Every finding on record at Benefis Senior Services - Grandview

Based on interview and record review, the facility failed to identify, assess, measure, document, monitor, and obtain physician orders promptly for the treatment and care of an avoidable pressure ulcer, including failing to develop and implement a baseline care plan for pressure ulcer prevention. The pressure ulcer developed within ten days of the resident's admission to the facility and worsened to a Stage IV, causing the resident pain. She did not want to be repositioned and voiced not wanting to live. The resident was placed in Hospice for end-of-life care and services for 1 (#27) of 5 residents sampled for pressure injuries. This deficient practice increased the risk of negative outcomes of the admission identification process of pressure injuries and residents at risk of developing pressure injuries.On [DATE] at 10:04 a.m., Immediate Jeopardy was announced to the Administrator, Chief Nursing Officer, and Director of Quality and Patient Safety for F686-Pressure Ulcers Care and Prevention. The Severity and Scope identified for the Immediate Jeopardy were identified to be at the level of J, and upon verification for the removal of the immediacy, be lowered to a G. An acceptable plan for the Removal of Immediacy was approved on [DATE] at 6:05 p.m.Findings include:During an interview on [DATE] at 8:03 a.m., NF3 stated resident #27 was admitted to the hospital due to a fall at home, which resulted in a hip fracture that required surgical repair. Resident #27 was then admitted from the hospital to the facility for rehab services on [DATE], before planning to return home. NF3 stated the resident did not have any pressure injuries while in the hospital, and her skin was intact when she was admitted to the facility on [DATE]. NF3 stated that the only skin concern resident #27 had when she was admitted to the facility was a surgical wound on her right hip, which was healing. NF3 stated she was made aware of the wound on resident #27's sacrum on [DATE]. She stated she was not aware of how long the resident had had the sacral wound since the facility had never informed her of the wound. NF3 stated she had a meeting with the facility in [DATE], and they had told her the wound was present upon the resident's admission to the facility. She stated she did not believe this to be true since the resident did not have a pressure injury while in the hospital, and the facility had never mentioned a sacral wound when the resident was admitted . NF3 stated the facility had not completed a skin assessment when resident #27 was admitted and had not implemented any wound prevention interventions for the resident until after the wound was identified. She stated that staff member G was the only staff member who had informed her of the pressure injury on resident #27's sacrum. She stated staff member G had told her they were going to order an air mattress and have the wound nurse assess the resident's wound. NF3 stated she was surprised and upset to find out these interventions were not in place sooner. NF3 stated that when the facility informed her of the sacral wound, she was told it was Unstageable (Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to determine true depth, the ulcer cannot be staged (severity classified) - as defined in the cited facility's policy). She stated that after resident #27's wound was debrided at the Wound Clinic, she was informed the sacral wound was a Stage IV (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Full thickness: Involves epidermis, dermis, and subcutaneous tissues, muscle, or bone - as defined in the cited facility's policy). She stated the resident was in a lot of pain from her sacral wound and no longer wanted to get out of bed or be repositioned. NF3 stated they decided to discharge the resident to an inpatient hospice on [DATE], and the resident died on [DATE]. NF3 stated she felt the facility's failure to identify and treat the sacral wound contributed to the resident's death.Review of resident #27's Hospital Discharge Care Plan, dated [DATE], showed a closed surgical wound, last assessed [DATE], as clean, dry, and intact. The Hospital Discharge Care Plan did not address a sacral pressure injury.Review of resident #27's Hospital Case Management Note, dated [DATE], showed the resident was transferred from the hospital to the facility on [DATE], for physical and occupational therapy following the surgical repair of her right hip fracture. The active problem list did not include a sacral pressure injury.Review of resident #27's Hospital Provider Discharge Note, dated [DATE], did not include a sacral pressure injury that was present upon the resident's discharge from the hospital to the facility.A. admission Assessment and Baseline Care PlanReview of resident #27's Facility Nursing admission Note, dated [DATE], showed skin was within normal limits and no pressure-related injury was present on admission. The Nursing admission Note did not include a skin assessment or identification of a sacral pressure injury.Review of resident #27's Provider admission Note and Orders, dated [DATE], did not show that a pressure-related injury was assessed or present on admission to the facility on [DATE].Review of resident #27's Care Plan Meeting, effective from [DATE] to [DATE], showed:- admission Team Discussion, dated [DATE], showed, Medical Problems: Wounds: No was documented.- admission Nursing Assessment, dated [DATE], showed, Skin [within normal limits]. No pressure related injury present on admission.- Dietitian Assessment, dated [DATE], showed, Nutritional Assessment Note. Braden Scale Score: 15 (At Risk). Wounds: surgical at right hip. A pressure injury was not noted.- Provider Assessment and Plan, dated [DATE], did not show that a pressure-related injury was assessed or present on admission.- Current Problems, showed, Pressure Injury of sacral region, unstageable, noted on [DATE]. The sacral pressure injury was not noted until [DATE]. Review of resident #27's Baseline Care Plan, with an effective date of [DATE] through [DATE], showed a Braden Skin Score, with no date, which was scored at 17 (Mild Risk). A skin assessment, with no date, showed, Integumentary [within defined limits], Skin Color: Pale, Skin Integrity: bruising, Bruising: [left upper extremity, right lower extremity, right groin]. Skin and Ulcer treatments: Pressure reducing device for chair, Pressure reducing device for bed, Turning/repositioning program, Pressure ulcer care. The baseline care plan did not include identification of a sacral pressure injury, location, Stage, wound characteristics, wound treatment, or provider orders, goals, or effective prevention interventions. Review of resident #27's Skin Assessment Flowsheets, dated [DATE] to [DATE], showed the following skin assessments:- [DATE]: Integumentary [within defined limits]. Skin Integrity: Bruising. Is resident at risk for pressure ulcer/injury: yes was documented.- [DATE]: Integumentary [within defined limits]. Is resident at risk for pressure ulcer/injury: yes was documented. - [DATE]: Integumentary [within defined limits]. Skin color: Pale. Is resident at risk for pressure ulcer/injury: yes. Skin and ulcer treatments: pressure reduction was documented.Resident #27's Skin Assessments completed on [DATE] and [DATE] did not identify a sacral pressure injury. No additional skin assessments were completed or documented for resident #27 from [DATE] to [DATE], 11 days.Review of resident #27's Braden Scale Flowsheets, dated [DATE] to [DATE], showed Braden Scale Assessments (a standardized assessment tool to predict the risk of developing pressure injuries) were completed on the following dates:- [DATE]: Score of 15 (At Risk)- [DATE]: Score of 15 (At Risk)- [DATE]: Score of 16 (At Risk)- [DATE]: Score of 16 (At Risk)- [DATE]: Score of 17 (Mild Risk)- [DATE]: Score of 17 (Mild Risk)Review of resident #27's Nursing Note, dated [DATE], showed, Situation: sacral [decubitus] Background: [Resident] was originally admitted for right femur [fracture]. During my assessment with the patient, she reported having 'butt pain'. [Resident] was encouraged to turn to her side with assistance [every two hours] and [as needed]. I was assisting [Resident] in repositioning, and she said do you want to look at my butt? I said yes absolutely. She was assisted in standing and walking to the bathroom. When she was finished using the bathroom I removed the dressing that was in place and assessed the wound. Action: I assessed the wound and redressed the wound. When she returned to the bed I assessed what level the (air mattress) pump is on and it was placed on a firmer setting. The bed setting was changed. Discussed my thoughts with the patient (resident) and her spouse. I told them I feel she needs to be sent to wound care and also placed on a specialty mattress. Reaction: [Resident] was given a [pressure relieving cushion] and 2 Percocet (5-325) for pain. Notified [staff members EE, FF, GG, and B] about my discovery today. [sic].Review of resident #27's Nursing Note, dated [DATE], showed, 5-Day Charting and Daily Notes: [Resident] has a new discovery of sacral wound. I messaged [Staff member EE] that I feel [resident] needs a wound care consult and a Hilrom [sic] air mattress. A Hillrom air mattress is a pressure reducing support surface designed to help prevent and treat pressure injuries. The interventions documented and provided in resident #27's baseline care plan included a pressure-reducing device for the bed and chair, which were not timely or effectively implemented to prevent the resident's pressure ulcer from initially developing or worsening.B. Timely Wound Identification, Assessments, Measurements, Documentation, and Physician OrdersReview of resident #27's Physician admission Orders, from [DATE] to [DATE], did not show physician orders for a sacral pressure injury.Review of resident #27's Nursing Note, dated [DATE], showed, . Skin: visualized skin intact, no unusual markings. 