Every finding on record at Benedictine Health Center Innsbruck

Based on interview and document review, the facility failed to comprehensively assess and implement an effective turning and repositioning program to prevent pressure ulcer development; failed to ensure the care plan was updated with new interventions to ensure implementation; and failed to ensure a developed pressure ulcer was accurately tracked and monitored in the medical record for 1 of 3 residents (R2) reviewed for pressure ulcer care. R2 needed physical assistance with repositioning, however, no consistent repositioning program was implemented and R2's care plan was not updated as she became more at risk for pressure ulcer development. R2 then developed multiple, avoidable stage II pressure injuries on her coccyx which constituted actual harm. Findings include: The Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM), Appendix PP - Guidance to Surveyors for Long Term Care Facilities, dated 7/23/2025, identified the current regulatory expectations for pressure ulcer care. This defined an avoidable pressure ulcer as, . means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Further, the SOM defined stage II pressure injury as a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed would be viable, pink or red, moist, and may also appear as an intact blister. A Vulnerable Adult Maltreatment Report (MAARC), dated 8/10/26, identified concerns about R2's care while at the care center. The report alleged R2 had been admitted to the center in late June 2026 and discharged back to her assisted living facility (ALF) on 8/3/26; however, R2 now had multiple pressure sores which had not been present prior.R2's Clinical Documentation (Admission), dated 6/29/26, identified R2 admitted to the care center and had intact long-term and short-term memory but with some difficulty making decisions about care in new settings. R2 had occasional bowel and bladder incontinence and occasional pain recorded. R2's initial Skin Risk Observation with Braden Scale, dated 6/29/26, identified R2 had clinical risk factors for skin breakdown including an acute condition and diabetes. R2 needed partial/moderate assistance with sitting-to-lying and vice versa. R2 used a brace/splint device (on her leg) and had no current, unhealed pressure injuries or other skin problems (i.e., diabetic ulcers, infections, moisture-associated skin damage [MASD]). R2 demonstrated no nutritional concerns (i.e., cachexia, edema, decreased output) and scored a 19.00 on her Braden Scale (tool used to help predict pressure injury development risk) which recorded her as, Not at Risk. A section labeled, Interventions, recorded specific interventions staff could implement with a checkmark being placed next to them. This recorded that no measures were taken (such as a blanket cradle, trapeze) but R2 was on a turning and repositioning program and on nutritional/hydration interventions to help manage skin problems. The evaluation concluded with, Continue Current Care Plan, and with referrals placed to physical and occupational therapy (PT/OT). R2's Weekly Skin Check, dated 7/2/26, identified a shower was provided and R2 had no current skin issues.R2's admission Minimum Data Set (MDS), dated [DATE], identified R2 had moderate cognitive impairment and demonstrated no rejection of care behavior. R2 had multiple medical conditions including diabetes mellitus, high blood pressure, and a bone fracture. R2 needed partial/moderate assistance with rolling in bed side-to-side, going from lying to sitting, and transferring from her bed to a chair. Further, R2 had no current, unhealed pressure injuries, she was determined as not at risk for developing them, was given a pressure reducing device for her chair and bed but was not on a turning and repositioning program. R2's corresponding Pressure Ulcer/Injury Care Area Assessment (CAA), dated 7/8/26, identified the CAA triggered due to R2 needing assistance with cares, urinary status and Braden Scale score. The CAA listed, partial/moderate for all bed mobility. The CAA then added, Resident Braden scale sore: 19, not at risk. R2 had no current pressure injuries but is at risk for skin breakdown. R2 received PT/OT and a care plan to minimize risks would be developed. R2's next Skin Risk Observation with Braden Scale, dated 7/11/26, identified R2 continued to have some clinical risk factors present and remained occasionally incontinent of bowel. R2 continued to use a brace/splint and now the evaluation marked, Limited Mobility/Bedfast. R2 had no current, unhealed pressure injuries or other skin problems. However, R2's Braden Scale score had now decreased and she was labeled, At Risk. The section labeled, Interventions, now only recorded a single intervention which was a pressure reducing device for her chair. The evaluation concluded with, Continue Current Care Plan.R2's Weekly Skin Check, dated 7/14/26, identified R2 had a shower provided and had no current skin issues. R2's next Skin Risk Observation with Braden Scale, dated 7/19/26, identified R2 continued to have some clinical risk factors, such as cardiovascular disease, and still needed partial/moderate help to turn left-to-right in bed and now needed substantial/maximal assistance with going from lying to sitting. R2 remained occasionally incontinent of bowel and no longer was using a brace/splint device as it was left unchecked. R2 continued to have no current, unhealed pressure injuries or other skin problems. However, R2's Braden Scale score had decreased further (more at risk with the lower the score), and she continued to be labeled, At Risk. The section labeled, Interventions, now had no interventions or measures checked or recorded and the evaluation concluded, Continue Current Care Plan.R2's care plan, last reviewed 7/14/26, identified R2 had an ADL self-care deficit and needed assistance of one for toileting. The plan recorded, Resident can verbally ask for assistance and is occasionally incontinent of bowel and bladder, adding further, Resident has a bowel and bladder plan that will help them remain free of skin breakdown . However, the plan lacked further details on the exact plan or timing with which R2 would be helped/offered/assisted with toileting. R2's skin care plan, dated 6/30/26, identified R2 was at risk for an alteration in skin integrity due to diabetes, decreased mobility and impaired circulation. The plan listed a goal which read, The resident will not develop further skin alterations. A single intervention was listed on the care plan which read, Resident has the following skin protective measures in place: (Special Mattress, barrier cream applied to dry areas as needed). The date of this intervention was listed as 6/30/26. The care plan lacked any further interventions, such as a turning and repositioning program, to help address R2's skin risk despite her having decreasing Braden Scale score(s), being recorded as at-risk for pressure injuries on her evaluations and having impaired mobility. R2's progress note, dated 7/24/26, identified an open area was now found on R2's inner buttocks. It showed redness and some minimal swelling. The note recorded, Continuing to use cream for skin tears and between buttocks. The note lacked any recorded measurements of the identified areas or other characteristics of the developed wound; nor evidence of what, if any, ongoing interventions the nurse placed to help promote healing of the wound. Registered nurse (RN)-B authored the note.R2's last completed Skin Risk Observation with Braden Scale, dated 7/25/26, identified R2 had diabetes mellitus, continued to need physical assistance with most mobility tasks, and continued to have bowel incontinence. The evaluation recorded R2 had no current, unhealed pressure injuries or other skin problems and listed a Braden Scale score which now showed R2 was not at risk for pressure injury development (despite the progress note on 7/24 showing an open area). The section labeled, Interventions, identified the staff would elevate her edematous extremities but no other interventions, including turning and repositioning program, were marked despite an open area developing the day prior. The evaluation concluded with, Continue Current Care Plan.R2's M Health Fairview Geriatrics note, dated 7/28/26, was authored by the nurse practitioner (NP)-A and recorded R2 as being seen for an episodic care visit. The note now added a concern which read, 4. Pressure ulcer of coccygeal region, stage 2 (H). The note continued, Patient seen for follow up . now PU [pressure injury] coccyx in cleft 2 X 0.5 cm [centimeters] plus R medial buttock 1 cm area and L buttock 1.2 cm area both excoriated and open, no discharge. The note listed a section labeled, Assessment/Plan, which reiterated the pressure injuries on the coccyx with dictation reading, . coccyx plus bilateral buttocks open areas with maceration/excoriation. NP-A directed to start barrier cream twice daily, have the wound nurse evaluate the area that week, and offload as possible.R2's Weekly Skin Check, dated 8/1/26, identified R2 was given a shower and recorded a skin issue as, Other type of alteration. The form outlined R2 as having excoriation and two open areas noted to coccyx area. The completed form lacked any written dictation of what, if any, interventions were done for the area or further wound characteristics (i.e., measurements, odor, drainage). R2's progress note, dated 8/4/26 (late entry for 7/28/26), identified the campus wound nurse (RN)-A had attempted to see R2 but she was not in her room. A subsequent note, dated 8/4/26 (late entry for 7/29/26), identified RN-A again attempted to see R2 but she was going to a medical appointment but R2 was seen by the nurse practitioner who had placed orders for the developed wound. These notes lacked evidence of any reapproach of R2 or what, if any, actions RN-A had given to other nurses for evaluating the wound or placing new interventions for it since they had been unable to do so. R2's Treatment Administration History (TAR), dated 7/2026, identified R2's recorded treatments with staff initials and date/time of them to show what was completed. This listed an intervention to apply barrier cream to the developed pressure ulcer twice daily with a start date recorded, 07/28/2026 - 08/03/2026 (DC Date). This was first recorded as completed on the evening medication pass on 7/28/26. The TAR lacked any interventions for offloading or barrier cream prior to 7/28/26 despite R2 needing assistance with mobility, having incontinence, and developing the pressure injury on 7/24/26 (four days prior).R2's Wound Management details, located within the medical record, identified R2 had multiple bruises which were identified upon admission. However, it lacked evidence that the developed pressure ulcers (first identified on 7/24) were added or tracked in this detail report until 8/3/26 when R3 discharged the care center back to her ALF. On 8/20/26 at 8:34 a.m., a telephone call was placed to R2's family member (FM)-D to discuss R2's care while at the care center. However, they were not reached. When interviewed on 8/20/26 at 8:40 a.m., NA-A stated care plans were communicated to the floor staff and directed how to transfer a resident and if they were on a repositioning program or not. NA-A stated all residents were on a check on them program every few hours. If someone was helped with toileting or repositioning, then it should be recorded in the POC charting each time the care was provided adding, Every time you go in the room [record it]. NA-A stated they vaguely remembered working with R2 and recalled applying barrier cream to R2's coccyx and bottom and believed it was something being done the entire time R2 had been admitted to the care center. R2 did not have any skin issues or wounds to NA-A's recall. When interviewed on 8/20/26 at 8:56 a.m., NA-B stated a resident on a repositioning program would be identified on the care plan which was then placed in a folder for staff to review each day to be aware of that. The staff just tracked the repositioning themselves using a pen and paper and whether that information was charted in the POC data would be a great question for the nurses. NA-B recalled there, at times, being a question about it on the POC to answer but it was rather just a single yes or no question about if you did it or not. NA-B stated they thought the nurses charted more specific interventions for pressure ulcer prevention in their records. NA-B recalled working with R2 when she was at the care center and described R2 as needing assist of one with transfers and most tasks except eating. R2 was also incontinent of bowel and bladder. R2 was not on a repositioning or toileting program but rather only just when she would ask [for help], adding R2 didn't like to lay in her bed much but rather spent a lot of time in her recliner chair. The staff would, if R2 asked for it, place R2's wheelchair cushion in the recliner, too. NA-B recalled working on 7/24/26 when they saw R2's coccyx and the wounds for the first time. They appeared a little red and like a little open wound. NA-B notified the nurse about it, who told them to apply barrier cream on it which had already been present in the room. NA-B stated they were unsure where or how long staff had been applying barrier cream to R2's coccyx prior to the wound development. NA-B reiterated R2 had not been on a turning and repositioning program prior to or following the wound developing to their recall. R2's Point of Care (POC) History report, dated 7/17/26 to 8/4/26, identified the care recorded by the nursing assistant (NA) staff members for the period. R2 had no recorded behaviors and had multiple episodes of bladder and bowel incontinence. R2's ability to go from sitting-to-lying and vice versa was recorded mostly as, Substantial/maximal assistance, with some, Dependent. The complete POC documentation lacked evidence that R2 was placed on a repositioning program or having any consistent turning and repositioning completed for the period. R2's medical record was reviewed and lacked evidence R2 had been started on a consistent turning and repositioning program to help prevent pressure ulcer development despite needing physical assistance with transfers and bed mobility; lacked evidence R2's skin ability to tolerate prolonged periods of pressure (i.e., tissue tolerance) had ever been considered or evaluated in the recliner chair since she spent much of her time there; lacked evidence the pressure ulcers were comprehensively assessed when they developed to determine what interventions were needed to promote healing and prevent continued decline; and lacked evidence of a consistent treatment being implemented until 7/28/26 which was four days after the area was first charted. Further, the record lacked evidence R2's skin care plan was ever adjusted with new interventions despite a worsening Braden Scare being charted. R2 then developed three stage II pressure ulcers as diagnosed by the provider. When interviewed on 8/20/26 at 9:42 a.m., RN-B explained if a new skin impairment, including a pressure injury, was identified then the nurse who first saw it was supposed to assess it and then update the wound nurse (RN-A) or the unit manager about it. The wound should also be measured and all the actions taken should be recorded in the progress notes. The wound nurse would then evaluate the wound, and they would stage it, if needed, and make further treatment recommendations and communicate with the physician. RN-B stated the Weekly Skin Check forms were to be completed on the scheduled bath day for the resident and should include both current and new skin impairments but if the wound had already been assessed, then staff would just recorded any changes to it on that form and not go into full detail about it. RN-B stated the floor nurses also complete the Skin Risk Observation/Braden forms and should place checkmarks next to the interventions they have orders to do for the person but just because there were no orders for someone to be repositioned, the nurses and aides could still do that adding, I feel like that is common sense. RN-B stated there had been some training on how to complete those skin forms when they started working at the care center a few months prior, but not down to the detail of exactly what check-marking the items meant or who then updates the care plan with those marked interventions. RN-B stated they felt the unit manager would be the person who updated the care plan with interventions as the floor staff more just identified the wound and then the unit manager would take over the care and care plan adjustments moving forward adding, We [floor nurses] don't do any changes to the care plan unless we're told to. RN-B recalled working with R2 and described her as pretty immobile and often sleeping in her recliner chair instead of her bed. There was rarely, if ever, a cushion used in the recliner seat to RN-B's recall but sometimes R2 would ask for a pillow on her side due to hip pain. R2 was pretty incontinent of bowel and bladder but did void in the toilet at times when assisted there. RN-B recalled the wound they saw on R2's bottom area on 7/24/26 and described it as red but with intact skin looking like two pennies next to each other. There were multiple areas present and the aide mentioned there was some barrier cream in the bathroom, so RN-B told the aide to just apply that. R2 reported the area was a little painful too. RN-B then updated the nurse they were working with that day for orientation about the wound but was unable to recall the nurse's name. RN-B stated they did not update the wound nurse about the wound as, at that time, they did not know who it was even; and they were unsure if the nurse they reported it to did either, rather the nurse they reported it to just said to apply the barrier cream and keep an eye on it. RN-B stated they could not recall if R2 was on a turn and reposition program or not but did recall seeing her often slide down in her wheelchair and having a slumped appearance, so staff would have to boost her back up often. RN-B stated they were unsure how the NA staff members chart repositioning if someone was on a repositioning program adding, I have never seen their charting. RN-B then stated they thought someone on a repositioning or offloading program would show up on the TAR with an intervention for the nurses to record. The nurses could also write it in a progress note, but nobody had ever directed them to do that, rather it was just to get the information into the medical record. RN-B verified R2 was pretty healthy and eating well during their stay at the care center. R2 was not considered in terminal condition, either. Further, RN-B stated they were unsure who or how often someone evaluates the skin tolerance to pressure (i.e., tissue tolerance) and did not know if occupational therapy (OT) had ever been involved with R2's skin interventions or not. When interviewed on 8/20/26 at 10:48 a.m., occupational therapist (OT)-A recalled working with R2 and reviewed her medical record. R2 had waxing and waning cognition and family had been considering memory care options at the end of her admission. R2 had a foot injury and wore a CAM boot due to fractures going from weight-bearing as tolerated (WBAT) to toe-touch weight bearing (TTWB) mid-stay after an orthopedics appointment. OT-A recalled R2 struggled at times to use the call light system as it was different than the style she had been using at her ALF. Upon admission, OT-A stated R2 needed moderate to maximum assistance with repositioning then progressed to needing more minimal to moderate assistance towards the end of her stay. OT-A stated they did not think R2 would know to reposition herself independently without cues or help and needed physical help to do that throughout her admission. OT-A stated they did not think R2 had ever been on a repositioning program and could not recall nursing staff ever reaching out to them (OT) about her spending a lot of time in her recliner chair. OT-A stated use of a recliner chair instead of a bed was something I want to look into more as it did not provide the same offloading pressure as a mattress would have. The OT could even then do a pressure-mapping on R2 to help determine more interventions to relieve pressure in the wheelchair or recliner. OT-A recalled doing a seat dumping on R2's wheelchair but that was more for her sliding and her falling. OT-A stated they were unaware R2 had developed pressure ulcers at the care center. On 8/20/26 at 11:29 a.m., a group interview was held with the director of nursing (DON), RN-A, nurse manager (RN)-D, and the regional director of clinical services (RDCS). RN-D explained that when a resident was admitted to the care center, a skin check was completed and recorded. If wounds existed, then they would be recorded in the Wound Management section and tracked, and RN-A would be updated about them. If there is no skin issue present upon admission, then a Braden Scale is completed and, depending on that result, they are placed on a repositioning program if they are at risk. The Braden Scale is then repeated weekly for four weeks by the floor nurses. The care plan normally was then updated by the manager if the person was at risk for skin breakdown. RN-A stated the floor nurses were also able to update the care plan with a reposition program and consult with other resources, such as the dietitian, if they determined they needed to do so about skin risk or wounds. DON explained they no longer have tissue tolerance review as part of their assessment process as the weekly skin checks and daily general observations of skin with care replaced it. RN-A stated if a resident was using a device frequently, like a recliner, then they could visit with OT and have them review it and provide a cushion for it, if needed, but the resident would still likely need to be offloaded by the staff. RN-D verified R2 needed physical help to reposition, and the care plan should be updated with interventions as the Skin Risk/Braden evaluations are completed. The timeline of events with R2's wound was reviewed. RN-D recalled seeing the progress note (dated 7/24) about the wound concern and updated the provider about it who saw it then (on 7/28) and ordered barrier cream for it. The provider only told them it was some excoriation but nothing major and never used the term 'pressure injury' which would have caused them to have a hastier response to it. RN-A and RN-D stated they both attempted to evaluate the wound between 7/24 and 7/28 but had been unable to connect with R2 which is why the notes were entered into the system late (after R2 discharged ). RN-A verified the floor nurses could also have fully assessed the wound and started treatments on it since they were unable to see it. RN-D verified the medical record lacked a re-assessment of the wound after it developed or revisions to the care plan and stated they never updated the care plan after the wounds developed as they wanted to evaluate the wound first before adding them to the care plan. RN-D also acknowledged that the care plan lacked any further interventions for skin risk other than the initial single intervention loaded despite the worsening Braden Scale scores being recorded. DON stated that if a resident was on a reposition program, the NA staff should be recording that in the POC charting or the nurses could record it on the TAR. However, R2 did not have this charting in her record and had not been placed on a reposition program per the care plan, either. DON stated the first time they had learned about R2 developing multiple pressure injuries was after R2 discharged and her ALF reached out asking about the wounds. When asked if R2 would have still developed the pressure injuries if all these actions, such as being placed on a repositioning program and having new care plan interventions added as her Braden Scale score worsened, had been taken, RN-D stated they didn't think R2 needed much help to reposition at the beginning of her admission and felt the nurses were checking on her routinely. DON stated they would keep looking for more information in the medical record to show what, if any, additional actions or interventions were being done and provide them if located. No further information was received.When interviewed on 8/19/26 at 1:49 p.m., NP-A stated they were the primary medical provider to R2 while she had been at the care center. NP-A stated they were first notified about the developed skin impairment for R2 on 7/28/26 which they went and evaluated. There were three areas total and each was a stage II pressure ulcer. The areas appeared, red and raw but had no depth or slough present rather just, raw, macerated areas. NP-A stated if a wound developed between care visits, then the unit manager could call and update them about it. NP-A stated the charting on 7/24/26 from the nurse wasn't maybe enough to warrant an update to the provider alone as some nurses are newer or more raw than others. NP-A stated the wound nurse should have been made aware when the skin was first seen, and they could have evaluated the wound and then contacted the provider for input if needed adding, That should have happened. The facility Prevention and Treatment of Skin Breakdown policy, dated 6/2026, identified residents were assessed upon admission and weekly thereafter for four weeks using the Skin Risk Assessment. The policy recorded, Those residents at an increased risk for impaired skin integrity are provided preventative measures to reduce the potential for skin breakdown. The policy outlined a care plan would be implemented and updated for skin risk interventions based on areas of risk, resident assessment, a Braden of 15 or less, and resident preferences. Resident's skin was observed daily with cares and concerns would be reported to the nurse; a therapy consult would be placed as appropriate. If a new pressure injury was identified after admission, the policy directed to document it in the medical record, initiate standing orders for wound care, notify the provider and resident representative, notify the supervisor (manager) and evaluate current pressure reduction interventions and revise the care plan. The documentation should reflect these actions completed.

