/12/25. Signed off not completed on 9/12/25 (1 time) (will administer when awake), 9/16/25 (1 time) (resident unavailable), and 9/24/25 (1 time) (did not get done in a.m.). R1's admission to hospital dated 9/5/25, identified admitted to hospital for post-surgical abscess and overlying abscess or previous left subtrochanteric femur fracture due to ground level fall status post ORIF with intramedullary nailing of left femur. Sepsis and increased left hip pain was due to the above. Orthopedics consulted, plan for surgery in a.m. Given her sepsis started on IV antibiotics Vancomycin and Rocephin. Today brought in by her son as over the last several days had noticed around her incision drainage and redness. Has noted a yellowish color to the drainage. Fever developed over the last 24 hours. She is also noted pain had increased in the left hip over the past few days to the point where she was unable to walk. It sounded like prior to this she was doing well. In the emergency department (ED) she had chills along with a fever of 100.0 degrees Fahrenheit (F), heart rate 114. Lab work completed shower elevated white blood cells (WBC) of 13.4 with left shift, stable hemoglobin, elevated C-reactive protein (CRP) (measures level of a protein in your blood that indicates inflammation) of 166 milligrams per liter (mg/L) (normal range less than 2.0 mg/L) and elevated erythrocyte sedimentation rate (ESR) (measures inflammation in the body) of 67 millimeters per hour (mm/hr.) (normal less than 30). CT scan showed abscess. Notable erythema over the proximal medial thigh extending over the lateral thigh midway down with increased erythema pronounced on the incision site. A bacterial culture with gram stain (laboratory test that helped diagnose harmful bacteria) of the left thigh tissue on 9/5/25, identified a rare staphylococcus aureus (a bacterial infection that can cause serious illness and become deadly if found in the blood stream, joints, bones, lungs, or heart, moderate white blood cells and treated with antibiotics), moderate white blood cells (WBC) ( body produces more to fight an infection by attaching and destroying invading pathogens), and many red blood cells (RBC). A bacterial culture with gram stain dated 9/5/25, specimen taken from deep left thigh fluid identified rare staphylococcus aureus and corynebacterium aurimucosum (a nosocomial (occur in healthcare settings) pathogen infecting hard-to-heal peripheral wounds, such as skin wounds, soft tissue abscesses and osteomyelitis) and many WBC. R1's care plan dated 9/10/25, identified at risk for skin alteration of skin due to limited/decreased mobility and pain. Staff were directed to observe skin integrity daily with cares, bathing, report any reddened, irritated, bruised or open areas and any new skin concerns taken to the nurse to address. The skin risk assessment with Braden scale/tissue tolerance completed per guidelines. She had a PICC to deliver fluids/medications due to a diagnosis of abscess of left leg and directed staff to administer medications/antibiotics as ordered. She required wound care treatment plan as follows: keep wound vac in place for 7 days or until battery dies and dressing changes to surgical site. R1's 5-day Minimum Data Set (MDS) dated [DATE], identified she was admitted on [DATE], hospitalized , and readmitted on [DATE]. Cognition was intact with no behaviors. Diagnoses included fracture of the hip, peripheral vascular disease (PVD) (narrowed blood vessels reducing blood flow to the limbs), chronic obstructive pulmonary disease (COPD), surgical site incision infection with cares, and cellulitis to right lower limb. She was at risk for pressure ulcers. She required substantial/maximal assistance with roll left to right in bed, sit to lying, and lying to sitting, dependent for toileting hygiene, lower body dressing, sit to stand, and all transfers. R1's orders from 8/1/25 through 9/13/25 identified: -8/3/25, leave occlusive dressing intact for: comments- keep Prevena (purple) dressing in place until wound vac dies. Remove and throw away. Replace with Mepilex. Change every 7 days with occlusive dressing. If incision is draining, ok to change dressing sooner. Keep covered until staple removal at 2 weeks pos-op. Nursing communication: if she is doing well, ok to remove staples at 2 weeks post-op at skilled nursing facility (SNF) and cancel follow-up appointment. -8/3/25, ice to affected area: ice to lower extremity, cold packs as needed for swelling a pain. Alternate 20 minutes on and 20 minutes off. Assess skin every 2 hours. Do not apply directly to skin. -8/19/25, change Mepilex dressing daily to left hip. May shower, cover incision with waterproof dressing so it does not get wet. -8/26/25, ok to remove staples on 8/26/25 if no drainage. If concerns call orthopedics. -9/10/25, cefazolin (Ancef) (antibiotic) 2,000 milligrams (mg) in sodium chloride 0.9%/50 millimeters (ml) administer IV every 8 hours for post op infection. -9/10/25, left hip incision/surgical site, abdominal (ABD) pad, secure with tape. Special instructions: incision has significant amount of drainage. Change as needed. -9/12/25, complete the weekly skin check observation.