5-Day Charting and Daily Notes: .Dressing to sacrum changed and documented in flowsheet. Review of resident #27's Flowsheet documentation for [DATE] showed, Integumentary [within defined limits]. Is resident at risk for pressure ulcer/injury: yes was documented. Review of resident #27's Nursing Note, dated [DATE], showed, Skin: incision intact, healing appropriately. No evidence of infection. The nursing note did not address the resident's sacral wound.Review of resident #27's Nursing Note, dated [DATE], showed, Skin: Dressing to sacrum soiled, changed.Review of resident #27's Nursing Note, dated [DATE], showed, Skin: visualized skin intact, no unusual markings. 5-Day Charting and Daily Notes: She stayed calm throughout the shift, took her meds and had her sacral ulcer dressed. [sic]Review of resident #27's Nursing Note, dated [DATE], showed, Skin: Sacral dressing intact. 5-Day Charting and Daily Notes: on alert charting for new admit [DATE]. The nursing notes from [DATE] to [DATE] failed to include the necessary identification, measurements, documentation, or information for the facility attempting to obtain physician orders to treat resident #27's sacral injury. Review of resident #27's Nursing Note, dated [DATE], showed, . Skin: .dressing to buttocks changed tonight. Pain: ongoing significant pain in hips and buttocks which is stable and controlled by [as needed] meds. pressure injury on buttocks and was added to the avatar. Dressing dated 2/22 was removed tonight, measurements taken, and redressed. Secure chat sent to [staff member H] nurse to assess [sic]. The nursing notes from [DATE] to [DATE] showed the sacral wound was not assessed, measured, and documented, as needed to prevent further deterioration of the wound. Review of resident #27's Physician Orders from [DATE] to [DATE] showed wound orders for the sacral wound were not implemented and in use until [DATE].Review of resident #27's Wound Assessment Flowsheets from [DATE] to [DATE] showed, Wound [DATE] Pressure Injury Mid Sacrum: Wound Properties Date First Assessed: [DATE]. Present on Original admission: [No]. Primary Wound Type: Pressure injury. (Comments): stage 4. Wound bed: 83% Slough. Margins: Poorly defined. Treatments: Cleansed site with normal saline, barrier cream, barrier film, impregnated gauze foam changed. [sic]Review of resident #27's Wound Assessment Flowsheets, dated [DATE], showed the sacral pressure wound description as: Old drainage, black, non-blanchable, erythema, yellow, purple, drainage, eschar, painful. Wound measurements showed: wound length: 4.2 cm, width: 3 cm, wound surface 9.9 cm [squared], wound depth: 0.2 cm.Review of resident #27's Wound Care Nurse Note, dated [DATE], showed, Significant Event. Wound [DATE]: Pressure Injury Mid Sacrum. Date First Assessed: [DATE]. Present on Original admission: No. The Wound Assessment showed, Site Assessment: Black, blanchable erythema, yellow, purple, drainage. Peri-Wound Assessment: Non-Blanchable erythema, painful. Wound Length: 4.2 cm, Wound Width: 3 cm, Wound Surface Area: 9.9 cm [squared], Wound Bed Slough: 83%, Margins: Poorly defined, Drainage: small, Drainage Description: Serosanguineous, Pressure Injury Stage: [Unstageable]. Staff to [turn and rotate] patient [every 2 hours] to offload sacrum, pump (for air mattress) on bed. [sic] Review of resident #27's Nursing Note, dated [DATE], showed, .Action: Issues/Changes this shift: Resident rests in bed the entire shift and reports being uncomfortable and in pain. Resident refuses to be repositioned or move to recliner. Resident given pain medication [as needed] that appears to be effective.Review of resident #27's Wound Care Nurse Note, dated [DATE], showed, Wound healing is not progressing as expected. Nutrition: status poor. [Patient] on Hilrom airbed, staff to [turn and reposition every 2 hours] to offload buttock. Referred [Resident] to [Wound Care Clinic], first visit [DATE]. [sic]Review of resident #27's Nursing Note, dated [DATE], showed, .Pain: ongoing significant pain in buttocks which is stable and controlled by PRN meds. 5-Day Charting and Daily Notes: .Pressure injury on buttocks. She was turned and repositioned every [two hours] and she wasn't happy with staff for this. Education was given about relieving pressure off the wound. She reluctantly stated understanding. She is pleasant and a little grumpy with staff tonight.Review of resident #27's Physician Wound Clinic Note, dated [DATE], showed, Diagnosis: Unstageable sacral pressure ulcer. This is a first-time evaluation. who apparently fell about 2-1/2 weeks ago and fractured her right femur. She underwent surgery with [Surgeon Name] to fix this fracture. In the interim she has developed a pressure ulcer on her sacral area. She recently received an air mattress and is working on protein intake because she has poor appetite and they are working on getting her [Pressure Relieving] cushion. She is a resident at the [Facility Name]. She has a wound on her sacral area which has been treated with Xeroform's and sacral Optifoam. [sic] The Debridement Notes showed: - Debridement type: surgical, Level of debridement: subcutaneous tissue. Pre-debridement measurements: Length (cm): 4.5, Width (cm): 3, Depth (cm): 0.2, Surface Area (cm) [squared]: 10.6.- Post-debridement measurements: Length (cm): 4.5, Width (cm): 3, Depth (cm): 0.5, Percent debrided: 95%, Surface Area (cm2): 10.6, Area Debrided (cm2): 10.07, Volume (cm3): 3.53.- Tissue and other material debrided: dermis, epidermis and subcutaneous tissue. Devitalized tissue debrided: fibrin, necrotic debris and slough. This was an excisional debridement. Plan: This is a first-time evaluation. There was necrotic tissue which I debrided. down to the subcutaneous tissue level. We will continue with Xeroform as well as sacral Optifoam which will be changed every other day. [sic]Review of resident #27's Wound Nurse Progress Note, dated, [DATE], showed, . Wound to sacrum is worsening. [Patient] 'I wish they would just let me go, I'm 94 and I just want to die, my butt hurts'.Review of resident #27's Provider Wound Clinic Note, dated [DATE], showed, . HPI: The patient returns today for evaluation of a stage IV mid sacrum pressure ulcer. She states she no longer wants to live. She reports being in extreme pain secondary to the sacral pressure ulcer. The medical record reflects a hospice consultation pending.Impression Plan:- 1. Sacral pressure ulcer dimensions have increased most likely reflecting evolution of the initial [Deep Tissue Injury]. The primary dressing will be changed to Vashe moistened gauze in an effort to facilitate debridement of devitalized debris through twice daily dressing changes.