Based on interview and document review, the facility failed to ensure physician orders for a heart monitor were acted upon and implemented as soon as possible to help prevent complication (i.e., arrythmia, cardiac arrest) for 1 of 1 resident (R1) reviewed who needed a heart monitor. R1 had orders upon admission to the care center to implement a remote cardiac monitor; however, this device was not obtained and/or started until 7/31/26 (8 days later) despite R1 having a history a bradycardia (slow heartbeat) and prior heart blocks (a delay or stoppage of the electrical signals that travel in the heart). Findings include:On 8/19/26 at 8:47 a.m., R1's family member (FM)-B was interviewed and expressed several concerns about the care provided to R1 while he was at the care center. R1 had discharged from the hospital to the care center with orders for a remote cardio monitor to be worn. The hospital reported that it had been ordered and sent to the care center; however, there was an unnecessary delay in getting it attached to R1 for some reason at the care center. FM-B finally asked a nurse about it and why it had not been attached to R1 yet, and the nurse responded they didn't know how to attach it and doing so was past our capabilities of nursing. FM-B stated this was unacceptable and concerning. R1's (Hospital) After Visit Summary (AVS), dated 7/23/26, identified R1 had been in the hospital for bradycardia (slow heartbeat) and listed orders to be done at the care center. A section labeled, Other Diagnostics, identified an order for ECG Ambulatory Real Time Cardiac Monitoring which would be mailed to the home for hook-up. R1 was to wear the monitor for 14 days. These orders were circled with handwritten circles and had handwritten dictation reading, Clarify ECG monitoring to be done here or post-DC? The handwritten items did not have any initials or signatures to show who did them.R1's subsequent M Health Fairview Geriatrics (Note), dated 7/24/26, identified R1 had been seen by the onsite nurse practitioner (NP)-A and evaluated. R1 had been in the hospital for multiple reasons which included bradycardia with Mobitz 1 and Mobitz 2 AV blocks. R2 was recorded on the examination as oriented, in no distress and ambulating despite being non-weight bearing (NWB). The note recorded, . not on cardiac monitor as thought [sic] indicated by hospital . The note included a review of R2's heart failure and directed, - contact Mayo cardiology for cardiac monitor. R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 7/2026, identified all R1's completed treatments. This included: - Heart monitor should be charged. Check in the telephone for percentage. Remove when going to shower, scheduled every shift. This had a start date recorded, 07/31/2026 - 08/03/2026. This was first signed off as completed on 7/31/26 in the morning shift.R1's MAR and TAR, dated 8/2026, identified R1's completed treatments for the month. This included: - MoMe Device [heart monitor]: Ask patient if he has received any phone calls from monitoring clinic. If so, assess [patient] and follow guidance ., scheduled every shift. This had a start date recorded, 08/03/2026 - 08/13/2026. This was first signed off as completed on 8/3/26 in the morning shift. - MoMe Heart Monitor . ensure placement each shift . This had a start date recorded, 08/03/2026 to 08/13/26. This was first signed off as completed on 8/3/26 in the morning shift. Both the MAR and TARs (dated 7/2026, 8/2026) lacked any recorded interventions for the device until 7/31/26 (eight days after R1 admitted ).R1's progress notes, dated 7/23/26 to 8/13/26, identified the following: On 7/23/26, R1 was admitted from the hospital and was alert and oriented. On 7/31/26, the heart monitor was connected to R1 and R1 had been shown how to record symptoms (i.e., chest pain, racing heartbeat) on it. Registered nurse (RN)-C authored the note. On 8/4/26, staff received a call from the heart monitor device clinic with concerns for serious heart rhythms from the heart monitor. R1 denied any symptoms when asked and the onsite provider evaluated him.When interviewed on 8/19/26 at 11:43 a.m., RN-C recalled working with R1 and explained when someone admitted with orders for a device then the health unit coordinators (HUC) would place those orders and address them; however, RN-C stated they were unsure if that applied to heart monitors or not before adding, I'm assuming it would also be [them]. RN-C then expressed, I am not 100% sure of the whole process. RN-C stated the floor nurse would just be responsible for applying the device when it arrived at the room. RN-C recalled having to apply R1's device to him on 7/31/26 and was not comfortable with doing that, so they asked the director of nursing (DON) for assistance. RN-C stated they were not sure why it took eight days to finally get it attached and connected to R1. RN-C stated they recalled R1's family member handing them the box with the device in it on 7/31/26 and asking why it had not been started yet adding, I had no idea what [they] were talking about. RN-C stated the box had the heart monitor inside and RN-C had seen that same box sitting in R1's room a few days prior when they worked but never opened it or asked about it. RN-C reiterated the box they saw sitting in the room was the same box the family handed them on 7/31/26. When interviewed on 8/19/26 at 12:14 p.m., HUC-D explained cardiac monitors were sometimes sent with the patient from the hospital to the care center, or at times, the family would bring them in. The orders are still entered into the system by the HUC but getting the device was done by the unit manager or someone else. HUC-D reviewed R1's AVS and verified it was their handwriting on the document around the cardiac monitor. HUC-D wrote that and placed it into the providers mailbox to be addressed. HUC-D stated that was the last time they addressed it and were unsure when or if the device ever arrived at the care center. HUC-D stated they usually do not hear about the resolutions the providers end up making with things like that. R2's medical record was reviewed and lacked evidence of when the cardiac monitor arrived at the care center or what, if any, actions were made to secure the device by the staff. The record lacked evidence or rationale of why the device was not received and immediately attached to R1 despite the box with the device being seen by staff in his room days prior to the family having to question it to them. On 8/19/26 at 12:25 p.m., the DON and unit manager (RN)-H were interviewed. RN-H stated there were multiple cardiac monitors used at times and didn't think there were orders for it upon admission for R1. RN-H was shown the AVS (which directed to use it) and stated the lack of access to that hospital's EPIC chart maybe contributed to the delay in getting it as the order did not come to them (RN-H). The nurses were supposed to check orders once entered on the MAR/TAR, but the heart monitor didn't have that trigger maybe, either. A care conference was held for R1 and the family expressed concerns with it then, which the family then called and got a device sent over. The family had got to us before the staff acted on the order. DON stated he was first told of the device order on 7/31/26 when asked to help apply it by the nurse. RN-H stated the order for it should have been entered into Matrix (the care center system) while awaiting clarification but that did not happen, so the communication for clarification never made it to the manager to be followed-up on. RN-H stated it was important to ensure orders for cardiac monitoring were implemented as soon as possible so cardiac events can be tracked and logged. RN-H reiterated they should have likely checked the whole AVS and not just the Matrix orders, and the DON added that maybe since the HUC was newer that process slipped. At 1:31 p.m., RN-H returned and stated they had investigated the situation more and the HUC sent the clarifications to the provider (addressed on 7/24) but it was not communicated with us right away. The provider did not write a physical order to follow up on the cardiac monitor just mentioned it in his note so that likely contributed to a delay in getting the device.A facility policy on cardiac monitors was requested; however, none was received.

Based on interview and document review, the facility failed to ensure a voiced allegation of potential neglect of healthcare was immediately reported to the administrator, or designee, then reported to the State agency (SA) within 24 hours for 1 of 4 residents (R4) reviewed. R4 alleged nursing assistant (NA)-D had deliberately connected her to an empty oxygen tank and wouldn't fill it when told it was empty. R2 then experienced shortness of breath and had low oxygen saturation levels due to no oxygen in the tank. Findings include: R4's annual Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and did not have delusional thinking (i.e., believing things which are not true). R4 had multiple medical conditions including coronary artery disease (CAD) and respiratory failure. R4's care plan, last revised 7/22/26, identified R4 had an alteration in respiratory status and directed staff to encourage compliance with oxygen use and keep the portable tank filled every shift. R4 was a vulnerable adult due to admission to the skilled nursing facility (SNF), and the plan directed to report and investigate allegations of suspected abuse, neglect, or exploitation. The care plan lacked evidence R4 had a history of false allegations against staff about abuse or neglect. R4's Search Vitals Results - 02 Saturation, printed 7/27/26, identified R4's recent oxygen saturation (the percentage of hemoglobin in the blood carrying oxygen; normal levels range from 95% to 100% and low values indicate hypoxemia) levels recorded in her medical record. From 7/1/26 to 7/4/26, the recorded saturation levels ranged from 91 to 98%. R4's progress note, dated 7/5/26, identified R4 was sitting in the dining room and suddenly stated, I can't breathe. R4 had blue-colored lips and a headache, and her oxygen saturation was 75%. The nurse immediately took R4 back to her room and connected her to her oxygen machine. The note recorded, [R4] stated, the [NA] who assist her in the morning deliberately connected her to an empty potable [sic] tank and refused to fill it after she being [sic] informed that the tank was empty. The note continued and recorded the NA stated they didn't have time to fill it when told it was empty and . walked away, leaving the resident connected to an empty patable [sic] tank. The note was authored by licensed practical nurse (LPN)-E and lacked any further text or dictation showing what, if any, investigation into the allegation was done to determine if the accusation was credible. The Centers for Medicare and Medicaid (CMS) Internet Quality Improvement and Evaluation System (iQIES) database lacked evidence that the allegation written in R4's medical record had been reported to the SA. Further, R4's medical record was reviewed and lacked evidence the allegation of potential neglect had been reported to the administrator on 7/5/26 despite the recorded progress note. R4 was hospitalized at the time of the abbreviated survey (exited 7/27/26) and unavailable for interview. When interviewed on 7/27/26 at 2:55 p.m., LPN-E stated they recalled the event on 7/5/26 and explained R4 had reported to them the NA had not filled her oxygen tank. When asked about the word 'deliberately' in the progress note, LPN-E stated aloud, That's what she told me. R4 had told the NA the tank was empty, and the NA still didn't fill it. LPN-E stated they could not recall what, if any, further investigation they did into that allegation as my focus was just on getting R4 reattached to oxygen. LPN-E stated they have a supervisor on-duty over the weekend hours and was unable to recall if they had reported the allegation to them or not. LPN-E stated if someone needed oxygen and was deliberately not given it that it would be not good, but they were hesitant to accuse someone of neglect for that as other factors may be involved. LPN-E reiterated the dictation in the progress note was just R4's voiced words adding, I was quoting my patient. On 7/27/26 at 3:32 p.m., the administrator and director of nursing (DON) were interviewed. They acknowledged being aware of R4's note (dated 7/5/26), and the administrator stated he had discovered it during a random audit of progress notes on 7/7/26. That was the first time he learned of the allegation. He then emailed the nurse manager to follow-up about it and did an investigation into the situation which was unsubstantiated. The DON stated staff should inform leadership right away of allegations of potential abuse or neglect, however, that did not happen in this situation as the nurse who heard the comment then did not let anybody know. The DON stated anytime an allegation is heard that they'd expect it to be reported to leadership. The administrator reiterated they felt the allegation to be unsubstantiated based on their review of it after learning about it; however, he stated that any allegation of neglect should be reported up to leadership so it could be reviewed. He added, We should be following our policy. Further, the administrator stated he questioned the wording choices in the progress note by the nurse and, again, felt the situation was maybe not accurately captured in those words. The facility Abuse Prevention Plan, dated 2/2024, identified new and existing staff would be trained in abuse and neglect prevention. The medical records would also be routinely monitored for indicators of potential abuse or neglect, and that any person with knowledge of suspected abuse or neglect should report it immediately. The policy directed the person-in-charge was to be notified immediately of ay reports who would then notify the administrator and other leadership. If the event didn't cause serious bodily injury or harm, then it should be reported to the SA within 24 hours after the suspicion was identified.