-9/12/25, Document in progress notes if these signs and symptoms are noted: temperature, pus present at wound skin or soft tissue site. New or increase in heat, redness, swelling, tenderness/pain, serous drainage at affected site, and change in mental status. Every shift: days/evening/nights. -9/13/25, Skill Charting: Pain-site/level/intensity/pharmacological/non-pharmacological interventions, medical doctor (MD) appointments, . special instructions: skilled charting should be therapy, IV antibiotic and skin. R1's Hospital Discharge summary dated [DATE], identified two days prior to admission to hospital she was noted to have redness and drainage at incision site. She was admitted to the hospital for surgical cellulitis, orthopedic surgery and infectious disease physician was consulted. Her intraoperative culture showed Morganella Morganii (an unusual opportunistic pathogen belonging to the Enterobacteriaceae (microorganisms that can grow in absence of oxygen such as gram-negative) family, primary associated with post-operative wound and urinary tract infections and known for its resistance to multiple antibiotics and evolving virulence. This bacterium often results in a high mortality rate with some infections) and a few peptoniphilus species (gram-positive, anaerobic (requiring absence of free oxygen) causes infections). She had been treated with broad-spectrum IV antibiotics during hospitalization and recommended to complete 6 weeks course of antibiotic discharging on IV Ertapenem per infectious disease physician recommendation. She also received wound VAC during this hospitalization and orthopedic surgery recommended to keep in place for 7 to 14 days or until battery dies, then place Mepilex over incision. Interagency Handoff Report dated 9/10/25, identified R1 was admitted to the hospital on [DATE], hospital events: presented to emergency department (ED) with complaints of left hip skin changes and drainage from surgical incision. ORIF of left hip with intramedullary nail placement on 7/29/25. Computerized tomography scan (CT) (imaging test that uses x-rays and a computer to create detailed pictures of your organs, bones, and tissues), showed large fluid collection. Intravenous (IV) fluids and antibiotics administered, orthopedics consulted, planned for incision and drainage (I&D) (procedure to drain pus from an abscess and clean it out to promote healing) tomorrow. Blood cultures completed and PICC inserted. During an observation /interview on 9/19/25 at 10:08 a.m. R1 sat in her wheelchair in her room fully dressed. She stated she had fallen at home and fractured her hip, had surgery, and then admitted to the nursing home. Her incision was healing pretty good, stitches were taken out but had a hard time when the nurse attempted to remove the two top stiches. The NA saw my incision was getting red on my upper thigh and told then nurse. She had also informed the nurse it was red, increased pain and drainage after the stiches came out. She had to be sent into ER, started on antibiotics and surgery to open it up twice to see where the infection was located. During an observation on 9/19/25 at 12:01 p.m. RN-D was in bathroom with R1 on the toilet. A clean brief was applied and pulled up to her thighs. She was lifted off the toilet with the PAL machinal lift with her feet placed on the platform. There was a Mepilex dressing approximately 1 inch wide located over her left hip incision dry and intact with small amount of shadow drainage with no redness on the surrounding skin or signs of infection per RN-D. R1 was getting ready to leave facility for a wound clinic visit scheduled for this afternoon. Peri cares completed, pants pulled up and lowered into her wheelchair. During an interview on 9/19/25 at 2:15 p.m. licensed practical nurse (LPN)-A stated after the staples were removed on 8/26/25, from R1's left hip incision there were two spots at the top of the incision that had a scant to moderate amount of bleeding and small amount of redness. She had cleaned it with warm mild soap, water and applied Mepilex dressing over it to catch the blood daily. On 9/1/25, R1 was more tender with purulent drainage noted at the top of the left hip incision whereas she did not have pain prior. She may have talked to the director of nursing (DON) that day, but nothing was documented so unsure. Usually with an incision that looked like this one on 9/1/25, could have indicated infection, a registered nurse (RN) should have been informed, assess it, and notify provider. Pictures could have been taken, sent to provider, and antibiotics ordered. The nursing assistants informed her a couple of times two days in a row it looked red, unsure which days those were, and she did not document it. R1's incision should have been reported to the provider on 9/1/25 or at least by 9/2/25 and was not documented. During an interview on 9/19/25 at 2:51 p.m. NA-A stated R1 had a one-inch-wide dressing on her left hip incision and redness was seen around the incision /dressing two days before she was sent to the hospital. She had informed the nurse both days. During an interview on 9/24/25 at 11:30 a.m. LPN-B stated the skilled nursing charting/documentation was required to be completed daily and should have included the skin assessment as well. We want to make sure there is no infection going on in the surgical incision. When there are signs of infection such as change in drainage, abnormal vital signs, redness around the incision, or increase in pain the RN should have been notified, and she would contact the provider. When a resident has a daily dressing, the nurse would be expected to assess the incision for signs and symptoms of infection and document at least daily on what their assessment showed. R1's provider should have been contacted right away when a change was seen in her left hip incision to help identify infection and prevent sepsis and most likely could have made a difference. Anytime a provider was notified the nurse would be expected to document it so that it can be tracked and followed up on. During an interview on 9/24/25 at 1:23 p.m. medical doctor (MD) stated R1's dressing change was ordered to be completed daily, and he would expect the nurse to assess, change the dressing and document daily. Would be important to complete a daily assessment to prevent infection and change the plan of care if necessary to promote healing. The nurse would be expected to rely on their judgement as to when to notify the provider. When the nurse identified signs of drainage, increased redness, and fever, he would have expected to be contacted right away. He was always available to be contacted and would have wanted to know as soon as signs and symptoms of infection were identified. He would have expected the nurse to contact him on 9/1/25, he was traveling at that time and on vacation and the on-call provider would have been the one to contact. He did not recall being contacted on 9/2/25 but had a message on 9/3/25 regarding R1. He was unsure of what the message was about. During an interview on 9/24/25 at 1:50 p.m. RN-B stated a weekly thorough skin assessment would be expected to be completed by the nurse and then a daily skin assessment if a daily dressing change was ordered to catch any changes and determine if any signs/symptoms of infection are present. She was asked to assess R1's left hip incision on 9/4/25, it was noted to be red, swollen with pain and erythema. R1 informed her the incision throbbed and ached and her temperature was 100.0 degrees F. All those signs and symptoms were of infection, and she needed antibiotic therapy. She left a phone page to MD, and he usually responded even if he was on vacation, very good about that. The nurse would be expected to document on her left hip incision/dressing daily to monitor for infection, catch it faster, less need for antibiotics, and decrease the likelihood of sepsis. During an interview on 9/24/25 at 2:45 p.m. hospital MD-B stated if R1 would have been brought to ER even a day or two earlier she may not have become septic. The sooner the sooner you can recognize signs and symptoms of infection, contact the provider, get them treatment the better the outcome. The abscess was quite big in her hip and required surgery, I&D. Cultures were completed, and antibiotics were started. Her sepsis could have been life threatening. During an interview on 9/24/25 at 4:00 p.m. LPN-C stated right after (unsure of date) R1 had her staples removed from her left hip incision on 8/26/25, the incision started oozing clear but pale-yellow scant amount of drainage from the top part. She did not document the drainage or the skin assessments of the incision when she changed the dressing. Unsure why she did not change the dressing on 9/3/25, no documentation provided in the progress notes. A provider should have been contacted when signs and symptoms of infection were present such as bleeding, uncontrollable pain/fever/signs, and symptoms to help prevent the resident's condition from getting any worse. During an interview on 9/25/25 at 1:00 p.m. RN-C stated she had completed daily skilled nursing assessments but was unsure what to click on and what areas were required to be documented on. She clicked on areas she thought was appropriate for each resident documented on. R1's assessment should have included her skin/incision each time to monitor for infection and make sure the incision was healing well without adhesions. The NAs are informed to let the nurse know if there are changes in skin and are good about doing that. She was unsure why she documented on 8/21/25, left hip dressing change was not completed d/t condition. The surrounding skin should have been assessed at that time and any changes documented to catch signs/symptoms of infection and prevent complications. The nurse would be expected to notify a provider right away when signs/symptoms of infection