- 3. As stated in the HPI, a hospice consult is pending for this patient who states she no longer wants to live. [sic]Review of resident #27's Provider Discharge Summary, for facility admission dates [DATE] to [DATE], showed: . She also developed a stage IV sacral wound with associated pain, requiring escalation of pain management and wound care interventions. In the final days of admission, she expressed a desire for hospice care due to continued decline, persistent pain, and lack of perceived quality of life, with family and care team in agreement. [sic]During an interview on [DATE] at 4:28 p.m., staff member G stated the facility currently had designated nurses who completed the new admissions. She stated the admission nurses would complete the initial skin assessments to identify any new or existing wounds. The staff would document those findings in the resident's record. Skin assessments were to be completed at least weekly and or on the resident's shower days. Staff member G stated that if a resident had an existing wound, the wound would be assessed and measured. The dressing would be changed per the physician's orders and documented in the resident's medical record. Staff member G stated that if a new pressure injury was noted, she would notify the provider, the family, and, depending on how complex the wound was, staff member H, and or the resident would be referred to the wound clinic. She stated she would update the resident's medical record to show the new wound care orders and other physician-ordered treatments. Staff member G stated that staff member H and the staff nurses could also take a picture of the wound and document the wound in the resident's medical record. Staff member G stated that pressure-relieving interventions were usually started upon a resident's admission. Depending on a resident's risk of developing pressure ulcers, those interventions would be modified to the resident's needs.During an interview on [DATE] at 5:01 p.m., staff member B stated that designated nurses completed resident admissions. Staff member B stated the expectation was that they would complete a head-to-toe skin assessment upon the resident's admission. If there were wounds present on admission, a picture was taken of the wound, the wound would be measured, and the details would be documented in the resident's record. Staff member B stated nurses should complete skin assessments weekly and complete a Braden assessment at the same time. Staff member B stated that a baseline care plan was usually developed by the nurse admitting the resident. The wound prevention interventions would be addressed in the care plan, including any wound characteristics, measurements, and provider orders. She stated that if there was a pressure wound, staff member H would also be involved in the resident's care and monitor, assess, measure, take pictures, dress, and document the findings in the resident's record. It was the expectation that for any newly identified pressure injuries, the nursing staff were to notify the family, the provider, obtain physician orders, send a message to staff member H, and document the wound in the resident's record. Staff member B stated she was made aware of resident #27's wound at the time it was discovered, but did not follow up on it at the time. Staff member B stated the facility had not identified pressure ulcers as an area of concern to be addressed or considered for process improvement using the facility's Quality Assurance Program. During an interview on [DATE] at 5:13 p.m., staff member H stated that when there was a new admission to the facility, she would review the resident's record to see if they had any wounds. She stated she had not completed a full head-to-toe skin assessment on a resident in a long time. She stated she managed mostly pressure wounds for three facilities, including this facility. Staff member H said that when she sees a resident for the first time for a pressure injury, she would review the resident's record first and then assess the wound. If the wound was not staged (severity classification) or if it did not have measurements, she would obtain those measurements, take pictures of the wound, document it, and get wound orders from the physician. She stated she would also refer residents to the Wound Clinic if the wound was complex. Staff member H stated she first assessed resident #27 after the resident had already been admitted . She stated she had assessed resident #27's sacral wound and determined the resident needed to be seen by the Wound Clinic because the resident's wound was not progressing (improving/healing). She stated they had tried positioning and turning the resident every two hours, but the resident did not wish to be moved. She stated that after the wound was identified, the resident was ordered [NAME] Boots (pressure-relieving), an air mattress, and a pressure-relieving cushion for her chair. Staff member H stated she would be able to assess a wound to determine if it was a Kennedy ulcer (Kennedy terminal ulcer (KTU) is a type of skin wound that develops rapidly in individuals who are nearing the end of life. It is a form of skin failure, where the body's skin breaks down as part of a multi-organ decline and a natural part of the dying process). Staff member H stated she did not feel resident #27's pressure injury was the result of a KTU. She stated the physicians at the Wound Clinic, where the resident was seen, also did not classify resident #27's pressure injury as a KTU. Staff member H stated that for the age of resident #27, although considered high-risk, resident #27's pressure ulcer would still be considered avoidable.During an interview and record review on [DATE] at 9:00 a.m., staff members B and D stated they had both reviewed resident #27's medical record, and although there was documentation of nurses' notes from [DATE] through [DATE], both staff members stated there was no documentation in the resident's record of skin assessments, wound assessments, or physician orders to treat the resident's sacral wound until [DATE]. Both staff members B and D stated the resident's baseline care plan addressed some bruising and did not address anything regarding a sacral wound with a comprehensive assessment of the wound before [DATE].During an interview on [DATE] at 10:05 a.m., staff member K stated he started completing admissions for the facility on [DATE]. He stated he would review a resident's record for any skin concerns and then complete a full head-to-toe skin assessment of the resident at the time of admission. Staff member K stated that for a new wound noted on admission, he would assess the wound, take measurements, obtain images of the wound, obtain provider orders, and document everything in the resident's record. He stated a baseline care plan should also be generated, which addressed the pressure injury, including the treatment orders for the wound and interventions to prevent the wound from worsening or new wounds from developing.A review of the facility's Policy and Procedure titled, Pressure Injury, with a revision date of 5/2026, showed: I. Pressure injury prevention is part of the standard of care for admitted Residents.II. A Braden Scale is completed on admit and weekly with skin assessments. Implement interventions to prevent skin breakdown for any patient scoring 16 or less.Score 15-16 = At Risk. IV. RN/LPN implements following measures to maintain skin integrity as indicated.- A. Reduce/relieve pressure against bony prominences.1. Reposition at least [every] 2 hours utilizing pillows or foam to keep bony prominences from direct contact with one another.2. Reposition [every] 1 hour when in chair. Teach to shift weight [every] 15 minutes when in chair.3. Position patient in 30-degree side lying position. Do not turn patient onto the trochanter.4. Relieve all pressure on heels. Use pressure redistribution boots or heel protectors.5. Apply lotion to dry, flaky skin.6. Utilize pressure redistribution mattresses as indicated .9. Use pressure redistribution wheelchair cushions for at risk patients when in chair.10. Use weight shifts, or pelvic tilts when necessary to relieve sacral pressure.A review of the facility's policy and procedure, titled Wound Assessment, with a last revised date of 7/2025, showed: .I. Document:B. Dimensions - in centimeters - length x width x depth/length - head to toe, width - side to side depth - deepest part of wound (utilize sterile swab).C. Type of wound.4. Pressure ulcer: a localized injury to the skin and/or underlying tissue usually over bony prominence, as a result of pressure, or pressure in combination with shear.8. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Area may be painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. May be difficult to detect in individuals with darker skin tones.D. Description of Wound- Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.- Unstageable: Full thickness tissue loss in which the base of the or ulcer is covered by slough (yellow, tan, gray, Necrotic green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and /or eschar is removed to determine true depth, the ulcer cannot be staged.- Full-thickness: Involves epidermis, dermis, and subcutaneous tissues, muscle, or bone.F. Wound base condition and color.G. Drainage - Note color, consistency, odor, and amount.H. Condition of Surrounding Skin - (example: intact, erythema, induration, dry, scaly, macerated, denuded).I. Signs and Symptoms of Infection - Edema, erythema in surrounding skin, purulent drainage, leukocytosis, odor, fever, increasing pain, confusion.J. Wound assessments are to be completed on admissions.b. Senior Services -Wound assessments and measurements are completed weekly.K. Skin assessments are completed quarterly for long-term residents.