Based on interview and document review, the facility failed to implement adequate nursing monitoring of a potential respiratory condition to help prevent complication (i.e., worsening) for 1 of 4 residents (R1) reviewed. R1 developed a semi-productive cough which required medication and diagnostic evaluation; however, no further ongoing vital sign or lung function monitoring was placed or recorded to ensure it resolved. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition, demonstrated no rejection of care behaviors, and had multiple medical conditions including chronic lung disease. R1's M Health Fairview Geriatrics progress note, dated 1/23/26, identified R1 was evaluated by the medical provider at the care center. R1's past medical history included severe protein-calorie malnutrition, pain, and history of bone fractures with routine healing. R1's fractures had an x-ray completed and her pain was controlled. The note recorded, Overall doing well. A physical exam was recorded which identified, RESP: lungs clear to auscultation, no respiratory distress. The note lacked evidence that R1 had complaints or current concerns about a productive cough. R1's progress note, dated 1/24/26, identified R1's tube feedings were all discontinued by provider order. R1's progress note, dated 1/26/26, identified R1's vitals were stable and she had no shortness of breath noted, lung sounds clear. However, R1's subsequent M Health Fairview Geriatrics progress note, dated 1/27/26, identified R1 was evaluated by the same provider (as 1/23) at the care center. R1's medical history now recorded, Cough, unspecified type. R1 had a coarse semi-productive cough, was afebrile, and had no apparent aspiration. A physical exam was completed which recorded, RESP: no respiratory distress, crackles bronchial. The provider ordered guaifenesin (an expectorant medication used to loosen mucus int he airways) and another chest x-ray. R1's progress note, dated 1/28/26, identified the x-ray results were received which recorded the lungs free of infiltrates or focal consolidations. However, there was a small loculated left pleural effusion (localized pocket of fluid). R1's subsequent M Health Fairview Geriatrics progress note, dated 1/30/26, identified R1 was evaluated by the same provider (as 1/23, 1/27) at the care center for follow-up. R1's cough remained with mild wheezes noted, but oxygen saturations over 90% on room air. The x-ray results (dated 1/28) were reviewed and considered clean, and R1 remained afebrile. The provider ordered albuterol nebulizer treatments four-times-a-day and directed, repeat CXR [x-ray] if not improving.R1's progress note, dated 2/1/26, identified R1 had breathing problems and listed her vital signs as 129/89 (BP), 98.0 (F), and oxygen level at 75%. The head of bed was raised and oxygen was applied. The on-call provider and family were notified. R1 was transferred to the acute care hospital.R1's Search Vitals Results, dated 1/25/26 to 7/27/26, identified R1's collected and recorded vital signs from those dates. This identified that from 1/27 (when the cough was identified by the provider) until 2/1 (when R1 transferred to the hospital) that only two vital signs were taken. These were recorded as: 01/28/26 - Weight - Not Taken. 01/30/26 - O2 Saturation - 94%. R1's medical record was reviewed and lacked evidence any other vital signs were recorded between 1/27/26 and 1/30/26; nor any evidence of what, if any, nursing monitoring of the developed cough was being done (i.e., lung sounds) to ensure it resolved and did not worsen which would possibly warrant additional x-ray diagnostics per the provider.When interviewed on 7/27/26 at 10:16 a.m., R1's family member (FM)-A stated R1 admitted to the care center from the hospital and voiced multiple concerns about the care provided to R1 during their admission. R1 had developed a cough which was potentially from her tube feeding so the center did a chest x-ray which was normal early on. R1 continued to have a cough though and just get sicker and sicker which led to another x-ray being done which FM-A had been told was normal. However, it showed a pleural effusion and R1 continued with the coughing episodes. FM-A stated they had R1's medical records and questioned the lack of recorded monitoring of R1's respiratory function despite multiple x-rays being done and R1 seeming to get worse at the end of her admission. FM-A stated the cough was a deep, gurgly cough and staff were aware of it including the provider. When interviewed on 7/27/26 at 12:15 p.m., licensed practical nurse (LPN)-B stated the response to a resident with a developed cough would be determined if it was a simple or not. If a more productive or forceful cough, then the unit managers would be notified, and they'd develop the plan for monitoring. LPN-B stated they would just make it known to the higher ups of a developed productive cough and they'd act on it. LPN-B stated they did not recall ever working with R1 while she had been admitted to the care center. On 7/27/26 at 1:55 p.m., the director of nursing (DON) and registered nurse manager (RN)-H were interviewed. DON explained R1 was a complex patient and had norovirus just prior to being admitted to the care center. DON felt R1's cough was more chronic versus acute and explained that monitoring of a respiratory condition should include vital signs being done every shift. If concerns with the vital signs, then a more in-depth assessment could be done such as lung sounds. DON reviewed the medical record and verified it lacked evidence of vital signs being monitored every shift after 1/27/26, despite R1 having an identified cough by the provider. DON stated they felt some education for the nurses would be helpful, adding it was important to ensure a change of condition is monitored to ensure the condition improves and does not worsen. The facility Change in Condition, Resident Examination and Evaluation policy, dated 11/2025, identified the facility would complete an evaluation upon admission, with a change in physical function, and with an acute change of condition. If a significant change was identified, the provider would be notified. A procedure was listed which directed a nurse to evaluate for a change, review the medical record, notify and supervisor and obtain a set of vital signs as needed/ordered. The policy then directed to notify the IDT and, Monitor and provide treatment as ordered by the attending provider. However, the policy lacked dictation on what ongoing monitoring would include or how it would be recorded in the medical record.

Based on interview and document review, the facility failed to ensure a stage III pressure ulcer (i.e., full-thickness skin loss) was accurately documented and adequately monitored for healing with weekly measurements and characteristic evaluations to promote continuity of care and reduce the risk of complication (i.e., worsening) for 1 of 4 residents (R1) reviewed. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition, was not diabetic, and demonstrated no refusal of care behaviors. Further, R1 had a current stage III pressure ulcer which was present on admission, and she remained at risk of continued pressure ulcer development. R1's progress note, dated 1/8/26, identified R1 admitted to the care center and had a tube feeding present. R1 had a history of malnutrition, pain and atrial fibrillation. R1 refused a skin check. R1's progress note, dated 1/9/26, identified the nurse completed a skin inspection. R1 had a Stage III pressure injury on her coccyx with slough (dead, non-viable tissue) present in the wound bed. It measured 1.9 X 2.0 centimeters (cm) in size and was likely from friction and/or shearing as R1 spent much of her time in bed. A subsequent note, dated 1/9/26, identified R1 was incontinent of bowel and used a Foley catheter. R1's Skin Risk Observation with Braden Scale, dated 1/11/26, identified R1 to be at risk of pressure ulcer development. R1 had several risk factors including acute condition, malnourishment, and needing help to complete mobility activities such as turning side to side. The evaluation identified R1 had current, unhealed pressure injury on her sacral region along with moisture-associated skin damage (MASD) present. A new care plan would be established, and referrals were placed to dietary and therapies. R1's care plan, dated 1/12/26, identified R1 had an alteration in her skin integrity evidence by a stage III pressure injury on her coccyx. A goal of healing the injury without infection was listed, and interventions included staff monitoring the area for healing, providing treatments as ordered, and updating the family or provider as needed. Further, the plan directed to review other applicable areas, such as nutrition, for their respective approaches. R1's subsequent Skin Risk Observation with Braden Scale, dated 1/19/26, identified R1 to remain at risk for pressure ulcer development along with several clinical risk factors including acute condition and cardiovascular disease. However, the evaluation now identified R1 had no current, unhealed pressure injuries. The evaluation identified the current care plan would be continued. R1's Weekly Skin Check, dated 1/20/26, identified R1 had no current alterations in skin integrity with a checkmark placed next to option reading, None (resident's skin is clean, dry, and intact). The form recorded there had been no changes in R1's skin since the last skin check and R1 did not have diabetes. R1's subsequent Skin Risk Observation with Braden Scale, dated 1/26/26, identified R1 had no clinical risk factors for skin breakdown with an option checked, None of the above. The evaluation again identified R1 had no current, unhealed pressure injuries and the current care plan would be continued.R1's final Skin Risk Observation with Braden Scale, dated 2/2/26, identified R1 now had clinical risk factors present again including chronic incontinence, malnourishment and refusal of care/treatment. R1 remained at risk of pressure ulcer development with a Braden score of 16.0, and now again had a current, unhealed pressure injury on her sacral region and the current care plan would be continued.R1's Wound Management Detail Report, dated 7/27/26, identified the entered evaluations for R1's pressure injury. This identified two recorded entries which were: 1/9/26 - The pressure injury measured 1.9 X 2.0 (cm), had no drainage, no odor, no undermining and was a Stage III injury. 100% of the wound bed was covered by slough and the wound was listed as, Stable. 1/14/26 - The pressure injury measured 1.9 X 2.0 (cm), had no drainage, no odor, no undermining and was a Stage III injury. 100% of the wound bed was covered by slough and the wound was listed as, Stable.R1's progress note, dated 2/1/26, identified R1 developed breathing problems and was transferred to the hospital. The note lacked any recorded measurements of the pressure ulcer upon her discharge. The report lacked any further recorded evaluations of the wound including measurements, characteristics, or if the wound remained stable or not. Further, R1's medical record was reviewed and lacked any further recorded measurements or evaluations of the pressure injury (including with characteristics) after 1/14/26 until 2/1/26, when R1 discharged the campus. Further, the record lacked clear rationale or reasoning why the ulcer was not recorded on the multiple evaluations completed (i.e., Weekly Skin Check) which recorded R1 as not having a pressure injury despite it remaining the entirety of her admission to the care center.When interviewed on 7/27/26 at 10:16 a.m., R1's family member (FM)-A expressed multiple concerns about the care R1 received at the care center. R1 would often have to wait for long periods before getting help with mobility which caused her to not want to get into her wheelchair as she was fearful she'd then be stuck there for hours. The center also would not allow R1 to have side rails on the bed to help her with turning as they were considered a restraint. FM-A stated they believed R1's pressure ulcer was just a very small red spot when she arrived but had worsened during her time there as when R1 arrived at the hospital (on 2/1), the wound was huge and very deep. FM-A stated there was treatment being done for it as there were multiple creams for it being placed on R1's windowsill. FM-A questioned if they were adequately tracking it or even following the physician's orders correctly due to the number of treatments being left in the room. When interviewed on 7/27/26 at 12:15 p.m., licensed practical nurse (LPN)-B stated if a resident had a pressure injury, then the unit manager would be notified and most often be the person who tracks it and records it in the chart. LPN-B stated they were not asked to do that as a floor nurse adding, The people who are in charge of the wounds [do that]. LPN-B stated any wound measurements of evaluation would be recorded in the progress notes or on the Weekly Skin Check form. On 7/27/26 at 1:55 p.m. the director of nursing (DON) and registered nurse manager (RN)-H were interviewed. RN-H verified R1 had admitted with the pressure ulcer, and it remained present for the duration of her admission to the care center. RN-H was the campus wound nurse and tracked the pressure injuries using the Wound Management Detail in the record. RN-H confirmed the last time the ulcer had any recorded measurements or characteristics was on 1/14/26 and expressed they had taken some time off during the month so that is likely why it had been missed. RN-H acknowledged the repeated assessments and charting by the other staff members which recorded the lack of any pressure ulcers or skin impairments, and RN-H stated that was likely due to staff thinking they just charted items which were new and not already present. RN-H stated some education on that was being planned. RN-H explained the ADON was the back-up person responsible to measure and record wounds if RN-H was absent, however, it had not been done for some reason. DON reviewed the medical record and verified the lack of documentation to show a, at minimum, weekly evaluation of the ulcer with measurements and characteristics. DON stated it was important to complete the weekly evaluations on the pressure ulcer so staff could monitor it and know if it was healing or not.The facility Prevention and Treatment of Skin Breakdown policy, dated 6/2026, identified a pressure injury as a localized injury to tissue over a bony prominence which resulted from intense or prolonged pressure being applied. The policy defined a Stage III ulcer as, Full thickness skin loss . Slough or eschar may be visible . Undermining or tunneling may occur. The policy directed weekly skin audits would be performance by a nurse and skin would be observed daily with cares. The policy added, Weekly the licensed nurse will stage, measure, and examine the wound bed and surrounding skin. If wound bed as deteriorated; notify provider. Further added was, Documentation reflects areas as addressed above.