are noted such as fever, redness around incision, change in drainage, pain, change in mental status. Purulent drainage meant there was puss and infection present on 9/1/25 and a provider should have been called and documented. During an interview on 9/25/25 at 1:39 p.m. RN-D stated on the electronic medication administration record (EMAR) skilled nursing assessment were scheduled for every shift, however nursing staff were only required to have completed it once a day according to the guidelines. The order was placed in there that way so that it would not get missed. R1's left hip incision should have been assessed and documented every shift especially with a daily dressing change so that signs and symptoms of infection could have been recognized early on and prevent sepsis from occurring. There was a noted change in R1's left hip skin/incision on 9/1/25, charge nurse and the provider should have been notified. There was an event created on 9/3/25, provider contacted but only for her foot. RN-D verified there was no skin/incision assessments completed from 8/27/25 through 8/31/25 (4 days) and should have been. On 9/1/25, documentation identified a changed in her incision, a decline, signs of infection which would have been considered a significant change. The nurse would have been expected to contact the provider and documented so that we could have followed up on it. Recognizing signs and symptoms of infection early was important. During an interview on 9/25/25 at 3:43 p.m. DON stated the skill nursing assessment charting should have been completed daily and included the skin/incisions. She verified from 8/27/25 through 8/31/25, there was no documentation of a skin assessment on R1's left hip incision and should have been completed at least once a shift to monitor for signs and symptoms of infection. The nurse would be expected to assess the incision, surrounding skin when the daily dressing was completed and document their findings. The nurse would be expected to contact the provider right away when signs and symptoms of infection are seen such as increase in pain, drainage, purulent drainage, fever, and redness. The nurse can contact the provider by texting or calling depends on the provider and document. If it had been over two hours the nurse would be expected to follow up with the provider again so that continuity in care can be provided. The provider should have been contacted on 9/1/25 when purulent drainage, redness, and tenderness were noted on R1's left hip incision area. Identification of an infection early and starting an antibiotic would be important to avoid sepsis. Facility document Infection Prevention and Control (dressing changes and wound care) undated identified read the care plan of seeing resident to know if/how the wound is be cleaned and what type of dressing if needed should be applied. After wound care and/or dressing change has been completed documentation was required. Facility policy Preventing Skin Infections dated 9/2023, identified the purpose was to promote wound healing while preventing infection. Skin injuries will be observed daily or as ordered. If dressing change is not indicated daily, there will still be a visualization of the surrounding skin condition. A comprehensive wound assessment will be completed on a weekly basis and include location of skin injury, length, width, and depth measurements recorded in centimeters. Direction of length of tunneling and undermining if present. Appearance of wound base. Type and percentage of tissue in wound such as eschar, slough, granulation, epithelial. Drainage amount and characteristics including color, consistency, and odor. Drainage identified as sanguinous: blood drainage; blood drainage in a chronic wound may represent a sign of increased microbial load in the wound, which indicates an assessment for signs of infection was needed. Localized signs of infection would be erythema, induration (hardening of tissue around the wound site can indicate inflammation/infection), increased drainage, change in character of tissue, foul odor, increased pain at wound site, delayed wound healing, general malaise, mental confusion, loss of appetite, leukocytosis, fever (often not present in elderly), hypothermia, blood sugar changes in diabetic. Document progress toward healing following facility protocol on when to request change of treatment. Facility policy Change in Condition dated 10/2/23, identified the provided care and services are based upon the current needs of the resident under the direction of the attending provider. When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident/resident representative. Assess significant change in the resident's condition noted through direct observation, interview, or report for [sic] other staff. Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed. If unable to contact the physician, contact the medical director as appropriate. Document symptoms, assessment, observations, resident/resident representative, and medical provider notification.