Based on observation, interview, and record review, the facility failed to obtain informed consent to include an explanation of the risks, benefits, and alternatives before the administration of psychotropic medications for 1 (#36) of 18 sampled residents. Findings include: During an observation and interview on 6/1/26 at 2:22 p.m., resident #36 was lying in bed. Resident #36 stated she was admitted to the facility on [DATE], after she had fallen at home and fractured her hip. Resident #36 stated she had increased sleepiness and all she wanted to do right now was sleep. Resident #36 stated she had a history of depression, but was not sure if that was what was causing her sleepiness.Review of resident #36's pharmacy medication regimen review, dated 5/29/26, showed: . Please obtain consent for duloxetine .Review of resident #36's physician orders, dated 5/29/26, showed duloxetine (antidepressant) 60 milligram capsule daily, which was ordered on 5/30/26.Review of resident #36's psychotropic informed consent form showed the form was signed by resident #36 on 6/1/26.Review of resident #36's medication administration record, dated 5/29/26 - 6/8/26, showed two doses of duloxetine were administered before the psychotropic informed consent form was signed.Review of resident #36's physician's orders, dated 6/3/26, showed mirtazapine (antidepressant) 7.5 milligrams nightly.Review of Resident #36's medication administration record, dated 5/29/26 - 6/8/26, showed five doses of mirtazapine were administered between 6/3/26 and 6/7/26.Review of resident #36's electronic medical record showed no signed informed consent form in the medical record before the administration of the first dose of mirtazapine on 6/3/26 at 9:16 p.m.During an interview on 6/2/26, at 8:14 a.m., staff member J stated that psychotropic medications required a consent form to be completed by the resident or the resident's representative.During an interview on 6/3/26 at 3:22 p.m., staff member C stated the expectation for psychotropic consents was for the consent forms to be completed per the facility's policy.During an interview on 6/3/26 at 3:44 p.m., resident #36 stated the facility staff did not discuss the risks, benefits, or alternatives of any of her medications, which included duloxetine and mirtazapine, before receiving the medications.Review of a facility policy titled, Appropriate Use of Psychotropic Drugs, dated 8/2025, showed: . II. Nursinga. Obtains a signed consent form for the psychotropic medication from the resident - if the resident is unable to sign, the POA must sign - and place in the resident's chart. [sic]

Based on interview and record review, the facility failed to report investigative findings to the State Survey Agency within the required timeframe of 5-working days for 1 (#6) of 18 sampled residents. Findings include:Review of the facility's reported incident, dated 12/18/25, showed, CNA went into resident (#6's) room during rounding and reports resident was walking back to bed from the bathroom in her socks with her cane. Resident reported to the CNA she had fallen. The resident was favoring her left leg and complaining of pain.Review of the facility's investigative findings for the incident involving resident #6, reported on 12/18/25, showed the investigation findings were submitted to the State Survey Agency on 1/29/26, 42 days after the incident occurred; therefore, the report was untimely. The investigative findings showed resident #6 sustained an acute left-sided pubic rami fracture.During an interview on 6/1/26 at 1:55 p.m., staff member B stated that at the time of the incident involving resident #6's fall, she was unaware that the findings of the investigation for the event had not been submitted within the required reporting timeframe. Staff member B stated she submitted the findings as soon as she identified it was not done.Review of a facility policy titled, Elder Justice Act & Reporting, dated 7/2025, showed no procedure or timeframe information for the submission of investigative findings.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for a resident that included the minimum necessary information needed to provide person-centered care for 1 (#39) of 18 sampled residents. This deficient practice increased the risk of the resident not receiving necessary care and services. Findings include: During an observation and interview on 6/2/26 at 9:10 a.m., resident #39 was sitting in a wheelchair watching television in her room. Resident #39 stated she was recently admitted to the facility on [DATE]. The resident planned on returning to an assisted living facility after her inpatient physical and occupational therapy. Resident #39 stated she needed staff assistance with her activities of daily living due to weakness and pain she experienced. Resident #39 stated she needed assistance with transferring, and the staff was using a mechanical lift for her transfers. During an interview on 6/2/26 at 9:20 a.m., staff member F stated resident #39 required staff assistance with dressing, toileting, personal hygiene, and transfers.During an interview on 6/3/26 at 12:17 p.m., staff member B stated that no baseline care plan was created for resident #39.During an interview on 6/3/26 at 4:00 p.m., staff member K stated that for new admissions, baseline care plans were to be initiated at the time of admission or no later than 48 hours after admission. Staff member K stated he wasn't sure how the baseline care plan was missed for resident #39.During an interview on 6/3/26 at 4:20 p.m., staff member M stated she had access to resident care plans. Staff member M stated she did not recall seeing a care plan in the medical record when resident #39 was admitted . Staff member M stated she was verbally told by other staff members that the resident needed assistance with transfers and activities of daily living.Review of resident #39's electronic medical record, on 6/3/26, showed that resident #39 was admitted on [DATE], and no baseline care plan was created within the first 48 hours. Review of a facility policy titled, Initial Nursing Assessment and Development of Interdisciplinary Resident Care Plans, dated 4/2025, showed: . Procedure:Admitting licensed staff completes the nursing assessment and baseline care plan upon admission. [sic]

Based on observation, interview, and record review, the facility staff failed to adhere to accepted infection control standards, including proper hand hygiene and glove use, during a medication pass for 2 (#s 33 and 39) of 18 sampled residents. This deficient practice increased the likelihood of the transmission of infections. Findings include:During an observation on 6/2/26 at 9:20 a.m., staff member F entered resident #39's room. No hand hygiene was performed by the staff member before entering the room. Staff member F walked over to the medication cabinet, which was located on the wall in the room. Staff member F used his badge to unlock and open the cabinet. Staff member F placed the handheld charting device called a Rover onto a flat surface. He picked up a medication card and scanned it with the Rover. He then placed the medication card over the plastic medication cup and pushed the medication from the card into the medication cup. Staff member F repeated this process four times. Staff member F walked over to the resident and handed her the medication in the cup. No hand hygiene was performed by staff member F after touching the medication cards or Rover device before handing the medication cup to resident #39. Staff member F walked back to the medication cabinet, picked up an inhaler, and handed it to resident #39. Resident #39 self-administered two puffs of the inhaler. Staff member F informed resident #39 he had to go to the medication room to get her B-12 vitamin injection. Staff member F exited the room. Staff member F returned to resident #39's room with a medication syringe. No hand hygiene was completed upon entering resident #39's room. Staff member F donned gloves and administered the injection to resident #39. No hand hygiene was performed before donning gloves