Based on interview and documentation review the facility failed to notify the medical provider of a change of condition for 1 of 3 residents (R1) reviewed when R1 reported to the nurse she was not eating or drinking because it hurts my intestine and rectum, and she had loose stools, staff notified the provider three days later. Findings include: R1's annual Minimum Data Sheet (MDS) dated [DATE], indicated she had no cognitive impairment, behaviors, or rejection of care. She used a walker independently and continent of bowel and urine. She did not have a risk for skin impairment or wounds. Her care areas triggered activities of daily living (ADLSs), and nutrition. R1's care plan dated 6/2/26, indicated she had pain from her left knee, decreased strength, needed staff to help with daily hygiene, and a fall risk. She was continent of bowel and bladder. RN-A's nursing progress note dated 6/14/26 at 11:08 p.m., indicated R1 told her she had loose stool since Friday (3 days earlier.) She did not tell nursing staff prior. RN-A offered Imodium (medication to treat loose stool), but she declined. RN-A indicated staff would update the provider on 6/15/26, and her vital signs were stable. R1's medical record indicated there were no progress notes dated 6/15/26. RN-D's nursing progress note dated 6/16/26 at 11:48 a.m., indicated R1 had loose stool on the night shift, but none at the time of her assessment. R1 stated I don't want to eat because it hurts my intestine and rectum. RN-D's intervention indicated staff would continue to monitor R1's status. RN-C's nursing progress note dated 6/17/26 at 11:35 a.m., indicated she updated the medical provider triage nurse about R1's complaint of loose stool, weakness, and rectal pain. RN-B's nursing progress note dated 6/17/26 at 12:28 p.m., indicated R1 complained of continuous rectal burning and pain. The pain worsened with activity. R1 stated her stool was black, and very loose. She stopped eating food for the past few days because when she ate anything, she would have increased stool and worsening pain. The nurse practitioner (NP)-A called back with an order for Imodium. NP-A's encounter note dated 6/18/26, indicated R1 had buttock pain and was unable to sit up. She found localized buttock soft tissue inflammation without exam and was concerned about cellulitis. Her plan was for staff to give Imodium as needed for loose stool, encourage food and fluids and if her condition did not improve staff should send her to the emergency room for an evaluation. RN-C's nursing progress note dated 6/18/26 at 1:15 p.m., indicated R1 continued to have unrelieved rectal pain, loose stool, weakness, short of breath, and anything she ate or drank passed right through her leading to increased pain. She was sent to the emergency room for evaluation. R1's facility event document dated 6/18/26 at 2:42 p.m., indicated on 6/12/26, she developed loose stool, rectal pain, weakness with shortness of breath. During an interview on 6/24/26 at 8:47 p.m., family member (FM)-A stated R1 complained about butt pain. She received a text message from R1 on 6/14/26 at 8:47 p.m., indicating she had been sick since Friday and if she did not improve, she would call 911. She was unable to eat because the food ran right through her. On 6/15/26 at 1:28 p.m. R1 indicated the staff were doing nothing but offering her Imodium but she declined because it would only make the loose stool worse. R1 added my rectum was on fire she was unable to sit on the edge of her bed. She felt the staff were doing nothing to help her. She tried to get ahold of someone at the facility, but no one answered or returned her phone call. During an interview on 6/24/26 at 2:14 p.m., R1 stated she did not feel good over the weekend. When the nurse came into her room, she asked her what the facility's protocol was when a resident was unable to eat or sit up. The nurse did not listen to her. While she took a shower, she could feel the rectal inflammation, but the evening nurse did not say anything. When the NP-A examined her the next day she was told the medical doctor would see her on Monday (four days later.) The hospital found a rectal wound infection, and it spread to her blood. She told the staff what was going on but all they told her was to eat and drink fluids and take Imodium. She said the staff did not listen to her concerns and felt like she was talking to the wall. She told the nurse on 6/17/26, she felt pressure on the inside of her rectum. During an interview on 6/24/26 at 4:00 p.m., RN-B stated earlier in the shift she noticed R1 was not up walking in the hallway. She checked in on her and found her lying in bed talking on her phone. R1 told her she had internal rectal pain, and every time she tried to eat food the loose stool would worsen causing her more pain. R1 declined an examination because the pain was internal not external. She updated RN-C. She received an order from the NP-A for Imodium, and she would visit R1 in the morning. During an interview on 6/24/26 at 4:36 p.m., RN-C stated she first learned about R1's loose stool on 6/15/26, when she returned to work. She spoke with R1 who told her the stool had stopped that morning. On 6/16/26, she was notified R1 stopped eating because it worsened her loose stool, but she did take some yogurt. On 6/17/26, RN-B told her R1 continued to have loose stool, and internal rectal pain. She called the provider's triage nurse. She added, the staff on 6/15/26, should have assessed her status and notified the NP of their findings. During an interview on 6/24/26 at 4:53 p.m., RN-D stated he assessed R1 on 6/16/26, and was told the loose stool had stopped. He checked her vital signs and encouraged her to eat and drink fluids. He did not update the provider because the loose stool stopped, and her pain was related to eating. He reported his findings to the next shift nurse. During an interview on 6/24/26 at 5:07 p.m., the director of nursing (DON) stated if R1 told her daughter she was having severe pain her daughter should have called the facility. If R1 was concerned about her care at the facility she could have spoken to the social worker because she made her own decisions and had no cognitive impairment. When NP-A examined her on 6/18/26, she left the building without talking to the staff or writing down any orders. When the staff reviewed her visit note later that day, they found staff should send R1 to the hospital if her condition worsened. He checked on R1 in the afternoon on 6/18/26, and asked R1 what NP-A told her. She replied she would have the provider see her on 6/22/26. R1 agreed to go to the hospital, and she was transferred. During an interview on 6/25/26 at 9:53 a.m., NP-A stated she first learned about R1's loose stool, rectal pain, weakness and not eating on 6/17/26. She sent an order for Imodium and planned to see her in the morning. On 6/18/26, she examined R1 who told her she had loose green, greasy looking stool, and internal rectal pain preventing her from sitting up. She examined the outer rectal area, noted red firmness, and thought it was irritation caused by the frequent loose stool. She tried to talk R1 into going to the hospital, but she declined and wanted to wait to see if she got better. After examining R1, she left the building without talking to staff. She would have preferred the staff to update her 6/15/26 when R1 first reported three days of loose stool. Interview on 6/25/26 at 10:27 a.m., facility medical director (MD-A) stated the NP-A ignored significant facts, and then later wrote her findings and instructions on her encounter note instead of talking to the nursing staff and writing her orders in the medical chart for processing. He added, the facility staff were monitoring R1 for three or four days, called the provider who gave them a weak order. The NP-A should have ordered blood work to look for an infection and stayed with the resident until she agreed to be transferred to the hospital for further evaluation. R1's face sheet dated 6/25/26, indicated she had an acute and chronic congestive heart failure, failure to thrive, anemia, swollen legs, chronic kidney disease, and diabetes. The facility policy Change in Condition, Resident Examination and Evaluation copyright date 2025, indicated nursing staff would work within their standard of practice to check for change in condition via observations, physical examination, interview, and discussion with other staff. If a resident refused the examination, they would report to the supervisor or DON and document findings in the chart. Staff would update the provider regarding the residents' concerns and findings. In addition, the family would be contacted, staff would document their findings, interventions, and provider orders.

Based on observation, interview, and document review the facility failed to ensure a dignified dining experience for 1 of 1 resident (R61). Findings include:R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of dementia and encephalopathy (disease of the brain that causes altered brain function or structure, often resulting in cognitive, behavioral, or neurological impairments). It further indicated R61 required substantial assistance with dressing.During observation on 4/15/26 at 7:11 a.m., R61 was sitting in the dining room at a table with 3 other residents. He was wearing a shirt and hip protectors (nude colored compression type shorts with padding on the hips). During observation and interview on 4/15/26 at 7:28 a.m., trained medication assistant (TMA)-A verified R61 was sitting in the dining room wearing a shirt and hip protectors stating the residents don't normally sit in the dining room just wearing their hip protectors because they are meant to be worn under clothes. R61 had been trying to get out of bed, and the day shift just arrived. TMA-A then went back to the medication cart and did not attempt to cover R61 with a blanket or bring him back to his room for pants. During observation on 4/15/26 at 7:30 a.m., social services (SS)-A walked past R61 looked down and saw he was only wearing his hip protector. SS-A went to the storage closet, got a blanket, and put it over R61's lap stating, Your legs looked a little cold.During observation on 4/15/26 at 9:34 a.m., (NA)-A stated hip protectors were meant to be worn under clothing and residents shouldn't be wearing it by itself, especially in common areas because it is like underwear. During interview on 4/15/26 at 9:47 a.m., NA-E hip protectors were meant to be worn under the resident's clothing, and they shouldn't be sitting in common areas or the dining room without clothing over them. During interview on 4/15/26 at 9:57 a.m., licensed practical nurse (LPN)-A stated residents should not be out in the common areas with just hip protectors on and they are meant to be worn under clothing. LPN-A also verified that wearing hip protectors without clothing over it, would not be considered a dignified experience.During interview on 4/16/26 at 9:33 a.m., registered nurse (RN)-C stated hip protectors were meant to be worn under clothes, and were like underwear, and shouldn't be worn in common areas. During interview on 4/16/26 at1:23 p.m., the director of nursing (DON) stated hip protectors should be worn under clothing and if the resident was resistive to getting dressed, the nursing assistants should ask for help and not just bring them out into a common area or dining room to sit. A facility policy titled resident's rights dated 11/28/17, indicated the facility acts to protect and ensure the rights of residents.

Based on interview and document review, the facility failed to ensure a resident's wishes for resuscitation were accurately documented in all areas of the medical record for 1 of 2 residents reviewed for inconsistent advanced directives. Findings include:R10's quarterly Minimum Data Set (MDS) dated [DATE], R10 had severe cognitive impairment, required substantial to maximal assistance for most activities of daily living (ADLs) and was receiving hospice care. R10's diagnoses included dementia, adult failure to thrive, and encounter for palliative care. R10's care plan dated [DATE], indicated, My code status will be honored.See M.D. order. R10's care plan further indicated resident received hospice services and that Resident's preferred wishes for end of life will be honored. R10's care plan instructed staff to coordinate with hospice providers and to refer to her hospice care plan. R10's admission clinical documentation assessments dated [DATE], [DATE] and [DATE], identified R10's advance care planning included DNR (do not resuscitate). R10's quarterly clinical documentation assessments dated [DATE] and [DATE], identified R10's advance care planning included DNR. R10's admission documents dated [DATE], indicated additional after hospital orders to include Treatment Options: DNR. R10's active provider order dated [DATE], indicated, Treatment Options: DNR. R10's order history report printed [DATE], indicated, Treatment Options: DNR/DNI [do not intubate] Special Instructions: See POLST [provider order for life-sustaining treatment] signed [DATE]. R10' order history from [DATE] through [DATE] lacked any evidence Full Code or CPR was ever ordered. R10's POLST dated by family member (FM)-B and nurse practitioner (NP)-A on [DATE], and scanned into the resident documents section of R10's electronic health record (EHR) indicated, Attempt Resuscitation/CPR.Full Treatment. Use intubation, advanced airway interventions, and mechanical ventilation as indicated. R10's provider visit note by NP-A dated [DATE], indicated, Reviewed POLST with patient and spouse, they would like her to be full code.CODE STATUS/ADVANCED DIRECTIVES: DNR/DNI. R10's health care directive dated [DATE], indicated, If I am in a terminal condition and cannot express my wishes, I wish to be allowed to die naturally and not be kept alive by artificial means or heroic measures. During interview on [DATE] at 5:28 p.m., licensed practical nurse (LPN)-A stated he would look in the EMAR (electronic medication administration record) in the resident's EHR to see their current code status. LPN-A pulled up his EMAR list which indicated DNR in bold, black letters within a red rectangle background under R10's name. LPN-A further stated the same indication was also seen in the resident header in the EHR. During interview on [DATE] at 5:30 p.m., registered nurse (RN)-B stated she would locate a resident's code status in the EHR under orders, on the face sheet or in the resident header. RN-B verified all three of those locations indicated DNR for R10. RN-B further stated code status could also be found in the resident's hard chart as well and opened R10's hard chart to the POLST. The original POLST (on yellow paper) in R10's chart was signed on [DATE] and indicated full code. There was a red line from the lower left corner to the upper right corner, and the word VOID was written on it. RN-B could not explain when this documented had been voided. During interview on [DATE] at 5:32 p.m., RN-C stated R10 was on hospice and so the updated POLST should be in the hospice binder. RN-C opened R10's hospice binder and found a copy of the POLST that was in her hard chart, signed and dated on [DATE], and did not indicate that the documented had been voided. RN-C could not explain why there was a discrepancy but stated she was positive R10's current code status was DNR. RN-C stated the health unit coordinator (HUC) should be able to provide an explanation and find the correct, updated POLST. During interview on [DATE] at 5:50 p.m., HUC confirmed the POLST in R10's EHR was scanned into resident documents on [DATE] and matched the POLST found in R10's hard chart and hospice binder. HUC stated R10 had returned to the hospital a couple times after initial admission and that she was admitted from the hospital as DNR each time. HUC could not explain why there was a discrepancy with the POLST and orders in R10's EHR. During interview on [DATE] at 1:58 p.m., FM-A stated his understanding was that R10 was DNR and had been since entering hospice back in July of 2025. FM-A stated he had a health care directive for R10 before her cognitive decline which indicated she wanted to have a natural death. During interview on [DATE] at 12:43 p.m., FM-B stated could not recall discussing or signing anything regarding R10's code status, but thought since R10 was on hospice, that meant they would not resuscitate and would allow a natural death. During interview on [DATE] at 12:54 p.m., RN-C state R10's POLST should have been reviewed and updated if needed when R10 signed onto hospice services. RN-C further stated code status should be reflected accurately throughout the resident's recorder-paper or electronic, to ensure the resident would receive their desired care in the case they were found unresponsive. During interview on [DATE] at 1:38 p.m., hospice nurse (RN-D) stated her understanding was that R10 was DNR and could not explain why the POLST in the hospice binder did not reflect that. During interview on [DATE] at 1:43 p.m., director of nursing (DON) stated the POLST should match the documentation in the residents EHR. DON further stated that the provider was responsible for ensuring the completion and accuracy of the resident's POLST. DON stated that in R10's case, hospice would be considered the provider, and they should have reviewed R10's POLST upon admission to hospice and ensured an updated and accurate copy was in her hospice chart. DON further stated the POLST that was uploaded to the resident document section should have been voided and a new POLST - when completed by hospice - should have been uploaded. DON understood there could be a concern since the uploaded POLST did not match the provider order in R10's EHR. Facility policy Medical Orders (POLST) undated, indicated a POLST was a medical order completed and signed by a healthcare professional as well as the resident or healthcare agent that outlined the resident's wishes concerning care at life's end. The policy further indicated the POLST would be uploaded into the resident's EHR in the Advance Care Planning section of resident documents.

Based on observation, interview, and document review, the facility failed to implement interventions for 1 of 1 resident (R47) who required alternate means of communication due to English as a second language.Findings include:R47's quarterly Minimum Data Set (MDS) dated [DATE], indicated R47 had severe cognitive impairment and diagnosed with aphasia (difficulty with communication) and dementia. Additionally, diagnosed with hemiplegia and hemiparesis following a cardiovascular accident affecting right dominate side, had reduced mobility. R47 required set-up help with eating, supervision for hygiene needs and impairment on one side, need assistance with dressing, and required moderate assistance for bed mobility. The MDS indicated R47 minimal difficulty with hearing, and was Vietnamese.R47's care plan dated 3/11/26, indicated R47 had behavioral symptoms with placing self on the floor, non-compliant with medication administration related to possible cognitive deficits. the care plan indicated R47 preferred to speak English unless otherwise noted. The care plan indicated that R47 was dependent on staff for meeting his emotional, intellectual, physical, and social needs. During an interview on 4/13/26 at 5:30 p.m., R47 (via interpreter) stated, he was not happy with the care, when he asked staff for something, it was not received. When he attempted to speak English to receive pain medication, he did not receive any. R47 didn't feel heard especially when it comes to meeting his needs. R47 stated he did not have additional ways to communicate with staff, no communication board with pictures, no pain pictures to point at, and staff did not obtain an interpreter. R47 further stated I am treated like I am nothing. He attempted to talk to staff, but staff did not understand or follow through. During an interview on 4/13/26 at 5:50 p.m., family member (FM)-D stated communication was a problem between staff and R47. FM-D didn't know about how the facility implements interpreter services. FM-D further stated the facility had not offered an interpreter, even for care conferences and it would be helpful if they did. Furthermore, FM-D stated the facility did not meet R47's communication needs.During an observation and interview on 4/14/26 at 9:06 a.m., R47 was in the dining room. R47 lifted his left hand up to gesture he needed something. The dietary staff member brought him a roll. When asked R47 if he received what he wanted, R47 shook head no.During interview on 4/16/26 at 11:05 a.m., director of nursing (DON) stated the expectation was for staff to utilize interpreter services, place it their plan of care and care conference, offer and document. Clear communication was important because it drives cares and what happens daily for the residents. During interview on 4/16/26 at 11:31 a.m., registered nurse (RN)-E stated the expectation was to provide interpreter services for English as a second language or non-English speaking residents. The process to obtain an interpreter was to contact health unit coordinator (HUC) she had a sheet of paper with the information. RN-E confirmed R47 received the cares he requires by asking and no other communication assistance was used.During interview on 4/16/26 at 12:32 p.m., social service (SS)-A stated the facility has residents that have alternative primary languages. The facility offered translation services, and the staff were trained to provide translation services. During interview on 4/16/26 at 2:43 p.m., nursing assistant (NA)-E stated she did not know how to obtain an interpreter for a resident but would ask the manager.The facility's Communication with Persons with Limited English Proficiency policy undated, indicated language assistance will be provided through use of competent bilingual staff, staff interpreters, contracts, or formal arrangements with local organizations providing interpretation or translation services, or technology and telephonic interpretation services.