to prevent the spread of infectious agents. During an interview on 6/2/26 at 9:28 a.m., staff member F stated he was previously educated on proper hand hygiene.During an observation on 6/3/26 at 8:32 a.m., staff member J went to resident #33's room for a medication pass. Staff member J walked over to the medication cabinet on the wall and used his badge to unlock and open it. Staff member J picked up a medication card, scanned the card with the Rover, placed the medication card over the plastic medication cup, pushed the medication out of the medication card, and into the medication cup. Staff member J repeated this process five times. Staff member J picked up the Rover and the medication cup and set them down on resident #33's bedside table next to her meal tray. Staff member J donned a pair of gloves, picked up the medication cup and handed it to resident #33. No hand hygiene was performed prior to donning gloves. Staff member J picked up the Rover and walked back to the medication cabinet. Staff member J placed the Rover onto a flat surface. Staff member J walked back to resident #33 and removed a nicotine patch. He then walked back to the medication cabinet, placed the nicotine patch in his left hand, and removed the glove. Staff member J donned a glove on the left hand. No hand hygiene was performed between doffing and donning a new glove. Staff member J picked up the Rover and scanned a new nicotine patch. Staff member J opened the nicotine patch and placed it on resident #33's chest area. Staff member J picked up the Rover and scanned the lidocaine patches. Staff member J removed scissors from his shirt pocket and opened three lidocaine patch packages. He walked over to resident #33 and placed the three lidocaine patches along her left side, low back, and hip area. Gloves were not doffed by staff member J after touching the dirty equipment or prior to placing the new medication patches onto clean areas for the resident. Staff member J doffed his gloves and donned a new pair. No hand hygiene was performed before donning new gloves. Staff member J picked up a tube of diclofenac cream and walked over to patient #33. Resident #33 refused the diclofenac cream. Staff member J doffed his gloves and left the room. No hand hygiene was performed after doffing his gloves.During an interview on 6/3/26 at 8:49 a.m., staff member J stated he had been educated on proper hand hygiene and when hand hygiene should be performed.During an interview on 6/4/26 at 12:27 p.m., staff member S stated that hand hygiene education was recently provided to staff. Staff member S stated the expectation for hand hygiene was to follow the policy and CDC (Centers for Disease Control) guidelines. Review of a facility policy titled, Hand Hygiene, dated 6/2025, showed: . Hand hygiene is expected of all employees before and after all patient/resident contacts, after glove use, . [sic]

Based on observation, interview, and record review, the facility failed to ensure staff member C followed proper infection control practices while performing blood glucose monitoring with a portable handheld glucometer between residents for 2 (#s 1 and 3); and failed to perform hand hygiene before donning clean gloves prior to blood glucose monitoring for 1 (#3) of 2 sampled residents for blood glucose monitoring. These deficient practices increased the risk of transmission of bloodborne pathogens between residents in the facility. Findings include:During an observation on 8/12/25 at 7:37 a.m., staff member C retrieved a portable handheld glucometer from a locked room by the nurses' offices. The glucometer was seated on a charger on the counter, next to a case which contained blood glucose monitoring supplies. During an observation on 8/12/25 at 7:38 a.m., staff member C entered resident #3's room and donned gloves to perform her blood glucose monitoring. Staff member C did not sanitize her hands before donning the gloves. Staff member C performed the blood glucose monitoring for resident #3, and then laid the handheld glucometer on a supply cart in the bathroom, doffed her gloves, and washed her hands. Staff member C then returned to her medication cart, prepared to perform another resident's glucose monitoring. She laid the handheld glucometer onto the top surface of the cart. Staff member C did not clean or sanitize the portable handheld glucometer.During an observation on 8/12/25 at 7:45 a.m. staff member C entered resident #1's room and performed her blood glucose monitoring. Staff member C returned the portable handheld glucometer to the locked supply room and placed it onto the charger, then left the room. Staff member C did not clean or sanitize the portable handheld glucometer before, in between residents, or after the use of the device. During an interview on 8/12/25 at 8:56 a.m., staff member C stated the portable handheld glucometer was to be cleaned with purple top Sani wipes, in between each resident use and after use, before returning the device to the charger. Staff member C stated she did not clean the handheld glucometer after each use, between each resident, and after use before it was placed onto the charger. During an interview on 8/12/25 at 8:56 a.m., staff member C stated hands were to be washed or sanitized before donning gloves and after doffing gloves. Staff member C stated she did not perform hand hygiene before donning gloves to perform resident #3's blood glucose monitoring.During an interview on 8/12/25 at 9:56 a.m., staff member B stated the portable handheld glucometer should be sanitized between each resident's use and after the last resident's monitoring before replacing the glucometer onto the charger. Staff member B stated hand hygiene should be performed before donning gloves and after the removal of gloves.Review of the facility's policy titled, Point of Care Testing Safety Manual, last revised 2/2024, showed:- . 4. Safe Handling of Portable Handheld Testing Devices- In order to prevent transmission of infection, portable handheld testing devices must be disinfected after each patient use.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan which included the minimum necessary instructions needed to provide effective and person-centered care of the resident for 3 (#s 3, 17, and 21) of 17 sampled residents. Findings include: During an observation on 5/17/25 at 3:02 p.m., resident #17 was lying in bed, receiving oxygen via nasal cannula. Review of resident #17's document titled, Baseline Care Plan, dated 4/7/25, did not include a problem, goals, or interventions for oxygen therapy. During an observation on 5/18/25 at 8:35 a.m., resident #3 was lying in bed, receiving oxygen via nasal cannula. Review of resident #3's document titled, Baseline Care Plan, dated 4/28/25, did not include a problem, goals, or interventions for oxygen therapy. During an observation and interview on 5/18/25 at 8:20 a.m., resident #21 was receiving supplemental oxygen via nasal cannula. Resident #21 stated he had a catheter in place due to urinary retention and needed a lot of assistance with toileting or to even get out of bed due to his cancer diagnosis. Review of resident #21's document titled, Baseline Care Plan, dated 4/14/25, did not include a problem, goals, or interventions for oxygen therapy, urinary catheter care, or any needed assistance for his extensive needs with activities of daily living. During an interview on 5/19/25 at 7:56 a.m., staff member C stated nursing started the baseline care plans for the residents at admission. Staff member C stated the baseline care plan should include activities of daily living, pain, urinary issues, falls, psych meds, and oxygen, in addition to other areas needed to provide the initial care for residents. During an interview on 5/20/25 starting at 8:56 a.m., staff member C stated when completing the initial care plan, they (facility staff) were not always including all the information for the continuity of care of the resident. Staff member G stated some of the system areas for the computer entry needed to be discussed so a thorough baseline care plan was completed.

Based on observation, interview, and record review, the facility failed to ensure the oxygen rate of delivery was included in the provider's oxygen orders for 4 (#s 3, 17, 78, and 129); failed to ensure a form of documentation was in place for when oxygen tubing was last changed for 5 (#s 3, 17, 21, 78, and 129); and failed to ensure proper infection control practices were adhered to for a respiratory nebulizer mask/mouthpiece for 1 (#17) of 17 sampled residents. These deficient practices had the potential to affect the correct rate of oxygen delivery and increase the risk for infections in residents with prescribed oxygen. Findings include: 1. Oxygen Orders During an observation on 5/17/25 at 3:02 p.m., resident #17 was lying in bed, receiving oxygen via nasal cannula. The oxygen concentrator was set at three liters per minute. Review of resident #17's Oxygen Therapy orders, dated 4/7/25 at 5:02 p.m., showed oxygen to be delivered continuous, via nasal cannula; and, Keep O2 Sat Above 90%. The provider's order for oxygen did not include a rate of delivery. During an observation on 5/17/25 at 3:19 p.m., resident #78 was seated in his recliner, receiving oxygen via nasal cannula. The oxygen concentrator was set at four liters per minute. Review of resident #78's Other Nursing orders, dated 4/30/25 at 1:38 p.m., showed, RT/RN to determine oxygen supplementation to maintain oxygen saturation > 92%. Review of resident #78's Oxygen Therapy orders, dated 4/30/25 at 1:38 p.m., showed oxygen to be delivered continuous, via nasal cannula; and, Keep O2 Sat Above 90%. The two provider's orders were contradictory and neither order defined the oxygen rate of delivery. During an observation on 5/17/25 at 3:49 p.m., resident #129 was lying in bed, receiving oxygen via nasal cannula. The oxygen concentrator was set at two liters per minute. Review of resident #129's Oxygen Therapy orders, dated 5/9/25 at 1:37 p.m., showed, oxygen to be delivered, (home O2 @ noc) [sic] continuous, via nasal cannula, Keep O2 Sat Above 88%. The provider's order for oxygen did not include a rate of delivery. During an observation on 5/18/25 at 8:35 a.m., resident #3 was lying in bed, receiving oxygen via nasal cannula. Review of resident #3's Oxygen Therapy orders, dated 4/28/25 at 4:54 p.m., showed oxygen to be delivered continuous, via nasal cannula; and, Keep O2 Sat Above 92%. The provider's order for oxygen did not include a rate of delivery. During an interview on 5/18/25 at 1:30 p.m., staff member D stated vital signs were recorded two times a day and oxygen saturation was monitored at that time. Staff member D stated oxygen orders were written all the time with only the titration of oxygen to a certain saturation level. He stated he felt comfortable with the titration orders for oxygen, but he had [AGE] years of experience in nursing. During an interview on 5/19/25 at 7:41 a.m., staff member B stated some oxygen orders for residents did not include a rate of delivery. Staff member B stated those oxygen orders were likely the orders when the resident was discharged from the hospital, before admission to the facility. Staff member B stated it had to do with the computer system used by both the hospital and the nursing facility. 2. Oxygen Tubing During an observation and interview on 5/17/25 at 3:02 p.m., resident #17 was receiving oxygen via nasal cannula. No visible date or labeling was on the oxygen tubing to show the last time the tubing was changed. Resident #17 stated they changed the tubing, the other day. During an observation on 5/17/25 at 3:19 p.m., resident #78 was receiving oxygen via nasal cannula. No visible date or labeling was on the oxygen tubing which showed the last time the tubing was changed. During an observation on 5/17/25 at 3:49 p.m., resident #129 was receiving oxygen via nasal cannula. No visible date or labeling was on the oxygen tubing which showed the last time the tubing was changed. During an observation on 5/18/25 at 8:22 a.m., resident #21 was receiving oxygen via nasal cannula. No visible date or labeling was on the oxygen tubing which showed the last time the tubing was changed. During an observation on 5/18/25 at 8:47 a.m., resident #3 was receiving oxygen via nasal cannula. No visible date or labeling was on the oxygen tubing which showed the last time the tubing was changed. During an observation and interview on 5/18/25 at 1:32 p.m., staff member D stated oxygen tubing was changed on Saturday nights but was unsure if there was any documentation in the computer system where it would be recorded. Staff member D stated each resident's oxygen tubing change date should be written on the oxygen tubing. Located in the nurse's lounge/room was a whiteboard with instructions for the changing of oxygen tubing. The whiteboard showed, Replace weekly on NOCS Saturdays, Nebulizer tubing/mask, O2 tubing, Date when changed. [sic] During an interview on 5/19/25 at 7:38 a.m., staff member B stated on Saturday nights, CNAs changed the oxygen tubing and marked/dated the tubing of the change. She stated there may have been a mix up this last Saturday due to the assigned CNAs filling in from a different campus location. Staff member B stated she had suggested the staff would place tape over the writing so it did not wear off the tubing and could be easily read. She was unsure if the oxygen tubing changes were documented in the resident's medical record. Review of the facility's policy titled, [Facility]-Respiratory Therapy, last revised 1/2001, showed: - . B. Equipment is cleaned or replaced in the following manner: - . 2. Cannulas are changed weekly or if soiled, completed by the night shift. 3. Nebulizer machine/mask/mouthpiece During an observation and interview on 5/17/25 at 3:02 p.m., resident #17's nebulizer machine was sitting on the carpeted floor, next to the trash receptacle. There were four used tissues/paper towels on top of the nebulizer mouthpiece, with the mouthpiece touching the floor. Resident #17 stated the staff had changed the nebulizer mouthpiece on 5/16/25. Review of resident #17's current scheduled medication orders, printed 5/18/25 at 12:19 p.m., showed: - albuterol 2.5 mg/3ml, 0.083% nebulizer solution, to be administered via nebulization, four times daily. During an observation on 5/18/25 at 8:33 a.m., resident #17's nebulizer machine was lying on the carpeted floor, next to the trash receptacle, with the mouthpiece touching the floor. During an interview on 5/18/25 at 1:38 p.m., staff member D stated resident #17's nebulizer machine and mouthpiece should not be lying on the floor. He stated it would not adhere to proper infection control practices. Staff member D stated resident #17 did move items around sometimes, but since she was unable to get out of bed independently, he doubted she would have placed the nebulizer on the floor. Staff member D stated he would replace the mouthpiece with a clean one. During an interview on 5/19/25 at 7:47 a.m., staff member B stated it would be poor infection control practice to place a nebulizer and mouthpiece on the floor.

Based on interview and record review, the facility failed to ensure psychotropic medications, prescribed on an as needed basis, were limited to 14 days unless the resident's medical record included documented rationale for continued use for 2 (#3 and #6) of 17 sampled residents. Findings include: 1. Review of resident #3's current as needed medication records, as of 5/18/25, showed: - alprazolam 0.25 mg, by mouth, nightly as needed. The medication order for resident #3 did not include an end/stop date or was limited to 14 days. During an interview on 5/19/25 at 7:44 a.m., staff member A stated antipsychotic or psychotropic medication orders were limited to 14 days. He stated there should be a stop date on the medication orders for these medications. 48268 2. During an interview on 5/19/25 at 11:28 a.m., staff member I stated PRN psychotropic medication orders were, usually for less than 14 days, but (resident #6) is on hospice, so I just don't know if it can be ordered for longer. Review of resident #6's physician orders showed two separate and active orders for as needed (PRN) lorazepam concentrated solution with a one year end date. The orders read as follows: - LORazepam (Intensol) concentrated solution . Route oral . Admin Dose 0.5-1 mg Frequency: Every 2 hours PRN . Start Date 4/18/25 . End Date 4/18/26 . - LORazepam (Intensol) concentrated solution . Route oral . Admin Dose 1-2 mg Frequency: Every 1 hour PRN . Start Date 4/18/25 . End Date 4/18/26 . [sic]

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative, in writing, of the facility's bed hold policy when transferring a resident to the hospital for 1 (#3) of 17 sampled residents. Findings include: During an interview on 5/19/25 at 2:37 p.m., staff member B stated the facility did not have documentation of a bed hold policy notification for resident #3's hospitalization on [DATE]. Review of the facility's policy titled, [Facility] Room Hold Policy, last revised 6/2024, showed: - . Policy: - . Resident and/or resident's representative will be notified in writing of [Facility] Room Hold Policy.