Based on observation, interview, and document review, the facility failed to ensure facial hair was removed for 1 of 1 resident (R3) who required assistance with hygiene and was reviewed for activities of daily living (ADL).Findings Include:R3's comprehensive Minimum Date Set (MDS) dated [DATE], identified R3 had severe cognitive. Diagnoses included cerebral infarction (stroke) aphasia (difficulty communicating) and hemiplegia/hemiparesis (weakness/paralysis) of the left side. The MDS indicated R3 required maximal assistance with upper and lower body, and dependent on staff for all personal hygiene.R3's care plan revised on 2/5/26, identified ADL self- care deficient related to cerebral infarction. Interventions included maximal staff assistance with dressing, bathing and personal hygiene. The care plan directed that R3's facial hair was to be shaved daily. R3 had a personal electric shaver available. R3's medical record lacked R3 had refused to be shaved. During an interview on 4/14/26 at 9:05 a.m., family member (FM)-C stated R3 needed assistance with all cares. and wanted to be shaved daily. During an observation and interview on 4/14/25 at 12:56 p.m., R3's companion was in the room. R3's companion asked if R3 wanted to be shaved. R3 nodded yes, and task was shaved. During an observation and interview on 4/15/25 at 2:26 p.m., R3 had multiple white facial whiskers approximately 1/8 inch in length on his cheeks, chin and around his mouth. When asked if he liked whiskers, R3 shook his head, no.During an observation and interview on 4/16/26 at 7:38 a.m., R3 had a full face of white whiskers approximately 1/4 inch in length. When asked if he wanted to be clean shaven, R3 nodded head yes. When asked if he liked having whiskers on his face, indicated, no.During an interview on 4/16/26 at 8:23 a.m., nursing assistant (NA)-F stated she had not provided morning care to R3. NA-F verified R3's facial hair looked long and confirmed the care plan required daily shaving. NA-F wasn't sure why R3 had not been shaved and stated assisting with shaving was important to maintain dignity. During an interview on 4/16/26 at 11:11 a.m., director of nursing (DON) stated staff were expected to provide care in accordance with the care plan. The DON stated refusals should be documented. The DON further stated staff were expected to assist residents with grooming tasks, including shaving, when residents were unable to do so independently. During an interview on 4/16/26 at 11:36 a.m., registered nurse (RN)-E stated staff were expected to follow the care plan and provide consistent care. RN-E stated ADL's, including grooming, were important to maintain resident dignity. The facility policy titled Activity of Daily Living (ADL) 6/21, indicated residents were to receive necessary services to maintain grooming, personal hygiene, nutrition and mobility. The policy required staff to provide ADL's care accordance with the resident's care plan.

Based on interview and document review, the facility failed to ensure coordination of care through on going communication with hospice services for 1 of 1 residents (R10) reviewed for hospice had discrepancy in code status documentation identified and not resolved timely. Findings include:R10's quarterly Minimum Data Set (MDS) dated [DATE], R10 had severe cognitive impairment, required substantial to maximal assistance for most activities of daily living (ADLs) and was receiving hospice care. R10's diagnoses included dementia, adult failure to thrive, and encounter for palliative care. R10's care plan dated [DATE], indicated, My code status will be honored.See M.D. order. R10's care plan further indicated resident received hospice services and that Resident's preferred wishes for end of life will be honored. R10's care plan instructed staff to coordinate with hospice providers and to refer to her hospice care plan. R10's admission clinical documentation assessments dated [DATE], [DATE] and [DATE], identified R10's advance care planning included DNR (do not resuscitate). R10's quarterly clinical documentation assessments dated [DATE] and [DATE], identified R10's advance care planning included DNR. R10's admission documents dated [DATE], indicated additional after hospital orders to include Treatment Options: DNR. R10's active provider order dated [DATE], indicated, Treatment Options: DNR. R10's order history report printed [DATE], indicated, Treatment Options: DNR/DNI [do not intubate] Special Instructions: See POLST [provider order for life-sustaining treatment] signed [DATE]. R10' order history from [DATE] through [DATE] lacked any evidence Full Code or CPR was ever ordered. R10's POLST dated by family member (FM)-B and nurse practitioner (NP)-A on [DATE], and scanned into the resident documents section of R10's electronic health record (EHR) indicated, Attempt Resuscitation/CPR.Full Treatment. Use intubation, advanced airway interventions, and mechanical ventilation as indicated. R10's provider visit note by NP-A dated [DATE], indicated, Reviewed POLST with patient and spouse, they would like her to be full code.CODE STATUS/ADVANCED DIRECTIVES: DNR/DNI. R10's health care directive dated [DATE], indicated, If I am in a terminal condition and cannot express my wishes, I wish to be allowed to die naturally and not be kept alive by artificial means or heroic measures. R10's hospice progress note dated [DATE], indicated, Son [FM-A] provided copy of [R10's] health care directive via email. He said he does not have a POLST form. R10's hospice progress note dated [DATE], indicated, Left son [FM-A] a VM [voicemail] message to provide update and to inquire whether family was planning to update POLST. During interview on [DATE] at 5:28 p.m., licensed practical nurse (LPN)-A stated he would look in the EMAR (electronic medication administration record) in the resident's EHR to see their current code status. LPN-A pulled up his EMAR list which indicated DNR in bold, black letters within a red rectangle background under R10's name. LPN-A further stated the same indication was also seen in the resident header in the EHR. During interview on [DATE] at 5:30 p.m., registered nurse (RN)-B stated she would locate a resident's code status in the EHR under orders, on the face sheet or in the resident header. RN-B verified all three of those locations indicated DNR for R10. RN-B further stated code status could also be found in the resident's hard chart as well, and opened R10's hard chart to the POLST. The original POLST (on yellow paper) in R10's chart was signed on [DATE] and indicated full code. There was a red line from the lower left corner to the upper right corner, and the word void was written on it. RN-B could not explain when this documented had been voided. During interview on [DATE] at 5:32 p.m., RN-C stated R10 was on hospice and so the updated POLST should be in the hospice binder. RN-C opened R10's hospice binder and found a copy of the POLST that was in her hard chart, signed and dated on [DATE], and did not indicated that the documented had been voided. RN-C could not explain why there was a discrepancy, but stated she was positive R10's current code status was DNR. RN-C stated the health unit coordinator (HUC) should be able to provide an explanation and find the correct, updated POLST. During interview on [DATE] at 5:50 p.m., HUC confirmed the POLST in R10's EHR was scanned into resident documents on [DATE], and matched the POLST found in R10's hard chart and hospice binder. HUC stated R10 had returned to the hospital a couple times after initial admission and that she was admitted from the hospital as DNR each time. HUC could not explain why there was a discrepancy with the POLST and orders in R10's EHR. During interview on [DATE] at 1:58 p.m., FM-A stated his understanding was that R10 was DNR and had been since entering hospice back in July of 2025. FM-A stated he had a health care directive for R10 before her cognitive decline which indicated she wanted to have a natural death. FM-A stated the social worker from hospice had tried to contact him, and he had not responded yet to her email or phone calls. FM-A stated he had a POLST form that he intended to have updated to reflect R10's wishes as DNR. During interview on [DATE] at 12:43 p.m., FM-B stated could not recall discussing or signing anything regarding R10's code status, but thought since R10 was on hospice, that meant they would not resuscitate and would allow a natural death. During interview on [DATE] at 12:54 p.m., RN-C state R10's POLST should have been reviewed and updated if needed when R10 signed onto hospice services. RN-C further stated code status should be reflected accurately throughout the resident's recorder-paper or electronic, to ensure the resident would receive their desired care in the case they were found unresponsive. During interview on [DATE] at 1:38 p.m., hospice nurse (RN-D) stated her understanding was that R10 was DNR and could not explain why the POLST in the hospice binder did not reflect that. RN-D further stated hospice social worker (SS-B) had discovered the discrepancy a while ago and had been attempting to reconcile it with FM-A for a few months. During interview on [DATE] at 1:50 p.m., SS-B stated had first reached out to FM-A regarding R10's POLST on [DATE] and requested to meet to review and update it. SS-B stated had visited R10 again [DATE] and [DATE] and both times attempted to contact FM-A about the POLST. SS-B stated understanding R10 had been DNR since admission to hospice and could not explain why the discrepancy had not been discovered or addressed before February. SS-B stated FM-A had not responded and agreed it was important to be taken care of as soon as possible. During follow up interview on [DATE] at 10:37 a.m., RN-C stated she was unaware of the discrepancy in the POLST document in R10's hospice chart and her provider orders prior to surveyor discovery on [DATE]. RN-C stated would have expected SS-B to have notified her as soon as it was discovered, so that the facility staff could have assisted in resolving the discrepancy. During interview on [DATE] at 1:43 p.m., director of nursing (DON) stated the POLST should match the documentation in the residents EHR. DON further stated that the provider was responsible for ensuring the completion and accuracy of the resident's POLST. DON stated that in R10's case, hospice would be considered the provider, and they should have reviewed R10's POLST upon admission to hospice and ensured an updated and accurate copy was in her hospice chart. DON further stated he was unaware until recently that there was a discrepancy and that SS-B had been working to resolve it. DON stated would have expected SS-B to notify the facility as soon as the discrepancy was discovered so that facility could assist and expedite to resolve the concern. Facility policy Hospice dated [DATE], indicated the facility's interdisciplinary team should collaborate and communicate with hospice representatives to ensure appropriate hospice care planning and quality of care for the resident and family.

Based on observation, interview, and document review the facility failed to follow up on a 1 of 1 resident (R45) who glasses were broken. Findings include: R45's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), and Type II diabetes, and Parkinson's disease (progressive neurological disorder that primarily affects movement). It further indicated he was dependent on staff for most activities of daily living (ADL). R45's eye consult dated 6/3/25, indicated R45 should continue with the same eyeglasses and encourage full time use for distance and reading. R45's medical record lacked documentation regarding R45 glasses being broken or what was being done about it. During observation and interview on 4/13/26 at 1:57 p.m., R45 was in his room, sitting in his wheelchair. He stated he turned in his glasses because they were broken, and he still hasn't gotten them back. R45 was not wearing glasses, nor were they in his room. During interview on 4/16/26 at 9:23 a.m., nursing assistant (NA)-D stated R45 had glasses, but they broke about a month ago, so he hasn't been wearing them. NA-D stated she told the supervisor (RN-C) about it. During interview on 4/16/26 at 9:33 a.m., registered nurse (RN)-C verified R45 wears glasses and they were broken. RN-C was unsure as to how long they have been broken but social services (SS)-A was aware of it because the nursing assistant told them and gave them the broken glasses. During interview on 4/16/26 at 1:44 p.m., SS-A stated he was aware of R45 glasses being broken and would need to look and see when it happened and for any documentation regarding whether or not new glasses had been ordered or where they were in the process. SS-A never got back to the surveyor and no additional information was sent. A policy regarding social services dated 11/28/17, indicated the resident received care and services to assists them in reaching and maintaining their highest level of mental and psychosocial functioning which includes speech, language, vision, and hearing issues.

Based on observation, interview, and document review, the facility failed to ensure fall interventions were in place for 1 of 2 residents (R10) reviewed for falls. Findings include:R10's quarterly Minimum Data Set (MDS) dated [DATE], R10 had severe cognitive impairment, required substantial to maximal assistance for most activities of daily living (ADLs) and mobility. The MDS further indicated that R10 had two or more falls without injury and one fall with injury since admission. The MDS indicated R10 did not exhibit rejection of care behavior. R10's diagnoses included dementia and history of fracture of right leg. R10's care plan dated 1/28/26, indicated R10 had self-care deficit in mobility and was at risk for falls. R10's care plan identified interventions included hip protectors on at all times to prevent further injuries, floor mat beside the bed, and call light in reach at all times when in room. During observation on 4/16/26 at 8:13 a.m., R10 was asleep in bed asleep. The bed was in a low position. The mat was folded and stored in the corner of the room and was not on the floor next to the bed. The call light was on the floor next to the bed. During observation and interview on 4/16/26 at 8:53 a.m., nursing assistant (NA)-C stated R10 was at risk for falls and was supposed to wear hip protectors all the time but did not like them and refused them at times. NA-C further stated additional interventions included low bed, mat on floor and call light in reach. NA-C went into R10's room and verified R10 did not have hip protectors on, mat was not on the floor by the bed and call light was on the floor and not in reach. NA-C stated that without the hip protectors on, it was very important all the other intervention were in place to prevent a fall and any injury from fall if it occurred. During interview on 4/16/26 at 9:09 a.m., licensed practical nurse (LPN)-B stated R10 was supposed to wear hip protectors but did have the right to refuse. LPN-B further stated R10 should also have a mat on the floor next to the bed whenever she was in bed especially if she refused the hip protectors. During interview on 4/16/26 at 10:37 a.m., registered nurse (RN)-C stated R10's fall interventions included hip protectors, call light in reach and mat on floor when in bed. RN-C further stated any refusals to wear the hip protector should be documented.During interview on 4/16/26 at 1:43 p.m., director of nursing (DON) expected falls interventions to be in place and would expect R10 to have hip protectors on unless refused. If R10 refused, it should be documented. DON stated R10 should also have a mat next to the bed whenever she was in bed. Facility policy Integrated Fall Management dated 9/2023, indicated, Fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls.