Based on observation, interview, and record review, the facility failed to initiate a person-centered comprehensive care plan to include the use of oxygen therapy for 2 (#s 3 and 17); and failed to include an increased risk of aspiration for a resident admitted to the hospital and returned after an event of food aspiration for 1 (#3) of 17 sampled residents. Findings include: 1. Resident #3 During an observation on 5/18/25 at 8:35 a.m., resident #3 was lying in bed, receiving oxygen via nasal cannula. During an interview on 5/19/25 at 12:23 p.m., staff member D stated since resident #3 returned from the hospital after an aspiration event, they (staff) either asked the resident to eat in the dining room, or where she could be watched. Staff member D stated if resident #3 remained in her room for meals, staff sat with her during that time. During an interview on 5/19/25 at 12:26 p.m., resident #3 stated staff never sat with her when she ate in her room, and it was her choice to stay in her room during meals. Review of resident #3's Nursing Admission Note, dated 4/29/25, showed she was admitted to the facility for management of aspiration and respiratory failure. Review of resident #3's Admission MDS, with an ARD of 5/4/25, Section K - Swallowing/Nutritional Status, showed: - Under K0100. Swallowing Disorder, - . C. Coughing or choking during meals or when swallowing medications, - D. Complaints of difficulty or pain with swallowing. Both areas were marked with an X, which designated they applied. Review of resident #3's Admission MDS, with an ARD of 5/4/25, Section O - Special Treatment and Programs, showed: - .C1. Oxygen therapy, while a resident. Review of resident #3's Comprehensive Care Plan, printed 5/18/25, did not include a problem, goals, or interventions for oxygen therapy or an increased risk for aspiration or swallowing difficulties. 2. Resident #17 During an observation and interview on 5/17/25 at 3:02 p.m., resident #17 was lying in bed, receiving oxygen via nasal cannula. Resident #17 stated she had been on oxygen since her admission into the facility on [DATE]. Review of resident #17's Admission MDS, with an ARD of 4/13/25, Section O - Special Treatment and Programs, showed: - .C1. Oxygen therapy, while a resident. Review of resident #17's Comprehensive Care Plan, printed 5/18/25, did not include a problem, goals, or interventions for oxygen therapy. During an interview on 5/19/25 at 8:36 a.m., staff member C stated the care area of oxygen therapy should be included in the comprehensive care plan for residents #17 and #3. Staff member C stated the MDS assessment care areas should be included in the comprehensive care plan.

Based on observation, interview, and record review, the facility failed to update resident care plans to include actual falls and updated fall interventions for 2 (#s 4 and 180) of 17 sampled residents. The failures placed the residents at risk for recurrent falls and injuries. Findings include: 1. During an observation and interview on 5/17/25 at 3:45 p.m., resident #4 was seated in a wheelchair, leaning to the right side, holding both arm rests. Resident #4 stated he had some falls in the past, stating, I think it's this chair. I don't know, I think I just slide out. During an interview on 5/18/25 at 9:15 a.m., staff member I stated, He (resident #4) has had some falls, I think. I am not sure what interventions were placed to keep him from falling. I have not been here a long time, so might not be the best person to talk to . I would look in the (medical) record, or the care plan if I wasn't sure how to care for him. Review of resident #4's progress notes showed he experienced an unwitnessed fall from bed on 10/5/24. Review of the facility document titled, Risk Management Worksheet, dated 10/5/24, showed resident #4 experienced a fall from his bed on 10/5/24 at 9:10 a.m. The report showed, BP normally low at times on BP meds . wife noted [resident name] is very impulsive . Care plan updated . [sic] Review of resident #4's care plan, dated 9/26/24, showed, Potential for Falls. The care plan did not reflect the fall on 10/5/24, did not reflect resident #4's impulsivity, and did not show new interventions post-fall. 32998 2. During an interview on 5/20/25 starting at 8:32 a.m., staff members B, C, and G stated an event report was triggered by nursing following every fall. Staff members B, C, and G stated the Risk Management team was also the fall committee. They stated the Risk Management team met weekly, and care plans were updated on Mondays, Wednesdays, and Fridays. Staff members B, C, and G stated the care planned interventions were reviewed, and evaluated for effectiveness to determine if any new interventions were to be added. Staff members B, C, and G stated the Post Fall Assessment had information on root cause analysis. Staff members B, C, and G stated a sample of chart audits were done weekly to determine if the steps for falls were completed. Staff member B, C, and G stated the 24 hour report was reviewed by the manager to determine if anything needed follow up. Staff member G stated the care plans did not update automatically. Review of resident #180's Significant Event report, dated 4/23/25, showed the resident was found on the floor, kneeling next to his bed. The resident was confused and stated he just rolled out of bed. There were no injuries documented. Review of resident #180's Significant Event report, dated 5/3/25, showed the resident was found with his upper body on the bed and his lower extremities on the floor. The resident sustained lacerations to both knees. No other injuries were documented. Review of resident #180's Significant Event report, dated 5/14/25, showed the resident was found lying on the floor, and partially on his wheelchair. The report showed the resident appeared to have slid out of his wheelchair to the floor. The resident was assessed and no injuries were documented. Review of resident #180's care plan showed interventions implemented on 4/20/25, two days following admission. There were no updated interventions following the falls on 4/23/25, 5/3/25, and 5/14/25, to attempt to reduce or pevent future falls, related to the root causes from the three falls.

Based on observation, interview, and record review, the facility failed to ensure staff member H adhered to sanitary hygiene practices, by wearing a beard net/covering while preparing residents' food trays in the kitchen area. This failure increased the risk of hair getting in food for any resident the employee was preparing food for, or from the area the employee was working in, when not wearing protective hair coverings. Findings include: During an observation on 5/19/25 at 8:50 a.m., staff member H was preparing four individual residents' breakfast trays on the countertop located in the 500-hall kitchen area. Staff member H was wearing a hairnet but did not have a beard net covering his facial hair. During an interview on 5/19/25 at 9:04 a.m., staff member H stated he should have worn a beard net while he prepared trays in the kitchen area. Staff members E and F stated a hat or hairnet, and beard net, if indicated, must be worn to prepare food in the kitchen area. Review of the facility's document titled, Food & Nutrition Services Dress Code, last revised 8/26/24, showed: - . Hair/Nails - Generally, hair must be restrained in foodservice area's. . If your hair is over 1/4 in length, you must wear one or a combination of the following: - . Facial hair restraint for facial hair longer than 1/4 inch. [sic]

Based on interview and record review, the facility failed to provide the required SNF Beneficiary Notification, Form CMS-10055 to 1 (#111) of 3 sampled residents who received Medicare Part A skilled services. Findings include: During an interview on 5/19/25 at 2:27 p.m., staff member A stated the facility had not completed the SNF Beneficiary Notification Form CMS-10055 when resident #111 was discharged from skilled care services. Staff member A was not able to explain why the notice was not completed. Review of the facility-provided document titled, SNF Beneficiary Notification Review, showed the start date for Medicare Part A skilled services was 4/10/25, with the last covered day of 5/12/25. The facility was not able to provide evidence the SNF Beneficiary Notification Form CMS-10055 was completed.

Based on interview and record review, the facility failed to ensure call lights were answered in an appropriate timeframe for 3 (#s 5, 6, and 10) of 4 sampled residents concerning call lights; and the facility failed to prevent falls for 1 resident (#5) requiring help after pushing the call light. This had the potential to result in more falls in the facility with those residents requiring help and pushing the call light button for assistance. Findings include: a. During an interview on 10/2/24 at 10:06 a.m., resident #10 stated she would wait the longest for her call light to be answered when it was shift change or after 6:00 p.m. Resident #10 stated she would often wait 20 minutes for her call light to be answered. Resident #10 stated staff would also turn off her call light and leave the room before all her needs were met. Resident #10 stated when she had spoken up in the past to staff, and she had been reprimanded by the staff about complaining. She stated, They say they'll be back in ten minutes and they don't. And sometimes the pagers (the pagers alert the staff call lights were going off) don't work at all. They're usually aware of it, but (it) still doesn't make you feel very good. Resident #10 stated, [Pagers are not working] It seems like it happens often. Review of a facility provided document, titled Call History, dated from 9/18/24 to 10/2/24, showed resident #10 had 15 call light uses, eight of those were over 15 minutes; two were 20 minutes, two were 27 minutes, one was 32 minutes, two were over 40 minutes, and one call light wait time was for an hour. b. During an interview on 10/2/24 at 11:25 a.m., resident #6 stated she pushed the call light, 15 minutes ago and she, often waits a long time. Review of a facility provided document titled Call History, dated from 9/18/24 to 10/2/24, showed resident #6 had 14 call light uses, 13 of those were over 15 minutes, including one for an hour wait, and one for a two-hour wait time. c. During an interview on 10/2/24 at 12:10 p.m., resident #5 stated he would wait over 45 minutes to get his call light answered. Resident #5 stated in one instance he was tired of waiting and had tried to get up without staff present. Review of a nursing note in resident #5's EHR, dated 9/5/24, showed resident #5 fell on [DATE] at 12:00 p.m. Review of a facility provided document titled Call History, dated 9/4/24 to 9/5/24, showed resident #5's call light had been on for 36 minutes, starting at 11:41 a.m., on the day of the fall. Review of a facility provided document titled Call History, dated from 9/18/24 to 10/2/24, showed the resident #5's had four call light uses; two were over 15 minutes, one was over 30 minutes, and one was a 59 minute call light wait time. During an interview on 10/2/24 at 3:21 p.m., staff member A stated the expectation for call lights to be answered was seven to nine minutes.

Based on interviews and record review, the facility failed to provide a safe and orderly discharge from the facility, to home, for 1 (#1) of 3 sampled residents, and the resident had not met his goals prior to the discharge, he had a wound/fistula, multiple medications, and needed ongoing rehabilitation services. The failure increased the risk of a poor outcome and safety concerns for the resident due to his inability to care for himself as needed. Findings include: During an interview on 10/2/24 at 10:18 a.m., NF1 stated resident #1 was discharged home alone, and the family had not seen any home health services since the discharge occurred, which was eight days prior. NF1 stated resident #1 lived alone, and the family lived in the same apartment complex but were not planning to provide fulltime care to resident #1 upon discharge. NF1 stated the facility relayed they would be sending physical therapy, occupational therapy, and nursing, to assist with resident #1's care needs and training once home. NF1 stated resident #1 was not able to provide himself peri care, he could barely walk out of the hospital with a walker, and was dropped off at the street of his apartment complex. He had to walk a long distance to his apartment, and go up eleven steps, to get to the apartment. NF1 stated resident #1 barely made the walk, with many stops along the way, and he had the assistance of NF2 holding him. NF1 stated the family was unsure of the resident's medications, with more than 30 pills to be taken at various times and were in fear of causing a medication error. NF1 stated resident #1 was falling at the facility and was again falling at home after discharge. NF1 stated she had attempted to get the primary care provider initial appointment moved up to a closer date, but was told there were no appointments sooner. NF1 stated she also contacted the home health agency and was told they could not assist resident #1 until the 10/8/24 appointment, because they needed orders to treat from the new primary provider. NF1 stated she contacted the facility, and spoke with staff member C, who told her the facility could no longer assist resident #1, because he was no longer a resident in the facility. During an interview on 10/2/24 at 11:41 a.m., NF2 stated resident #1 was barely able to walk out of the facility with a walker, and the nurse was concerned about resident #1 needing a wheelchair. NF2 stated resident #1 was now wheelchair bound at home and he was trying to assist resident #1 with his walker to get him some strength. NF2 stated resident #1 stated when he cannot see his legs, he cannot walk. NF2 stated he was assisting resident #1 with diabetic pressure wounds on his feet, that he had on discharge from the facility, by using iodine soaks. NF2 stated he had the idea to use iodine soaks from resident #1, who had used iodine soaks on his prior pressure ulcers. NF2 stated there were no wound care or fistula instructions provided in the discharge paperwork. During an interview on 10/2/24 at 11:49 a.m., NF3 stated she attended a care conference to discuss resident #1's discharge plans. NF3 stated staff member C began to become angry and was blaming resident #1 for not getting the care he needed prior to discharge. NF3 stated staff member C was mad because the family was asking too many questions about the discharge plan. During an interview on 10/2/24 at 1:20 p.m., with staff member A and C, staff member C stated the required elements for a discharge included the resident meet their prior level of ADL status or their new baseline, based on their diagnosis; the resident would need a safe place to discharge to; and we would try to get a home evaluation, if possible. Staff member C stated her role was to set-up the home health, physical therapy, and occupational therapy. Staff member C stated she did send a referral for services for resident #1 and was not aware the services were never started. Staff member C stated she did not follow-up with the residents or family following a discharge from the facility, and did not the contact referral agency to confirm services would be in place for discharge. Staff member C stated the family of resident #1 was not pleasant to work with, and the agency usually contacted the family or resident directly to start care. During an interview on 10/2/24 at 1:55 p.m., resident #1 stated he had current swelling at his fistula site and down his arm with a pain level of a 5-6 out of 10. Resident #1 stated he had reported pain and swelling when he was in the facility, and the facility said he would need to talk to his primary provider on the 10/8/24 appointment. Resident #1 stated the parking lot (at his residence) was under construction, and he nearly had a fall getting to his apartment, and NF2 had to catch him. Resident #1 stated he was still very weak, had no balance, and my brain is still messed up [confusion and foggy]. Resident #1 stated the facility tried to say he was refusing therapy, but he never did. Resident #1 stated the facility even made him get up at 6:00 a.m. and miss breakfast to do therapy. Resident #1 stated he was not a morning person, but he did the therapy so he could get better. During an interview on 10/2/24 at 4:21 p.m., NF4 stated the facility was aware of the regulations requiring the primary physician to write orders for services provided after the discharge. NF4 stated the agency could not start services until the 10/8/24 appointment with the new primary physician, so new orders could be written for services. NF4 stated she did not know why the facility discharged the resident prior to the appointment. Review of resident #1's After Visit Summary, dated 9/24/24, reflected the following: - A follow-up appointment with the new primary physician was scheduled for 10/8/24, - Follow-up with Home Health for skilled nursing, physical therapy, and occupational therapy, - Medication orders with medications to be picked up at pharmacy. The After Visit Summary did not contain wound care orders for the diabetic wound care to the left foot or treatment/care of the fistula. Review of resident #1's Occupational Therapy Discharge Report, dated 9/23/24, reflected resident #1 had not met the following goals: - Safely completing grooming tasks progressing from seated tasks to standing; - Safely perform toilet transfer and toileting tasks using standard commode and grab bars; - Safely perform bathing tasks; - Demonstrate improved ADL safety by increasing Modified Barthel score from 37 to 80 or better to safely return home with least restrictive assist. The Occupational Therapy Discharge report showed the recommendation included home health occupational therapy. Review of resident #1's Physical Therapy Discharge Report, dated 9/23/24, reflected the assessing physical therapist recommended, . continued physical therapy intervention via home health services to ensure safe transition into prior level of living and continue to maximize functional gains. Review of resident #1's Physician Discharge Summary, dated 9/24/24, reflected the follow: - Resident #1 was homebound, requiring skilled home health services; - The physical therapy content showed, . the patient does not believe he feels prepared to discharge home; - Wound care needs for diabetic wounds; - PT and OT were recommended. The facility failed to ensure necessary services, including skilled nursing, physical therapy and occupational therapy were in place prior to discharging resident #1 home alone, putting resident #1 at risk for a negative outcome.