Based on observation, interview, and document review, the facility failed to ensure oxygen therapy was administered and maintained for 2 of 2 residents (R49, R9) reviewed for respiratory therapy.Findings include:R49's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of acute respiratory failure with hypoxia (serious condition where the lungs cannot adequately supply oxygen to the blood, leading to low oxygen levels (hypoxemia) and potentially life-threatening complications), shortness of breath, and congestive heart failure (chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts). R49's physician's orders dated 2/24/25, indicated continuous oxygen wean as able per nasal cannula to keep oxygen saturation greater than or equal to 90%. Current oxygen flow rate 2 liters per minute (LPM) every shift. R49's care plan dated 6/24/2024, indicated an alteration in respiratory status related to (pneumonia, respiratory Infection, chronic respiratory failure with hypoxia bronchitis, sleep apnea, and respiratory failure) as evidenced by (shortness of breath, abnormal lung sounds, oxygen use, Low oxygen saturation levels, and signs and symptoms respiratory distress. It further included the following interventions:-Resident will achieve oxygenation saturation percentage within normal limits and to keep oxygen saturation greater than or equal to 90%.-Administer nebulizers/inhalers as ordered-Auscultate lung sounds/breath sounds PRN-Avoid lying flat which causes Shortness of Breath-Cue/remind resident to rest when experiencing respiratory distress-Encourage compliance with 02. Ensure that portal oxygen is filled up Q shift.-Measure & document O2 saturation rates as needed-Observe for increased s/s of respiratory distress, change in LOC-Observe for side effects and the effectiveness of medications-Oxygen as ordered, fill the portable oxygen tank every shift-Update doctor or nurse practitioner on status as needed. During observation and interview on 4/13/26 at 4:52 p.m. R49 was in bed with continuous oxygen via nasal cannula. She stated her oxygen rate was supposed to be set at 2 LPM. Surveyor looked at her oxygen rate, and it was set to 3 LPM. During observation and interview on 4/15/26 at 8:25 a.m., nursing assistant (NA)-G and NA-A was assisting R49 to get up and ready for the day. R49 was in bed with continuous oxygen via nasal cannula. The oxygen rate was set at 3 LPM. NA-G verified it was set 3 LPM. During observation on 4/16/26 at 7:10 a.m., R49 was in bed sleeping with oxygen via nasal cannula set at 3 lpm. During observation and interview on 4/16/26 at 7:22 a.m., registered nurse (RN)-F verified R49's oxygen rate was set at 3 LPM and it should have been set at 2 LPM per doctor's orders. During interview on 4/16/26 at 9:43 a.m. registered nurse (RN)-C stated nurses were responsible for ensuring the residents oxygen rates were set according to the doctor's orders. If a resident requested their oxygen rate to be adjusted, the nurses were responsible for calling the physician and getting an order before adjusting the rate. During interview on 4/16/26 at 1:23 p.m. the director of nursing (DON) stated nurses were responsible for making sure the residents oxygen rate matches the physician's orders each shift and if the resident requests a change in the oxygen rate, they should be calling the physician and getting a new order. R9 R9's quarterly MDS dated [DATE], identified C9 had intact cognition and required partial to substantial assistance with most activities of daily living (ADLs). R9's diagnoses included chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypoxia. R9's nursing care sheet dated 4/10/26, indicated C9 required oxygen therapy at 2 liters per minute (lpm) using a nasal cannula. R9's provider orders indicated the following: -Oxygen Therapy.Oxygen liter flow: 2 liters. Start date 6/23/24 -Change nebulization tubing, humidifier, and oxygen tubing every Sunday and as needed. Start date 12/31/23. During observation on 4/13/26 at 12:16 p.m., R9 was in her room in a wheelchair, using a portable oxygen tank. R9's oxygen tubing did not have a label indicating when it was last changed. The liquid oxygen tank in the room had a humidifier which was labeled 1/26/26 AK. R9 stated the staff were not good at changing the tubing or humidifier and often said they could not find any to replace them with. During observation on 4/14/26 at 9:15 a.m., R9's oxygen tubing was unlabeled, and the humidifier was labeled 1/26/26. During observation and interview on 4/14/26 at 9:22 a.m., RN-A stated it was the nurses' responsibility to change oxygen tubing and humidifier weekly, and they should be labeled to identify when it was last changed. In R9's room, RN-A verified R9's oxygen tubing was unlabeled, and the humidifier was labeled 1/26/26. RN-A stated that date indicted the last time the humidifier was changed and not changing the humidifier and tubing timely could lead to respiratory infection. During interview on 4/15/26 at 12:54 p.m., RN-C stated oxygen tubing, and the humidifier should be changed weekly. RN-C stated a date of 1/26/26 on R9's humidifier indicated it had not been changed since then, and that not changing it could increase likelihood of R9 acquiring a respiratory infection. During interview on 4/16/26 at 1:43 p.m., director of nursing (DON) stated expectation for oxygen therapy to be maintained per provider orders and tubing/humidifier should be changed weekly. Facility policy Oxygen Therapy dated 5/28/24, indicated, Oxygen therapy is provided to residents in a safe manner as identified by a prescribed provider. Furthermore, the policy directed the staff should obtain physician orders for specifics regarding administration.

Based on interview and document review, the facility failed to ensure medication orders were transcribed correctly (according to the physician orders) for 1 of 1 resident (R9) who was prescribed an antibiotic.Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE] indicated intact cognition and diagnosis of Prurigo nodularis (chronic skin condition characterized by intensely itchy, firm, raised nodules that often result from persistent scratching. R9's after visit summary dated 3/31/26, indicated a new order for Doxycycline 100 milligram (mg) capsule (antibiotic). Take 1 capsule (100 mg) by mouth two times daily for 10 days with meals. R9's physician's orders indicated to monitor adverse reaction to antibiotic every shift from 3/31/26-5/10/26.R9's care plan dated 4/15/26, indicated R45 was taking an antibiotic known as Doxycycline for Prurigo nodularis with an intervention to receive the antibiotic as ordered by the physician. R9's progress note dated 3/31/26, indicated R9 returned from a scheduled appointment with an order to start doxycycline 100 mg capsule twice a day for 10 days with meals. R9's medication administration record (MAR) from 4/1/26-4/15/26, indicated R9 had received doxycycline 100 mg, two times per day and on 4/16/26 had received doxycycline 100 mg, one time. According to the physician's orders, this medication should have been discontinued after 10 days (4/10/26). During interview on 4/13/2026 at 12:32 p.m., R9 stated she came back from a doctor's appointment on 3/31/26 with a new prescription for an antibiotic (Doxycycline) and she thought she was only supposed to take it for 10 days but was still receiving it. During interview on 4/16/26 at 9:33 a.m., registered nurse (RN)-C stated when a resident was going to an appointment, they would send a referral form with the resident and when they returned and had a new order, the doctor would write the order on the referral form and it would also be on the after visit summary. Then those new orders are entered into the computer by either a health unit coordinator (HUC) or a nurse. Then another nurse was required to verify those orders and if there were any inconsistencies, they should call the provider for clarification. The nurses were also expected to be documenting any medication changes in the progress notes, so everyone knows there was a change and the reason why it had changed. This process was important to ensure orders were entered correctly. RN-C verified R9 was only supposed to be taking Doxycycline for 10 days and was still receiving it even though it should have been discontinued. It had been entered to be discontinued on 5/10/26 instead of 4/10/26. During interview on 4/16/23 at approximately 10:00 a.m., the health unit coordinator (HUC) stated the process for entering new orders when a long-term care resident was admitted or came back from an appointment was for a nurse to enter in the orders and then another nurse was required to verify those orders. If the resident was not a long-term care resident, the process was for the HUC to enter in the orders and then a nurse was required to verify them. If there were any discrepancies, the nurse was required to call the provider for clarification. During interview on 4/16/26 at 1:23 a.m., the director of nursing (DON) stated the process for entering new orders when residents come back from appointments was for a nurse or HUC to enter the orders and then another nurse was required to verify those orders. If there was a discrepancy, the nurse would call the physician to clarify the order. The DON further stated, R35 came back from a doctor appt on 3/31/26, with new a new order for Doxycycline for 10 days and the staff made an error when entering the order and it was entered as being discontinued on 5/10/26 instead of 4/10/26. That was why they have two staff verifying the orders, in order to prevent mistakes like this. The managers should be double checking; these things have to be done. A facility policy regarding medication administration was requested and received but did not address transcribing orders.

Based on interview and document review the facility failed to ensure medication was discontinued according to physician's orders for 1 of 1 resident (R9) receiving an antibiotic. Furthermore, the facility failed to ensure side effect monitoring was in place for 1 of 1 resident (R35) receiving an anticoagulant (blood thinner). Findings include: R9R9's quarterly Minimum Data Set (MDS) dated [DATE] indicated intact cognition and diagnosis of Prurigo nodularis (chronic skin condition characterized by intensely itchy, firm, raised nodules that often result from persistent scratching. R9's after visit summary dated 3/31/26, indicated a new order for Doxycycline 100 milligram (mg) capsule. Take 1 capsule (100 mg) by mouth two times daily for 10 days with meals. R9's physician's orders indicated to monitor adverse reaction to antibiotic every shift from 3/31/26-5/10/26. R9's care plan dated 4/15/26, indicated R45 was taking an antibiotic known as Doxycycline for Prurigo nodularis with an intervention to receive the antibiotic as ordered by the physician. R9's progress note dated 3/31/26, indicated R9 returned from scheduled appointment with an order to start doxycycline 100 mg capsule twice a day for 10 days with meals. R9's medication administration record (MAR) from 4/1/26-4/15/26 indicated R9 had received doxycycline 100 mg, two times per day and on 4/16/26 had received doxycycline 100 mg, one time. According to the physician's orders, this medication should have been discontinued after 10 days (4/10/26). During interview on 4/13/2026 at 12:32 p.m., R9 stated she came back from a doctor's appointment on 3/31/26 with a new prescription for an antibiotic (Doxycycline) and she thought she was only supposed to take it for 10 days but was still receiving it. During interview on 4/16/26 at 9:33 a.m., registered nurse (RN)-C stated when a resident was going to an appointment, they would send a referral form with the resident and when they returned and had a new order, the doctor would write the order on the referral form and it would also be on the after visit summary. Then those new orders are entered into the computer by either a health unit coordinator (HUC) or a nurse. Then another nurse was required to verify those orders and if there were any inconsistencies, they should call the provider for clarification. The nurses were also expected to be documenting any medication changes in the progress notes, so everyone knows there was a change and the reason why it had changed. This process was important to ensure they are catching any mistakes. RN-C verified R9 was only supposed to be taking Doxycycline for 10 days and was still receiving it even though it should have been discontinued. It had been accidentally entered to be discontinued on 5/10/26 instead of 4/10/26. R35 R35's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of congestive heart failure (when the heart is not pumping as well as it should) and atrial fibrillation (an irregular and often very rapid heart rhythm). It further indicated she received an anticoagulant on a routine basis. R35's physician's orders dated 4/9/26-4/22/26, indicated the following:-Warfarin tablet 2 milligrams (mg) oral. Once a day on Monday, Tuesday, Wednesday, and Friday.-Warfarin tablet 3 mg oral. Once a day on Sunday, Thursday, and Saturday. R35's medication administration record (MAR) and treatment administration record (TAR) from 4/1/26-4/15/26, lacked documentation of anticoagulation monitoring. R35's care plan dated 3/12/24, lacked indication of anticoagulation monitoring. During interview on 4/16/26 at 7:22 a.m., registered nurse (RN)-F verified R35 was receiving an anticoagulant medication (Warfarin) but was unable to find an order or documentation she was receiving anticoagulant monitoring (side effects such as bleeding, bruising, etc.) and should have been. During interview on 4/16/26 at 9:33 a.m., registered nurse (RN)-C stated residents receiving an anticoagulant should also have anticoagulation monitoring in place. This monitoring would be documented in the MAR or the care plan. RN-C further stated anticoagulation monitoring was important in order to ensure the resident did not have internal bleeding and to determine if the medication was working. During interview on 4/16/26 at 1:23 a.m., the director of nursing stated the process for entering new orders when residents come back from appointments was for a nurse or HUC to enter the orders and then another nurse was required to verify those orders. If there was a discrepancy, the nurses should be calling the physician to clarify the order. The DON further stated, R35 came back from a doctor appt on 3/31/26, with new a new order for Doxycycline for 10 days and the staff made an error when entering the order and it was entered as being discontinued on 5/10/26 instead of 4/10/26. That was why they have two staff verifying the orders, in order to prevent mistakes like this. Additionally, the DON stated residents taking an anticoagulant should have anticoagulant monitoring in place. R35 had gone to the hospital, and the overnight nurse accidentally discontinued the order for anticoagulation monitoring. The managers should be double checking; these things have to be done. A facility policy regarding medication administration dated 8/31/23, indicated medications will be administered in accordance with the doctor's orders. The policy did not address anticoagulation monitoring.

Based on record review and interviews the facility failed to update the care plan for 1 of 1 resident (R1) reviewed for communication.Findings include:R1' s undated face sheet, indicated R1 was Vietnamese, admitted on [DATE], was moderately cognitively impaired, and had the following diagnoses: intercranial hemorrhage, hemiplegia and hemiparesis (loss of use of one side of the body), chronic kidney disease, hypertension, aphagia and pain. R1's social services assessment dated [DATE], indicated R1's preferred language was Vietnamese.R1's Care plan reviewed on 2/3/25, lacked identification of or interventions related to language or communication needs.On 2/3/26 at 3:25p.m., upon entering the room R1 immediately requested to have an interpreter because they could not understand writer. Via translation, R1 stated they felt like the facility did not care for them. R1 did not understand what was happening with their care, or to them. They stated they did not know how to communicate with the facility staff which was very frustrating.On 2/3/26 at 3:20 p.m., the nursing assistant (NA)-A stated they would usually communicate with R1 via broken English and hand gestures. NA-A stated there was nothing on the care plan about ways or options to communicate with R1 and it would be useful information to include in the care plan.On 2/4/26 at 11:53p.m., the director of nursing (DON) stated they felt R1 was able to communicate their needs. However, it was their right to understand fully and know what was happening to and around them. The DON stated it was important to include R1's communication needs in their care plan to be able to understand and meet their needs better.On 2/4/26 at 12:16p.m., the administrator confirmed their expectation to have communication/language preferences included in each resident's care plan.The facility policy Comprehensive Assessments and Care Plan last reviewed 10/2/23, indicated the facility must conduct an assessment to include communication needs in addition other needs, and use the assessment to develop, review, and revise the resident's person-centered comprehensive care plan.

Based on observation, interview, and document review the facility failed to ensure proper hand hygiene practices for 2 of 2 residents (R62, R59) observed during personal cares. In addition, the facility failed to ensure appropriate room assignment for 6 of 10 residents (R26,R23,R136,R74,R12,R11) reviewed for transmission based precautions (TBP). Also, the facility failed to ensure consistent and appropriate personal protective equipment (PPE) use for 5 of 10 residents (R11,R12,R73,R76, R59) reviewed for TBP and staff handling soiled laundry. Findings include: Room Assignment From CDC website: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) and is placed in a private room. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be roomed together. Residents on Contact Precautions are recommended to be restricted to their rooms except for medically necessary care, including restriction from participation in group activities. Contact Precautions are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation. Facility provided infection precautions for Transmission Based Precaution (TBP) list printed 5/14/25, indicated R12, R26, and R136 were on contact precautions due to Methicillin-resistant Staphylococcus aureus (MRSA). The list did not indicate R11, R23, and R74 were on contact precautions. Facility provided infection precautions for Enhanced Barrier Precautions (EBP) list printed 5/14/25, indicated R23 was on EBP due to a urinary catheter. Resident census dated 5/12/25, indicated R26 and R23, R136 and R74, and R11 and R12 shared double occupancy rooms. During interview on 5/14/25 at 12:50 p.m., infection preventionist (IP) and director of nursing (DON) stated ideally residents not requiring TBP should not be sharing a room with residents who do require TBP. In the example where a resident on contact precautions for MRSA shared a room with a resident not on contact precautions, the whole room should be treated with contact precautions and staff would need to gown and glove prior to entrance into the room. During interview on 5/15/25 at 11:03 a.m., IP stated R23 was on EBP due to a urinary catheter and was considered high risk for contracting a facility acquired organism, R23 should not be sharing a room with R26 who was on contact precautions due to MRSA. Facility policy Contact Precautions dated 9/2023, indicated resident placement would be made on a case by case basis, and consideration would be given to risk of transmission to a roommate. Considerations included, Cohort residents who are infected or colonized with the same pathogen. Additional considerations included, Avoid placing residents on Contact Precautions in the same room with residents who have conditions that place them at risk of adverse outcomes, should they become infected - or that may facilitate transmission. This includes, but is not limited to: .Those with any form of tube - foley catheter, G/J tube for feeding. TBP R11 and R12 R11's admission Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact, was dependent on staff for many activities of daily living (ADLs), and had a fracture of the right shoulder. R11's care plan dated 4/17/25, lacked evidence of need for any transmission based precautions (TBP). R11's provider orders lacked evidence of need for any TBP. R12's quarterly MDS dated [DATE], indicated R12 was cognitively intact, required substantial/maximal assistance with most ADLs, occasionally incontinent of bowel and bladder, and had a recent hip replacement. R12's diagnoses included MRSA infection, infection and inflammatory reaction due to internal right hip prosthesis, and bacteremia. R12's care plan dated 5/14/25, indicated R12 was on isolation contact precautions due to MRSA of the urine. R12's care plan indicated R12 would be isolated to the room to prevent spread of the infection. The care plan further instructed staff to wash hands, wear gown, mask, gloves and goggle as needed to prevent spread of infection. R12's provider order dated 1/10/25, indicated, Contact Isolation ESBL [extended-spectrum beta-lactamase-an enzyme produced by a bacteria that causes resistance to several antibiotics], MRSA [methicillin-resistant staphylococcus aureus-a staph bacteria resistant to many antibiotics]. Facility resident census indicated R11 and R12 shared a double occupancy room. During observation on 5/13/25 at 8:53 a.m., signage indicating Contact Precautions was posted outside R11/R12's room. An unidentified housekeeper was cleaning the room and was not wearing a gown. Director of spiritual care also in the room speaking to R11 and was not wearing any PPE. During observation on 5/13/25 at 8:54 a.m., nurse practitioner (NP) entered R11/R12's room and did not don any PPE. During observation on 5/13/25 at 9:21 a.m., activities personnel (A)-A entered R11/R12's room without donning PPE. A-A asked both invited both residents to attend morning exercise group upstairs. Both declined. During observation on 5/13/25 at 9:53 a.m., A-A entered R12's room and did not perform hand hygiene and did not don any PPE. A-A invited R12 to a different activity and R12 accepted. A-A pushed R12 out of the room to the elevator. During interview on 5/14/25 at 7:45 a.m., nursing assistant (NA)-D stated R12 was on contact precautions and R11 was not on precautions, therefore if she needs to just drop something off to R11, PPE was not necessary, but would use PPE if providing any cares for either R11 or R12. NA-D was not sure if someone on contact precautions should be leaving the room and joining activities. During observation on 5/15/25 at 8:07 a.m., licensed practical nurse (LPN)-A entered R11's room to administer medications. LPN-A did not don any PPE. R73 and R76 During observation on 5/14/25 at 11:36 a.m., nurse practitioner (NP) entered R73 and R76's room without donning a gown or gloves. The room had signage indicating Contact Precautions. NP stopped to talk R76 into seeing podiatry today. NP touched R76's bedside table to move it out of the way, pulled off R76's socks and touched and assessed his feet and toenails. NP was not wearing gloves or gown. NP went over to R73's side of the room and moved R73's bedside table out of the way touching it without gloves. During observation at 5/14/25 at 11:37 a.m., NA-B donned gown and gloves to enter and deliver R76's meal to his bedside table. During observation on 5/14/25 at 11:41 a.m., R76 wheeled self out of room to go to visit podiatry. During observation on 5/14/25 at 11:43 a.m., NA-C entered room to deliver R73's meal and did not don gown or gloves prior to entrance. During interview on 5/14/25 at 11:49 a.m., NP stated R73 had diagnoses history of right lower extremity wound and MRSA. NP stated R76 had a history of MRSA with location not classified. NP stated neither R73 nor R76 had active infections and did not think they were on contact precautions; therefore he did not gown and glove prior to entrance. NP did not agree the two residents required contact precautions, but stated if signage directed staff to use contact precautions the sign should be followed, and precautions should be utilized. NP stated thinking the signage was in place due to facility policy and that they just follow policy when the state comes in. NP stated, we are just spreading it. Laundry During observation on 5/15/25 at 10:15 a.m., laundry aide (LA)-A was sorting dirty clothes and linen in the soiled laundry room. LA-A had gloves on but did not have a gown on. Director of environmental services (DES) stated the expectation was for staff to be wearing gown and gloves whenever handling and sorting soiled linen. During interview 5/15/25 at 10:16 a.m., LA-A stated she usually wore a gown and gloves when sorting soiled linen and could not explain why she was not wearing a gown now. During interview on 5/15/25 at 10:57 a.m., infection preventionist (IP) stated expectation for staff to wear correct PPE to include gown and glove anytime they were handling soiled linen. Laundry workers should wear a gown and gloves when sorting soiled laundry. During interview on 5/15/25 at 11:29 a.m., Administrator stated expectation that staff follow the policy and wear gown and glove when handling and sorting soiled clothing and linen. Facility policy Linen and Laundry, undated, indicated, Soiled health care textiles must be assumed to be contaminated; personnel who handle soiled textiles must follow Standard Precautions including gloves and a gown. R62 R62's discharge MDS dated [DATE], indicated intact cognition and diagnoses of quadriplegia, traumatic rupture of cervical intervertebral disc (C5-6), spinal stenosis, and neurogenic bladder. It further indicated R62 required substantial assistance with toileting and was always incontinent of urine. During observation on 5/14/25 at 8:42 a.m., NA-F entered R62's room to answer his call light and asked him if someone had changed his brief yet. R62 responded no. NA-F washed her hands and put on gloves, handed R62 a wet washcloth to wash his face, and then removed his bilateral heel protectors. NA-F removed R62's gown and brief (which was visibly full of urine) and assisted him to turn on his right side, and wiped his bottom with wipes. Then NA-F removed the pad from underneath him (which was also visibly wet), put it in a plastic bag, assisted him to turn onto his back, and wiped his peri area. NA-F then fastened his brief, pulled up his pants, touched the back of his shoulder, put on his shoes, grabbed a pack of wipes and put them on his dresser, and touched the door handle. NA-F then removed her gown and gloves but did not perform hand hygiene. NA-F then grabbed the EZ stand lift from the hallway, got new gloves from R62's bathroom, touched the bed remote, applied the sling, and NA-E assisted her to transfer R62 to his wheelchair. Once he was in his chair NA-F made the bed and then removed her gown and gloves, brought the EZ stand lift out into the hallway, brought a bag of dirty laundry to the soiled utility room, and did not perform hand hygiene. NA-F then applied new gloves and went into another resident's room and shut the door. During interview on 5/14/25 at 9:15 a.m. NA-F stated when entering a resident's room to perform cares, she washes her hands and puts on gloves and then when the cares have been completed, she will remove her gloves and wash her hands. NA-F verified she had not removed her gloves or performed hand hygiene after removing R62's wet brief and did not perform hand hygiene in between glove changes and should have. During interview on 5/14/25 at 9:30 a.m., registered nurse (RN)-D stated when going from a dirty area to clean area while performing personal cares for a resident, staff should change gloves and then perform hand hygiene. This was important in order to prevent spreading germs. During interview on 5/14/25 at 2:00 p.m., (NA)-G stated when you are performing cares and you go from a dirty area (changing a wet/soiled brief) to a clean area (assisting a resident to get dressed), staff should change gloves, wash their hands/use hand sanitizer, and apply new gloves. During interview on 5/15/24 at 10:56 a.m., the DON stated when staff are performing personal cares and going from a dirty area to a clean area, they should change gloves and perform hand hygiene. Staff should also be performing hand hygiene in between glove changes. This was important because there was the potential of spreading germs to other residents or the staff. R59 (hand hygine/TBP) R59's admission Minimum Data Set (MDS) dated [DATE], indicated R59 was cognitively intact and had diagnoses of bilateral humerus (upper arm) fractures. Furthermore, R59 had occasional incontinence and required staff assistance with toileting. R59 did not require isolation due to active infectious disease. R59's provider order dated 4/22/25, indicated R59 required contact precautions due to Methicillin-resistant Staphylococcus aureus (a resistant bacteria MRSA) of the nare. R59's care plan dated 4/22/25, indicated R59 was on contact precautions due to MRSA of the nares and R59 would be isolated to their room to prevent the spread of infection. Interventions directed staff to wash hands, wear gown, mask, gloves and goggles as needed to prevent spread of infection. Staff were also required to perform hand hygiene upon entrance and exit of R59's room. An observation on 5/12/25 at 1:42 p.m., R59's room had a sign that read contact isolation on their door. The sign further instructed staff to gown and glove when entering the room. An observation on 5/12/25 at 5:18 p.m., NA-I was picking up dinner trays. NA-I had gloved hands on and pushed a cart near R59's room. Without gowning, hand hygiene or glove exchange, NA-I entered R59's room came out with the dinner tray and placed it on the cart. With the same gloves, NA-I entered room [ROOM NUMBER] and exited with the dinner tray and placed it on the cart. With the same gloves, NA-I entered room [ROOM NUMBER]-I and exited with the dinner tray and placed it on the cart. With same gloves, NA-I pushed the cart down to the kitchen area. When interviewed on 5/12/25 at 5:18 p.m., NA-I verified they had not donned a gown as instructed when entering R59's room and had worn the same gloves in all three resident rooms. NA-I stated hand hygiene should have been done and new gloves placed for each room. NA-I stated other staff were waiting for the dirty dishes and they were in a hurry. An observation on 5/13/25 at 9:37 a.m., after donning gown and gloves, NA-J entered R59's room to assist with morning cares. After helping R59 choose clothing, NA-J assisted R123 with putting on gripper socks, placed a transfer belt on and assisted walking R59 to the bathroom. R123 walked by the toilet and NA-J then assisted R59 with pulling down the brief. NA-J removed the soiled brief and placed in the garbage. R59 sat on the toilet. NA-J then removed gloves and without hand hygiene, placed donned new gloves. NA-J then assisted with washing face, arms, back and legs. R59's gown was removed and NA-J assisted R59 with putting on a shirt. NA-J then assisted putting a clean brief and pants around R59's ankles before assisting R59 to stand. Once standing, NA-J used wipes to provide peri cares for front and back. NA-J removed gloves and without hand hygiene donned new gloves. R59's clean brief and pants were pulled up and R59 was assisted out of the bathroom to their wheelchair. NA-J assisted R59 to be positioned in the wheelchair in the room and provided R59 the call light. NA-Jthen removed gown and gloves before exiting room and performed hand hygiene upon exit. When interviewed on 5/13/25 at 10:12 a.m., NA-J verified they had not performed hand hygiene after glove removals and was supposed to. NA-J stated R59 was on contact precautions but was not sure why. NA-J stated they follow the signs on the doors. When interviewed on 5/13/25 at 10:16 a.m., registered nurse (RN)-I stated R59 was on contact precautions for MRSA. RN-I further stated the MRSA was not active and many times contact precautions were placed as more of a precautionary basis. R73 R73's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and diagnoses of high blood pressure and diabetes. The MDS also reported she received application of ointment(s) to areas other than her feet during the lookback period. R73's physician order report dated 4/1/25 - 4/30/25 included the following orders: - Unna Boots - every Friday. Remove, cleanse with warm water, re-wrap Unna and Coban cover once daily every Friday, dated 9/27/24 (Unna Boots are a type of compression bandage and Coban is a brand of self-adherent wrap). The physician order report further indicated R73's diagnoses included non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity, and methicillin-resistant Staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere-RLE (right lower extremity). R73's care plan dated 12/7/24, identified she was on contact precautions related to MRSA and directed all staff to wash hands; wear gown, mask, gloves and googles as needed to prevent spread of infection. An undated nursing assistant (NA) care sheet identified R73 was on contact precautions for MRSA. R76 R76's quarterly MDS date 4/1/25, indicated he had intact cognition with diagnoses of high blood pressure and high cholesterol. The MDS also reported he received application of ointment(s) and dressings to areas other than his feet. R76's Care Area Assessment (CAA) dated 10/5/24 for Activities of Daily Living (ADLs) triggered related to needing assist with cares and mobility due to his cellulitis-MRSA/pseudomonas in his lower extremities. The CAA indicated he required assist of 1 with cares and mobility and directed staff to the plan of care to support his care mobility needs. R76's CAA dated 10/5/24 for Pressure Ulcer/Injury indicated he had recurring open aeras on both legs and the CAA triggered related to cellulitis - MRSA/pseudomonas. R76's physician order reported dated 4/1/25 - 4/30/25 included the following orders: - Bilateral leg dressing; Change twice weekly; cleanse, apply 2 grams ammonium lactate lotion to each leg, apply Vaseline gauze to open areas wrap Unna boots. Do not leave leg unwrapped for > [sic, greater than] 30 min. [sic, minutes]. Once Click or tap here to enter text. day and once a day as needed, dated 4/17/25. The order report also identified diagnoses including cellulitis of right lower limb (a bacterial skin infection), non-pressure chronic ulcer of unspecified lower leg with unspecified severity - bilateral (meaning both sides), MRSA infection, and pseudomonas (aeruginosa) (mallei) (psedomallei). R76's care plan last reviewed/revised 4/8/25, identified under diagnosis his MRSA and pseudomonas (aeruginosa) (mallei) (pseduomalleli), however, lacked documentation of measurable objectives and timeframes to meet his medical and nursing needs related to his MRSA and pseudmonas infection and lacked documentation of interventions related to transmission-based precautions (TBP). An undated NA care sheet identified R76 was on contact precautions. Per observation on 5/12/25 at 5:39 p.m., R73 and R76 were on contact precautions evidenced by the signage posted outside their shared room next to the door frame at approximate standing eye-level. The sign read, Contact Precautions: Everyone Must: clean hands when entering and leaving room. Doctors and Staff Must: gown and gloves at door. During observation on 5/13/25 at 8:52 a.m., nursing assistant (NA)-N pushed a four-wheeled meal cart down the unit hallway. NA-N stopped the cart outside of R73 and R76's room and walked past the contact precautions signage into the room without performing hand hygiene or donning personal protective equipment (PPE) of gown and gloves. NA-N walked back out of the room, did not perform hand hygiene, returned to the cart and poured liquid from a carafe into a cup and re-entered the room without performing hand hygiene and without donning PPE. NA-N exited the room again and returned to the cart, without performing hand hygiene, picked up utensils from the cart, and walked past contact precautions signage and into the room without performing hand hygiene or donning PPE. NA-N walked out of the room and back to the cart, did not perform hand hygiene, and picked up the carafe and poured liquid into a cup and picked up condiments from the cart and walked past the contact precautions signage and into the room without performing hand hygiene or donning PPE. NA-N exited the room, did not perform hand hygiene, and used bare hands to push the meal cart down the hallway to the next room. NA-N did not perform hand hygiene before entering the next room and told the unidentified resident, I have your breakfast. NA-N exited the room, did not perform hand hygiene, and used bare hands to pick up a white plate with food on it and walked it into the unidentified resident's room. NA-N exited the room, did not perform hand hygiene and stated, lord tell me I didn't forget a fork, and used bare hands to grab the handle of a fork. NA-N re-entered the unidentified resident's room without performing hand hygiene. NA-N exited the room without performing hand hygiene, walked across the hallway to a covered linen cart, used bare hands to pick up towels. At 8:55 a.m., NA-N re-enters the resident's room and sets up the bedside table with the meal before exiting the room without performing hand hygiene. Per follow-up interview at 8:55 a.m. with NA-N, staff should wear PPE for contact precautions when doing the cares. NA-N and the surveyor walked to R73 and R76's shared room to review the contact precautions signage. When asked when to wear gown and gloves in their shared room, NA-N stated, I can ask my manager, and then asked the surveyor if they could return to delivering the breakfast so it doesn't get cold. Surveyor asked NA-N to review the contact precautions signage and asked when staff should wear PPE and NA-N stated, when doing cares, before walking away. During observation and interview on 5/13/25 at 8:58 a.m., NA-M was at R73 and R76's shared door and performed hand hygiene before donning a gown and gloves. NA-M entered the shared room and delivered two mugs with lids. NA-M remarked how warm the room temperature was and offered to submit a work order for them. With the room door open, NA-M was observed doffing the gown and gloves at the doorway, then performing hand hygiene before exiting the room. At 9:01 a.m., NA-M stated staff should wear PPE whenever going in or out of the room just in case you come in contact with them or something. When asked if NA-N should have donned gown and gloves as the signage indicated outside R73 and R76's shared room, NA-M confirmed, the general rule is you should do what you read but said everybody kinda just does their own thing. Per interview on 5/13/25 at 9:03 a.m., licensed practical nurse (LPN)-B confirmed both R73 and R76 were on contact precautions and verified staff were expected to follow TBP signage instructions if they were posted on the resident's door. Per interview on 5/14/25 at 9:27 a.m., registered nurse (RN)-E would expect staff to follow [transmission-based] precaution signs posted on the resident's doorway. When asked if staff would be expected to don full PPE of gown and gloves for a resident room identified as having contact precautions to deliver meal trays, RN-E stated if staff were not expecting to come into contact with a resident for cares, they would not need to don full PPE. During the interview, RN-E and surveyor reviewed the Center for Disease Control (CDC)'s recommendations for Transmission-Based Precautions dated 4/3/24, which indicated, Wear gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Additionally, RN-E and the surveyor reviewed the CDC's Contact Precautions signage, which indicated, providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. RN-E acknowledged there was confusion among staff with TBP and requested to speak with the facility's infection preventionist (IP) to clarify. RN-E stated the expectation was staff follow the CDC's recommendations for precautions. Per interview on 5/15/25 at 12:38 p.m. with the director of nursing (DON), staff were expected to follow the signage on a resident's door as it related to TBP. The DON stated if staff were unsure what PPE to wear or had questions about in what situations they needed to wear PPE, they knew they could ask either the DON or the IP. Per facility policy titled Contact Precautions last revised 9/23, contact precautions were used to prevent nosocomial spread of organisms that could be transmitted by direct resident contact or indirect contact of environmental surfaces or contaminated resident care equipment. The policy directed staff to perform the following steps for appropriate contact precaution procedure: 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 part of contact precautions, however, just as with Standard Precautions, these items are own during resident care activities that are likely to create splashes or sprays of blood, bodily fluid, secretions, and excretions. 5. Hand hygiene is performed between glove changes and when removing gloves. Furthermore, the policy directed associates to practice hand hygiene and don gown and gloves before entering and remove gown and gloves prior to exiting room per CDC guidelines. Hand Hygiene must occur once PPE is removed.

Based on observation and interview the facility failed to maintain dignity for 1 of 1 resident (R62) reviewed for dignity. R62's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of quadriplegia, traumatic rupture of cervical intervertebral disc (C5-6), spinal stenosis, and neurogenic bladder. It further indicated R62 required substantial assistance with toileting, was always incontinent of urine, and received a diuretic on routine basis. R62's care plan dated 4/25/25, indicated the potential for alteration of bowel and bladder related to a diagnosis of a neurogenic bladder and included an intervention of R62 requiring 2 person assistance to use the toilet upon rising in the morning, before and after each meal, bedtime, on night rounds, and as needed. R62 also required assistance with all toileting tasks and used brief/pads for incontinence protection indicating he was not able to reliably notify staff of his need to be toileted. During interview on 5/12/25 at 5:25 p.m. R62 stated he had to wait 20-45 minutes (on average)almost every time he needed to use the urinal. Since his spinal cord injury, he doesn't have much notice when having to urinate and often ends up urinating in his brief. When that happens he then had to wait long periods of time sitting in his urine or feces. R62 also stated he had reported this to RN-E and the DON but nothing ever happened to fix the problem stating It's a culture here to not help each other out. I put my call light on and wait for staff to respond. When they don't respond, I go out into the hallway (in my wheelchair) to get help and I am often told by staff they're not my aide and then continue to play on their phone. During observation on 5/14/25 at 7:04 a.m., the following events occurred: -7:15 a.m. R62 put his call light on. -7:28 a.m. NA-E answered call light for another resident who's room was in close proximity to R62's room (exited the room at 7:34 a.m.) but failed to answer R62's call light when she was finished assisting the other resident. -7:35 a.m. NA-F was walking down the hall towards R62's room with the vital signs (VS) machine. NA-F entered the room and asked R62 what he needed because his call light was on. He stated he had to urinate but he already urinated in his brief because he couldn't hold it. NA-G stated that was okay, proceeded to take his blood pressure, then left the room stating I will come back later and get you up when she's (unknown) done. -7:45 a.m. NA-F assisted another resident with a shower. -8:01 a.m. registered nurse (RN)-D entered R62's room with medications, blood sugar monitor, and stethoscope. RN-D asked his name, date of birth , took his VS, tested his blood sugar, administered his medications, and gave him a nebulizer treatment. RN-D did not change R62's brief. -8:30 a.m. RN-D exited R62's room. -8:34 a.m. R62 stated RN-D did not change him while she was in his room and that he put his call light on at 7:15 a.m. when he first had to go to the bathroom. -8:40 a.m. R62 put on his call light again. -8:42 a.m. NA-F answered R62's call light and R62 stated he was still waiting for his brief to be changed. NA-F changed his brief (which was visibly full of urine) and removed the pad underneath him which was also visibly wet. During interview on 5/14/25 at 9:15 a.m. NA-F verified R62 told her he had urinated in his brief when she answered his call light at 7:35 a.m. NA-F stated was waiting for the nurse to go in and do what she needed to do but she should have changed him right away before the next call light went on. During interview on 5/14/25 at 9:30 a.m. RN-D stated anyone can answer call lights but it was usually the NA's who answer them. They try to answer call lights within 15 minutes and if a resident stated they need to be changed, staff should try to do that immediately or as soon as possible and changing a brief would take precedence over giving a resident a shower. RN-D further stated NA's are assigned to a group of residents but the other NA's are expected to answer the call lights and help each other out. If the nurse needs to administer medications or perform cares, etc. they can wait if a resident needed to be changed. RN-D verified she did not change R62 when she was in his room because she was unaware he needed to be changed. There was no reason he needed to wait to be changed until after she was done working with him. During interview on 5/14/25 at 2:00 p.m. NA-D stated NA's are assigned to a certain group of residents and we stick with our residents, unless someone is really busy, but everyone can help. NA-D further stated they try to answer call lights within 15 minutes and changing a residents brief should be done before giving a resident shower. An hour was too long for a resident to wait to have their brief changed and stated 10 minutes should be the longest they should have to wait unless they were really busy. During an follow up interview on 5/15/25 at 11:16 a.m., R62 stated if he hadn't fallen, he would still be able to do all all the things the staff do for him by himself and it took awhile for him to get used to staff having to help him and when he has to sit in his own urine or feces he feels useless and worthless. When it takes 45 minutes to an hour for staff to come, It makes him think staff don't want to help him and it's embarrassing and degrading. During interview on 5/15/24 at 10:56 a.m., the director of nursing (DON) stated he did not think an hour was too long for a resident to have to sit in a wet brief and there wouldn't be any negative outcomes as a result (specifically skin breakdown). The DON further stated changing a residents brief didn't necessarily take precedence over giving another resident a shower and would depend on the situation. He was unable to provide an approximate amount/range of time he would expect a residents call light to be answered or a residents brief to be changed (once they put their call light on.) A facility policy reagrding dignity was requested but not received.

Based on observation, interview, and document review the facility failed to ensure personal privacy during activities of daily living (ADLs) was provided for 1 of 2 residents (R9) reviewed for privacy. Findings include: R9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, used a wheelchair, and required substantial assist with toileting hygiene, and partial to moderate assist with dressing. R9's optional state assessment (OSA) dated 4/11/25, indicated R9 required assist with bed mobility, transfers, and toileting. R9's Facesheet undated, indicated the following diagnoses: rheumatoid arthritis, Myelodysplastic syndrome, weakness, history of falling, and Alzheimer's disease. R9's care plan dated 4/14/25, indicated R9 had an alteration in ADLs and required assist of one with dressing, and grooming. R9's care plan dated 4/14/25, indicated R9 had an alteration in mobility and required assist of one with transfers and ambulating. R9's care plan dated 4/14/25, indicated R9 had an alteration in toileting and interventions included to assist with toileting upon rising before and after meals, at bedtime, on night rounds and as needed. R9'S care sheet undated, indicated R9 required assist of one with toileting. During observation on 5/13/25 at 8:57 a.m., nursing assistant (NA)-H entered R9's room and asked if she was ready to get up. At 9:01 a.m., NA-H asked resident if she wanted to go into the bathroom and stated they bring R9 to the bathroom and complete cares in the bathroom. At 9:03 a.m., NA-H assisted R9 to the bathroom and R9 stood up in the bathroom using the sink and sat on the toilet. At 9:03 a.m., registered nurse (RN)-F entered R9's room. At 9:08 a.m., NA-H donned R9's hip protector and pants. R9's wheelchair was outside the bathroom door and R9's room mate was in bed sleeping across from the opened bathroom door. There was no privacy curtain located on the track on the ceiling to provide privacy between the bathroom and R9's roommate. At 9:17 a.m., R9 was assisted by NA-H to stand up and R9's pants were down, the bathroom door was opened, and R9's roommate was in bed. NA-H wiped R9's bottom with the door open and pulled up R9's incontinent brief, hip protector and pants as R9 held on to the sink. During interview on 5/13/25 at 9:24 a.m., NA-H verified there was no privacy curtain and stated there used to be a curtain because there were hooks on the track and further stated it would be important to have for privacy and stated the bathroom was crowded and R9 liked to sit on the toilet in the a.m. During interview on 5/13/25 at 10:02 a.m., RN-F verified there was no privacy curtain between the bathroom in R9's room and R9's roommate and stated she thought it was taken off to be washed and stated there could be a reason for why the curtain wasn't on the track and further stated it was important for privacy and added even though a resident had dementia, you still provide them with privacy. During interview on 5/13/25 at 3:42 p.m., the director of nursing (DON) viewed R9's room and stated one of the staff members informed the DON the curtains went down to the laundry and stated he expected staff provide privacy if a resident was in the bathroom with the door wide open with another resident in the room. A form, Combined Federal and State [NAME] of Rights, dated 6/18/19, indicated the resident has a right to personal privacy. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.

Based on interview and document review, the facility failed to follow physician orders to provide a resident nothing by mouth for 1 of 5 residents (R1) reviewed for diet orders. This resulted in an immediate jeopardy (IJ) for R1 when he was provided with a pastry, orange juice and coffee by staff, and later became hypoxic and was sent to the hospital. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 11/4/24 at 8:45 a.m. when nursing assistant (NA)-A provided R1 with a pastry, orange juice and coffee. The administrator and director of nursing (DON) were notified of the IJ on 11/8/24 at 2:48 p.m. The facility implemented corrective action on 11/5/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's Face Sheet dated 11/1/24 indicated R1's diagnoses included acute respiratory failure and pneumonitis (inflammation of the lung tissue). R1's care plan dated 11/2/24 indicated R1 was at risk for aspiration (when something swallowed enters the airway or lungs), and directed tube feedings for nutrition. The care plan also indicated R1 had dementia and cognitive loss. R1's Physician Order dated 11/1/24, directed nothing to eat or drink by mouth, no food, no water, no ice chips. On 11/4/24 at 8:45 a.m., a progress note indicated R1 was served 120 cubic centimeters (cc) of coffee, 60 cc of orange juice, and one Danish pastry. Staff removed the remainder of the food and assisted the R1 to his room. R1's provider and family were notified. On 11/4/24 at 10:27 a.m., a progress note indicated R1 had large amount of emesis on his bathroom floor. On 11/4/24 at 10:27 p.m., a late entry progress note indicated at 6:26 p.m. R1 was unresponsive, he had crackles in his lungs, an elevated heart rate of 112/minute, low oxygen saturation level of 84% on room air. Oxygen at 4 liters/nasal cannula was initiated and 911 was called at 6:10 p.m. R1 was admitted to the hospital for pneumonia. On 11/4/24 a hospital note indicated R1 was admitted for probable recurrent aspiration pneumonia and acute hypoxia respiratory failure. R1 remained hospitalized . On 11/7/24 at 12:10 p.m. NA-A stated she served R1 a pastry, coffee, and orange juice on 11/4/24. She did not realize R1 was NPO until a coworker informed her. She immediately informed registered nurse (RN)-A who instructed her to remove the food from R1. On 11/7/24 at 1:15 p.m., RN-A stated she was responsible for the care plans and NA assignment sheets upon resident admission. She became aware R1 was served food on 11/4/24 around 8:45 a.m. when NA-A told her. She assessed R1's his lung sounds, which were clear at that time, and updated the nurse practitioner (NP)-A. At approximately 10:30 a.m., R1 began coughing, and had an emesis on his bathroom floor. She assessed his lung sounds which had crackles (can indicate fluid in lungs) and updated R1's physician who ordered a chest x-ray. RN-A stated NA-A should have checked the care plan prior to providing R1 with food. On 11/8/24 at 9:56 am. NP-A stated on 11/4/24, he was informed R1 received food and drink by mouth. R1 should not have received food or fluids by mouth, and this could have led to aspiration pneumonia. On 11/8/24, the director of nursing (DON) stated all staff were given the assignment sheets and were expected to check the assignment sheet to determine a resident's diet plan. The facility policy Diet Orders dated 2012, directed each resident will receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician and/or assessed by the interdisciplinary team to support the treatment and plan of care. The past noncompliance immediate jeopardy began on 11/4/24. The immediate jeopardy was removed and the deficient practice was corrected by 11/5/24, after the facility implemented a systemic plan that included the following actions: Education to all staff regarding dietary orders, a review of dietary policy and procedure, audits on all residents to ensure those with NPO status did not receive anything by mouth, and those residents on special textured diets received the proper diet texture foods. Verification of the correction action was confirmed by observation, interview and document review on 11/7/24 and 11/8/24.

Based on interview and record review the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical condition for 1 of 5 residents reviewed, Resident #1, when the resident experienced a change in condition. Findings include: Resident #1's medical record was reviewed and his face sheet revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 vital signs flow sheet during his stay revealed that Resident #1's oxygen saturations (a measure of oxygen in the bloodstream) were consistently between 90 and 100 % on room air. Nursing notes dated 7/20/2011 revealed that Resident #1 was being treated for [REDACTED]. A review of Resident #1's record revealed that Resident #1 had not complained of any shortness of breath. Nursing notes revealed that on 7/22/2011 staff members and family noted increased [MEDICAL CONDITION] (swelling) to Resident #1's legs. The nursing notes from 7/22/2011 indicate that although a staff nurse attempted to call Resident #1's primary physician, the staff nurse was unable to reach Resident #1's physician and the supervisor was going to get in touch with his physician. There is no indication that Resident #1's physician was informed of this new symptom. On 7/23/2011 at 6:05 p.m. Resident #1 was noted to have continued [MEDICAL CONDITION] in both legs, with new complaints of pain to both legs when touched. On 7/24/2011 at 12:30 a.m. Resident #1 was noted to be short of breath, require the extensive assist of 2 to reposition in bed, was lethargic and not answering questions, could only mumble, was not understandable, his respirations were elevated at 28, and his oxygen saturations were 77% on room air. Although this was a significant change to Resident #1's condition and oxygen was started, Resident #1's physician was not updated. Later in the morning at approximately 10:30 a.m. Resident #1's physician was updated and ordered him to be sent to the emergency room for evaluation. A review of the hospital record from the 7/24/2011 hospital admission revealed that Resident #1 was admitted on [DATE] with shortness of breath and [MEDICAL CONDITION] to both legs and diagnosed with [REDACTED]. When Resident #1 was catheterized in the emergency room he had over 2 liters of urine removed immediately. He was admitted to ICU. During an interview with Employee (C)/RN Evening Supervisor on 10/4/2011 at 11:25 a.m. she stated that she worked on 7/22/2011 on the evening shift, but she did not contact Resident #1's physician about the new symptom of [MEDICAL CONDITION]. During an interview with Employee (D)/ RN on 9/28/2011 at 4:15 p.m., the nurse working on 7/24/2011 when Resident #1 developed shortness of breath and required the initiation of oxygen, she stated she did not call Resident #1's physician to inform him of this change in condition. The policy titled Change in Condition dated 12/2002 provided by the facility was reviewed. The policy stated: 1. Except in a medical emergency or when a resident is incompetent, the facility must consult with the resident immediately and notify the resident's physician, and if known, the resident's legal representative or interested family member. a. A significant change in the resident's physical, mental or psychosocial status. b. A need to alter treatment significantly. 2. A significant change means deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications.