Every finding on record at Bethany Rehab & HCC

Based on interview and record review the facility failed to process and administer an ordered antibiotic for a resident. This applies to one of three residents (R1) in the sample of three reviewed for medications. This past compliance occurred from 7/13/26 to 7/22/26.The findings include:The facility face sheet for R1 shows diagnoses to include but not limited to Type 2 Diabetes Mellitus, obesity, chronic obstructive pulmonary disease and urogenital implants. The facility assessment dated [DATE] shows R1 is cognitively intact and requires extensive assistance with his activities of daily living.On 8/4/26 at 9:06 AM, R1 said he was supposed to be started on an antibiotic before his cystoscopy procedure (a urological procedure that shows the urinary bladder and tubes), but the nurses didn't get the medication, so my procedure had to be cancelled. The after-visit summary dated 7/13/26 shows R1 was to start an antibiotic (Fosfomycin) prior to a procedure on 7/21/26.A nursing note dated 7/21/26 shows the nurse received a call from the hospital regarding R1, stating the cystoscopy was cancelled due to R1 not receiving the ordered antibiotic.On 8/4/26 at 11:28 AM, V3 (Assistant Director of Nursing/ADON) said the nursing staff did not catch the order for the antibiotic on the after-visit summary.On 8/4/26 at 12:24 PM, V4 (Registered Nurse/RN) said when a resident comes back from an appointment, the after-visit summary should be reviewed and checked for new orders. The new orders should then be processed right away.On 8/4/26 at 12:30 PM, V5 (RN) said all new orders should be processed right away after receiving them. On 8/4/26 at 2:20 PM, V2 (Director of Nursing/DON) said she expects the nursing staff to process all new medication orders immediately after receiving them.The POS (Physician Order Sheet) dated August 2026 shows an order for the antibiotic Fosfomycin 3 grams orally every other evening for periurethral abscess dated 7/31/26.The facility reported they did not have a policy regarding transcribing Physician orders.Prior to the survey of 8/4/26, the facility had taken the following action to correct the noncompliance:Past Noncompliance - Medication ErrorOn 07/22/2026:The facility identified past noncompliance related to a medication error in which medication administration was not completed in accordance with the prescriber's order and/or accepted standards of practice. Upon identification of the concern, the resident was assessed, the physician and responsible party were notified as indicated. Procedure was delayed and rescheduled.Root Cause AnalysisA root cause analysis was conducted by the Director of Nursing and the QAPI Committee. The analysis identified the primary contributing factor was failure to enter the physician order.Immediate corrective action was implemented at the time the concern was identified. The licensed nurse involved was re-educated regarding the facility's medication administration policy, including verification of the resident, medication, dose, route, time, documentation, and review of medication orders prior to administration. The medication administration record and physician orders were reviewed to ensure accuracy and to confirm that ordered medications were available and administered as prescribed.To address the potential for systemic concerns, nursing leadership completed education with licensed nursing staff regarding medication error prevention, timely reporting of medication errors, documentation requirements, and notification procedures. Medication pass observations and medication record audits were initiated to validate ongoing compliance with facility policy and regulatory expectations.The Director of Nursing or designee will continue to monitor medication administration practices through audits and direct observations. Audit findings will be reviewed through the facility's QAPI process to identify trends, ensure sustained compliance, and implement additional corrective action as needed.

Based on interview and record review, the facility failed to report allegations of abuse immediately for one of seven residents (R1) reviewed for abuse in the sample of seven. This failure has the potential to affect all 58 residents that reside in the facility. This past noncompliance occurred from 6/29/26 to 6/30/26.The findings include:The facility Data Sheet dated 7/13/26 shows facility total census of 58.R1's admission Record shows that R1 was recently admitted to the facility on [DATE] with diagnoses including epilepsy, noncompliance with other medical treatment, morbid obesity, major depressive disorder, anxiety disorder, insomnia, and personality disorder. On 7/13/2026 at 9:37 AM, V1 (Administrator) said R1 was a resident for a short time prior to her allegations against V3 (Certified Nursing Assistant/CNA). V1 said that she was notified of a sexual abuse allegation regarding R1 and V3. V1 said R1 reported the allegation to V4 (Registered Nurse/RN) during night shift. V1 said police were notified and two detectives arrived at the facility. At 1:38 PM, V1 said that if staff get a report of abuse, the staff should make sure the residents are safe and notify the administrator immediately. On 7/13/2026 at 1:21 PM, V4 (RN) said she went into R1's room to change her incontinence brief at about 4:00 AM when R1 said that V3 (CNA) inserted his finger into her vagina when he was changing her. V4 said that R1 did not show any signs of distress. V4 said that R1 was not in distress. V4 said that V3 was on a break when the allegation was brought to her attention. V4 said she thought that V3 came back to the facility at about 4:30 AM. V4 said that V3 did not go back into R1's room but was taking care of residents until 6:00 AM at the end of the hallway after the allegation was reported to V4. V4 said she called the on-call nurse manager at about 6:15 AM. V4 said she did not report the allegation immediately because she had never been in that situation before. V4 said since the incident, she has been educated that any abuse allegation should be reported immediately. V4 said that V3 was not removed from resident care immediately after the allegation, Now I feel like I should have removed him from resident cares. On 7/13/2026 at 1:57 PM, V2 (Director of Nursing/DON) said that if floor staff receive an allegation of abuse, then it should be reported to V1 Administrator immediately. V2 said that V4 reported the allegation to the on-call nurse manager, the nurse manager reported the allegation to V2 and V2 notified V1. On 7/14/26 at 10:35 AM, V5 (Certified Nursing Assistant/CNA) said if a resident reports an allegation of abuse, the administrator should be told immediately. The facility's Abuse, Prevention and Prohibition Policy dated November 2025 shows, The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknow origin or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or his/her designated representative in the Administrators absence.Prior to the survey date of 7/14/26, the facility had taken the following action to correct the noncompliance:1. Corrective action which will be accomplished for those residents found to have been affected by the deficient practice:a. The facility staff were re-educated regarding abuse prevention, identification, reporting requirements, resident rights, mandatory reporting timelines, preservation of evidence, resident protection, and immediate interventions required following any allegation of abuse with return demonstration.b. The agency CNA was DNR' d from [NAME] Rehab. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice:All residents have the potential to be affected by the alleged deficient practice.The Administrator, or designee, completed interviews with residents who were able to participate, reviewed incident reports, abuse allegations, staffing assignments, and grievance documentation to determine whether any additional residents may have been affected. No additional residents were identified as requiring follow-up related to this allegation. 3. The measures the facility will take or systems the facility will alter to ensure that the problems will be corrected and will not recur:The Director of Nursing, or designee, provided education to all licensed nurses, certified nursing assistants, department managers, and ancillary staff regarding the facility's Abuse Prevention Program, with emphasis on recognizing, preventing, immediately reporting, and responding to allegations of abuse, including sexual abuse. Education also included resident protection measures, mandatory reporting requirements, documentation expectations, and timely notification of facility leadership and regulatory agencies.The facility reviewed the Abuse Prevention Policy, investigation procedures, employee reporting expectations, and staff orientation process. Existing policies and procedures were determined to adequately address abuse prevention; therefore, no revisions to the policy were necessary. Leadership reinforced definitions of sexual abuse. 4. Quality Assurance Plans to monitor facility performance to ensure corrections are achieved and are permanent:a. The Administrator and/or Director of Nursing will audit all abuse allegations and investigations weekly for four weeks to ensure allegations are immediately reported, resident protection measures are implemented, required notifications are completed timely, investigations are initiated promptly, and appropriate follow-up actions are documented.b. Any concerns identified during the audits will be immediately addressed through additional education and corrective action as appropriate. Audit findings and trends will be reviewed through the QAPI process to ensure ongoing compliance and sustainability.Completion Date: 6/30/26

Based on interview and record review, the facility failed to ensure staff were removed from resident care after an allegation of abuse was received for one of seven residents (R1) reviewed for abuse in the sample of seven. This failure has the potential to affect all 58 residents that reside in the facility. This past noncompliance occurred from 6/29/26 to 6/30/26. The findings include:The facility Data Sheet dated 7/13/26 shows facility total census of 58.R1's admission Record shows that R1 was recently admitted to the facility on [DATE] with diagnoses including epilepsy, noncompliance with other medical treatment, morbid obesity, major depressive disorder, anxiety disorder, insomnia, and personality disorder.On 7/13/2026 at 1:21 PM, V4 (RN) said she went into R1's room to change her incontinence brief at about 4:00 AM when R1 said that V3 (CNA) inserted his finger into her vagina when he was changing her. V4 said that R1 did not show any signs of distress. V4 said that R1 was not in distress. V4 said that V3 was on a break when the allegation was brought to her attention. V4 said she thought that V3 came back to the facility at about 4:30 AM. V4 said that V3 did not go back into R1's room but was taking care of residents until 6:00 AM at the end of the hallway after the allegation was reported to V4. V4 said she called the on-call nurse manager at about 6:15 AM. V4 said she did not report the allegation immediately because she had never been in that situation before. V4 said since the incident, she has been educated that any abuse allegation should be reported immediately. V4 said that V3 was not removed from resident care immediately after the allegation, Now I feel like I should have removed him from resident cares.On 7/13/2026 at 9:37 AM, V1 (Administrator) said R1 was a resident for a short time prior to her allegations against V3 (Certified Nursing Assistant/CNA). V1 said that she was notified of a sexual abuse allegation regarding R1 and V3. V1 said R1 reported the allegation to V4 (Registered Nurse/RN) during night shift. V1 said police were notified and two detectives arrived at the facility. At 1:38 PM, V1 said that if staff get a report of abuse, the staff should make sure the residents are safe, and the alleged staff member should be removed from residents.On 7/13/2026 at 1:57 PM, V2 (Director of Nursing/DON) said if an allegation of abuse is received, then the staff member should immediately leave the facility pending the investigation.On 7/14/26 at 10:35 AM, V5 (Certified Nursing Assistant/CNA) said if a resident reports an allegation of abuse, the alleged staff member should be removed immediately until the investigation is done.The facility's Abuse, Prevention and Prohibition Policy dated November 2025 shows, When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation. Prior to the survey date of 7/14/26, the facility had taken the following action to correct the noncompliance:1. Corrective action which will be accomplished for those residents found to have been affected by the deficient practice:a. The facility staff were re-educated regarding abuse prevention, identification, reporting requirements, resident rights, mandatory reporting timelines, preservation of evidence, resident protection, and immediate interventions required following any allegation of abuse with return demonstration.b. The agency CNA was DNR'd from [NAME] Rehab. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice:All residents have the potential to be affected by the alleged deficient practice.The Administrator, or designee, completed interviews with residents who were able to participate, reviewed incident reports, abuse allegations, staffing assignments, and grievance documentation to determine whether any additional residents may have been affected. No additional residents were identified as requiring follow-up related to this allegation. 3. The measures the facility will take or systems the facility will alter to ensure that the problems will be corrected and will not recur:The Director of Nursing, or designee, provided education to all licensed nurses, certified nursing assistants, department managers, and ancillary staff regarding the facility's Abuse Prevention Program, with emphasis on recognizing, preventing, immediately reporting, and responding to allegations of abuse, including sexual abuse. Education also included resident protection measures, mandatory reporting requirements, documentation expectations, and timely notification of facility leadership and regulatory agencies.The facility reviewed the Abuse Prevention Policy, investigation procedures, employee reporting expectations, and staff orientation process. Existing policies and procedures were determined to adequately address abuse prevention; therefore, no revisions to the policy were necessary. Leadership reinforced definitions of sexual abuse. 4. Quality Assurance Plans to monitor facility performance to ensure corrections are achieved and are permanent:a. The Administrator and/or Director of Nursing will audit all abuse allegations and investigations weekly for four weeks to ensure allegations are immediately reported, resident protection measures are implemented, required notifications are completed timely, investigations are initiated promptly, and appropriate follow-up actions are documented.b. Any concerns identified during the audits will be immediately addressed through additional education and corrective action as appropriate. Audit findings and trends will be reviewed through the QAPI process to ensure ongoing compliance and sustainability.Completion Date: 6/30/26

Based on interview and record review the facility failed to notify the physician of R2's critical low blood glucose for a resident with history of critical glucose levels and recent diabetic medication changes for 1 of 13 residents (R2) reviewed for physician notification in the sample of 13. This failure resulted in R2 being found with a critical low blood glucose then R2's heart stopping.The Immediate Jeopardy began on (05/09/2026) when R2's critical low blood sugar was not reported to the physician. V1 Administrator was notified of the Immediate Jeopardy on 06/17/2026 at 3:38PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 06/17/2026 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:R2's Physician Orders dated 05/08/2026 shows, call physician if Blood Sugar is less than 70 milligrams per deciliter or greater than 401 milligrams per deciliter.R2's Vital Sign record dated 05/09/2026 at 7:43AM, shows R2's Blood Glucose was critical low at 55 milligrams per deciliter.R2's Medical Record shows, No physician notification of R2's 05/09/2026 critical low blood sugar.R2's Ambulance Patient Care Record dated 05/10/2026 at 6:55AM, shows, R2 Vital Signs: unable to obtain a blood pressure, no pulse, no respirations, unable to obtain a blood oxygen level. R2's Death Certification shows, Time of Death 05/10/2026 at 7:44AM.R2's Physician Note by V6 DO-Doctor of Osteopathic Medicine, dated 05/10/2026 at 7:48 AM, shows, R2 blood sugar was 32 milligrams per deciliter. R2 sent urgently to the Emergency Department. On 06/16/2026 at 10:03AM, V10 RN-Registered Nurse said on 05/09/2026 R2 did not have any signs or symptoms of low blood sugar. R2 would not get up out of bed. I gave R2 oral glucose and performed another blood sugar check and then gave another thing of oral glucose. R2 ate 25% of breakfast. I administered glucagon intramuscularly and sent R2 to dialysis. The dialysis center was not ready to give R2 dialysis and R2 was sent back to the facility. I gave R2 a drink of juice and started a dextrose intravenous drip in the midline catheter. The power of attorney for health care was notified and was OK with the situation. V3 Nurse Practitioner was in the facility and made aware. I used the facility's standing orders to administer the medication I provided.R2's Medication Administration Record dated May 9, 2026, did not show V10's interventions of oral glucose, intermuscular glucagon, intravenous midline dextrose drip, or notification of V3 Nurse Practitioner.On 06/16/2026 at 10:22AM, V3 NP-Nurse Practitioner said, I was not notified about R2's critical low blood sugar (05/09/2026). I was not in the facility during that time. Many will write they told me, but that is throwing me under the bus, V10 RN did not tell me. There would be orders for an intervention, 15-minute re-check, update physician, and orders for blood glucose monitoring every 2 hours. If I was told, where are my recommendations? Where is the standing order for low blood sugar the nurse claims to follow? If notified that morning (05/09/2026) of a critical low, I would have revised R2's insulins. The last time I wrote orders on R2 was for hyperglycemia (high blood glucose/sugar). I increased R2's insulin. R2's blood sugar was critically high at 398. A normal fasting blood glucose level is 70-100. The long-acting insulin R2 received before bedtime will cause low blood glucose in the morning.R2's MAR-Medication Administration Record dated 05/09/2026 at 9:00PM, shows R2 received 10 units of long-acting insulin.On 06/16/2026 at 11:15AM, V4 RN-Registered Nurse said, a glucose of 55 is critical low, we must call the doctor. The interventions are based on the physician's order.On 06/22/2026 at 10:51AM, V6 DO said, R2 was discharged from the facility when the staff reported the blood sugar of 32 to me. I was not contacted to provide treatment orders. The call was letting me know R2 had been discharged from the facility. V7 RN and V13 CNA-Certified Nursing Assistant, the staff assigned to care for R2 on 05/10/2026, were not available for interview during the survey. On 06/17/2026 at 3:22PM, V2 DON-Director of Nursing said, the facility does not have a policy for the staff to follow when residents have a critical low blood sugar.The Immediate Jeopardy that began on 05/09/2026, was removed on 06/17/2026 , when the facility took the following actions to remove the immediacy.A house-wide review of all current residents with blood glucose monitoring was completed to ensure the existence of orders of glucagon were present. Completed 6/17/2026.A house wide review of all current residents with blood glucose monitoring was completed to ensure no other critical values requiring physician notification. Completed 6/17/2026.All licensed nurses were immediately re-educated on change in condition and physician notification requirements. Emphasis on timely reporting of abnormal/critical blood glucose results, timeframes and documentation standards. Complete 6/17/2026The facility reinforced change in condition and clear parameters for physician notification of blood glucose results, including defined critical values and required escalation timeframes. Completed 6/17/2026.The facility initiated a 100% audit of all diabetic residents receiving insulin to ensure blood sugar parameters were in place and glucagon orders are in place. Completed 6/17/2026.The facility initiated a 100% audit of all blood sugar results to ensure abnormal/critical values are timely reported to the physician and documented appropriately. Completed 6/17/2026.Audits will occur daily for 14 days then weekly for four weeks then monthly through QAPI.The Director of nursing/designee will review all abnormal glucose results and corresponding physician notifications daily to ensure compliance (monitoring during clinical QA meeting).An Ad Hoc QAPI meeting will be held 6/18/2026 with medical director and team.

Based on interview and record review the facility failed to monitor a resident's blood glucose levels for a resident with history of critical blood glucose levels and recent diabetic medication changes for 1 of 13 residents (R2) reviewed for Quality of Care in the sample of 13. This failure resulted in R2's blood sugar becoming critically low then R2's heart stopped.The Immediate Jeopardy began on ([DATE]) when R2's critical low blood sugar was not reported to the physician; the facility failed to develop a treatment plan with R2's physician for the critical low blood sugar. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 3:38PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE]. Non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:Normal fasting Blood Glucose/sugar level is 70mg/dl milligrams per deciliter to 100mg/dl (70-100).R2's Face Sheet on [DATE] shows, R2 had multiple diagnoses including Diabetes Mellitus treated with fast acting and long-acting insulin.R2's Vital Sign record dated [DATE] at 7:43AM, shows R2's Blood Glucose was critical low at 55.R2's Medical Record on [DATE] shows no interventions to treat R2's [DATE] critical low blood sugar or Physician notification of R2's [DATE] Critical low blood glucose at 7:43AM.R2's Vital Sign record shows, No Assessment of R2's blood sugar after 5:03PM, on [DATE].R2's Ambulance Patient Care Record dated [DATE] at 6:55AM, shows, R2's Vital Sign: unable to obtain a blood pressure, no pulse, no respirations, unable to obtain a blood oxygen level. R2's Death Certification shows, Time of Death [DATE] at 7:44AM.R2's Physician Note dated [DATE] at 7:48 AM, shows, R2's blood sugar was 32.On [DATE] at 10:03AM, V10 RN-Registered Nurse said, on [DATE] R2 did not have any signs or symptoms of low blood sugar. R2 would not get up out of bed. I gave R2 oral glucose and performed another blood sugar check and then gave another thing of oral glucose. R2 ate 25% of breakfast. I administered glucagon intramuscularly and sent R2 to dialysis. The dialysis center was not ready to give R2 dialysis and R2 was sent back to the facility. I gave R2 a drink of juice and started a dextrose intravenous drip in the midline catheter. The power of attorney for health care was notified and was OK with the situation. V3 Nurse Practitioner was in the facility and made aware. I used the facility's standing orders to administer the medication I provided.R2's Medication Administration Record dated [DATE], did not show V10's interventions of oral glucose, intermuscular glucagon, intravenous midline dextrose drip, or notification of V3 Nurse Practitioner.On [DATE] at 10:22AM, V3 NP-Nurse Practitioner said, I was not notified about R2's critical low blood sugar ([DATE]). I was not in the facility during that time. Many will write they told me, but that is throwing me under the bus, V10 RN did not tell me. There would be orders for an intervention, 15-minute re-check, update physician, and orders for blood glucose monitoring every 2 hours. If I was told, where are my recommendations? Where is the standing order for low blood sugar she is claiming to follow? If notified that morning ([DATE]) of a critical low, I would have revised R2's insulins. The last time I wrote orders on R2 was for hyperglycemia (high blood glucose). I increased R2's insulin. R2's blood sugar was critically high at 398 milligrams per deciliter. A normal blood glucose level is 70-100milligrams per deciliter. The long-acting insulin R2 received before bedtime will cause low blood glucose in the morning. Long-acting insulin given at 9:00PM, will peak at 3:00AM. Where is the glucose check for 9:00PM, insulin? The blood glucose level must be assessed prior to giving any type of insulin.R2's Vital Sign Record shows no blood sugar check on [DATE] at 9:00PM, prior to insulin administration.R2's Vital Sign Record on [DATE] shows, R2's last blood sugar check was documented on [DATE] at 5:03PM.R2's MAR-Medication Administration Record dated [DATE] shows, at 9:00PM, R2 received 10 units of long-acting insulin.On [DATE] at 11:15AM, V4 RN-Registered Nurse said, a glucose of 55 is critical low, we must call the doctor. The interventions are based on the physician's order. The nurse can place verbal orders in the chart for the physician, or the physician can write the orders directly into the chart, remotely if needed. The resident's blood sugar level is checked before meals. If the resident is given insulin before bed the glucose is checked.On [DATE] at 10:51AM, V6 DO-Doctor of Osteopathic Medicine said, on [DATE], I was told R2 had blood glucose of 32 milligrams per deciliter. R2 was sent out urgently. Fasting blood glucose is 70 milligrams per deciliter to 120 milligrams per deciliter. The body cannot go for a prolonged period of time without glucose.On [DATE] at 9:40AM, V8 Medical Director agreed, the heart muscle needs glucose; along with other factors, in theory, after a prolonged period without glucose the heart will stop.On [DATE] at 3:22PM, V2 DON-Director of Nursing said, the facility does not have a policy or protocol for the staff to follow for residents with critical low blood sugar. We are able to provide basic CPR. We do not have emergency medications; we do not have intravenous glucose. V7RN and V13 CNA-Certified Nursing Assistant, the staff assigned to care for R2 on [DATE], were not available for interview during the survey. The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy.A house-wide review of all current residents with blood glucose monitoring was completed to ensure the existence of orders of glucagon were present. Orders were added for any resident not noted to have order. Completed [DATE]All residents will have blood glucose monitored prior to administration of insulin. Orders to reflect glucose monitoring.All licensed nurses were immediately re-educated on change in condition and physician notification requirements, with emphasis on timely reporting of abnormal/critical blood glucose results, required timeframes and documentation standards. Education included verbal competencies. Completed [DATE]All licensed nurses have been educated on hyper/hypo glycemic events to include notifying the physicians, following the physician's orders, increased blood sugar check, monitoring of side effects when medications are changed and critical thinking. Completed [DATE]Licensed staff will not be permitted to work until education is complete.The facility reinforced change in condition and clear parameters for physician notification of blood glucose results, including defined critical values and required escalation timeframes. Completed [DATE].The facility initiated a 100% audit of all diabetic residents receiving insulin to ensure blood sugar parameters were in place and glucagon orders are in place. Completed [DATE].The facility initiated a 100% audit of all blood sugar checks results to ensure abnormal/critical values are timely reported to the physician and documented appropriately. Completed [DATE].Audits will occur daily for 14 days, weekly for four weeks then monthly through QAPI.The Director of Nursing/designee will review all abnormal glucose results and corresponding physician notifications daily to ensure compliance (monitoring during clinical QA meeting).Ad Hoc QAPI meeting will be held [DATE] with medical director and team.

Based on observation, interview, and record review the facility failed to report an allegation of abuse for 1 of 18 residents (R1) reviewed for abuse in the sample of 18.The findings include: On 06/15/2026 at 12:30PM, R1 was sitting on the side of the bed with an incontinent brief and strong odor of urine.On 06/15/2026 at 12:30PM, R1 said, the staff do not answer lights. The staff have talked mean to me in the past. I do not know their names; they have no name tags.On 06/16/2026 at 12:30PM, V5 Housekeeping said, R1 was in the bathroom with the call light on. V9 CNA was in another resident's room with the other CNA. I told V9 CNA one of the residents needed help. V9 CNA asked if it was the small one or the fat one. I said, the larger person. Both CNAs laughed, I walked away. I did not need to report the incident. R1's nurse overheard what V9 CNA was saying. The nurse confronted V9. The nurse was going to report V9's actions. Then V9 got loud and started cursing at the nurse. I do not remember who the nurse is. On 06/16/2025 at 12:46PM, V1 Administrator said, I do not know the nurse or the day it happened. It will be challenging to figure out what nurse was on duty. I first heard about V9 CNA and R1 yesterday (06/15/2026) during the State Agency complaint investigation. The facility Abuse Prevention and Prohibition policy dated November 2025 shows, resident abuse must be reported immediately to the administrator. The facility employee or agent, who becomes aware of abuse or neglect.shall immediately report the matter to the facility Administrator.

Based on interview and record review the facility failed to identify pressure ulcers prior to an advanced stage, failed to accurately assess the pressure ulcers and failed to put interventions in place to prevent further skin breakdown for two residents R1 and R3. These failures resulted in R1 developing an unstageable pressure injury to her sacrum on 3/19/26 and R3 developing a pressure injury containing slough (devitalized tissue) to his sacrum on 5/9/26.The findings include: 1.R1's Physician's Order Sheet dated May 2026 shows that she was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Type 2 Diabetes Mellitus, Mild Cognitive Impairment and Dependence on Renal Dialysis. R1's Skin assessment dated [DATE] shows new skin Issue. Location: Sacrum. Issue type: Moisture associated skin damage (MASD). Progress: New: new wound. MASD: IAD Incontinence Associated Dermatitis. Wound acquired in-house. It is unknown how long the wound has been present. Length 5.7 Width 3.83 (cm) Granulation: 70%. Slough: 30%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Additional care: Pressure reducing device for chair. Additional care: Nutrition / dietary supplementation. R1's next Skin assessment dated [DATE] shows Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Stalled: previously improving wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure ulcer / injury. Unstageable ulcer due to slough and / or eschar. Wound acquired in-house. It is unknown how long the wound has been present. Length 5.95 Width 4.28 (cm) Granulation: 50%. Slough: 10%. Eschar: 40%. Exudate amount: Light. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Additional care: Nutrition / dietary supplementation.R1's Initial Wound Physician Assessment (done by V6 (Previous Wound Nurse Practitioner) dated 4/7/26 (19 days after wound identified) states, The patient presents today for an initial visit with wounds on the sacrum . The provider has recommended the patient receives NUTRITIONAL SUPPORT with daily supplemental protein supplied 1x daily with a meal. The provider recommends the patient is consulted by a dietitian and food intake is monitored, with intermittent re-evaluations as needed to optimize nutritional status for wound healing . This wound assessment shows the wound is 11-20% adherent yellow slough and 71-80% Moist Black Eschar measuring 6.65 x 7 x 0.1 cm. On 5/22/26 at 1:00PM V3 (RN- Wound Care) stated, (R1) stopped eating and drinking. We turned her and no matter what we did her skin continued to break down. Her albumin was awful. She was incontinent of bowel and bladder- it was a hard area to keep clean. At first the wound bed was moist- it was MASD (moisture associated skin damage) not pressure- we changed the dressing daily and monitored her. She was very immuno-compromised, she was referred to the dietitian, she was just not eating. The wound nurse practitioner doesn't see residents for MASD. Then I think he didn't see her because she was at dialysis. We got a new wound nurse practitioner just a couple weeks ago.On 5/22/26 at 2:05PM V4 (Wound Nurse Practitioner) stated, I saw (R1) twice. The last time I was there she was in the hospital. The time before that she had just come back from dialysis and she was wiped out. She needed to be fed but I am not sure how well she could eat after dialysis. The first time I saw her I asked if she had everything she needed, like supplements and such and I was told yes. I do not know when that stuff was ordered. When I saw the dressings after dialysis, they were saturated, but I would expect that as the wounds were draining so much. If the original assessment had slough, then it was not MASD. I have seen MASD with pressure underneath but if there was slough then that is not MASD, that is pressure.The dietary notes dated 3/31/26 state, RD Dialysis/Weight Review: Ht: 66 in, Wt: 143.4 lb (3/25), BMI: 23.1 which is classified as WNL. Wt down 2.2% in 1 month (not significant), wt down 13.2% in 3 months (significant), and wt down 12.5% in 6 months (significant). Current diet is regular diet, regular texture, and regular consistency. Meal intakes generally 0-100% per intake record. No concerns with dialysis noted at this time. Per progress notes, resident with MASD of sacrum. Meds and labs reviewed. Recommend continuing current diet and encourage intake. Recommend adding Renal Supplement - 1 carton once daily. Recommend adding 30 mL Liquid Protein BID. RD to continue monitoring monthly weights and labs as available. Refer to RD as needed. R1's Physician Note dated 4/16/26 states, Abnormal weight loss: weight loss, with a decrease from 143.4 lbs on 3/25/2026 to 119.8 lbs on 4/13/2026, ordered daily weight, dietitian and nutritionist consults and labs . The dietary note dated 4/21/26 states, RD Dialysis/Weight/Wound Review: Ht: 66 in, Wt: 115.6 lb (4/21), BMI: 18.7 which is classified as underweight for age. Wt down 20.1% in 1 month (significant), wt down 30.7% in 3 months (significant), wt down 29.1% in 6 months (significant). Current diet is regular diet, regular texture, and regular consistency. Meal intakes generally 0-100% per intake record. Resident recently admitted to hospice and dialysis was stopped, however, hospice was revoked per family decision. Per progress notes, resident with stage IV pressure wound of sacrum (stable) . Recommend continuing current diet and encourage intake. Recommend adding Renal Supplement - TID/three times a day. Recommend adding 30 mL Liquid Protein TID, 1 packet Arginaid BID/twice a day, and start renal multivitamin to aid in wound healing. Recommend referring MD to poor appetite and possible need for appetite stimulant. Continue daily weights. RD to continue monitoring monthly weights and labs as available. Refer to RD as needed. R1's Physician's Order Sheet dated May 2026 shows that Liquid Protein 30ml three times a day and Arginaid (Wound Healing Supplement) twice a day were not ordered until 5/8/26. (38 days after the dietitian's initial recommendation and 31 days after the wound nurse practitioner's initial recommendation) On 5/22/26 at 3:25PM V2 (Interim Director of Nursing), The dietitian comes in once a month, and she writes her notes, and we email them to the doctor with her recommendations and then we get orders from the doctor. On 5/22/26 V5 (Dietitian) was called for an interview, and a message was left but no return call was received prior to the exit of this survey. 2.R3's Physician's Order Sheet dated May 2026 shows that R3 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart and Chronic Kidney Disease, Type 2 Diabetes mellitus and Chronic Obstructive Pulmonary Disease. R3's Skin assessment dated [DATE] done by V4 (Wound Nurse Practitioner) shows that R3 had no open wounds. R3's Skin assessment dated [DATE] shows, New skin Issue. Location: Buttocks Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. It is unknown how long the wound has been present. Length: 2.49 Width 5.71 Granulation: 30%. Slough: 40% (70%?) Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Other wound bed: pink or red. Surrounding tissue: Fragile. Surrounding tissue: Erythema. Surrounding tissue: Excoriated.On 5/22/26 at 11:30AM R3 was in bed watching TV. R3's incontinent brief was removed and R3 was positioned on his side by V3 (RN- Wound Nurse and V7 (RN). R3 had a large reddened, angry appearing area to his buttocks with a quarter sized odd shaped open area in the center over his sacrum. On 5/22/26 at 1:00PM V3 stated, Oh, why did I click slough for a stage 2? You can't have that. That must have been an error. I must have meant the rest was pink and epithelial tissue. (To equal 100% of wound bed). I don't know how long the wound has been there, so I always write that I do not know how long, that was just my first assessment. The facility policy entitled Pressure Ulcer/Pressure Injury Prevention revised on 3/2022 states, Interventions for the prevention of pressure ulcer/pressure injury will be individualized to meet the specific needs of the resident. Interventions will consider the assessment of risk and skin condition of the resident. This same policy states, Consider supplementation as indicated by the assessment of the Registered Dietitian.

Based on observation, interview, and record review, the facility failed to honor resident's preference to be up for breakfast for 1 of 3 residents (R2) reviewed for resident's rights in the sample of 6.The findings include:R2's facility assessment dated [DATE] shows she has no cognitive impairment-BIMS (Brief Interview for Mental Status) of 15.On 5/1/26 at 9:00 AM, R2 was in bed waiting to get up. R2 was very upset. R2 said this was the 4th time she was not up for breakfast. R2 stated she has been a resident in this facility for four years and that staff are all familiar with her daily schedule. R2 said it was her preference to be up by 6:30 AM to eat breakfast in the main dining room. R2 said staff should respect her preference. R2 said the staff that have been taking care of her lately seemed not to know her established routine.On 5/1/26 at 9:05 AM, V7 (Certified Nursing Assistant-CNA) said she was just pulled to replace R2's assigned CNA that did not show up this morning and got R2 as her resident just now. R2 will be gotten up very soon. V7 (CNA) said this was her 5th day after training.On 5/1/26 at 2PM, V3 (Assistant Director of Nursing) said R2's favorite meal is breakfast. R2 is an early get up at around 6: 30 AM, to be able to eat her breakfast in the main dining room. V3 said these past days, there have been a lot of schedule changes. R2's assigned CNA called off and was replaced by another CNA, R2 then was not gotten up before breakfast. Yesterday, an agency CNA was cancelled and was replaced by a facility CNA but could not get up R2 in time for breakfast. These schedule changes affected R2's routine for the past 4 days. Starting tomorrow, R2 will be gotten up before breakfast per her preference, it was R2's right to keep her established routine.The Facility Policy entitled Resident's Rights dated 12/24 show, each resident residing in this community has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination, or reprisal. Each resident will have autonomy and choice to the maximum extent possible about how each resident wishes to live his or her everyday life and receipt of care subject to the communities' policies and procedures

Based on observation, interview, and record review, the facility failed to ensure resident's safety during a wheelchair transport for 1 of 3 residents (R1) reviewed for safety in the sample of 6.The findings include:The Facility Reported Incident (FRI) sent to state agency with incident date of 4/5/26 (date of report as 4/6/26) shows, R1, fell when she abruptly stood up while staff were transporting her, R1 sustained laceration to forehead. R1 was sent to ED (emergency department) via ambulance for treatment and evaluation. A thorough investigation has been completed. R1, who is with impaired balance and unsteady gait requires assistance with all transfers. R1 returned to facility after the evaluation with negative x-rays and adhesive used for forehead laceration. Staff statements show R1 suddenly stood up and fell. R1's wheelchair did not have foot pedals. Fall interventions are in place and include using foot pedals on wheelchair when transporting the residents.R1's ED note dated 4/5/26 shows fall on the same level from slipping, tripping or stumbling. Cut on forehead (laceration) treated with glue.On 5/1/26 at 9AM, R1 was in her room, sitting in her wheelchair. R1 was noted to have a purplish discoloration in her mid-forehead measuring approximately 1 centimeters (cm) x 1.5 cm with no depth. When asked what happened, R1 said she was ok but cannot remember how she got the bruise. R1's leg rests were not applied to her wheelchair.On 5/1/26 at10:36 AM, V4 (Registered Nurse-RN) said she was the Nurse working last 4/5/26 in the evening shift. V4 said it was past 9PM, R1 was not in her room, she needed to check R1's blood sugar. V4 said she looked for R1. R1 was in the dining room sitting in her wheelchair. When R1 was being transported back to her room, suddenly, she fell forward, it happened so fast, not sure how she would have stood up while the wheelchair was moving. V4 said she cannot recall if R1 had foot pedals. V4 stated the foot pedals would help R1 to position her legs correctly during wheelchair transport.On 5/1/26 at 11:18 AM, V5 (Certified Nursing Assistant -CNA) said she was R1's CNA last 4/5/26. She last saw R1 around 7PM, R1 was in her wheelchair in the hallway. At around 9PM, R1's Nurse (V4) said she was looking for R1 for blood sugar check. R1 was noted in the dining room sitting in her wheelchair asleep. V5 said she was wheeling R1 back to her room when R1 put her legs to the floor and fell forward. V5 said foot pedals should have been applied in R1's wheelchair for safety. A document entitled interdisciplinary fall note dated 4/8/2026 documents, IDT Fall Note Details of fall: Resident was sitting in dining room and staff went to transport resident back to her room when R1 stood up during transport and fell. Factors contributing to fall: R1 did not have foot pedals on wheelchair. Root cause of fall: Resident stood up during transportation, did not have foot pedals. Interventions: Ensure the resident has on foot pedals for staff transport. Care plan updated, YesR1's care plan with a revision date of 7/15/25 show, R1 is at risk for falls due to deconditioning, gait and balance problem, incontinence and hearing problems, with intervention dated 2/27/2023-ensure foot pedals are on wheelchair if resident doesn't self-propel with feet. This intervention was reinitiated on the day of fall 4/5/2026.

Based on observation, interview, and record review, the facility failed to ensure residents received a shower/bath at least twice a week for 1 of 3 (R1) residents reviewed for activities of daily living (ADLs) in the sample of 5.The findings include:On 3/31/26 at 8:48 AM, R1 was lying flat in bed on a low air loss mattress. R1 said her last shower was six to seven weeks ago. R1 said they don't offer to shower her, but staff mentioned giving her a shower yesterday and didn't do it. R1 said staff later mentioned giving her a bed bath but didn't do it either. R1's hair appeared greasy, and she had dry, flaky skin on her feet.On 3/31/26 at 9:40 AM, V6, (Certified Nursing Assistant-CNA), said residents are to be showered at least twice a week.On 3/31/26 at 9:47 AM, V8, (CNA), said showers are given at least twice a week to each resident. V8 said there is a shower schedule in the shower book at the nurse's station. V8 provided the book and showed the schedule. V8 said they chart the resident showers in the resident's chart.On 3/31/26 at 1:22 PM, V2, (Director of Nursing-DON), said if the CNA offers a resident a shower and the resident refuses, the CNA should inform the nurse. The nurse should confirm with the resident they don't want their shower and should reeducate them on the benefits, etc. Then, if the resident still refuses their shower, the nurse should write a progress note indicating that. V2 said the X's on the shower sheet are non-shower days, if there is a blank, the shower was not given and wasn't documented. V2 said showers should be given twice a week. On 3/31/26 at 2:30 PM, V2 said they have no ADL/shower policy, just a guide on what should be done with showers.R1's Documentation Survey Report for February and March of 2026 shows she received a total of four showers/baths, on 02/02/26, 2/16/26, 3/5/26, and 3/12/26. No shower/bath refusals were documented in R1's chart from February to March of 2026.R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact and is dependent on staff for showers/baths. R1's admission Record dated 3/31/26 shows her diagnoses include, but are not limited to, weakness, left hand and wrist contracture, and need for assistance with personal care. R1's Order Summary Report dated 3/31/26 shows R1's shower days are Mondays and Thursdays, and if R1 refuses, nurse must educate R1, notify her Power of Attorney (POA), and document those actions.The facility's CNA Professional Orientation Guidebook (undated) under the heading Bathing shows the following: report all refusals to bathe to the nurse. You may need to re-approach the resident several times to encourage them to bathe.

Based on interview and record review, the facility failed to ensure routine dental care was provided and failed to provide transportation to an oral surgery procedure for 2 of 3 residents (R1 and R2) reviewed for dental care in the sample of 5.The findings include:1.On 3/31/26 at 8:48 AM, R1 said she needs to see an oral surgeon because a tooth needs to be pulled. R1's teeth appeared to be in poor condition. On 3/31/26 at 10:30 AM, V1, Administrator, said she spoke to R1's sister, V10, about R1's teeth. V1 said R1 needs to see an oral surgeon.R1's Progress Notes dated 4/10/26 at 11:46 AM shows R1 is set up for tooth extraction on 4/15/26 at the hospital with V11, oral surgeon. R1's primary care provider was made aware R1 needed medical clearance for the procedure and planned to see R1 on 4/11/26. R1's Progress Notes dated 4/11/26 at 9:21 AM shows staff left a voicemail informing V10 about R1's tooth extraction appointment on 5/15/26. A request for transportation was left with the former Transformation Specialist, V12. R1's Progress Notes dated 4/14/26 at 11:57 PM show no ride is scheduled, no rides are available, and R1's oral surgery procedure will be rescheduled.R1's Minimum Data Set, dated [DATE] shows she is dependent on staff to transfer from the bed to chair and chair to bed. R1's current care plan initiated on 12/22/17 shows R1 requires two staff participation and is totally dependent on transferring with a Hoyer (mechanical lift). 2. On 3/31/26 at 9:28 AM, R2 said she needs two teeth removed because the cavities have gotten too big. R2 said she has not seen the dentist because they (the facility) cannot find her a dentist. R2's teeth appeared to be in good condition. The last documented dental visit found in R2's electronic medical record (EMR) is dated 4/29/24. The facility was unable to provide documentation of a more recent dental visit for R2 after 4/29/24 and before 3/30/26.On 3/31/26 at 11:05 AM, V2, Director of Nursing (DON), said she does not know how often residents are supposed to see the dentist; she assumes at least yearly, but perhaps even every six months. V2 said the dentist comes to the facility every three months to see residents. V2 said R1 needs to have all her teeth removed and will need dentures. V2 said R2 needs to have her teeth cleaned and needs a root canal done prior to her having cancer treatments, so they need to get her set up. On 3/31/26 at 1:02 PM, V2 said there's a broken process. Once a resident is seen by the dentist and gets a follow up ordered, then they should automatically be put on the list to be seen; they shouldn't have to wait for a request to come.On 3/31/26 at 12:30 PM, V3, Social Services Director, said the residents are put on the list to be seen by the dentist if a nurse, family, or the resident requests a visit to be seen. If no one asks or requests, then the resident will not be seen; she can only add them to the list per request. V3 said she does not know how R1's transportation to see the oral surgeon did not get scheduled (in April 2025). V3 said she does not know if the facility is responsible for arranging transportation for residents' appointments, and she does not know how they arrange transportation at this time.On 3/31/26 at 1:05 PM, V9, Transportation Director, said she is responsible for making sure transportation is set up for residents' appointments. V9 said the family is not responsible for residents' transportation to appointments. V9 said the facility either needs to make transportation arrangements or the family can transport the resident if they choose. V9 said if the resident can stand and pivot, she transports them herself in the van, if they are a mechanical lift, they go by a third-party transportation service which can accommodate stretchers. V9 said there are no problems with the third-party transportation service not showing up or cancelling transportation appointments. V9 said she calls them, and they know their schedule at least several months in advance. V9 said she has never had problems with the facility's van not being available for her to transport residents to appointments. V9 said it should never happen that a resident has an appointment, and no transportation has been arranged forcing them to reschedule the appointment.The facility was unable to provide a policy or procedure for routine dental care or transportation policy.

Based on interview and record review the facility failed to ensure a gait belt was used for a resident during a transfer for 1 of 7 residents (R1) reviewed for quality of care/safety in the sample of 7.The findings include:The Grievance Form dated 2/10/26 for R1 showed R1 was upset that the certified nursing assistants (CNA) on third shift lifted her up by her arms instead of using a gait belt. R1 did not have any injuries. On 3/10/26 at 2:30 PM, V4 (Physical Therapy Assistant) stated when a resident is a one person or two person assist a gait belt should be used. V4 stated it was important for the gait belt to be used because the resident could lose their balance; it is for safety. On 3/10/26 at 3:40 PM, V1 (Administrator) stated a third shift CNA did not use a gait belt when transferring R1. The CNA held R1 up under her arms. V1 stated R1 reported it and she went to talk to her. V1 stated the CNA should have used the gait belt for the safety of the resident and themselves.The Care Plan dated 12/24/25 for R1 showed she has an activity of daily living self care deficit related to impaired balance. R1 required 1 staff participation with transfers with a gait belt.The Face Sheet dated 3/10/26 for R1 showed diagnoses including influenza, chronic obstructive pulmonary disease, type 2 diabetes mellitus, asthma, hypertension, low back pain, hyperlipidemia, obstructive sleep apnea, weakness, acute bronchitis, schizoaffective disorder, hypo-osmolality and hyponatremia, osteoarthritis, bipolar disorder, anxiety disorder, and depression.The facility's Gait Belt policy (no date) showed, always use a gait belt for one and two person transfers. They should fit snugly at the resident waist. Never chicken wing, or transfer a resident by lifting under their arms with your arms.

Based on observation, interview, and record review, the facility failed to provide medications as ordered for five of ten residents (R1, R2, R4, R5, R9) reviewed for medications in the sample of ten.The findings include:1.R1 was admitted to the facility on [DATE], with diagnoses including epilepsy, weakness, morbid obesity, contracture of left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis. R1's Medication Administration Record (MAR) dated February 1, 2026-February 28, 2026 shows orders for buspirone tablet 15 mg (milligrams) two times a day related to anxiety disorder scheduled at 9:00 AM and 5:00 PM, carbamazepine extended release tablet 100 mg give three tablets two times a day for antiseizure at 9:00 AM and 5:00 PM and two tablets by mouth at 12:00 PM, and losartan potassium 50 mg by mouth daily for high blood pressure hold if top number in blood pressure < 100. On February 23, 2026, at 11:16 AM, V4 Registered Nurse (RN) took R1's blood pressure. R1's blood pressure was 107/60. R1 complained of nausea, so V4 gave R1 an antinausea medication and said she will come back to administer the above morning medications. At 1:14 PM, V4 was asked if she had given R1 her morning scheduled medications and V4 said, No, not yet.R1's MAR shows that V4 held R1's losartan potassium although R1's blood pressure was not below the doctor's parameters to hold the medication. 2.R2's admission Record shows she was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, cognitive communication deficit, dementia, disorder of central nervous system, urinary tract infection, deep vein thrombosis, dysphagia, and major depressive disorder. R2's MAR dated February 1, 2026-February 28, 2026, shows an order for propranolol 10 mg give one tablet by mouth three times a day related to high blood pressure scheduled at 9:00 AM, 1:00 PM, and 9:00 PM, and an order for primidone 50 mg give two tablets by mouth five times a day related to disorder of central nervous system scheduled at 6:00 AM, 9:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM. On February 23, 2026, at 10:30 AM, V3 RN administered R2's 9:00 AM scheduled morning medications.3. R4's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus with unspecified diabetic retinopathy with macular edema, history of falling, pain, weakness, age related nuclear cataract, macular degeneration, dry eye syndrome, and major depressive disorder. R4's MAR dated February 1, 2026-February 28, 2026, shows an order for Preservision oral tablet (multiple vitamins with minerals) give one tablet by mouth two times a day related to type 2 diabetes with diabetic retinopathy with macular edema scheduled at 9:00 AM and 5:00 PM.On February 23, 2026, at 10:08 AM, V3 RN said she did not have R4's ordered eye vitamin.4. R5's admission Record shows he was admitted to the facility on [DATE], with diagnoses including polycythemia vera (rare chronic blood cancer) osteoarthritis, dysphagia, high blood pressure, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falling.R5's MAR dated February 1, 2026-February 28, 2026, shows orders for cyanocobalamin (a vitamin) 1000 mcg (micrograms) daily at 9:00 AM, hydroxyurea (chemotherapy medication) 500 mg give two capsules by mouth daily at 9:00 AM related to polycythemia vera, metoprolol 25 mg give 1/2 tablet at 9:00 AM and 9:00 PM every morning and bedtime related to high blood pressure, Mucinex extended release tablet 600 mg at 9:00 AM and 9:00 PM every morning and at bedtime, diltiazem 30 mg give one tablet by mouth three times a day at 9:00 AM, 1:00 PM, and 8:00 PM related to high blood pressure and heart failure, and Systane eye drops in both eyes three times a day at 9:00 AM, 1:00 PM, and 9:00 PM for dry eyes. On February 23, 2026 at 10:36 AM, V4 RN administered the above medications to R5 (over one hour late). V4 administered cyanocobalamin 50 mcg instead of the ordered 1000 mcg, gave one tablet of hydroxyurea instead of the ordered two tablets, held R5's metoprolol although there were no parameters to do so, administered Mucinex 400 mg instead of the ordered 600 mg, administered diltiazem over one hour late, and said she did not have the ordered eye drops for R5. 5. R9's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, weakness, unsteadiness on feet, dysphagia, anxiety disorder, high blood pressure, heart disease, gastro esophageal reflux disease, and osteoarthritis. R9's MAR dated February 1, 2026-February 28, 2026 shows orders for docusate sodium 100 mg two times a day for constipation at 9:00 AM and 5:00 PM, famotidine 20 mg give one tablet by mouth two times a day for acid indigestion at 9:00 AM and 5:00 PM, and metoprolol succinate tablet 25 mg give one tablet by mouth two times a day at 9:00 AM and 5:00 PM. On February 23, 2026, V4 administered R9's 9:00 AM scheduled medications at 11:00 AM.On February 23, 2026, at 3:01 PM, V5 Regional Nurse Consultant said medications should be administered within one hour before or one hour after the scheduled time. The nurse should let the doctor know if the medications are late to see if there's any new orders. Medications should only be held if there are doctor ordered parameters. If there are no parameters, then the doctor should be called. V5 said she believe artificial tears to be a facility stock medication. V5 said she also believed that eye vitamins are a facility stock medication, but if they are not, then the staff should order the medication through the pharmacy. The facility Medication Administration Schedule policy approved on November 2025 shows, Medication shall be administered according to established schedules.

Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided to residents that required assistance for three of ten residents (R9, R1, R2) reviewed for ADLs in the sample of ten.The findings include:1.R9's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, weakness, unsteadiness on feet, dysphagia, anxiety disorder, high blood pressure, heart disease, gastro esophageal reflux disease, and osteoarthritis. R9's Care Plan shows R9 has an ADL self-care performance deficit. R9 requires the assistance of one staff member with bathing, personal hygiene, and oral care. R9 has refused to be shaven, if R9 resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time.On February 23, 2026, at 1:17 PM, R9 was sitting in her wheelchair in her room. R9 had long gray hairs on her chin. R9 said, I need a shave and rubbed the hair on her chin. R9 said she likes her chin to be shaved.2. R1's admission Record shows she was admitted to the facility on [DATE], with diagnoses including epilepsy, weakness, morbid obesity, contracture of left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis. R1 Care Plan shows R1 has an ADL self-care performance deficit. R1 has a contracture to her left hand. R1 requires assistance with one staff member for bathing, personal hygiene, and oral care.On February 23, 2026, at 10:49 AM, R1 was laying on her back in her bed. R1 had small hair on her chin/neck area. R1 said she has asked to be shaven. R1 said she would like facility staff to shave her chin.3. R2's admission Record shows she was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, cognitive communication deficit, dementia, disorder of central nervous system, urinary tract infection, deep vein thrombosis, dysphagia, and major depressive disorder. R2's Care Plan shows R2 has an ADL self-care performance. R2 requires one staff member to help with bathing, personal hygiene, and oral care.On February 23, 2026, at 9:26 AM, R2 was sitting in her wheelchair in her room. There was a splint to R2's right hand. R2's nails on her right hand were long especially her pinky nail. R2's ring finger was also long with a substance under her nails. R2 said she would like the nails on her right hand to be shorter. On February 23, 2026, at 3:01 PM, V5 Regional Nurse Consultant said certified nursing assistants should shave residents and cut their nails, unless the resident is a diabetic. V5 said if a resident is a diabetic, then the nurse does it. The facility's Activities of Daily Living policy approved September 24, 2025, shows, This facility provides each resident with care, treatment, and services according to the resident's individualized care plan.

Based on observation, interview, and record review the facility to ensure medications were administered and administered at the prescribed time for two of two residents (R5, R4) observed during the medication pass. There were 25 opportunities with 7 errors, resulting in a 28% error rate.The findings include:1.R5's admission Record shows he was admitted to the facility on [DATE], with diagnoses including polycythemia vera (rare chronic blood cancer) osteoarthritis, dysphagia, high blood pressure, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falling.R5's MAR dated February 1, 2026-February 28, 2026, shows orders for cyanocobalamin (a vitamin) 1000 mcg (micrograms) daily at 9:00 AM, hydroxyurea (chemotherapy medication) 500 mg (milligrams) give two capsules by mouth daily at 9:00 AM related to polycythemia vera, metoprolol 25 mg give 1/2 tablet at 9:00 AM and 9:00 PM every morning and bedtime related to high blood pressure, Mucinex extended release tablet 600 mg at 9:00 AM and 9:00 PM every morning and at bedtime, diltiazem 30 mg give one tablet by mouth three times a day at 9:00 AM, 1:00 PM, and 8:00 PM related to high blood pressure and heart failure, and Systane eye drops in both eyes three times a day at 9:00 AM, 1:00 PM, and 9:00 PM for dry eyes. On February 23, 2026, at 10:36 AM, V4 RN administered the above medications to R5 (over one hour late). V4 administered cyanocobalamin 50 mcg instead of the ordered 1000 mcg, gave one tablet of hydroxyurea instead of the ordered two tablets, held R5's metoprolol although there were no parameters to do so, administered Mucinex 400 mg instead of the ordered 600 mg, administered diltiazem over one hour late, and said she did not have the ordered eye drops for R5. 2. R4's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus with unspecified diabetic retinopathy with macular edema, history of falling, pain, weakness, age related nuclear cataract, macular degeneration, dry eye syndrome, and major depressive disorder. R4's MAR dated February 1, 2026-February 28, 2026, shows an order for Preservision oral tablet (multiple vitamins with minerals) give one tablet by mouth two times a day related to type 2 diabetes with diabetic retinopathy with macular edema scheduled at 9:00 AM and 5:00 PM.On February 23, 2026, at 10:08 AM, V3 RN said she did not have R4's ordered eye vitamins.On February 23, 2026, at 3:01 PM, V5 Regional Nurse Consultant said medications should be administered within one hour before or one hour after the scheduled time. The nurse should let the doctor know if the medications are late to see if there's any new orders. Medications should only be held if there are doctor ordered parameters. If there are no parameters, then the doctor should be called. V5 said she believe artificial tears to be a facility stock medication. V5 said she also believed that eye vitamins are a facility stock medication, but if they are not, then the staff should order the medication through the pharmacy. The facility Medication Administration Schedule policy approved on November 2025 shows, Medication shall be administered according to established schedules.

Based on observation, interview, and record review, the facility failed to ensure significant medication errors did not occur for two of ten residents (R1, R5) reviewed for medications in the sample of ten.The findings include:1.R1 was admitted to the facility on [DATE], with diagnoses including epilepsy, weakness, morbid obesity, contracture of left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis. R1's Medication Administration Record (MAR) dated February 1, 2026-February 28, 2026, shows orders for carbamazepine extended-release tablet 100 mg (milligrams) give three tablets two times a day for antiseizure at 9:00 AM and 5:00 PM and two tablets by mouth at 12:00 PM, and losartan potassium 50 mg by mouth daily for high blood pressure hold if top number in blood pressure < 100. On February 23, 2026, at 11:16 AM, V4 Registered Nurse (RN) took R1's blood pressure. R1's blood pressure was 107/60. R1 complained of nausea, so V4 gave R1 an antinausea medication and said she will come back to administer the above morning medications. At 1:14 PM, V4 was asked if she had given R1 her morning scheduled medications and V4 said, No, not yet.R1's MAR shows that V4 held R1's losartan potassium although R1's blood pressure was not below the doctor's parameters to hold the medication. 2.R5's admission Record shows he was admitted to the facility on [DATE], with diagnoses including polycythemia vera (rare chronic blood cancer), osteoarthritis, dysphagia, high blood pressure, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falling.R5's MAR dated February 1, 2026-February 28, 2026, shows orders for hydroxyurea (chemotherapy medication) 500 mg give two capsules by mouth daily at 9:00 AM related to polycythemia vera, metoprolol 25 mg give 1/2 tablet at 9:00 AM and 9:00 PM every morning and bedtime related to high blood pressure, and diltiazem 30 mg give one tablet by mouth three times a day at 9:00 AM, 1:00 PM, and 8:00 PM related to high blood pressure and heart failure.On February 23, 2026, at 10:36 AM, V4 RN administered the above medications to R5 (over one hour late). V4 administered one tablet of hydroxyurea instead of the ordered two tablets, held R5's metoprolol although there were no parameters to do so, and administered diltiazem over one hour late. On February 23, 2026, at 3:01 PM, V5 Regional Nurse Consultant said medications should be administered within one hour before or one hour after the scheduled time. The nurse should let the doctor know if the medications are late to see if there's any new orders. Medications should only be held if there are doctor ordered parameters. If there are no parameters, then the doctor should be called. Pain medications, blood pressure medications, and seizure medications are all significant medications.The facility Medication Administration Schedule policy approved on November 2025 shows, Medication shall be administered according to established schedules.The facility does not have a policy in regard to significant medications.

Based on interview and record review, the facility failed to notify the physician following a fall incident that subsequently resulted in a significant injury and failed to notify physician of a hospital transfer for one of three residents (R1) reviewed for falls in the sample of three. The findings include:R1's face sheet documented admission date of 08/28/2023 with past medical history not limited to left femur fracture, weakness, history of falls, cognitive communication deficit and adjustment disorder with mixed anxiety and depressed mood.R1's fall incident report dated 12/30/2025 at 06:45 PM (1845) indicated that resident had a fall incident in the bathroom. Staff was present at time of fall. Report documented under agencies/people notified that only V2 (Assistant Director of Nursing/ADON) was notified on the same day at 07: 58 PM (1958). Fall report did not document that R1's primary care physician (V4-Medical Doctor/MD) was notified of the fall. Health Status Note dated 12/30/2025 at 07:31 PM (19:31) documented at 6:50 PM, R1 was standing in the bathroom so a certified nursing assistant (CNA) could perform care after resident's bowel movement. Resident could not hold balance and started to lean to the left and CNA assisted him to the floor. Resident stated he started to fall after standing. Resident stated he was holding on to the grab bar then let go.power of attorney and NP nurse practitioner were notified. Note did not indicate which practitioner was notified, how or when they were notified, the number of attempts to contact made, and/or the practitioner's response to R1's fall.R1's physician progress note dated 12/31/2025 at 06:14 PM (18:14) reads in part, [AGE] year-old male residing at [facility] for long-term care reports a fall occurring approximately two days prior to evaluation .On 01/13/2026 at 10:25 AM, V3 (Certified Nursing Assistant) said on day of R1's fall incident, after dinner she had walked past R1's room and saw him entering the bathroom. R1 was seated in his wheelchair. V3 said she put a gait belt on R1 and helped him to stand up and sit down onto the toilet. After R1 was done, he stood up and was holding onto the handrail that was next to the toilet. While he was standing, he was facing the wall and holding on to the handrail. The wheelchair was behind him. V3 said she was standing next to him and had reached to get the wipes on the counter in the bathroom that was next to her when R1 let go of the handrail and fell to the floor on his left side.On 01/13/2026 at 11:18 AM, observed R1 sitting in his wheelchair in the bathroom of his room. Regarding fall incident, R1 said someone helped him get on the toilet. After he finished, he stood up, was holding the bar, lost his balance and fell to the floor and landed on his left side.On 01/13/2026 at 01:27 PM, V5 (Registered Nurse) said she was called to R1's room on day of fall, 12/30/2025 around 6:45 PM. When she entered the room, R1 was on the floor in the bathroom, lying on left side. V5 assessed R1 and found no apparent injuries and had no complaints of pain.On 01/13/2026 at 03:25 PM, V4 (MD) indicated that he saw R1 on 12/31/2025 at the facility for a routine visit and was notified by R1 and a staff member (did not recall who) during this visit that R1 had a fall incident on 12/30/2025. V4 said he was notified at any other time by the facility that R1 had a fall on the previous day (12/30/2025). V4 said when he returned to office, he did not see any notification of R1's fall incident. V4 added that he was also not notified of R1's hospital transfer on 01/01/2026 after x-rays were obtained and results showed a fracture.On 01/13/2026 at 04:04 PM, V2 (ADON/assistant director of nursing) said the medical doctor should be notified on the same day after a fall incident and/or change of condition.Review of R1's medical record at facility on 01/13/2026 showed a hospital transfer form was completed on 01/01/2026 that listed V4 as R1's primary care physician. No progress note was found that indicted V4 (MD) was notified that R1 left the facility or was transferred to the hospital. Progress note dated 01/05/2026 at 05:31 PM (1731) indicated R1 arrived in the facility at 05:15 PM in a stable condition. R1's hospital after visit summary provided by the facility on 01/13/2026 documented R1 was hospitalized from [DATE] - 01/05/2026 for a closed left hip fracture. Significant Condition Change and Notification policy with date approved of 12/2024 reads in part: to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as but not limited to, an accident or incident with or without injury, that has the potential for needed medical practitioner intervention and transfer of the resident from the facility.Procedures: when any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner.The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays.Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. In a non-emergent situation, the primary medical practitioner will be called unless he/she has left an alternate name to call. If after two attempts, there is response to calls, the medical director will be contacted.

Based on interview and record review, the facility failed to ensure the necessary care and services were given to a resident by not immediately obtaining a diagnostic test (x-ray) following a fall, and failed to ensure there was no delay in evaluation and treatment for a resident following a fall for one of three residents (R1) reviewed for falls in the sample of three. The findings include:R1's face sheet documented admission date of 08/28/2023 with past medical history not limited to left femur fracture, weakness, history of falls, cognitive communication deficit and adjustment disorder with mixed anxiety and depressed mood.R1's fall incident report dated 12/30/2025 at 06:45 PM (1845) indicated that resident had a fall incident in the bathroom and staff was present at time of fall.Health Status Note dated 12/31/2025 at 10:56 AM indicated writer noted a small bruise to R1's left knee and resident complained of pain in left leg and knee. Writer called his primary physician and left an urgent note with medical assistant with the fall information.R1's physician progress note completed by (V4-Medical Doctor/MD) dated 12/31/2025 at 06:14 PM (18:14) reads in part, [AGE] year-old male residing at [facility] for long-term care reports a fall occurring approximately two days prior to evaluation. Resident currently presents lying prone toward the left side and endorses ongoing left lower extremity pain. He reports use of acetaminophen with minimal relief. No imaging studies have been completed to date. Given persistent pain status post fall, diagnostic X-rays of the left hip, femur, and knee have been ordered to evaluate for possible acute injury. The resident will be closely monitored, and if pain persists or worsens, further medical evaluation will be indicated.Health Status Note dated 12/31/2025 at 08:55 PM (20:55) documented, received phone call from [V4's] office and received telephone order for x-ray of left hip, femur, and knee related to fall and acute pain to left lower extremity. Order was documented as being processed via mobile diagnostic provider and in R1's electronic medical record. R1's order details summery dated 12/31/2025 at 08:53 PM (2053) showed x-ray to left hip, left femur, and left knee STAT (immediately) for pain, fall.R1's Situation Background Assessment Recommendation (SBAR) summary for providers dated 1/1/2026 at 12:13 PM reads in part, the change in condition/s reported on this [evaluation] are/were: falls.New testing orders: x-ray.R1's diagnostic report dated 01/01/2026 indicated under findings, acute subcapital left femoral neck fracture. Report was stamped with faxed but did not indicate to whom results were faxed to or the date and time faxed.On 01/13/2026 at 10:25 AM, V3 (Certified Nursing Assistant) said on day of R1's fall incident, after dinner she had walked past R1's room and saw him entering the bathroom. R1 was seated in his wheelchair. V3 said she put a gait belt on R1 and helped him to stand up and sit down onto the toilet. After R1 was done, he stood up and was holding onto the handrail that was next to the toilet. While he was standing, he was facing the wall and holding on to the handrail. The wheelchair was behind him. V3 said she was standing next to him and had reached to get the wipes on the counter in the bathroom that was next to her when R1 let go of the handrail and fell to the floor on his left side.On 01/13/2026 at 11:18 AM, observed R1 sitting in his wheelchair in the bathroom of his room. Regarding fall incident, R1 said someone helped him get on the toilet. After he finished, he stood up, was holding the bar, lost his balance and fell to the floor and landed on his left side.On 01/13/2026 at 01:27 PM, V5 (Registered Nurse) said she was called to R1's room on day of fall, 12/30/2025 around 6:45 PM. When she entered the room, R1 was on the floor in the bathroom, lying on left side. V5 assessed R1 and found no apparent injuries and had no complaints of pain.On 01/13/2026 at 01:53 PM, V6 (Registered Nurse) said on 12/31/2025 at approximately 11:00 AM, she went to assess R1 in his bed. R1 was moaning and had facial grimacing. His feet were off the bed and V6 said she was trying to get his legs back to the center of bed. V6 asked R1 where the pain was, and he said that his left knee was hurting. V6 did a skin assessment and found a bruise to his left knee. V6 said she did not recall giving him any pain medicine. V6 said she called R1's primary physician and left an urgent note with his medical assistant with the fall information but did not hear anything back upon the end of her shift at 03:00 PM. V6 then said she was told by another nurse that there was a stat order in place for an x-ray on 12/31/25 but nobody showed up. V6 indicated that they came the next day on 01/01/2026 to do R1's x-rays. Review of R1's electronic medication record on 01/13/2025 showed an order for acetaminophen 650 milligrams (mg) by mouth one time a day for left lower extremity pain at 09:00 AM (start date of 09/11/2023) that was administered on this day by V6.On 01/13/2026 at 03:25 PM, V4 (MD) indicated that he saw R1 on 12/31/2025 at the facility for a routine visit and was notified by R1 and a staff member (did not recall who) during this visit that R1 had a fall incident on 12/30/2025. V4 said during his assessment, he suspected that something was wrong due to R1's position in bed and overall appearance. R1 was lying prone (on stomach) toward the left side and complained of ongoing left lower extremity pain. V4 then said after returning to his office and speaking with his nurse, he phoned in a stat (immediately) order for x-rays of R1's left lower extremity. V4 added that if the facility had informed him at the time of R1's fall and per his professional judgement, he would have ordered stat x-rays due to R1's medical history and limited functionality. V4 also said that he was surprised the x-rays were not done until the next day and believed this caused a delay in R1's fracture being diagnosed and evaluated. R1's hospital after visit summary provided by the facility on 01/13/2026 documented R1 was hospitalized from [DATE] - 01/05/2026 for a closed left hip fracture. On 01/13/2026 at 05:10 PM, during exit conference, both V1 (Interim Administrator) and V2 (Assistant Director of Nursing) indicated that unless a stat order is received for x-rays, if they are not completed within four hours, the facility would contact the physician to inform them of this and ask how the physician would like to proceed. When surveyor informed V1 and V2 that R1's x-ray order was a stat order that was verified by V4 (MD), no further response was given. Physician's Orders policy last revised 04/2021 reads in part: when necessary, telephone orders may be taken by a registered nurse or license practical nurse. All such orders shall be immediately written on the physician order sheet or electronic medical record and a telephone order form and signed by the physician within ten working days. (No directions related to diagnostic testing was documented).

Based on observations, interview, and record review the facility failed to obtain daily weights for a congestive heart failure resident (R52). This failure resulted in R52 gaining 60 pounds in one month and requiring hospitalization. The facility also failed to ensure follow-up care was completed after a resident fell (R60).This applies to 2 of 5 residents (R52, R60) reviewed for quality of care in the sample of 48. Findings Include: 1.On 9/2/25 at 10:22 AM, R52 was seated in a bariatric wheelchair with oxygen in place at 4 liters per nasal canula. R52 was able to speak, but did get short of breath during the interview. R52 stated, “I'm sick of this fluid. I've gained over 43 pounds, and it just seems to keep going up.” R52 said the facility does weigh her, but she doesn't think it's every day. R52 said she has been seen in the past by Cardiology for issues with fluid retention. R52 was obese and had generalized edema noted. R52 said she was on a “water pill” and the facility had added another recently. At 12:30 PM, R52 was seated in her wheelchair in the dining room, feeding herself a grilled cheese sandwich. R52 started coughing and placed her hand on her chest. The surveyor asked R52 if she was okay and replied, “Yes, I think I just have too much mucous in my chest.” R52 ate some more of her meal. At 1:02 PM, V10 (Agency Licensed Practical Nurse) pushed R52's wheelchair back to her room. R52 slid her butt toward the seat of the wheelchair to provide more mobility between her abdomen and chest. V10 provided breathing treatments and notified V14 (Nurse Practitioner). V14 went in room see R52. R52's Hospital admission Record dated 9/2/25 showed she came to the hospital with shortness of breath that started 3 days ago. The patient reported increased lower extremity swelling and possibly 60-pound weight gain. Due to worsening shortness of breath, she was sent to the emergency room. The patient does report some chest pain along with some productive cough with phlegm. On arrival her oxygen saturation was 89% on room air and she was placed on an open mask. The patient's troponin (cardiac marks for heart tissue damage) was negative and her BNP was normal. This document showed R52's chest x-ray showed mild pulmonary edema. The document showed R52 was admitted with acute on chronic respiratory failure with hypoxia, acute asthma exacerbation, volume overload versus CHF (Congestive Heart Failure) exacerbation, and morbid obesity. This document showed the plan to treat R52's volume overload was strict intake and output, daily weights, intravenous diuretics, and cardiology consult. R52's Facesheet dated 9/3/25 showed diagnoses to include but not limited to acute on chronic respiratory failure with hypoxia, moderate persistent asthma, severe morbid obesity, CHF, Chronic Obstructive Pulmonary Disease (COPD), weakness, lymphedema, need for assistance with personal cares, dysphagia, generalized anxiety disorder, and peripheral vascular disease. R52's Physician Order Sheet dated 9/3/25 showed an order for “Daily weights in the morning,” to start 8/21/25. On 8/1/25, the resident weighed 486.6 lbs. On 9/1/25, the resident weighed 548.4 lbs which is a 12.7% Gain (61.8 pounds). R52's Weight report was missing daily weights on 8/22, 8/23, 8/24, 8/26, 8/27, 8/28, 8/30. R52's weight on 9/1/25 was 548.5 pounds and she showed a 5.4 weight loss on 9/2/25 (weight was 543 pounds). R52's August Medication Administration Record (MAR) did not contain any daily weights. R52's Progress Notes were reviewed on these dates and there was no documentation of refusals. R52 was seen by the V14 (Nurse Practitioner) on 9/2, 9/1, and 8/27. R52's Progress notes showed had a pulmonary consult on 8/25/25. On 9/3/25 at 11:50 AM, V11 (Wound Care Nurse) said she had several roles at the facility. V11 said one of those roles was doing post-acute work and working to prevent rehospitalizations. V11 said R52 had several chronic health issues, and she can be non-complaint with diet and fluids. V11 said R52 has severe CHF but has the mindset that she can eat and drink as she pleases and go to the hospital to get intravenous medications to remove excess fluid. Then she feels better, and we start all over. V11 said the V15 (Previous DON – Director of Nursing) was responsible for following the weights. V11 said now she is just making sure the weights are done. V11 said the weights should be obtained as ordered by the provider. V11 said daily weights are important for CHF residents to ensure there is no fluid overload and/or tracking the progress of our interventions. The surveyor asked if the order should include when to call the Provider. V11 looked at the order and replied, “We have a standing order for CHF.” V11 said if the resident gained 2-3 pounds overnight or 5 pounds in a week, then the nurse should notify the Provider. V11 said special cases like V11, the resident may gain weight at a faster rate. The surveyor asked V11 to view R52's Electronic Medical Record (EMR). V11 said there is no good reason those weights shouldn't be charted, unless she refused. V11 said if R52 refused then there should be a progress note that she refused to be weighed. V11 said she didn't see any progress notes showing that R52 refused to be weighed on 8/22, 8/23, 8/24, 8/26, 8/27, 8/28, and 8/30. V11 said the CNA or nurse can obtain the weight. V11 said the weight should be charted in the EMR and the nurse should be checking for trends. V11 said she didn't know why that wasn't happening. V11 said on 9/2/25, V12 (Respiratory Therapist) came to assess R52, and they got the order to transfer her to the hospital. V11 said R52 was admitted to the hospital for shortness of break. V11 said the facility was aware there was a problem with these weights, and they are working on this issue. On 9/3/25 at 3:14 PM, V10 (Agency LPN) said she only works at the facility every couple of weeks for 1-2 shifts. V10 said she works wherever she is needed, so she doesn't have a consistent assignment. V10 said the weights should be taken by the CNA and the nurse enters the weights. V10 said the nurse should be following the physician's orders for daily weights and monitoring for changes. V10 said the nurse should notify the Provider if there is a greater than 3-pound weight gain in 1 day and 5 pounds in a week. V10 said she didn't work for the last week, so she didn't know if anyone looked at the weights. V10 said the nurse should have been making sure the daily weights were completed and reporting weight gain. V10 said she didn't realize R52 had gained so much weight. V10 said weight gain can be a sign of fluid retention and could have contributed to R52's breathing issues. V10 said she was R52's nurse on 9/2/25 and R1 was complaining of shortness of breath in the morning, but her vital signs were stable. V10 said R1's oxygen saturation was 89-90% on 4 liters per nasal cannula. V10 said she did assessments and she was stable. V10 said after lunch she started to get a little worried and gave her breathing treatments. V10 said she notified V14 (NP). V10 said V14 assessed R52 and said she didn't need to go to the hospital at this time. V10 said a few hours later V12 (Respiratory Therapist) did an assessment, and it was decided to send R52 to the hospital for shortness of breath and she started to complain of some chest pain. R52 was starting to lean back in the wheelchair to breath better. On 9/3/25 at 10:23 AM, V14 (NP) said she works at the facility Monday through Friday. V14 said R52's case is very complicated, and she has several comorbidities. V14 said on 8/20/25 she ordered daily weights to track R52's fluid balance. V14 said R52 gained 60 pounds in 6 months, so I thought it was important we get the daily weights on track. V14 said when she orders a daily weight, she expects the order to be followed. V14 said R52 was already on Bumex (a diuretic medication) twice a day so she consulted a Pulmonology. V14 said they were discussing R52's case because she was having more difficulty breathing and felt like she was retaining fluid. V14 said she started R52 on Spironolactone, ordered a bladder scan, and labs. V14 said R52 reported she didn't feel like she was urinating enough, so we started Flomax. She was gaining weight, but on 9/1/25 (the day before she went to the hospital) she was being noncompliant with her fluid restriction, and I had to have a discussion with her. V14 said she ordered Strict Intake and Output for her on 9/1/25 and an Echocardiogram (doppler ultrasound of the heart). V14 said she was trying to explain to the resident that she needs to allow time for the interventions to help, but the resident does have times where she was non-compliant. V14 said V10 (LPN) called me on 9/2/25 and wanted to send her to the emergency room. V14 said she did an assessment and had a conversation with R52, and she didn't feel it was necessary to transfer at that time. V14 said she felt R52 needed to allow time for interventions, but when she started to complain of chest pain. The decision was made to transfer her to the emergency room. V14 said she checked R52's hospital record and she was admitted for shortness of breath, respiratory failure, and CHF. V14 said the daily weights are important part of R52's chronic disease management, but not the only part. V14 said if a daily weight is ordered, it needs to be done. V14 said if the staff are not doing the weights, then she would expect them to explain why and report it to her. V14 said if R52's weights were done as ordered and interventions were performed sooner it's possible the outcome could have been better, but it's hard to know for sure. V14 said R52 had lost weight the last day and she felt the interventions were starting to work. V14 said R52 needed intravenous medications to manage her fluid status at this time. V14 said she agreed that there was an issue with her weights. V14 said her expectation are higher than some others, but when it comes to human life it should be. The facility did not have a policy for obtaining weights for CHF patients or following physician's orders. The facility provided a Care Path Symptoms of Heart Failure diagram. This diagram showed that symptoms or signs of HF included unrelieved shortness of breath or new shortness of breath at rest, unrelieved or new chest pain, wheezing or chest tightness, inability to sleep without sitting up, weight gain or 3 pounds in 3 days or 5 pounds in 7 days, and worsening edema. This diagram showed if oxygen saturations were less than 90% (in addition to the above listed symptoms) then they should notify the Provider. 2. R60's Final Fall Report dated 7/28/25 showed R60 was placed in the TV room directly across the hall from the nurses' station. This report showed that R60 has agitation and restless and a non-pharmacological intervention includes placing her in quiet area with TV to promote a decrease in behaviors and calm the resident. This report showed R60 was reaching for the TV remote and fell onto her left side. A head-to-toe assessment was complete and R60 was noted with left shoulder pain and an order for X-ray was placed. The X-ray results showed a left clavicle fracture. This form showed R60's physician and hospice were notified of the results and splint was placed for immobilization and pain management orders were adjusted. The resident's pain is being controlled and resident wishes to remain in the facility. On 9/2/25 at 11:43 AM, R60 was sitting up in reclined wheelchair. R60 was moving her arms and feeding herself with no difficulty. R60 was no longer wearing a sling to her left arm. R60's Facesheet showed diagnoses to include, but not limited to primary generalized osteoarthritis, chronic kidney disease, hypothyroidism, dysphagia, left clavicle fracture, dementia, generalized anxiety disorder, macular degeneration, peripheral vascular disease, and stroke. R60's Physician's Order Sheet showed an order was placed for a 2 view Xray of the shoulder due to pain from a fall on 7/26/25. These orders showed an order for an external splint to left shoulder if pain noted was entered 7/28/25. R60's Progress Note dated 7/26/25 at 10:12 PM showed R60 fell out of her chair and complained of left shoulder pain during assessment and an X-ray was ordered for Monday. (2 days later). The notes showed did not show evidence that the facility called to check the status of the Xray. R60's progress notes on 7/27/25 showed R60 was experiencing pain, had bruising to the left shoulder, and had limited range of motion to the left arm. These notes showed that R60 was treated for pain, but did not have the sling in place, nor had the Xray been completed. On 7/28/25, R60's X-ray results were reported to the physician and orders for a sling were obtained for additional support. R60's Left Shoulder Xray Report dated 7/28/25 showed an acute displaced fracture of the left clavicle. On 9/2/25 at 2:01 PM, V15 (previous Director of Nursing – DON) said she was notified R60 fell out of her chair on 7/26/25. V15 said she did the investigation on Monday (7/28/25) and she called X-ray to follow-up because they hadn't come yet for the Xray. V15 said the Xray order was placed for Monday and R60 shouldn't have had to wait that long. V15 said V18 (Agency RN) didn't place a stat order, and they didn't ensure the X-ray was completed or the sling order was obtained in a timely manner. V15 stated, “Just because [R60] is on hospice doesn't mean we don't treat people. On 9/4/25 at 10:40 AM, V14 (Nurse Practitioner) said she wasn't here when R60 fell, but if she fell directly on her left side and complained of pain an X-ray order should have been entered to be done immediately. They shouldn't have waited until Monday. That's a delay of care. V14 reviewed R60's chart and said she already had pain medication on board, but it looks like the sling wasn't ordered until after the Xray results. V14 said the facility should have ensured Xray was ordered immediately, completed within 24 hours, and the interventions were placed. V14 said it's important to make sure the fracture isn't displaced or puncturing something. V14 said based on R60's injury there isn't much they can do for her. V14 said R60's care would be more conservative, but it was important to get the Xray results timely. The facility's policy and procedure approved 12/2024 showed, “Fluid Restriction, Policy: Only those resident's that have a practitioner's order will be on fluid restriction. Procedure: 1. Verify medical practitioner order. 2. Notify dietary consultant of order for fluid restriction… 3. Remove the resident's water pitcher and cup from the room. Store in designated area…”

Based on observations, interviews and record reviews, the facility failed to consistently provide sufficient staffing to meet the care needs of its residents. This failure has the potential to affect all 68 residents residing at the facility. Findings Include:On 09/02/2025, V1 (Administrator) provided facility assessment dated [DATE] that documented on page 29 of 52, sufficient nursing staffing: the facility will provide help and care needed without the resident waiting a long time (as perceived). The staff will respond to call lights timely. Resident roster provided by facility and CMS form 802 both dated 09/02/2025, showed an in-house census of 68 residents. Review of nursing schedules and daily work log from 08/2025 through 09/04/2025 provided by facility showed several nursing and/or aide staffing shortages as follows: On 08/01, six aides and one trainee were scheduled for day shift but only five aides worked that shift. On 08/02, four aides were scheduled for third shift but only three aides worked that shift. On 08/03, four aides were scheduled for third shift but only two aides worked that shift. On 08/04, seven aides were scheduled for day shift but only four aides worked that shift. On 08/05, five nurses were scheduled for day shift but only two nurses worked that shift. On 08/06, four nurses were scheduled for day shift but only two nurses worked that shift. On 08/07, seven aides were scheduled for second shift but only six aides worked that shift; and five nurses were scheduled for day shift but only two worked that shift. On 08/09, seven aides were scheduled for second shift but only six aides worked that shift.On 08/10, five nurses were scheduled for day shift but only three nurses worked that shift.On 08/11, seven aides were scheduled for day shift but only five aides worked that shift; and four aides were scheduled for third shift but only three aides worked that shift.On 08/13, six aides were scheduled for day shift but only four aides worked that shift.On 08/16, six aides were scheduled for day shift but only five aides worked that shift.On 08/17, six aides were scheduled for day shift but only five aides worked that shift; and seven aides were scheduled for second shift but only six aides worked that shift.On 08/22, four aides were scheduled for third shift but only three aides worked that shift.On 08/23, four aides were scheduled for third shift but only three aides worked that shift.On 08/24, four nurses were scheduled for day shift but only three nurses worked that shift.On 08/25, six aides were scheduled for day shift but only five aides worked that shift. On 08/27, seven aides were scheduled for second shift but only six aides worked that shift.On 08/29, three nurses were scheduled for third shift but only one nurse worked that shift.On 08/30, four aides were scheduled for third shift but only three aides worked that shift.On 08/31, six aides were scheduled for day shift but only five aides worked that shift.Review of resident council meeting minutes for the last six months showed concerns with call lights not being answered in a timely manner during the 03/03/2025 meeting. Unsatisfaction with call light response time during the 04/07/2025 meeting. Concerns with call lights being turned off by staff without providing assistance, long call light response time, aides ignoring lights, aides stating they will come back to assist a resident but do not return, aides not assisting residents they are not assigned to and clinical staff shortages on weekends and holidays during the 07/16/2025 meeting. Concerns with call lights not being answered in a timely manner and residents not being showered on scheduled shower days, and lunch/dinner meals being served late during the 08/20/2025 meeting. Review of grievance forms from May 2025 through current revealed the following: Form dated 05/20/2025 from family council documented concerns with weekend staffing and lengthy call light response times. Anonymous form dated 05/21/2025 documented concern of facility being short staffed because V1 (Administrator) is not nice. R15's form dated 07/21/2025 documented one day this past week, call light was left on for 73 minutes with no follow up done due to unknown date of incident. R1's form dated 08/09/2025 submitted by her spouse indicated thatR1 was left laying in feces for 50 minutes. Findings showed call light had been on for 69 minutes because the aides were on break at the same time and the nurses were passing medications. Photo attached to grievance form showed call light for room [ROOM NUMBER]-A was on for 69 minutes. R1's face sheet documented admission date of 06/30/2025. R1's census log showed she admitted into room [ROOM NUMBER]-A and discharged on 08/21/2025.On 09/02/2025 at 11:20 AM, R28 was observed lying in bed. R28's hair was greasy, and her skin appeared dry and flaking. R28 said she prefers bed baths and was supposed to get them every week. The surveyor asked her when her last bed bath was and R28 replied, you don't want to know. R28 said it's been 3-4 weeks since her last bed bath but did state that she refused last week because she wasn't feeling well. R28 said that was the only time she refused, and they didn't come try again. R28 said her skin gets itchy and she just feels gross. R28 said the call lights can take a while to get answered. R28 said it really depends on who is working. R28 said it can take a couple minutes, but a week and half ago she waited 1.5 hours. R28 stated, I really had to poop. It was awful. I think they have a problem here with staffing. I can control my bowel and bladder pretty good, but sometimes the wait is too long, and I have an accident. That's really embarrassing. R28 said another problem is they might come in at 9:00 PM to change me for the night and I might not see anyone again until morning. R28 said the facility does have some really good CNAs, but they also use a lot of agency staff. R28 said some of the agency CNAs will come in, turn off my call light, say they will be back, but they never come back. R28 said there definitely doesn't seem to be enough staff. R28's facility assessment dated [DATE] showed she was cognitively intact; required substantial to maximal assistance for shower/bathing and was dependent for toilet hygiene. On 09/02/2025 at 12:37 PM, R11 stated that last month he wanted 85 minutes for his call light to be answered by staff that caused him to soil himself. R11's facility assessment dated [DATE] showed he was cognitively intact; required substantial to maximal assistance for shower/bathing and for toilet hygiene.On 09/03/2025 at 2:32 PM, V26 (Scheduler) said she schedules four nurses and six aides on day shift, three nurses and seven aides on second shift, and two nurses with four aides on third shift during the week and on weekends. V26 added that the staff to patient ration on days and second shift is 1:8, and 1:16 on third shift. V26 indicated that when a call off occurs, they communicate the opening one staffing agency and a mass text is sent through on-shift for in-house staff to be inform of availability. V26 then said there has never been a time when a call off was not covered and she was not made aware of any staffing issues. On 09/04/2025 at 8:38 AM, V9 (Certified Nursing Assistant-CNA) said she no longer works at the facility and 7/26/25 was her last day. V9 said she worked full-time days and floated around the facility. V9 said there were days when they were short staffed and they would have difficulty delivering meals on time, getting to call lights in a timely manner, completing showers/bed baths, and obtaining weights. V9 said it could be overwhelming at times. V9 said on the days they were short staffed they just did their best to keep the residents safe and dry. Then if we had a day with more staff, then we would try to make up for some of the things we missed. There were definitely residents that had to wait for us to get incontinence care. We'd try to work together and just go from one end of the hall to the other.On 09/04/2025 at 12:43 PM, V6 (Regional Director of Operations) said the facility has no policy for call light use or response time.On 09/04/2025 at 01:15 PM, V2 (Assistant Director of Nursing) said, we staff to meet the needs of the residents and are staffed based on the census and acuity of care, her expectation is for any staff member in building to answer a call light to see what the issue is, and the call light should be answered within 3-5 minutes then provide the resident with a timeframe to assist with their needs if helping another resident.On 09/04/2025 at 01:18 PM, R11 said he had to use a bell for the last 6-7 days while call light was being repaired and had to wait an average of 50-60 minutes every time he rang the bell for staff to respond. R11 then said, they need more staff here to help answer the call lights. Undated Resident Grievance Process policy provided by facility reads in part: it is the intent of each community to encourage residents, their representatives or family members, opportunities to communicate any concerns, suggestions, complaints, or opportunities for improvement in care or services.

Based on observation, interview and record review, the facility failed to ensure dressing changes and wound assessments were completed as ordered, failed to ensure a dressing was in place, and failed to identify a wound prior to it becoming an advanced stage for 2 of 3 residents (R1, R5) reviewed for wounds in the sample of 8. This failure resulted in R1 being sent to a local hospital and admitted to the hospital with a diagnosis of wound infections to his bilateral lower extremities. The findings include: 1. R1's Admission Record, provided by the facility on 3/25/2025, showed he had diagnoses including, but not limited to, end stage renal disease, stage 5, dependence on renal dialysis, type II diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes causing pain or numbness in the legs or feet), chronic diastolic heart failure, atherosclerotic heart disease, pain in right thigh, pain in right hip, anemia, primary generalized osteoarthritis, chronic peripheral venous insufficiency, lumbago with sciatica (a condition where pain in the lower back radiates down one or both legs), peripheral vascular disease, chronic pain, and muscle spasm of back. R1's facility assessment dated [DATE] showed he is cognitively intact, requires substantial/maximal staff assistance for upper body dressing, and partial/moderate staff assistance for lower body dressing. On 3/24/2025 at 11:47 AM, V9 (Dialysis Center Administrator) said on 3/18/2025 R1 received dialysis at the dialysis center. V9 said she saw R1's wound dressing on 3/18/2025. It was dirty and smelled like rot. V9 said one of the nurses drew a picture on the wound dressing on 3/18/2025 to see if it would be changed when he came to dialysis two days later. V9 said when R1 returned two days later, the same dressing was on him and the drawing was still on the dressing. V9 said R1 told dialysis staff on 3/20/2025 that he asked the nurse to change his dressing, and they either refused or ignored his request. On 3/25/2025 at 11:25 AM, V9 (Dialysis Center Administrator) said R1 did not show up for dialysis that day (3/25/2025) because the facility sent him to the hospital due to his leg wounds on 3/24/2025. V9 said R1 was admitted to the hospital. On 3/25/2025 at 11:37 AM, V10 (Assistant Director of Nursing-ADON) said R1 was sent out the previous day (3/24/2025) to a local hospital. V10 said V16 (R1's daughter) had called her the previous Thursday (3/20/2025) about his wounds. V10 said V16 wanted to see wound care for R1. V10 said she told V16 that she had already done the dressing change for R1 that day with a police officer present, and the next time the dressing was scheduled to be changed was on Monday 3/24/2025. V10 said V16 took pictures of R1's wounds and sent the pictures to the Nurse Practitioner (NP-V20) that R1 was seeing from the wound care clinic. V10 said based on the pictures that V16 sent the NP, the NP wanted R1 sent to a local hospital for a vascular workup. V10 said the local hospital admitted R1 to the hospital. V10 looked at R1's progress notes in his electronic medical record and said the notes showed R1 was admitted to the hospital with a diagnosis of wound infection. V10 was asked to provide surveyor with R1's last three wound assessments. V10 provided the last three assessments to this surveyor. The wound assessments provided to this surveyor were dated 3/24/2025, 3/20/2025, and 1/20/2025. V10 was asked to provide the wound assessment prior to 3/20/2025. V10 looked through R1's electronic medical record and said she did not see any wound assessment for R1's leg wounds that were completed between the 1/20/2025 and the 3/20/2025 wound assessments. V10 said R1 was not followed by the wound doctor in the facility. He wanted his wound doctor at the wound clinic. V10 was asked when was the last time R1 was seen by his wound clinic doctor. V10 said she was not sure and would look into it further. V10 was asked to provide the notes from R1's last visit with the wound clinic doctor/NP (these notes were not provided prior to exiting the facility on 3/26/2025). V10 said the nurses working the floor do the dressing changes and the skin checks. V10 said the skin checks are not full assessments of the wound and do not document the wound measurements or characteristics of the wound. V10 was asked to bring up R1's electronic Treatment Administration Record (TAR) for March 2025 on her computer. V10 said she did the dressing changes to R1's bilateral leg wounds on 3/20/2025 and 3/24/2025. V10 said R1's March 2025 TAR showed the dressing changes were not signed off as being completed on 3/10/2025, 3/14/2025, and 3/17/2025. V10 said the order is to do the dressing changes every Monday and Friday. V10 said, It is important to make sure that the dressing changes and wound assessments are being completed as ordered, because we need to know if the wound is improving, or if there have been any changes, like signs of infection. To see if what we are doing is helping, or if we need to update the doctor and make changes. On 3/25/2025 at 4:20 PM, V16 (R1's daughter) said she called V10 (ADON) and asked her when she was going to do the dressing changes for R1 next because she would like to be present during the dressing changes. V16 said V10 told her that she had just changed the dressings on 3/20/2025 with V19 (Police Officer from a local police department) present, and the next dressing change would be on Monday 3/24/2025. V16 said she took pictures of R1's leg wounds because she did not like what the wounds looked like. V16 said the wound was open and it looked like raw meat. V16 said she had a cold, so she was not sure if there was any odor from the wound. V16 said she sent the pictures to V20 (Nurse Practitioner from wound clinic) and V20 called her and said this was terrible, she had never seen it that bad. V16 said V20 had been treating R1's wounds for about 15-[AGE] years. V16 said R1 had not been going to see V20 for a while, but he was going to start seeing her again. On 3/26/2025 at 10:05 AM, V16 (R1's daughter) provided photos of R1's bilateral leg wounds from 1/25/2024 and 3/5/2024 from his Wound Clinic visits with V20 (NP from wound clinic), as well as photos that were taken and sent to V20 (NP) on 3/24/2025 when she observed the dressing change done by V3 (ADON) in the facility. (note: No May 2024 photos were provided which was the last time V20 said R1 was seen at the wound clinic). On 3/26/2025 at 12:25 PM, V20 (NP from wound clinic) said she last saw R1 in May of 2024. V20 said the facility R1 was at was providing the wound care for him. V20 said on 3/24/2025 V16 sent her pictures of R1's wounds and she recommended R1 be sent to a local hospital to manage his vascular issues. V20 said based on the pictures V1 sent her, it looked like there were slough issues and blood circulation issues. V20 said based on the appearance of R1's wounds, dressing changes twice a week is not appropriate. V20 also said based on the pictures and V16's description of the wounds, she felt R1 should have been sent out sooner. V20 said it is important to do the dressing changes as ordered, and do wound assessments at least weekly or more often, to monitor the wounds and determine if the wounds are improving or declining, to monitor for signs/symptoms of infection, so a wound specialist or the resident's doctor can be updated to get a new order if needed. On 3/26/2025 at 1:28 PM, R1 was observed at a local hospital. An IV (intravenous) pole was next to R1's bed with empty antibiotic and antifungal medications listed on the empty bags. R1 said the nurses at the facility were not changing the dressings on his leg wounds. R1 said he had been asking them to change his dressings because his legs were stinging and burning. R1 said the only reason they finally got changed was because they started noticing an odor. R1 said the facility nurses were not assessing his leg wounds either. R1 was not able to identify who all he asked to change his wound dressings. On 3/26/2025 at 10:33 AM, V19 (Police Officer from a local police department) said she went to the facility on [DATE] and went with V10 to see R1's wound dressings. V19 said when V10 removed the dressing from R1's leg, there was a bad odor coming from the wound, even with a face mask on. (note: R1's Weekly Wound assessment dated [DATE] by V3 (ADON) documented no odors were present). On 3/26/2025 at 1:40 PM, V22 (R1's nurse at the local hospital) said R1 was receiving two IV antibiotics and an oral antifungal medication for bilateral leg wound infections. V22 looked at R1's most recent wound notes in his electronic hospital medical record. The notes showed that the hospital was waiting on the final culture and sensitivity results before decreasing R1's IV antibiotic medications. V22 said she did not think R1 had osteomyelitis. The notes showed Proteus mirabilis and Staph Aureus as the organisms identified in R1's leg wounds. R1's care plan initiated on 1/5/2025 showed he had right hip pain. R1's Risk of skin impairment care plan, initiated on 1/5/2025, showed he had a risk of skin impairment, had a diagnosis of peripheral vascular disease and had reopened stasis ulcers to his bilateral lower extremities. Interventions listed on the care plan showed to administer the treatment as ordered and monitor for effectiveness. The interventions showed, Document location of wound, amount of drainage, peri-wound area, pain, edema, and circumference measurements weekly. Evaluate wound for: Size, depth margins, peri-wound skin, sinuses, undermining (a separation of the wound edges from the surrounding healthy tissue creating a pocket under the wound surface), exudates (fluid coming from wound), edema, granulation (new connective tissue that develops at the wound site in the process of healing), infection, necrosis (a pathological process where cells and tissues die prematurely due to injury or disease), eschar (dead tissue), and gangrene (dead tissue cause by an infection or lack of blood flow). The interventions also showed to document the progress in wound healing on an ongoing basis. Notify Physician as indicated. Monitor/document/report to doctor for signs and symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from wound, excessive pain, fever. R1's 1/9/2025 care plan showed he had skin alteration related to vascular wounds to both lower extremities. Interventions listed were to monitor wounds for signs of infection, weekly wound assessments with wound rounds and wound care as prescribed. R1's Weekly Skin Checks from 1/24/2025 through the present showed no new changes. The Weekly Skin Checks do not provide measurements, or wound characteristics. R1's Weekly Wound Evaluations from 1/20/2025 through 3/26/2025 were requested. The only Wound Weekly Evaluations-Non-Pressure that were provided were the evaluations from 1/20/2025, 3/20/2025, and 3/24/2025. The 3/20/2025 Wound Weekly Evaluations-Non-Pressure for R1's left lower extremity and right lower extremity both documented no odor was present (even though V19 said it smelled very bad). R1's March 2025 TAR showed on 3/10/2025, 3/14/2025, and 3/17/2025 the dressing changes were not signed off as being completed. The TAR showed the dressing changes were scheduled to be done every Monday and Friday. The wound orders on the TAR also showed to call physician or go to ER (emergency room ) with increased redness, pain, swelling, drainage, warmth, odor, or fever. R1's progress notes from 1/20/2025 through 3/26/2025 were reviewed. The progress notes did not show R1 refusing to allow staff to change the wound dressings or do wound assessments. The facility's 1/2025 policy and procedure titled Skin Identification, Evaluation, and Monitoring Policy showed Licensed Nurse Weekly: A. Complete a Weekly Skin Check to evaluate for changes in skin integrity. B. Document in medical record the finding of weekly skin assessment. a. If wounds are present and previously identified: i. Document integumentary findings in weekly skin assessment. ii. Appearance of the wound, including measurements if the wound is due for a treatment change, if not, assess the dressing and document this in the assessment. iii. Complete weekly re-evaluation of previously identified skin alterations/wounds. iv. Treatment applied/initiated per health care provider order in the medical record. 34891 2. R5's face sheet printed on 3/26/25 showed diagnoses including but not limited to pressure-induced deep tissue damage of other site, diabetes mellitus, chronic kidney disease, spinal stenosis of lumbar region, and cervical disc disorder. On 3/26/25 at 10:10 AM, R5 was lying in bed while V10 (Assistant Director of Nurses) performed wound care. V10 rolled R5 to his side and lifted his shirt. A deep, dime size open wound was observed in the middle of his back. There was no dressing covering the wound. V10 said it is a chronic wound from a surgical procedure. V10 stated she had no idea why the dressing was off and did not receive any reports from floor staff that a new one was needed. V10 said the dressing is important to prevent infection and to help the wound heal. V10 removed R5's left sock and a dark purple wound was noted on the second toe. V10 said she was doing a facility wide sweep on wounds and just found it yesterday. V10 said it is a DTI (deep tissue injury). V10 stated skin checks should be done during all CNA daily cares. Floor nurses should be doing weekly skin checks from head to toe. R5's toe wound absolutely should have been found prior to becoming an advanced stage. Infection and slow healing is a big problem. V10 said R5 had just been seen by the wound physician for the weekly rounds yesterday and assessed the toe as a DTI and measured it at 0.4 x 0.4 x unknown centimeters. R5's March 2025 physician order summary report showed an order start dated 3/18/25 for daily wound care to his back including cleansing, calcium alginate, and cover with a dressing. The most recent wound assessment dated [DATE] showed a non-pressure chronic ulcer of the back measuring 1.3 x 0.7 x 0.5 centimeters. R5's March 2025 physician order summary report showed an order start dated 3/25/25 for pressure injury to left second toe and betadine ointment every evening shift. R5's most recent wound assessment dated [DATE] showed a deep tissue injury to the left second toe. On 3/26/25 at 1:14 PM, V12 (Wound Physician) stated R5 should always have a dressing on the back wound. Drainage needs to be contained. The wound ointment needs to stay in place. Without any dressing the ointment can run down his back and irritate normal skin. V12 stated R5's toe wound is vascular in nature and denied any assessment of a DTI. V12 stated he had no control over how facility staff are charting the stage of wounds or wound care orders. V12 stated he was just notified of the open toe area at his visit yesterday. V12 said early treatment is important to lower the risk of infection and reduce the risk of further complications. The facility was unable to supply any documentation of the 3/25/25 visit by the wound physician during the survey. The facility Skin Identification, Evaluation, and Monitoring Policy dated January 2025 states: A licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified. The nursing assistant will observe the resident's skin when assisting with activities of daily living and report changes to the nurse.

Based on interview and record review, the facility staff failed to provide Cardiopulmonary Resuscitation (CPR) to a resident that was a full code. Failed to recognize the resident's code status, and failed to immediately perform life-saving interventions once the resident's code status was identified, for 1 of 3 residents (R1) reviewed for advanced directives in the sample of 3. No CPR was provided to R1 until after emergency medical services arrived at R1's bedside. This failure resulted in R1 experiencing a delay in life-saving medical care and subsequent death. The Immediate Jeopardy began on [DATE] at 5:35 PM when V4 (Licensed Practical Nurse-Agency staff) was informed by V10 (R1's visitor) that R1 was not breathing. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:17 PM. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1 was no longer in the facility during this investigation. R1 expired in the facility on [DATE]. On [DATE] at 12:54 PM, V4 (Licensed Practical Nurse-LPN/Agency Nurse) stated he was standing by his medication cart right by R1's room on [DATE] around 5:00 PM. V4 stated one of the CNAs (Certified Nursing Assistants) took R1's meal tray into her room and came right back out. V4 stated he could hear R1's family saying she needed to wake up and eat. V4 stated a short while later, V10 (one of R1's visitors) came out of R1's room and informed V4 that R1 was choking. V4 stated he went into check on R1, and she had food in and around her mouth. V4 stated R1's bed was not in the upright position. V4 stated R1's son (V8) was trying to push R1 from behind, V8's wife (V25) was grabbing R1's hands and R1's granddaughter (V9) was pushing forward on one of R1's shoulders, to try to put R1 into an upright position. V4 stated he placed R1's head of bed in the upright position and removed food from R1's mouth. V4 stated he could hear R1 gurgling, so he informed R1's family that he was going to go call 911 and send her out to a local hospital, because he believed she had aspirated. V4 stated no other staff were in R1's room when he went out to call 911. V4 stated he went out to call 911 and was just finishing up with the call at 5:35 PM, when V10 came out of the room and informed him that R1 was not breathing. V4 stated he grabbed the crash cart, located in the room behind the nurse's station and went back into R1's room. V4 stated R1's bed was in the flat position, and her family was leaning over her. V4 stated he was about to start CPR (cardiopulmonary resuscitation) when the paramedics entered the room. V4 was asked about his statement in the facility's investigation regarding being informed that R1 was not breathing at 5:35 PM and was getting ready to start CPR when the paramedics arrived at 5:41 PM (6 minutes later). V4 was asked what he was doing from 5:35 PM until 5:41 PM. V4 stated he has a disability and does not run quickly. (note: R1's room was located directly in front of the nurse's station). On [DATE] at 10:15 AM, V5 (Registered Nurse-RN) stated she worked on [DATE]. V5 stated V4 came up to her when she was passing medications to residents and told her that she needed to come with him to verify. V5 stated she asked V4 to verify what, and V4 told her to verify a resident's death. V5 stated she went with V4 to R1's room and R1 had already passed. No heart rate, no respirations. V5 stated this all happened before the paramedics arrived at the facility. V5 stated V4 did not call a code or initiate CPR so she thought R1 was a DNR (Do Not Resuscitate). On [DATE] at 2:23 PM, V6 (Certified Nursing Assistant-CNA) stated she was not sure what time it was that one of R1's family members informed her and V4 that R1 was not breathing. V6 stated she went in to check R1's vitals and there was no pulse and no respirations. V6 stated CPR was not started until the paramedics arrived. V6 was unable to say how much time had elapsed between being informed R1 was not breathing and the paramedics arriving. On [DATE] at 12:00 PM, V12 (Post acute Nurse-on call nurse on [DATE]) stated if a resident is a full code and goes into cardiac arrest; no pulse, not breathing, she would expect the nurse to initiate CPR as soon as they make sure that the resident's airway is cleared, and they verify that the resident is a full code. On [DATE] at 10:05 AM, V11 (the facility's Medical Director/R1's physician) stated the nurse should have started CPR immediately when no respirations or pulse were present. V11 stated You must start CPR immediately to achieve the best outcome. Ten minutes is way too long to wait and could definitely affect the outcome of a resident. V11 stated the nurse is obligated to start CPR immediately on a resident that is a full code. If the family did not want to continue CPR, then they (the facility) would have that conversation with the family. On [DATE] at 11:00 AM, V14 (Paramedic from a local fire department) stated the initial call came in from the facility at 5:32 PM. V14 stated they (paramedics) arrived at the facility at 5:39 PM. V14 stated initially they were stopped in the hallway by a male nurse, informing them R1 had passed away. V14 stated he advised the nurse that the paramedics still needed to go in and assess the resident, per their protocol. V14 stated when he walked into R1's room, he did not believe there were any staff in the room, only family. V14 stated CPR was not being performed on R1 when he entered the room. V14 stated he asked if R1 was a DNR and was told she was a full code. V14 stated he informed R1's family that CPR was going to be initiated. V14 stated V8 (R1's son) stated he did not want the paramedics to perform CPR on R1. V14 stated he asked if any of the family members were R1's POA (Power of Attorney) and were told they were not. V14 stated he informed V8 that according to protocol, CPR must be initiated because R1 was a full code, and none of the family members were her POA. V14 stated he informed V8 that they would start CPR and notify the hospital doctor to inform them of the family's wishes. V14 stated CPR was initiated at 5:43 PM. The local hospital was notified to let them know that R1's next of kin did not wish to continue with life-saving measures. The doctor at the hospital allowed the paramedics to discontinue CPR. V14 stated CPR was discontinued at 5:51 PM. V14 stated if there is no DNR, he would expect CPR to be started. It is important to start and initiate life-saving measures. Six to ten minutes is a long time to wait to start CPR. There would be no blood return to the brain and brain death/cell death occurs. On [DATE] at 7:58 AM, a message was left on V8's (R1's son) voicemail informing him who this surveyor was and that I wanted to see if he had any concerns regarding the events surrounding R1's passing. Surveyor's phone number left on voicemail. No return call was received prior to exiting the facility on [DATE] at 2:00 PM. R1's Transfer/Discharge Report, printed on [DATE], showed R1 was a Full Code. R1's Order Summary Report, printed by the facility on [DATE], showed R1 was a Full Code. R1's progress note dated [DATE] showed: Patient lying in bed comfortably with eyes closed and oxygen intact, while writer medication cart is by her door. Writer started setting up medication for the evening at (4:00 PM). While writer setting up the medications a call from a family member of (R1) asking about her, writer mention that (R1) has been sleeping on and off, ate 25% of her lunch, resting comfortably. At (4:30 PM) two family members arrive and go into her room and closed the door. The room door has been wide open during writer's shift for close observation by the staff. At (4:15 PM), a gentlemen approached me (V4) wanting information on (R1), I question who he was, he then informed me that he was the son. He then asked writer how (R1) was doing, I explained that she has been sleeping on and off during the day and exhibited facial expression of pain and was given a (Norco). He then said that explains why she looks very sleepy. (5:00 PM) more members showed up to visit, the granddaughter (V9) and the boyfriend (V10) and closes the door. All this time writer is next to (R1's) room setting up medications. At (5:30 PM) writer at the nurse's station is approached by granddaughter boyfriend stating, she is choking. Writer enters the room and noticed the bed at 45-degree semi-Fowlers position, while son was pushing his mother into a sitting position pushing her forward, while granddaughter pushing her by the arm, and son's wife pulling on her arms. I immediate ask to allow me to assess her and I placed the bed on a 0-degree position and patient sitting upright. Writer notice food around her mouth and drooling from the left side. Writer proceeded to clean her mouth and remove any food particle still in her mouth. Patient responsive and breathing, no sign of universal sign of (choking) or unable to breath. I just listen to a gargling noise from her mouth. I mentioned that I believed (R1) aspirated and would like to call 911 to take her to the ER (emergency room ). (5:35 PM) while writer calling 911, boyfriend approach nurses' station waving his hand across his neck, I ask what happen, he stated she stop breathing. Writer rushed for the crash cart, but when I entered the room the son and granddaughter was holding her and the bed now completely flat. I was going to start CPR, when at (5:41PM) EMT (emergency medical technicians) arrives and (initiated) CPR. The son requests for (EMT) to stop CPR and EMT got on the phone and spoke with doctor from (local hospital), which he announced her death @ (at) (5:51 PM). The son was talking to EMT about autopsy and at (6:55 PM) the body was released by (County Coroner). The son and wife remained in the room because granddaughter left with boyfriend @ (6:40 PM). I spoke with the son, and he wanted (a local funeral home) to come get the body which they (arrived) and released the body at (7:25 PM). Son spoke with funeral staff regarding (autopsy). Document signed by funeral home for the release of body. Patient teeth were given to funeral staff, which she was not wearing during eating. The [DATE] ambulance run report from the local fire department showed the call came in at 5:32:47 PM on [DATE]. EMS (Emergency Management Service) was dispatched at 5:33:20 PM. The report showed paramedics arrived at patient's side at 5:42 PM. The incident notes from the local fire department showed EMS was dispatched to the facility for a female who aspirated and became unresponsive. The notes showed no CPR was being provided to R1 when the paramedics arrived at R1's side. R1's Skilled Nursing Note dated [DATE] showed Requires skilled nursing services .burn victim .Eating performance is extensive assistance .Complaints of difficulty or pain when swallowing. R1's Nutrition Comprehensive Data Collection assessment dated [DATE], showed she had a chewing/swallowing problem related to facial pain from her burn wounds. Interventions included monitoring for shortness of breath, choking, labored respirations, lung congestion, and to monitor, document, report to nurse/dietitian/Doctor/as needed for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, and pocketing food in mouth. The facility's ,d+[DATE] policy and procedure titled Cardiopulmonary Resuscitation Policy showed 5. Depending on the underlying cause, the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. Identification of residents that have the potential to be affected by the deficient practice: Current residents and all new admissions have the potential to be affected by the deficient practice. New admissions code status will be reviewed upon admission. Immediate actions implemented to decrease resident risk: Director of Nursing, Assistant Director of Nursing, Post Acute Nurse, MDS (Minimum Data Set) Nurses, Wound Care Nurse, Regional Director of Nursing, Charge Nurse or Designee educated clinical staff beginning on [DATE] or prior to working next scheduled shift and new hires during the orientation process regarding CPR policy and procedure and Advanced Directive policy and procedure including identification of when CPR is needed. Current Resident orders reviewed by regional nurse on [DATE] and [DATE] to confirm resident preference aligned with code status. Mock codes conducted by Assistant Director of Nursing and Regional Nurse on [DATE] and [DATE] with clinical staff to ensure adherence with facility CPR policy and procedure. Ad Hoc QAPI meeting held on [DATE] with QAPI team members in person and medical director (V11) via phone. CPR policy reviewed and no changes are needed to the current policy. The Advance Directive policy was reviewed, and no changes are needed to the current policy. To ensure compliance is maintained the Director of Nursing or designee will conduct a mock code with clinical staff once per month on each shift for 3 months and will interview 3 staff 4 days a week for 6 weeks to verify understanding of CPR policy and procedure and Advanced Directive policy and procedure, including identification of when CPR is needed. Audit results will be reviewed by the Quality Assurance Committee monthly, and concerns will be addressed immediately. Date Completed: [DATE]

Based on interview and record review, the facility failed to ensure staff provided feeding assistance and supervision for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. This failure resulted in R1 aspirating, becoming unresponsive, and expiring in the facility on [DATE]. The Immediate Jeopardy began on [DATE] at 5:00 PM when V7 took R1's dinner tray into her room and left it on the bedside table for R1's family to feed her. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:17 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1 was no longer in the facility. R1 expired in the facility on [DATE]. On [DATE] at 12:54 PM, V4 (Licensed Practical Nurse-LPN/Agency Nurse) stated he was standing by his medication cart right by R1's room on [DATE] around 5:00 PM. V4 stated one of the CNAs (Certified Nursing Assistants) took R1's meal tray into her room and came right back out. V4 stated he could hear R1's family saying she needed to wake up and eat. V4 stated a short while later, V10 (one of R1's visitors) came out of R1's room and informed V4 that R1 was choking. V4 stated he went into check on R1, and she had food in and around her mouth. V4 stated R1's bed was not in the upright position. V4 stated R1's son (V8) was trying to push R1 from behind, V8's wife (V25) was grabbing R1's hands and R1's granddaughter (V9) was pushing forward on one of R1's shoulders, to try to put R1 into an upright position. V4 stated he placed R1's head of bed in the upright position and removed food from R1's mouth. V4 stated he could hear R1 gurgling, so he informed R1's family that he was going to go call 911 and send her out to a local hospital, because he believed she had aspirated. V4 stated no other staff were in R1's room when he went out to call 911. V4 stated he went out to call 911 and was just finishing up with the call at 5:35 PM, when V10 came out of the room and informed him that R1 was not breathing. V4 stated he grabbed the crash cart, located in the room behind the nurse's station and went back into R1's room. V4 stated R1's bed was in the flat position, and her family was leaning over her. V4 stated he was about to start CPR (cardiopulmonary resuscitation) when the paramedics entered the room. V4 was asked about his statement in the facility's investigation regarding being informed that R1 was not breathing at 5:35 PM and was getting ready to start CPR when the paramedics arrived at 5:41 PM (6 minutes later). V4 was asked what he was doing from 5:35 PM until 5:41 PM. V4 stated he has a disability and does not run quickly. (note: R1's room was located directly in front of the nurse's station). On [DATE] at 2:23 PM, V6 (CNA) stated she was busy with another resident so V7 took R1's tray into her room. V6 stated she asked V7 if she (V6) needed to go in and feed R1. V6 stated V7 told her no, the family stated they were going to try to feed her. On [DATE] at 12:40 PM, V3 (Speech and Language Pathologist) stated staff should have been the ones to feed R1, to implement the swallow precautions, and to monitor her for signs of difficulty swallowing, aspiration, etc. Staff would be better at feeding R1 due to how sick she was. V3 stated with R1's facial and neck burns, R1 was slow to chew and swallow foods. V3 stated instructions for R1's swallow precautions were listed on a sheet on her wall. V3 stated R1's family was not provided education on how to feed R1, or what to watch for while feeding her. V3 stated V8 had been in the room one time when she was feeding R1 small bites of nectar-thick liquids. V3 stated she informed V8 of what interventions were going to be in place, however, no education on how to feed R1, with a return-demonstration was given, to ensure V8 understood the precautions. On [DATE] at 12:17 PM, V7 (Certified Nursing Assistant-CNA) stated she was the one that took the tray into R1's room during the dinner meal on [DATE]. V7 stated R1's family was in the room, and she believes it was R1's granddaughter (V9) that told her that she could leave the tray on the bedside table, and she would try to get R1 to eat something. V7 stated she was not aware if R1 was a feeder or not. V7 stated she was not aware if R1 had special swallowing precautions with eating, or if R1's family had received any education regarding safe feeding techniques for R1. On [DATE] at 12:00 PM, V12 (Post-Acute Nurse/Nurse on-call on [DATE]) stated she would expect the staff to feed R1. V12 stated R1 had swallow precautions and was on a mechanical soft, nectar-thickened liquid diet. V12 stated R1 has to be sitting at a 90-degree angle when eating. V12 stated if it says on staff required for eating, R1 should have a nurse or a CNA feeding her. R1 who was admitted on [DATE] care plans showed she has a chewing/swallowing problem related to facial pain from her burn wounds. Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. Monitor for shortness of breath, choking, labored respirations, lung congestion. Monitor/document/report to Nurse/Dietitian and Doctor as needed for difficulty swallowing, holding food in mouth, prolonged swallow time, repeated swallows per bite, coughing, throat clearing, drooling, and pocketing food in mouth. R1's care plans showed she has a nutritional problem, or potential nutritional problem due to facial burns-eating is hard at times and soft foods are best at this time. R1 is on an altered diet at this time. R1's care plans also show she requires one staff participation to eat. R1's ADL (activities of daily living) care plan initiated on [DATE] showed: R1 requires one staff participation to eat. R1's facility assessment dated [DATE] showed she had severe cognitive impairment and required supervision or touching assistance with eating. R1's Speech Therapy Discharge Summary showed (R1) was always positioned fully upright for intake with V3 (Speech Language Pathologist-SLP) and appeared to tolerate upright position well .Patient was able to follow simple, bodily directions and functional tasks on feeding self. SLP posted swallow protocol above patient's bed for staff to follow (mechanical soft diet with nectar-thick liquids, sit as fully upright as patient tolerates and 20 minutes after meals, feed on right side of mouth due to burn on left side, small bites/sips, no straws, nasal cannula oxygen during meals only . R1's swallow protocol provided by the facility on [DATE] showed: 1. Mechanical soft diet and nectar thick liquids. 2. Push softer foods. 3. Meds crushed in applesauce 4. No straws 5. Feed/spoon food/ liquid on right side of the mouth. 6. Sit as upright as patient tolerates. Keep up 20 minutes after meals. R1's progress note dated [DATE] showed: Patient in lying in bed comfortably with eyes closed and oxygen intact, while writer medication cart is by her door. Writer started setting up medication for the evening at (4:00 PM). While writer setting up the medications a call from a family member of (R1) asking about her, writer mention that (R1) has been sleeping on and off, ate 25% of her lunch, resting comfortably. At (4:30 PM) 2 family members arrive and go into her room and closed the door. The room door has been wide open during writer's shift for close observation by the staff. At (4:15 PM), a gentlemen approached me (V4) wanting information on (R1), I question who he was, he then informed me that he was the son. He then asked writer how (R1) was doing, I explained that she has been sleeping on and off during the day and exhibited facial expression of pain and was given a (Norco). He then said that explains why she looks very sleepy. (5:00 PM) more members showed up to visit, the granddaughter (V9) and the boyfriend (V10) and closes the door. All this time writer is next to (R1's) room setting up medications. At (5:30 PM) writer at the nurse's station is approached by granddaughter boyfriend stating, she is choking. Writer enters the room and noticed the bed at 45-degree semi-Fowlers position, while son was pushing his mother in to a sitting position pushing her forward, while granddaughter pushing her by the arm, and son's wife pulling on her arms. I immediately ask to allow me to assess her, and I placed the bed on a 0-degree position and patient sitting upright. Writer notice food around her mouth and drooling from the left side. Writer proceeded to clean her mouth and remove any food particle still in her mouth. Patient responsive and breathing, no sign of universal sign of (choking) or unable to breath. I just listen to a gargling noise from her mouth. I mentioned that I believed (R1) aspirated and would like to call 911 to take her to the ER (emergency room ). (5:35 PM) while writer calling 911, boyfriend approach nurses' station waving his hand across his neck, I ask what happen, he stated she stop breathing. Writer rushed for the crash cart, but when I entered the room the son and granddaughter was holding her and the bed now completely flat. I was going to start CPR, when at (5:41PM) EMT (Emergency Medical Technicians) arrives and (initiated) CPR . Document signed by funeral home for the release of body. Patient teeth were given to funeral staff, which she was not wearing during eating. On [DATE] at 1:08 PM, V22 (Regional Director of Operations) stated the facility did not have a policy and procedure for assistance with feeding residents with swallow precautions. At 1:21 PM, V1 (Administrator) provided the facility's Skills Checklist showing feeding assistance and other tasks the nurses and CNAs would have to show competency in during orientation. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Identification of residents that have the potential to be affected by the deficient practice: a) All Residents currently residing in the community that require assistance eating due to swallowing precautions have the potential to be affected by the alleged deficient practice. 4 Residents have been identified of having swallow precautions. New admissions will be assessed for swallow problems, any residents identified will have a speech therapy evaluation to determine if swallow precautions need to be implemented and the physician will be notified of need for speech therapy due to concerns. Immediate actions implemented to decrease resident risk: Director of Nursing, Assistant Director of Nursing, Post Acute Nurse, MDS Nurses, Wound Care Nurse, Regional Director of Nursing, Charge Nurse, CNA Mentor or Designee educated clinical staff beginning on [DATE] or prior to working next scheduled shift for [NAME] nursing department staff and agency staff regarding feeding assistance with return demonstration, how to identify resident with swallow precautions and staff responsibility regarding feeding and monitoring of residents with swallow precautions. New hires will be educated during orientation on feeding assistance and swallow precautions procedures. Return demonstration conducted by Director of Nursing, Assistant Director of Nursing, Post Acute Nurse, MDS Nurses, Wound Care Nurse, Regional Director of Nursing, Charge Nurse, CNA Mentor or Designee beginning on [DATE] or prior to working next scheduled shift. Ad Hoc QAPI meeting held on [DATE] with QAPI team members in person and medical director (V11) via phone. Procedure for swallow precautions and feeding assistance was reviewed with necessary changes made to the procedure regarding speech therapy swallow precaution recommendations for residents. To ensure compliance is maintained the Director of Nursing or designee will conduct an audit 3 times a week for 8 weeks on clinical staffs knowledge of feeding assistance via return demonstration and observe 3 staff a week for 4 weeks that are providing feeding assistance to ensure compliance with speech therapy recommendations. Audit results will be reviewed by the Quality Assurance Committee monthly, and concerns will be addressed immediately. Date Completed: [DATE]

Based on observation, interview, and record review the facility failed to ensure a resident was transferred safely with a gait belt for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a distal femur fracture. The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including a history of falls and weakness. The 12/18/24 facility incident report documents the CNA (certified nursing assistant) was transferring a resident (R1) from a wheelchair to a bed using a gait belt. During the transfer, the resident's knees gave out, and the CNA lowered the resident to the floor. The same report notes R1 to be alert and oriented. R1's admission assessment and care screening of 12/22/24 showed her to be cognitively intact, risk for falls and had impairment to both of her lower extremities. The same assessment documents she required maximal assist for mobility including sit to stand/hoyer for transfers related to weakness in knees. R1's 12/27/24 nursing progress notes show she had returned from her scheduled orthopedics appointment and was to have diagnostic scans on her shoulders but was complaining of right knee pain. A scan of the right knee showed a fracture to the right knee and R1was given a knee brace for support. After follow-up with her primary care physician, an x-ray was ordered at the facility to verify the fracture. R1's 12/31/24 right knee x-ray report documents age-indeterminate fractures of the distal femur just proximal to the knee prosthesis and at the superior aspect of the patella (kneecap). The impression shows it to correlate with timing of trauma and pain. On 1/10/25 at 11:40 AM, R1 was sitting up in her wheelchair with a brace to her right leg, and a mechanical lift sling under her. R1 stated on the day of the incident it was late at night, and she should not have stayed up so late. R1 stated while transferring herself into bed, her knees gave out and she fell forward onto her knees. R1 stated the CNA was in the room but was just standing there and did not help her in anyway. R1 denied any previous falls in the facility. R1 stated she now has to use the mechanical lift to transfer due to a hairline fracture to her right leg. R1 stated she did not have any pain in her leg. On 1/10/25 at 10:30 AM, V3 CNA stated she was advised by other aides to transfer R1 with a gait belt, and she was a one person assist. V3 stated she had the gait belt around R1 and was transferring her from the wheelchair to the bed. During the transfer, R1 did not want to stand up so she was standing behind R1 holding onto the gait belt and helped her stand up, then moved the wheelchair out of the way. As R1 was pivoting her knees gave out and she lowered her to the ground on her buttocks. V3 stated she then left the room to get the nurse. On 1/10/25 at 12:00 PM, V5 LPN (Licensed Practical Nurse) stated when she entered R1's room with V3, R1 was sitting on the floor, alert and oriented. V5, stated she did not recall seeing the gait belt around R1 when she entered the room. V5 stated after she assessed R1, she found no initial injury and R1 had no complaints of pain. V5 stated V3 then placed a gait belt around R1 and transferred her into the bed. V5 stated she was not in the room when the fall happened but did see V3 place the gait belt while R1 was on the floor. On 1/10/25 at 12:30 PM, V2 DON (Director of Nursing) stated she spoke with R1, and she was told the same details of the fall, in that the CNA was in the room watching while she transferred herself and V3 did not assist her (R1) or use a gait belt. V2 stated she did believe R1, and the transfer occurred without a gait belt, resulting in R1 falling and fracturing her leg. She found V3's statement to be untruthful regarding the events that took place. V2 stated because of the fracture, R1 is now non-weight bearing and is a mechanical lift for transfers. A policy for gait belt transfers was requested and V2 said there was no policy for gait belt transfers. On 1/10/25 at 1:45 PM, V2 said the facility follows best practice when doing gait belt transfers. In this case the best practice would have been for the CNA to use a gait belt during the transfer.

Based on observation, interview and record review, the facility failed to ensure the theft of a resident's charge card and debit card did not occur for 1 of 3 residents (R1) reviewed for theft in the sample of 9. This failure resulted in R1 being very distraught, crying, and needing to be consoled by facility staff. The findings include: R1's Admission Record, provided by the facility on 9/24/24, showed she was admitted to the facility on [DATE]. R1's facility assessment dated [DATE], showed she was cognitively intact, with no hallucinations, delusions, or behaviors. The assessment showed R1 had limitations to her range of motion on her bilateral upper and lower extremities. The assessment showed R1 required substantial/maximal assistance from staff for toileting and lower body dressing, and partial/moderate assistance from staff for upper body dressing, bed mobility, and transferring from her bed to her wheelchair and back to bed. The assessment showed R1 did not ambulate during the look-back period of the assessment. On 9/24/24 at 8:55 AM, V3 (Insurance Coordinator for R1) stated she was speaking with V4 (R1's daughter/Power of Attorney-POA) and V4 informed her that R1's (Store credit card) and debit card were missing from her room at the facility. V3 stated she informed V4 that she would be reporting R1's missing cards to the State Agency. V3 stated she had not talked to V4 since she (V3) had reported the missing cards to the State Agency. On 9/24/24 at 12:40 PM, V4 stated R1 had her (Store credit card) and debit card at the facility, and they were both missing. V4 stated she spoke with the local police on 8/25/24. V4 stated at that time, she did not see charges on R1's (Store credit card). V4 stated the following day there was a $470.24 charge on R1's (Store credit card). V4 stated it looked like the (Store credit card) was tried several times before it went through on 8/26/24. V4 stated R1's debit card was used twice at a local department store in Algonquin, IL; twice at a local gas station in [NAME] IL; once at a local department store in [NAME], IL; at a local department store in Carpentersville, Illinois; and twice for an rideshare company. V4 stated between both cards, about $1200.00 was charged on R1's cards. At 3:44 PM, V4 stated she spoke to the night nurse the day R1 discovered the cards missing. V4 stated she does not recall the nurse's name. V4 stated the nurse said she had to console R1 because she was crying. V4 stated the night nurse told her that she reported the missing cards to V1, and he was going to call the police and file a report. On 9/24/24 at 9:46 AM, R1 stated she had her (Store credit card) and her debit card in her small, zippered purse in the caddy that was on her bedside table. R1 picked up the wallet-sized zippered purse that was in the clear caddy, sitting on her bedside table and said she always kept her cards in that purse. R1 stated she was not sure how much money had been charged on her cards because her daughter handles that. R1 stated when she noticed the cards were no longer in the zippered purse, she was crying and beyond distraught. R1 stated she was very upset, and it was very disturbing. R1 stated, They took my Christmas money, that is why it is so sad. R1 stated she was still upset about it. R1 was visibly upset while talking about the missing cards. R1 said she always kept the cards in the small, zippered purse and had not purchased anything with the cards since being admitted to the facility. On 9/24/24 at 3:54 PM, V6 (Social Services) stated when a resident is admitted , the CNA (Certified Nursing Assistant) on duty fills out the inventory list as to what the resident comes to the facility with. V6 stated she was not aware that R1 had any credit or debit cards in her room. At 4:04 PM, V7 (Licensed Practical Nurse-LPN) stated she was familiar with R1. V7 stated she was assigned as the nurse for R1 every day she worked. V7 stated R1 had a small coin purse that she kept in a clear, lazy [NAME]-type caddy on her over-the-bed table. V7 stated she did not know that R1 had any credit cards in the small purse because R1 did not open the purse when V7 was in her room. R1's progress notes from admission through the present were reviewed, with no documentation regarding the missing (Store credit card) and debit card. R1's care plans were reviewed showing R1 had an ADL (activities of daily living) self-care performance deficit related to impaired balance. The care plan showed R1 needs the assistance of one staff member for toileting, dressing, bed mobility, and transfers. The facility's initial report to the State Agency dated 8/25/24 showed R1 stated that on 8/24/24 she was not able to find her debit card. She (R1) states the last time she saw her card was on 8/19/24. The report showed the police were notified and an investigation was initiated by the local police and by the facility. The facility's 9/24/24 update to the final report that was sent to the State Agency on 8/30/24, showed V1 spoke with V4 on 9/24/24 as a follow up to the incident. The report showed V4 stated approximately $1,100.00 was charged on R1's debit card and (Store credit card). The updated report showed Through review of medical records, resident interviews and staff interviews, the facility is able to substantiate abuse towards resident (R1). V4 provided R1's bank and (Store credit card) statements showing the fraudulent charges.

Based on observation, interview, and record review the facility failed to identify, assess, and treat a resident's pressure injuries before becoming unstageable and Stage 3, failed to ensure pressure prevention interventions were in place, and failed to do weekly skin assessments for 4 of 6 residents (R51, R224, R3, R62) reviewed for pressure injuries in the sample of 17. This failure resulted in R51 developing an unstageable pressure injury to his left heel, a stage 2 pressure injury to his right heel and a Stage 3 pressure injury to his right scapula and R224 developing a Stage 3 pressure injury to her coccyx. The findings include: 1. On 07/22/24 at 12:18 PM, R51 was in bed that was low to the floor with fall mats on both sides of bed. R51's heels were flat on the bed and there were heel boots sitting in the chair at the bedside. On 07/24/24 at 9:37 AM, V8 Wound Nurse stated heel boots are for wound healing and prevention. R51 had heel boots for prevention and now for healing. V8 stated R51 did not have wounds when he was admitted here. V8 stated the nurse informed her of R51's wounds when they were found, and she assessed them. V8 stated when R51's wounds were discovered, R51's left heel had dark brown eschar which she classified as unstageable because she couldn't see the wound bed, R51's right heel had a fluid filled blister which is a stage 2 and R51's right scapula was found as a stage 3. V8 stated R51 can be non-complaint with care, but still the wounds should have been found much sooner. V8 stated wounds should be found before they became open areas, staff should be assessing the residents skin when providing care. R51's Braden Scale for Predicting Pressure Score Risk dated 6/13/24 shows R51 is at very high risk for pressure. R51's Pressure Ulcer Weekly Wound Assessments dated 7/10/24 show: R51 has an acquired during stay, unstageable pressure injury to his left heel measuring 6.0 x 3.0 cm x unknown depth, described as dark brown eschar. The air mattress was previously requested from hospice company and again was requested today. R51 has an acquired during stay, stage 3 pressure injury to his right scapula measuring 0.4 x 0.5 x 0.1 cm, described as round in shape with moist red tissue, light serosanguineous drainage, area sensitive to touch. R51 had an acquired during stay, stage 2 pressure injury to his right heel measuring 3.0 x 3.5 x unknown depth, described as an intact fluid filled blister to the right heel. R51's Care Plan dated 7/11/24 shows Air mattress in place to bed set appropriately and in proper working condition. May adjust firmness per resident's request for comfort. Effective 7/11/24 (after pressure was acquired). 2. On 07/22/24 at 8:58 AM, R224 was sleeping in bed. V20 (R224's husband) was sitting beside the bed. V20 stated he was here all day with her until 9 PM. V20 stated sometimes they have to wait 1.5 hours for them to change her. They come in and turn call light off then don't come back, so I have to put the call light on again. I would change her myself, if I had the stuff. Last night the nurse found a crack that opened up on her butt and she was supposed to get patch for it. V20 stated he hadn't heard anything yet about it and no one had come to assess it or put a dressing on it. On 07/23/24 at 08:19 AM, R224 was in bed with V20 at the bedside. V8 came in with this surveyor for a skin check. V20 stated the staff noticed the crack on R224's butt and stated they were going to put something on it and never did. V8 rolled R224 to her right side and lowered R224's brief. R224 had an open slit in the crack of her coccyx area that was visibly open and red in color. V8 stated R224 has history of a stage 3 pressure injury there, that R224 was admitted with. V8 stated it now is open again. V8 stated she would call it a stage 3 since it re-opened and previously was a stage 3. V8 stated the nurse that found it should have called the doctor and got orders and let V2 Director of Nursing know. V8 stated there should have been an assessment done and staff should have let me know yesterday (Monday). On 07/23/24 at 08:57 AM, V8 stated R224 has all the pressure interventions in place, not being changed or repositioned could cause wound to reopen. V8 stated she spoke with the doctor and got treatment orders. At 09:01 AM, V8 cleansed the open crack. The wound bed was reddish/pink in color and measured 3.5 x 0.6 x 0.1 cm. V8 used skin prep around wound, applied gauze with medihoney, and a foam dressing. On 07/23/24 at 1:13 PM, V24 Physician said he was just notified today of R224's wound and the nurse should have called when wound was found and get treatment orders. R224's Pressure Ulcer Weekly Wound Evaluation dated 7/23/24 shows re-opened stage 3 pressure injury to coccyx measuring 3.5 x 0.6 x 0.1 cm. R224's Braden Scale for Predicting Pressure Score Risk dated 7/19/24 shows R224 is at very high risk for pressure. 3. On 07/22/24 at 10:24 AM, V21 and V22 Certified Nursing Assistants (CNA) went into R3's room to change and clean R3 up. When V21 and V22 rolled R3 to her right side and lowered the bedding, R3 was covered with stool from the middle of her thigh to the middle of her back. R3 had an open wound on her left posterior thigh that was covered in stool. There was no dressing on the wound. V22 stated there was no dressing on R3's thigh and there wasn't one in the bedding. At 10:55 AM, V8 Wound Nurse came into the room to do R3's dressing change. V8 stated there was supposed to be a dressing on her wound, R3 has stage 3 pressure injury. R3's Most recent Pressure Ulcer Weekly Wound Evaluation was dated 7/8/24 (2 weeks ago) and shows R3 has a Stage 3 pressure injury on her left thigh that has been present since admission. R3's Physician Orders dated 6/21/22 shows Left posterior thigh pressure injury: Cleanse with the wound cleanser, pat dry, apply Calcium Alginate, apply silicone dressing. Everyday shift and as needed for wound care. On 07/24/24 at 09:37 AM, V8 stated if a resident has pressure, skin assessments should be done weekly. V8 stated she was out last week sick and V3 Assistant Director of Nursing (ADON) was doing the skin assessments. On 07/24/24 at 11:53 AM, V3 stated she did pressure wound assessments last week, but was unable to do R3 and R51's assessment because they were up in the chair. 4. On 07/23/24 at 08:32 AM, R62 was sitting up in bed, leaning to her left side, eating breakfast. R62's air mattress was completely deflated and R62's outer edge of both her feet and heels were resting directly on the deflated mattress. R62's air mattress machine did not have any lights on and there was a detached cord hanging under the bed. R62 stated she was able to move her arms but needed help moving her legs. R62 stated she thought she had some wounds on her bottom. On 07/23/24 at 08:35 AM, V16 CNA stated the bed is not on. I think it's broken, it had been beeping. I'm not sure why it's not on. The bed works, the light is on to the remote to move the bed, but not on pressure unit. V16 turned the button on pressure machine box on and off, but no light turned on. V16 saw the plug hanging disconnected underneath and said she was not sure where the plug goes. On 07/23/24 at 08:50 AM, V8 came into the room with this surveyor and said the bed is not working, the mattress is deflated. V8 state R62 needs to be moved out of the bed, she is laying on the metal frame. V17 Licensed Practical Nurse and V16 came in and got R62 out of the bed. On 07/24/24 at 9:37 AM, V8 stated R62's air mattress is for her wound to heal and for her to not acquire any more pressure injuries. R62's most recent Pressure Ulcer Weekly Wound Evaluation is dated 7/12/24 (11 days ago) shows R62 has a Stage 3 pressure injury to her sacrum. The facility's Pressure Ulcer/Pressure Injury Prevention Policy dated 3/2022 shows A facility must: Implement, monitor, and interventions to attempt to stabilize, reduce, or remove underlying risk factors, and if a pressure ulcer is present, provide treatment to heal it and prevent the development of additional pressure ulcers. Implementation: interventions for the prevention of pressure ulcer/pressure injury will be individualized to meet the specific needs of the resident- Protect heels, float, if possible, manage moisture by providing toileting at regular intervals; provide prompt incontinent care, utilizing preventative skin products, pressure redistributing support surface for chair and bed, skin checks weekly by Licensed Nurses, daily observations of skin during care given by CNAs.

Based on observation, interview, and record review the facility failed to ensure residents pain medications were administered for 2 of 17 residents (R223, R67) reviewed for pain in the sample of 17. This failure resulted in R223 suffering with pain due to metastatic breast cancer with lesions to the bone and liver. The findings include: 1. On 07/22/24 at 9:16 AM, R223 was in bed watching TV. R223's face and arms were yellow in color. When asked how everything was going, R223's face appeared sad, and R223 stated It was a horrible start since admission. I felt rushed being discharged from the hospital, they weren't even ready for me here. They didn't have my medications. I got here Thursday night (7/18/24) and they didn't' have my pain medications until Saturday morning (7/20/24). The pain by that time was and 8 out of 10. I was so uncomfortable and upset, why not wait for discharge so all my medications can be ready? R223's Face sheet shows R223 was admitted to the facility on [DATE]. R223's Hospital History and Physical dated 7/5/24 shows Metastatic breast cancer with metastases to the iliac and femoral bone and liver. Plan: As needed pain control. On 07/23/24 at 12:47 PM, R223 stated she had pain Thursday night and all-day Friday and she had told the nurse. R223 stated the nurse she said she was working on the medications and needed a code to get into the medications. On Friday it was still the same, they were working on my medications, and I couldn't get any pain medications because they needed a code to get into the machine. I don't recall being told there was any problems with my medication orders. Friday my medications were delivered at midnight. I woke up Saturday morning around 2:00 AM, in pain, and was finally able to get my pain medication. Friday my pain was a 6-7 throughout day due to my physical therapy evaluation and I was doing quite a bit. The nurses never asked me my pain level or where my pain was. I kept asking about getting my medications and I just kept getting told I had to wait for pharmacy, and they didn't have a code. My pain was pretty bad, I was very uncomfortable. R223's Physician Progress Note dated 7/19/24 (day after admission) shows Assessment: Septic Shock/ CMV virus, Metastatic breast carcinoma, anemia, anxiety, chronic pain, status post right nephrectomy. Plan: We will certainly prescribe oxycodone as she has been taking it. There is no doubt that she is experiencing some pain given her bony lesions. I think it is very appropriate. We will assist with making sure she is comfortable and encourage her with her rehabilitation. On 07/23/24 at 10:49 AM, V18 Licensed Practical Nurse stated according to R223's Individual Resident Controlled Substance Record, R223's oxycodone was ordered on 7/19/24 (day after admission) and delivered on 7/20/24. V18 stated the pharmacy delivers every evening Monday to Saturday, but there is no Sunday delivery. R223's Physician Orders for July 2024 shows R223's oxycodone was ordered on 7/19/24. R223's Controlled Substance Record shows R223 did not receive a dose of oxycodone until 2:00 AM on 7/20/24. On 07/23/24 at 12:53 PM, V2 Director of Nursing stated nurses need a password to get into emergency box for narcotics. The nurses have to call the pharmacy to get the code and 2 nurses verify. All nurses, including agency nurses have access and follow the same procedure to get the code and get the medication from the emergency box. On 07/23/24 at 12:55 PM, V19 Post Acute Nurse Supervisor stated R223's oxycodone ordered showed discontinued on the hospital paperwork. The hospital called and notified us it was supposed to be continued and electronically faxed a prescription. V3 Assistant Director of Nursing (ADON) spoke to the hospital and got an order. V19 stated while waiting for medications to be delivered, the nurses could get the pain medication from emergency box with a code from pharmacy. V19 stated the nurses should have been assessing R223's pain and calling the hospital if there was any question about R223's orders on discharge. On 07/24/24 at 10:45 AM, V3 ADON stated she spoke with a nurse at the hospital the next day (7/19/24) around noon, and the nurse stated the hospital orders had oxycodone discontinued by mistake. R223 stated the nurse gave a verbal order and faxed the pharmacy. V3 stated the nurse could have called hospital to clarify that night if the resident was having pain. V3 stated with an order, the nurse could have gotten the medication from the emergency box. On 07/23/24 at 12:44 PM, V18 stated R223 has pain and usually asks for pain medications in the afternoon and in early morning around 5-6 AM. R223's Medication Administration Record shows that since Oxycodone was received, R223 has taken the medication at least one time daily. R223's Care Plan shows R223 is at risk for pain related to left breast cancer with mets to bone and to liver. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Anticipate R223's need for pain relief and respond immediately to any complaint of pain. The facility's Critical Care Pharmacy Emergency Medication Kit Policy shows A Stat Safe Machine, containing a limited but broad rand of drugs, is available for immediate use. The Stat Safe Machine is available to licensed nursing personnel only. 2. On 07/22/24 at 10:19 AM, R67 stated I don't have a pain patch yet. I have been waiting since 7:00 AM. My pain is now a 7, it's low back pain. I'm supposed to have a pain patch. R67 leaned forward in her wheelchair and showed this surveyor her lower back and pointed to where on her back the patch was supposed to go. There was no patch observed on R67's lower back. R67's Medication Administration Record (MAR) for July 2024 shows an order Lidoderm patch 5% (Lidocaine) Apply to per additional directions topically in the morning for pain and remove per schedule. Apply 6:00 AM. The same MAR shows R67 has diagnoses of lumbago with sciatica and wedge compression fractures to her second and fifth lumbar vertebra. On 07/23/24 8:45 AM, R67 stated the pain patch helps a lot with my pain. I don't have one on this morning yet. V16 Certified Nursing Assistant came into the room and assisted R67 to lower the back of her pants and show this surveyor, there was no pain patch observed on R67's back. On 7/23/24 at 8:50 AM, V17 Licensed Practical Nurse, when asked about R67's pain patch, stated she had not done R67's patch yet. When asked when the patch was due, V17 stated it's due at 6:00 AM, but it had already been signed off by the night nurse. V17 stated she would check and apply the patch. On 07/24/24 at 10:45 AM, V3 ADON stated medications should be given as ordered and on time. V3 stated medications should not be signed off unless administered. On 7/23/24 at 8:12 AM, V1 Administrator said the facility does not have a policy on pain. The facility's Critical Care Pharmacy Policy and Procedure Manual shows It is our purpose to provide to the facility quality care and services which enables the facility to provide and maintain the resident's optimum quality of live within the scope of the resident's physical and psychological well-being. All medications, including non-legend medications (cathartics, headache remedies, vitamins, etc.) shall be given only upon written order of the physician.

Based on observation, interview, and record review the facility failed to thoroughly assess a resident's malfunctioning catheter. This failure resulted in the resident (R3) experiencing bleeding, catheter pain and needing to be admitted to the local hospital. The facility also failed to prevent a suprapubic catheter from being displaced during care. This applies to 2 of 3 residents (R3 and R1) reviewed for catheters in the sample of 4. The findings include: 1. On 5/28/2024 at 12:50PM, R3 stated staff tried to put a catheter in and wasn't sure what happened. R3 stated his p**** started bleeding and wouldn't stop. R3 stated blood was all over the place. R3 stated he was sent to the hospital and ended up in the intensive care unit. On 5/28/2024 at 1:25PM, V7 Licensed Practical Nurse (LPN) stated she was caring for [R3] on 5/20/2024 during the day shift (7:00AM - 3:00PM). V7 said between 1:00PM - 2:00PM [R3] said this damn thing is hurting referring to his p****. V7 said [R3] told her the tip of his p**** was hurting and burning. V7 said she told [R3] she could flush the catheter to see if that helps. V7 said she looked at [R1's] p**** and didn't see any visible trauma. V7 said she did see some sediment in the tubing, but no blood or bleeding noted. V7 said [R3] has a behavior of pulling on his catheter and wrapping it around his wheelchair too tight. V7 said she had re-educated [R3] that because he had been pulling on his catheter. V7 said she did not flush [R3's] catheter before her shift ended that day. V7 said she did not notify a physician regarding [R3's] complaint that the head of his p**** was burning. V7 said if it would have been something more than just the head if his p**** burning, she would have investigated it further. V7 said she did not obtain vitals on [R3]. V7 said she did notice he had a little urine in the bag but not sure how much. On 5/28/2024 at 12:55PM, V4 LPN said she was working on 5/20/2024 and was caring for [R3]. V4 said she worked the 3PM to 11PM shift that day. V4 said after she received report from the day shift nurse she saw [R3] it was for something. V4 said when she saw [R3] he had a large towel around his catheter because it was leaking. V4 said [R1] was having a lot of pain. V4 said she gave [R3] pain medication per resident's request and came back to see him later after the pain medication had time to work. V4 said [R3] had about 200mLs of urine in the Foley drainage bag, no blood in urine noted at that time. V4 said she didn't come back to see [R3] until sometime after dinner. V4 said she deflated [R3's] balloon because he was complaining of pain 10 out of 10. V4 said when she deflated the catheter balloon the resident expressed immediate relief and decreased pain. V4 said the resident began urinating and then blood started coming out. V4 said she estimates the blood loss to be 100-200mL. V4 said when the catheter was removed [R3] started urinating and it was spraying all over and looked like the resident had been retaining urine. V4 said [R3] does play with his p**** and has scaring at the head of his p**** from years of having catheters in place. V4 said she obtained vitals on [R3]. V4 said she contacted the [V9 Physician] regarding [R3's] continued bleeding from his p**** and received orders to send him to the hospital. V4 said [R3] was admitted to the hospital for UTI, displaced foley and hypotension. V4 said [R3] was supposed to come back to the facility but ended up in the ICU. V4 said when the resident left for the hospital, he was alert and oriented talking about seeing her when he gets back. On 5/28/2024 at 1:46PM, V2 Director of Nursing (DON) said signs and symptoms of a UTI/urinary tract infection would be complaints of pain or burning while urinating. V2 said a UA is normally ordered when a resident complains of burning in their genital area or with urination. V2 said complaints of burning should be assessed right away and the physician notified as soon as possible. V2 said a leaking catheter could be a sign of a malfunctioning catheter. V2 said the catheter may need to be removed, repositioned, or flushed. V2 said a leaking catheter should be addressed right away because the resident is at risk for retaining fluid and UTI. V2 said catheters can be uncomfortable but shouldn't cause 10/10 pain that is abnormal. V2 said something is wrong if its leaking, pain is present, and blood is present upon urination. On 5/28/2024 at 2:48PM, V9 Physician said we sent out [R3] because of the blood being displayed. V9 said catheter problems do occur. V9 said he can't say the UTI is what caused his admission. V9 said he was admitted for a host of issues. V9 said it's not unusual for residents having bladder issues to have hypotension due to a vasovagal response. V9 said sepsis is more of a general term these days and doesn't have the strict requirements it once did to be considered sepsis. V9 said without seeing his labs he wouldn't be able to say he was actually septic or not. R3's Catheter Output documentation shows no documented output on 5/20/2024 for the AM or PM shift. R3's total output trend for per day on 5/14/2024 1400mL, 5/15/2024 1100mL, 5/16/2024 2040mL, 5/17/2024 1400mL, 5/18/2024 600mL, 5/19/2024 600mL. The only set of vitals found on 5/20/2024 were from 6:22-6:23PM, B/P 122/67, HR 64, T 97.6, R18, 97% on RA. Pain Scale documentation from 5/20/2024 shows pain values of 1 at 12:00PM, 7 at 4:12PM, and 8 at 6:11PM. Hospital records indicate [R3] arrived at the hospital on 5/20/2024 in the ER/emergency room at 9:31PM for acute UTI, hypotension, and displacement of foley catheter. [R3] was started on Norepinephrine (vasopressor used to increase blood pressure) on 5/21/2024 at 6:30AM. Hospital H&P (History and Physical) completed on 5/21/2024 states reason for consult septic shock. Patient was seen in ED/emergency department after hematuria (blood in urine) when exchanging Foley catheter. Patient was noted to tachypneic febrile rigorous mildy hypoxia on nasal cannula. Patient became hypotensive was given IV/intravenous fluids started on norepinephrine admit to the ICU and critical care was consulted. Appears to have received 2L fluids in the ED . Foley catheter chronic for years per patient. drips/pressors: norepinephrine at 5 normal [NAME] at 83. LABS . chemistry shows creatinine likely consistent with acute kidney injury given baseline somewhere between 0.4 0.5 and now 0.69 . urine could be consistent with UTI 3+ blood red cell. HGB 10-11 . potential problems hypotension septic shock probably hypovolemia. R3's Admission Record shows he was admitted on [DATE], original admitted [DATE]. 2. On 5/28/2024 at 8:50AM, R1 said he does have a catheter but it's a suprapubic catheter. R1 said last week during care a CNA pulled down his brief and pulled out his suprapubic catheter. R1 said the CNA was in a hurry. R1 said his nurse was unable to put in another catheter and he had to go to the hospital to get one placed again. On 5/28/2024 at 11:58AM, V6 CNA said she was working with [R1] the day his catheter came out (5/20/2024). V6 said she had assisted [R1] to the bathroom and [R1] wanted his pull up off because he had already started going to the bathroom. V6 said she tore the left side of the brief off and the brief shifted, and the catheter came out. On 5/28/2024 at 11:33AM, V4 LPN said she was caring for [R1] on 5/20/2024. V4 said [V6] had reported to her [R1's] catheter had come out during care. V4 said she attempted to reinsert the catheter but was unsuccessful. V4 said she reached out to [V8 - Physician] and [R1] was sent out to the hospital for catheter placement. V4 said [R1] returned later that day. V4 said suprapubic catheters shouldn't come out. V4 said they are secured with a balloon inflated inside of the bladder. On 5/28/2024 at 9:27AM, V2 Director of Nursing (DON) said the goal is for catheters not to be dislodged during care. R1's MDS (Minimum Data Set) section C dated 5/1/2024 lists R1's BIMs score at 15, cognitively intact. R1's Progress Notes dated 5/20/2024 state at 4:28PM CNA came to [V4] stating that his suprapubic catheter came out . resident picked up by ambulance service at 4:40PM . resident returned to the facility at 7:30PM.

Based on observation, interview and record review the facility failed to have staff on duty trained in the use of emergency medical equipment. The facility failed to ensure their policy was followed to use the AED (Automated External Defibrillator) during CPR (Cardiopulmonary Resuscitation). This failure resulted in R1 expiring at the facility. This applies to 24 of 24 (R1, R3-R24) residents in the sample of 24 reviewed for emergency care/CPR. The immediate jeopardy began on [DATE] at 2:22 AM when R1 was pronounced expired after having a sudden cardiac arrest, the staff in facility were unsure of the policy of what to do, how to provide CPR, and did not use the available AED (Automated External Defibrillator). The immediate jeopardy was identified on [DATE]. V1 Administrator was notified of the immediate jeopardy on [DATE]. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on [DATE], but noncompliance remains at a level 2 because additional time is needed to evaluate implementation and effectiveness of the in-service training. The findings include: The facility face sheet shows R1 was admitted to the facility on [DATE] with diagnosis of a stage 4 pressure ulcer to the sacral region, type 2 diabetes, obesity, acute respiratory failure, sepsis, pneumonia, heart failure, hypertension, atherosclerotic heart disease and anemia in chronic kidney disease. The facility assessment dated [DATE] shows him to require extensive ADL (Activities of Daily Living) assistance. R1's Physician orders for [DATE] shows him to be a full code. On [DATE] at 8:30 AM a crash cart was observed on the north hall of the facility. A sign in sheet for checking the crash cart for supplies showed it was checked on [DATE], [DATE], [DATE] and [DATE]. The crash cart observed on the south hall had a sign in sheet for checking the crash cart for supplies shows it was checked on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. At 1:25 PM the logs to the crash carts were no longer on the cart. A copy of the logs was requested from the DON (Director of Nursing) at 1:25 PM and I was provided with the logs completely filled in and up to date. On [DATE] at 8:40 AM, a white box labeled AED was observed on the wall behind the south nursing station. The box was empty. On [DATE] at 2:15 PM the facility AED was observed with the battery out. Attached to the AED were 2 used pads. V2 DON said these pads were used during the mock code on Thursday. The pads are attached to the AED and held in place by a removable clear cover that says PULL on it. There was no maintenance tag attached to the AED. V2 DON said there were no additional pads available in the facility. A nursing note for R1 dated [DATE] at 3:05 AM shows on [DATE] R1 was found in his bed not breathing and had no pulse. A code blue was called, Cardio Pulmonary Resuscitation (CPR) was initiated and 911 was called. When Emergency Medical Services (EMS) arrived, they took over CPR and notified the hospital and were told to stop CPR and a time of death was recorded as 2:22 AM. The EMS report shows they arrived at the facility to find R1 unconscious and not breathing. They took over CPR. Facility staff said R1 was last seen at 11:00 PM and CPR had been going on for 20 minutes and that they had already pronounced him expired but were still providing CPR to the resident. The crew was informed the resident was a full code. EMS crew noted R1 to have mottled skin and was cool to touch. The hospital was notified with condition and a snapshot of the asystole rhythm strip and was directed to pronounce his death at 2:22 AM. Facility staff stated when two nurses are present that they are able to pronounce the resident after resuscitation efforts. On [DATE] at 10:52 AM, V6 Registered Nurse (RN) said she was the nurse working on R1's unit the night he coded. She said she is an agency nurse and did not come on duty until 12:30 AM. A nurse from the second shift stayed until she got there. The outgoing nurse had checked vitals on R1 at 10:59 PM and they were within his normal limits. V6 said she could not remember what time it was, but when she went into his room to give him his intravenous antibiotic he was not responding. V6 said she checked for pulses and found none. V6 called for the other nurse to come, and CPR was started and called 911. V6 also called the manager on duty for guidance as to what to do. V6 said she did not know the policy and procedure for finding a resident without a pulse. V6 said when she was looking for supplies and making phone calls her coworker, V7 was doing CPR. V6 said she could not find the back board so the mattress R1 was lying on was deflated. V6 said the Automated External Defibrillator (AED) did not have any pads available for her use. On [DATE] at 11:50 AM, V7 Licensed Practical Nurse (LPN) said she was called to R1's room for a code blue. V7 said she assisted with CPR until the EMS got there. V7 said no back board could be found so the mattress was deflated. V7 said she never saw an AED. On [DATE] at 4:13 PM, V8 Certified Nursing Assistant (CNA) said she was the CNA assigned to R1 that night. V8 said she had not had any interaction with R1 since coming on shift. V8 said she saw R1 from the doorway during shift change. V8 said during the code she was asked to go wait for the EMS to come to the door. On [DATE] at 2:55 PM, V9 LPN said she was the manager on call for the facility and was called by the agency nurses at the facility regarding R1 not breathing and had no pulse. V9 said V6 told her she did not know what to do. I told her to start CPR and do it until EMS got there. V9 said V6 told her she could not find the crash cart and did not know where to look for it. V9 said V6 just kept saying she did not know what to do. On [DATE] at 5:40 PM, V4 Paramedic said he responded to the facility and found R1 receiving CPR from two facility nurses. V4 said R1 was cool to the touch and the nursing staff said R1's last time observed alive was at 11:00 PM and it was now after 2:00 AM. V4 said they took over CPR, attached the heart monitor and found he did not have a heart rhythm. V4 said CPR was completed for two more minutes and another rhythm was observed as absent. V4 said the local hospital was called and R1 was pronounced expired. V4 said after the resident's death was pronounced, he stopped and spoke with the nurses, and they told V4 they were agency nurses and did not know the facilities protocol for declaring a resident deceased . V4 said they told him usually two nurses can pronounce a resident death. On [DATE] at 1:10 PM, V2 DON said there were pads for the AED that night because the AED alarms if no pads are attached to it. The agency nurses must not have known how to use the AED. I would expect the staff to use the AED in a code situation. The nurses are to follow AHA (American Heart Association) guidelines for completing a code blue. The last pads for the AED were used during a mock code blue on [DATE] and new pads have been ordered but not yet in the facility. On [DATE] at 1:36 PM, V1 Administrator said the facility has no policy for the AED and expects the staff to use the manufacturer's guidelines for its use. On [DATE] at 1:46 PM, V5 Medical Director said R1 had an immense cardiac history and was known to have heart arrhythmia. V5 said if the facility has an AED, it should be used, and the staff should be trained to use it. V5 said all equipment needed for a code situation should be maintained and staff trained to use it. V5 said due to R1's health and unknown time without a pulse an AED would likely not have been helpful but should have been used on R1 since one was available. The manufacturer's guidelines for the AED shows the AED should be stored with spare pads in the carrying case. A maintenance tag provided with the AED should be used to record the expiration dates of the installed pads. Do not leave the AED without pads installed, the defibrillator will start chirping and the button will start flashing. The single use pads must be replaced after being used. The facility policy dated ,d+[DATE] for Emergency procedure for cardiopulmonary resuscitation shows personal have completed training on the initiation of CPR/basic life support in victims with sudden cardiac arrest. 4. maintain equipment and supplies for CPR in the facilities at all times. 1. The facilities procedure for administering CPR shall incorporate the steps covered in the current American Heart Association guidelines for CPR. The adult life support algorithm for healthcare providers provided to this writer on [DATE] at 1:36 PM shows to obtain the AED and emergency equipment and to use as soon as it is available. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove immediacy. To remove immediacy, the facility initiated the following steps: Identification of residents that have the potential to be affected by the deficient practice: Current residents choosing full code have the potential to be affected by the deficient practice. A. Current Resident orders reviewed to confirm resident preference aligned with code status. Immediate actions implemented to decrease resident risk: A. AED has been removed from service at facility and will be reviewed on a quarterly basis for need. B. Re-educated current associates to location of the crash cart or at the beginning of their next scheduled shift and ongoing as needed. C. Re-educated current clinical services associates related to facilities current CPR policy and procedure, including identification when CPR is needed or at the beginning of their next scheduled shift and ongoing as needed. D. Agency Staff provided guidance on location of crash cart and facilities current CPR policy and procedure, including identification when CPR is needed at the beginning of the scheduled shift and ongoing as needed. E. To ensure compliance is maintained the Director of Nursing or designee will audit 3 times a week for 8 weeks associate knowledge of location of crash cart and current CPR policy and procedure, including identification when CPR is needed. Audit results will be reviewed by the Quality Assurance Committee. The facilities Emergency Procedure- Cardiopulmonary Resuscitation policy was updated on [DATE] and has been reviewed and approved by the Medical Director, Administrator and Acting Director of Nursing. Date Completed: [DATE]

Based on interview and record review the facility failed to ensure wound assessments and treatments were performed for a resident with pressure injuries for 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 7. This failure resulted in R1 developing necrotizing fasciitis that required surgical intervention and then expired. The finding include: R1's Face Sheet shows that she was admitted to the facility on [DATE]. R1's admitting diagnoses include displaced fracture of base of neck of left femur, weakness, difficulty walking, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side and pressure-induced deep tissue damage of sacral region. R1's Discharge Summary from the local hospital dated [DATE] shows, Orthopedics completed left hip hemiarthroplasty on [DATE] sacral suspected deep tissue injury hospital acquired, [adhesive foam dressing] sacrum dressing changed every 3 days and as needed. R1's Admission assessment dated [DATE] shows that she does not have any impairment in skin integrity. R1's Daily Skilled Nurse's Notes dated [DATE] shows, [R1] has the following skin issues: no new issues. R1's Physician's FYI/Order Request form dated [DATE] shows, Resident has blister to L (left) heel. Can we have order to apply betadine to L heel BID? Physician's Response/orders .OK Date: [DATE]. R1's Electronic Medical Record does not document any assessment of the wound on her left heel. R1's August Treatment Administration Record (TAR) does not show any treatments were performed on this wound. R1's Physician's Order Sheet (POS) printed on [DATE] does show an order for Betadine to left heel blister twice a day was ordered on [DATE] but there is no start date listed. R1's Daily Skilled Nurse's Notes dated [DATE] shows, Coccyx area noted to be bleeding, new dressing applied. R1's Health Status Note dated [DATE] shows, Treatment to sacral wound completed. [R1] is complaining of increased pain to area. No warmth, no drainage, no foul odors. POA (Power of Attorney) updated. Wound care MD (Physician) to round early next week. R1's Health Status Note dated [DATE] shows, Wound care provided to sacral area. R1's Weekly Skin Assessment Forms dated [DATE], [DATE], [DATE], [DATE] and [DATE] all show that she had no new areas of skin impairment. R1's Electronic Medical Record does not document any assessments of the wound on her coccyx. R1's July and August TAR does not show any treatments were performed on this wound. R1's POS printed on [DATE] shows an order dated [DATE] for: Cleanse sacrum wound with NS (normal saline), apply [antimicrobial cleanser] soaked gauze and place [bordered foam dressing] daily and as needed with a start date of [DATE] (2 days after discharge). R1's Nursing Notes dated [DATE] show, Resident found with eye open nonverbal but will track you with eyes Wound on coccyx bleeding now [sic] dressing applied 911 ambulance took resident to [local emergency room ] for eval (evaluation) and tx (treatment). R1's emergency room Report dated [DATE] shows, Quarter sized circular opening mid lower sacrum/coccyx draining serosanguinous fluid. Skin over lower back is warm, hot, erythematous, and tender. Able to express fluid with palpation. Foul smelling drainage. R1's CT (computerized tomography) Chest, Abdomen and Pelvis dated [DATE] shows, Nonspecific soft tissue gas identified in the bilateral gluteal cleft as well as in the bilateral gluteal soft tissue/musculature may be due to ongoing infection with possible overlying ulceration R1's Discharge Summary dated [DATE] shows, During initial evaluation .Noted to have decubitus ulcer over the buttocks. Was placed on Zosyn and Vanco (antibiotics).She was taken to OR (operating room) on ,d+[DATE] and had extensive necrosis of the buttocks. She had sharp excision of the skin/subcutaneous tissue and muscle .Suffered cardiac arrest on [DATE], resuscitated .Repeat dressing change to left gluteal abscess, debridement of skin subcutaneous tissue and muscle secondary to necrotizing fasciitis on [DATE] .Patient made DNR (Do Not Resuscitate) on [DATE] Patient extubated at 11:48 AM on [DATE] At 12:09 PM patient has passed away peacefully. R1's Death Certificate shows cause of death as sepsis, gluteal abscess necrotizing fasciitis and atrial fibrillation. On [DATE] at 2:30 PM, V4 (Wound Physician) stated that wound care is important to protect the wound, prevent infections, capture drainage, and promote wound healing. V4 stated that if a wound did not receive treatment, it could become stagnant, deteriorate, infected or auto resolve. V4 stated that necrotizing fasciitis has a high mortality rate with rapid progression. V4 stated some signs of necrotizing fasciitis would be crepitus under the skin from gas build up, migrating erythema, abnormal lab values, unstable vitals and could have increase pain. V4 stated that if a resident has an untreated wound, they could develop necrotizing fasciitis. V4 stated he would expect the staff to notify him or the primary physician when a new wound is identified or there are any changes to a current wound so new treatment orders could be given. On [DATE] at 9:28 AM, V5 (Wound Licensed Practical Nurse) stated that on admission, a skin check should be performed and all wounds including pressure wounds and surgical wounds should be documented. V5 stated that the documentation should include the location, size, and characteristics of the wound. V5 stated that the physician should be notified on admission of the wound and orders placed in the computer for treatment. V5 stated that orders for treatment would show up on the residents TAR. V5 said that all wounds should be assessed weekly, and the assessment should include the location, size and characteristics of the wound. V5 said that weekly assessments are important to make sure the wound is healing, and treatment does not need to be changed. V5 said that if a resident develops a new wound while at the facility, the nursing staff should notify management right away so the team can do an assessment and get treatment orders. V5 said that a blister on the heel is typically a DTI (deep tissue injury) cause by pressure or some type of trauma. R1's Skin Integrity Care plan initiated on [DATE] documents that R1 has pressure-induced deep tissue damage of sacral region with interventions of: Administer treatments as ordered and monitor for effectiveness .Document location of wound, amt of drainage, per-wound area, pain, edema, and circumference measurements (q week (every week)) Evaluate wound for: size, depth, margins, peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated Monitor/document/report to MD (Physician) PRN (as needed) for s/sx (signs and symptoms) of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever . The facility's Wound Assessment Policy revised on ,d+[DATE] shows, It is the policy of the facility to assess each wound initially either at the time of admission or at the time the wound is identified. Each wound will be assessed weekly thereafter or with any significant noted change in the wound A thorough assessment includes the following: location, size, depth, stage (appropriate for Pressure Ulcer/Pressure injury only), exudate (amount, type, odor), Tissue (epithelial, granulation, necrotic, slough or eschar), signs of infection (fever, erythema, edema, purulent drainage), per wound skin condition, pain .Treatment Options .Wound healing is optimized and the potential for infection is decreased when all necrotic tissue, exudate, and metabolic wastes are removed from the wound The facility's Significant Condition Change and Notification Policy revised on ,d+[DATE] shows, Purpose To ensure medical practitioners are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status. (See below for examples) Bleeding .New wounds symptoms of infectious process abnormal, unusual or new complaints of pain .

Based on observation, interview, and record review the facility failed to identify pressure injuries prior to becoming unstageable, as a result of this failure R8 developed multiple pressure injuries to her heels. The facility also failed to ensure current wound treatments were completed, failed to ensure pressure ulcer prevention measures were in place and failed to clean a pressure wound in a manner to prevent cross contamination for 2 of 3 residents (R34, R51) reviewed for pressure injuries in the sample of 17. The findings include: 1. R8's Admission Record shows she was admitted to the facility on [DATE]. The June 2023 POS (physician order summary) shows an order to float heels while in bed every shift for prevention of skin breakdown. The orders include skin prep daily and as needed for wound care to the right heel and the left heel starting 6/23/23. The 4/18/23 Facility Admission Assessment documents R8 to have severe cognitive impairment. The same assessment shows she is dependent on staff for bed mobility and transfers between her bed and wheelchair. R8's Skin Condition Assessment shows she was admitted with 1 stage 4 pressure injury and no unstageable wounds. This same assessment also shows she is at risk of developing pressure ulcers/injuries. The nursing progress notes for R8 were reviewed for 6/22/23 and 6/23/23 and does not indicate any new wound to the right or left heel. The progress notes show on 6/26/23, R8's daughter was notified of breakdown of heels. The 6/26/23 the Pressure Ulcer Weekly Wound Evaluation for R8 shows a DTPI (deep tissue pressure injury) and is 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. The Wound Evaluation shows the identification on 6/22/23 during the wound doctor visit, and the family was not notified until 6/26/23. The wound was noted to be a facility acquired DTPI to the right heel measuring 1.5 cm (length) by 1.5 cm (width). A second Pressure Ulcer Weekly Wound Evaluation for 6/26/23 documents a DTPI to the left heel identified on 6/22/23. The left heel measured 2.2 cm by 1.5 cm and was identified on the doctor wound visit. On 6/28/23 at 10:40 AM, V4 LPN (Licensed Practical Nurse)/ wound nurse said he was notified last week of R8's breakdown of both of her heels. He said the wounds were identified on 6/22/23. He said R8 should have had her heels floated and/or wearing boots. V4 said the heel wounds were due to pressure on her heels being in the same place for an extended time. The wounds could have been prevented. He said the staff should have ensured she had on her protective boots and check on her heels more often. On 6/28/23, R8 was observed lying in bed with boots to both feet. Her right and left heels were noted to have reddened circular areas. On 6/29/23 at 9:10 AM, V2 DON (Director of Nursing) said staff should ensure all interventions are in place for pressure injury prevention. The aides and nurses should be monitoring residents skin condition daily with care and showers. V2 said any skin breakdown should be noted on Shower Sheets and reported to the nurse and wound nurse. V2 said any pressure injury should be identified prior to becoming unstageable or a stage 2. R8's Care Plan for impaired skin integrity was revised on 6/23/23 with the addition of the left and right heel DTPI, and no new interventions added to the plan of care. The facility's 3/2022 policy for pressure ulcer/ pressure injury prevention documents to minimize pressure: turning and repositioning every two or three hours when in bed, or more frequent depending on the need of the resident. Relieve pressure to heels by using pillows or other devices. Do not depend on heel protectors, they do not provide pressure reduction/relief. Pressure reduction/relief devices should serve as adjuncts and are not replacements for repositioning protocols. 34491 2. R51's Admission Record, printed by the facility on 6/29/23 showed she had diagnoses including multiple sclerosis, generalized muscle weakness, a stage 3 pressure ulcer of right heel, and unspecified dementia. On 6/27/23 at 2:49 PM, R51 was sitting in her geriatric chair. R51 was alert and oriented. R51 did not have any pressure relieving boots on her bilateral heels. There was no pillow or cushion under R51's legs to offload pressure to her bilateral heels. R51's heels were resting against the leg rest of the geriatric chair. R51 said she only wears the pressure-relieving boots when she is in bed. R51 said she has never refused to wear the pressure-relieving boots. R51's Facility assessment dated [DATE] showed she was cognitively intact and was dependent on staff for bed mobility, transfers, dressing, personal hygiene, toileting and eating. The same assessment showed R51 had a stage 3 pressure ulcer. R51's Braden Scale for Predicting Pressure Sore Risk dated 5/25/23 showed she was at high risk (score of 12) for developing pressure sores. R51's 6/9/23 Pressure Ulcer Weekly Wound Evaluation showed she had a stage 3, full thickness tissue loss pressure ulcer to her right heel measuring 1.4 cm (centimeters) x 0.6 cm x 0.2 cm. The evaluation showed the pressure ulcer was identified on 5/25/23. The evaluation also showed the pressure ulcer was debrided on 6/8/23 R51's Wound Specialist assessment dated [DATE] showed the right heel pressure wound measured 0.2 cm x 0.2 cm x 0.2 cm on that day. The 6/22/23 Wound Specialist Assessment showed R51 refused the assessment on that day. R51's Order Summary Report, showing active orders as of 6/29/23, showed bunny boots (pressure-relieving boots) every shift check for placement. The order summary report also showed Right heel pressure wound- cleanse with wound cleanser, pat dry, skin prep to wound bed and LOTA (leave open to air) daily and as needed. On 6/28/23 at 1:47 PM, V4 (Wound Nurse) cleaned R51's right heel with wound cleanser and gauze. V4 moved the gauze in a circular motion, going from periwound to the wound bed. V4 covered the wound with silicone dressing. On 6/28/23 at 2:52 PM, this surveyor reviewed R51's orders with V4. V4 said the wc in the bunny boots order stands for wound care. V4 said the order showed to make sure the boots are on every shift. When asked when the boots should be on, V4 said mostly in bed. V4 said the order does not specify. This surveyor asked V4 to read the treatment orders for R51's right heel wound. V4 read them. V4 was asked if that was the treatment, he performed for R51's right heel. V4 said no. V4 said he did the treatment that was listed on the weekly wound report. V4 said R51 still has a small open area to her right heel. On 6/28/23 At 3:32 PM, V2 (Director of Nursing-DON was shown the order for the pressure-relieving boots. V2 said the boots should be on R51 at all times. On 6/29/23 at 10:30 AM, V2 you should wipe from the center out when performing wound care, you do not want to get any bacteria from the surrounding skin into the wound bed. V2 said the wound treatment should be done according to the current orders. V2 said if a resident has a stage 3 pressure ulcer on their heel, and there is an order to have pressure-relieving boots on you, would want to make sure the boots are in place, to keep pressure off the area. On 6/29/23 at 12:20 PM, V4 said he should have dabbed the wound to clean it and not have gone in a circular motion to prevent bacteria from the periwound entering the wound bed. 6/29/23 12:22 PM, V15 (Wound Specialist) said R51 should have the boots on when she is up in the chair to reduce pressure on her heel and to promote healing. At 12:28 PM, V15 said as long as there is a pillow under the posterior calf in the chair, it would offload the heels. The facility's Weekly Pressure Ulcer report dated 6/21/23 showed R51 had a deep tissue injury to her right heel that was facility acquired and identified on 5/25/23. The weekly wound report showed the pressure injury to her right heel measured 2.0 cm x 0.9 cm x unknown. R51's Skin Integrity Care Plan, with a revision date of 6/5/23, showed Administer medications as ordered and monitor for effectiveness. The facility's policy and procedure titled Pressure Ulcer/Pressure Injury Prevention, with a revision date of 3/2022, showed A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing a PU/PI upon admission and thereafter; Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI; Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and if a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PIs. The policy showed one of the interventions that should be implemented for residents at high risk for developing pressure ulcers (score of 10-12) is Protect heels, float heels. 34891 3. R34's FaceSheet printed on 6/29/23 indicates R34's diagnoses including but not limited to cerebral infarction, diabetes mellitus, dementia, heart disease, palliative care, and stage 2 pressure ulcer of the sacral region. R34's Facility assessment dated [DATE] showed severe cognitive impairment and staff assistance needed for bed mobility, dressing, toilet use, and hygiene. The same assessment showed R34 is always incontinent of urine and bowel. R34's Braden Scale for Predicting Pressure Sore Risk dated 5/1/23 showed at risk for pressure ulcer development. R34's electronic medical record showed a current weight on 6/29/23 of 162.6 pounds. On 6/27/23 at 10:24 AM, R34 was lying in bed on his back. R34 stated he never gets out of bed because he can't walk. At 1:06 PM, R34 was in the same position. On 6/28/23 at 8:13 AM, R34 was in the same position. On 6/29/23 at 9:55 AM, R34 was in the same position. R34 was not observed out of bed at any time during the survey from 6/27 to 6/29/23. On 6/29/23 at 10:00 AM, R34's pressure ulcer mattress setting was observed with V4 (Wound Care Nurse). The mattress setting was at the 300-to-425-pound level. V4 stated (R34) had a stage 2 pressure ulcer on his coccyx. It is closed now, but interventions are needed to keep it closed. The mattress setting is based on weight. It helps him because he doesn't get out of bed much. He refuses to get out of bed most of the time and doesn't change position well by himself. If the mattress setting is not at the right level, it could cause skin breakdown again. Too hard of a mattress can cause too much pressure on the area already prone to pressure ulcers. V4 said the mattress is definitely at the wrong level and should be checked by the nurses during each shift to ensure it is correct.

Based on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors and received their scheduled coumadin as ordered. This applies to 3 of 6 residents (R1, R2 & R4) reviewed for medication administration in the sample of 6. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on February 14, 2023, when R1's coumadin orders were transcribed incorrectly and he was given the wrong dose of coumadin for 13 days/doses. V1 Administrator was notified of the Immediate Jeopardy on March 21, 2022. The surveyor confirmed by observation, interview, and record review the Immediate Jeopardy was removed, and the deficient practice corrected on March 16, 2023, prior to the start of the survey and was therefore Past Noncompliance. The findings include: 1. On March 18, 2023, R1 was lying in bed watching television. He stated, he was recently hospitalized because of a seizure and a brain bleed. R1's electronic medical record (EMR) lists his diagnoses to include: nontraumatic intracerebral hemorrhage affecting the left non-dominant side, traumatic subdural hemorrhage without loss of consciousness, & paroxysmal atrial fibrillation. R1's coaguchek [sic (statement is correct)] xs patient test log (coumadin (anticoagulation/blood thinner) flow sheet) shows, Date: 2/14, Patient: R1, Old Dose: 5 mg (milligrams) & 2.5 or 7.5 mg (handwriting is ineligible and hard to determine if it is a 2 or 7), New Dose: same, Test Results: 3.0 international normalized blood test (INR). R1's medication administration record (MAR) for February shows an order entered on February 14, 2023, for: Coumadin oral tablet 7.5 mg (warfarin sodium), give 1 tablet by mouth in the evening every Tue, Wed, Thu, Fri, Sat, Sun for anticoagulation until 2/27/2023. The same MAR shows, R1 was given 7.5 mg of coumadin on 2/14-2/19/23, 2/21-2/26/23 and 2/28/23 (13 doses). The same MAR also shows, R1 received 5 mg of coumadin on 2/20/23 & 2/27/23. R1's facility provided local coumadin clinic physician orders show, INR telephone 2/14/2023: Warfarin Maintenance Plan: 5 mg every Monday, 2.5 mg all other days. Starting 2/14/2023. Next INR: 2/28/23. (R1 received 13 doses of 7.5 mg and should have received only 2.5 mg). R1's facility provided local coumadin clinic calendar shows, R1 was supposed to be receiving 2.5 mg of coumadin on 2/14-2/19/23, 2/21-2/26/23, 2/28/23 and 5 mg of coumadin on 2/20/23 & 2/27/23. R1's progress notes dated February 28, 2023, shows, PT/INR not able to be performed. Call placed and orders received to give regular scheduled dose and have PT/INR drawn in the morning . On March 18, 2023, at 11:28 AM, V8 Licensed Practical Nurse (LPN) stated, on February 28, 2023, when they took R1's INR it was so high the machine would not give them a reading. They called and got orders for the lab to draw the INR the next morning. R1's progress notes dated March 1, 2023, shows, At 1603 Lab here to redraw INR. AT 1658 call received from lab stating results are inconclusive, further stating results were run four times and all had different results. Lab to be drawn again in the AM by local lab. R1's progress notes dated March 2, 2023, shows, Approximately 10, writer was notified that resident's speech was slurred than usual. Writer went to check on resident, vitals stable and to continue monitoring. 11:30 his speech was becoming more slurred paged MD (medical doctor) & NP (nurse practitioner) to get further orders, no response. Called 911, transferred out to ER . [sic (statement is correct)]. R1's progress notes dated March 2, 2023, shows, local lab notified writer of critical INR of 21.54 at 1315 (1:15 PM). Resident was sent to hospital at 1145 for slurred speech and difficulty finding words. Results were called in to V9 medical doctor MD as FYI (for your information). R1's laboratory results dated [DATE], shows, Prothrombin time (PT): 181.5H (high), INR: 21.54C* (critical). Reference Range: PT: 19.7-28.8, INR: 2.00-3.00. R1's progress notes dated March 2, 2023, shows, Update from local Hospital- resident had an acute left subdural hematoma noted after a STAT CT (emergency cat scan) at the hospital and has since been transferred to ICU (intensive care unit). Called family, they had already been notified by local ER staff of the transfer and were now at hospital and R1 was in ICU. R1's history and physical dated March 13, 2023, shows, Chief Complaint: Hospital Follow-up. History of Present Illness: R1 is a long-term care resident of a local nursing facility with a past medical history that includes alcohol withdrawal seizures, benign prostatic hypertrophy, depression, essential hypertension (benign), gastroesophageal reflux disease, hyperlipidemia, hypothyroidism muscle spasms, osteoarthritis (shoulder), paroxysmal atrial fibrillation, personal history of pulmonary embolism, restless leg syndrome, right MCA stroke, slurred speech, subdural hematoma, and squamous cell carcinoma in situ (Bowen's disease, left anterior tibial biopsy-proven). He had a hospital admission from 03/02/2023 thorough 03/08/2023 at local hospital due to left frontoparietal subdural hematoma. He was discharged back to the facility, however, sent out the same day 03/08/2023, due to slurred speech. He remained in the hospital until 03/11/2023 regarding slurred speech, history of seizures, paroxysmal atrial fibrillation, late effect of stroke, history of right MCA stroke, essential hypertension (benign), long-term anticoagulation use, personal history of pulmonary embolism, GERD, subdural hematoma, and focal seizures. Consultations included neurology. He was given ativan, a loading dose of keppra and a repeat CT scan of the brain which showed no evidence of acute territorial infarction. There were no findings on MRI (magnetic resonance imaging) of brain. An EEG (electroencephalogram) was done which was unremarkable for any epileptiform discharge. keppra was increased to 1,750 mg twice daily. He did develop atrial fibrillation with rapid ventricular response on 03/10/2023. He required a cardizem drip for less than 24 hours and was transition to oral cardizem and metoprolol. He was not placed on any anticoagulation therapy due to recent history of subdural hematoma. Neurology services suggested a focal seizure likely provoked due to subdural hematoma and that previously thought alcohol withdrawal seizures were now symptomatic seizures. Recommendations were to continue to monitor for any new symptoms and continue keppra 1,750 mg twice daily, seizure precautions, systolic blood pressure less than 130, with no further workup recommended with local neurology as he will be following up with neurology at local hospital. Current nurse has no concerns at this time. She does report that patient does not seem to be himself. He seems to have lost some of his cognitive function. He does not really seem to understand everything anymore . R1's risk watch/incident report dated March 16, 2023, shows, Type: medication error, Injuries: type: hematoma, location: right side of crown, Date/Time: 2/14/2023 1700 (5:00PM), Details: subdural hematoma, Witness statement of what happened: On 3/15/23 this RN (registered nurse) was discussing concerns of super therapeutic INR on 3/2/23. This RN stated that a review was performed on 3/2/23 for the most recent order and the order entered into the electronic medical record ordering system did match the order written on the coumadin log for the most recent INR check. The NP (nurse practitioner) asked what the facility order was entered as; informed NP the 2/14/23 order was written 5 mg m (Monday), 7.5 the rest of the week with a recheck scheduled for 2/28/23. The NP then informed that the coumadin clinics order reflected 5 mg Mon, 2.5 mg the rest of the week. This RN confirmed the coumadin log showed the order as the 2/14/23 old order written as 5 mg m, 7.5 mg rest of the week the new dose was entered as same and the order reflected as updated in PCC. The 2/28/23 order again showed the old order written 5 mg m, 7.5 the rest of the week. The RN immediately notified DON (director of nursing) and administrator of reconciliation error . [sic (statement is correct)] On March 18, 2023, at 2:41 PM, V3 Assistant Director of Nursing (ADON) stated, she was aware of R1's critical INR on March 2, 2023, when the laboratory notified her of the critical lab. On March 21, 2023, at 10:06 AM, V3 ADON clarified, she verified the orders in the facility and did not find anything wrong at that time. The coumadin flow sheet matched the orders. It wasn't until March 15, 2023 when V10 Nurse Practitioner called and they were discussing problems with management of coumadin that she discovered R1's orders entered on February 14, 2023, were incorrect and were supposed to be 2.5 mg of coumadin and not 7.5 mg. 2. R4's EMR lists her diagnoses to include: fracture of carpal bone, right wrist, fracture of neck of right femur, and permanent atrial fibrillation. R4's coaguchek xs patient test log (coumadin flow sheet) shows, Date/Time specimen collected/tested : 2/24, Name: R4, Old dose: left blank, New dose: left blank, Test results: 1.4 (INR). R4's facility provided physician orders dated February 24, 2023, shows, Per V9 MD orders to increase warfarin (coumadin) to 4 mg on Friday and Sunday, 2 mg on Saturday, re-check PT/INR on Monday 2/27. Faxed to facility. R4's MAR for February 2023 shows, warfarin sodium oral tablet 2 mg (warfarin sodium), give 1 tablet by mouth in the evening for blood thinner. The MAR shows, she did not receive 2 mg of coumadin on 2/23 or 2/25. The MAR shows, it was held on 2/26 as well showing, 6: see progress notes (there is no progress note showing why it was not given). R4 received 2 mg on 2/27 & 2/28. The same MAR also shows another order for: Warfarin sodium oral tablet 4 mg (warfarin sodium), give 1 tablet by mouth in the evening every Sat, Sun for blood thinner. The MAR shows she received 4 mg on 2/26. R4 was supposed to receive 4 mg of coumadin on 2/24 and 2/26 and 2 mg of coumadin on 2/23 and 2/25. She missed 2 doses of 2 mg and one dose of 4 mg. R4's MAR for February 2023 shows, she continued to receive 2 mg of coumadin on 2/27 & 2/28. R4's MAR for March 2023 shows, she continued getting 2 mg of coumadin on 3/1-3/7. The same MAR also shows another order showing, Warfarin sodium oral table 4 mg, give 1 tablet by mouth in the evening every sat, sun for blood thinner. The MAR shows she received 4 mg on 3/4 & 3/5 in addition to her 2 mg totaling 6 mg of coumadin. There are no orders for coumadin on 3/6. R4's coaguchek xs patient test log (coumadin flow sheet) shows, her PT/INR was not checked on 2/27 as ordered by V9 MD. The next PT/INR that was checked was on 3/6/23. R4's laboratory results dated [DATE], shows, Prothrombin Time: 143.8 elevated, INR: 11.7 elevated. R4's progress notes dated March 6, 2023, shows, received a call from local lab r/t (related to) critical INR 11.7, on call doctor notified at 1805 (6:05 PM). Returned call at 1810 (6:10 PM) with new order received. 1. vitamin K 5 mg PO (by mouth) x 1 dose, 2. PT/INR on 3/7, 3. Call primary MD before 5 pm . R4's MAR for March 2023 dated March 6, 2023, shows, vitamin K oral tablet, give 5 mg by mouth one time only for anticoagulant critical INR. R4's March MAR continues to show, she is to continue to receive 2 mg of coumadin and she did not receive any coumadin 3/13-3/15. On March 18, 2023, at 5:10 PM, V3 ADON stated, she noticed on March 9, 2023, that the PT/INR was not done on February 27, 2023. She did the PT/INR and notified the doctor. She was aware at that time that the orders were incorrect up until March 9, 2023. 3. R2's EMR shows, she was admitted to the facility on [DATE]. Her diagnoses are listed to include fracture of 5th cervical vertebra, fracture of the 4th metacarpal bone of left hand and atrial fibrillation. R2's admission medications from the hospital shows, Warfarin 3 mg tablet, take 0.5 tablets (1/2 tablets) by mouth daily with dinner. Dose: 1.5 mg. Next Dose Due: 3/13 evening. R2's MAR for March 2023 shows, no coumadin orders for the day she was admitted ,d+[DATE]. She did not receive any coumadin at the facility or hospital. The same MAR shows, Warfarin Sodium oral tablet 3 mg, give 1 tablet by mouth in the evening for anticoagulation. The MAR shows, she was given a whole tablet equaling 3 mg and not the ordered 1/2 tablet of 1.5 mg on March 14, 2023. On March 18, 2023, at 2:18 PM, R2 was lying bed. She stated, she did not receive her coumadin the first day she was here. R2's risk watch/incident report dated March 15, 2023, shows, Type: Medication Error. How was the medication error discovered? Coumadin clinic identified error upon relaying previous dose for INR update/coumadin order. On March 21, 2023, at 2:24 PM, V3 ADON clarified, she entered R2's orders incorrectly. On March 15, 2023, the coumadin clinic was made aware of the error. The coumadin clinic called V10 NP and let her know there was an error. V10 NP told her that she was concerned that there had been residents with super therapeutic levels. During that conversation, V10 NP reviewed the orders that were in place at the coumadin clinic. That is when V3 ADON was made aware of the medication error with R1. She was already aware of the error with R2 and R4. The facility's physician order policy dated April 2021 shows, A. All medications, including non-legend medications (cathartics, headache remedies, vitamins, etc.) shall be given only upon written order of the physician. All such orders shall have the handwritten or electronic signature of the physician. These medications shall be given as prescribed by the physician and at the designated time. The Immediate Jeopardy that began on February 14, 2023, was removed and the deficient practice was corrected on March 16, 2023, after the facility took the following actions to correct the noncompliance. Staff were educated by Director of Nursing, Assistant Director of Nursing, and Nurse Management team regarding 10 rights of administration, the PT/INR machine, the temporary process of machine/contracted laboratory, any malfunctions with machine DON must be notified immediately. Physician must be notified if INR/labs cannot be drawn and request new orders. Staff education was completed by March 16, 2023 Audit lab drawn INRs for accuracy when entered, audit all coumadin logs, contracted laboratory draws PT/INR along with utilizing our machine for one month on our coumadin residents for accuracy, 2 nurses to verify coumadin order when entered. Audits completed by Director of Nursing and Assistant Director of Nursing by March 16, 2023. To ensure ongoing compliance, DON or designee will audit NEW orders and review labs/medications daily and audit the dosing calendars from the Coumadin clinic side-by-side with coumadin logs weekly for all residents on coumadin to ensure policy and procedures are being followed. Weekly audits will be submitted to DON or designee for review. Any identified issues or concerns will be immediately addressed. The QA committee will review this plan of correction until such time consistent substantial compliance has been met as determined by the QA committee. Audit findings will be discussed by the QA committee and monitoring will be adjusted as determined by the QA committee. An emergency QA meeting was held with the facility Medical Director (via telephone), Nurse Practitioner (via telephone), Corporate Director of Risk Management and Education, Corporate [NAME] President of Operations, Corporate Director of Clinical Operations (via telephone), facility administrator Director of Nursing, Assistant Director of Nursing (infection preventionist) to review and update the facility's PT/INR and coumadin ordering process.

Based on observation, interview, and record review, the facility failed to serve liquids at a safe temperature to prevent [CONDITION(S)], and failed to ensure a walker was maintained in a manner to prevent injury for three of three residents (R1-3) reviewed for safety in the sample of 6. This failure resulted in R1 sustaining a burn to her left arm and flank area. The findings include: 1. R1's face sheet showed an [AGE] year-old female with diagnoses of malignant neoplasm of the right lung, anxiety disorder, [CONDITION(S)], [CONDITION(S)] due to [CONDITION(S)], hypertension, and malignant pleural effusion. On 8/31/22 at 9:59 AM, V4, Dietary Manager, poured hot water into a carafe from the coffee pot. The water measured 188.8 degrees Fahrenheit. At 10:30 AM, V4 checked the temperature of the water in the covered carafe, and it was 152.9 degrees F (30 minutes later). At 10:45 AM, V4 checked the water temperature, and it was 146.6 degrees F (45 minutes later). At 11:00 AM, V4 checked the water temperature, and it was 140.3 degrees F (one hour later). On 8/31/22 at 9:40 AM, V5, Registered Nurse (RN), said she was on duty when R1 was burned by the hot tea. V5 said V6, Certified Nursing Assistant (CNA), was repositioning R1 in bed, and a cup of tea spilled on R1. V5 said, (R1's) left lower arm got edematous 'right away'. The first layer of skin was off. It (the wound) was big. It involved the majority of (R1's) lower left arm anteriorly and posteriorly. There was also another wound to the left flank. On 8/31/22 at 9:50 AM, V3, Senior District Manager, said they follow the corporate policy for hot liquids. It's posted by the coffee machine. Hot liquids can be 158-160 degrees Fahrenheit when in the carafes (covered insulated pitchers) and 140-150 degrees when served to the residents to prevent [CONDITION(S)] and scalding. On 8/31/22 at 10:05 AM, V7, Task Aide, said the Certified Nursing Assistants (CNAs) and Task Aides deliver hot water and coffee to the residents. The kitchen is supposed to put ice in coffee and water to bring temperature down to an acceptable temperature. It's up to the kitchen to make sure it's at a safe temperature. We don't check the temperature (before serving). On 8/31/22 at 11:02 AM, V6, CNA, said she was the aide caring for R1 when her burn occurred. V6 said for some reason, the kitchen sent her hot water in a Styrofoam cup with a lid, instead of us getting it from the pitchers. V6 said the bedside table was over R1. V6 said she removed the cup's lid, and put a tea bag in it. V6 said she went to push the table closer to R1, and the cup of tea spilled and splashed on R1's left arm. It should have been in a regular cup not a Styrofoam cup. Usually, the kitchen sends down a pitcher of coffee and a pitcher of water. Then we put it into regular coffee cups for the residents. I don't know why they sent it in a Styrofoam cup that day. I have told the kitchen staff they shouldn't use the Styrofoam cups. The water is always hot. (R1) was alert and oriented when this happened. The skin was peeling off (R1's) arm and kept saying she was in pain. I made hot chocolate for myself and had to wait 30-40 minutes before I could drink it. Sometimes staff refill the water and coffee pitchers by themselves. I've gotten additional water and coffee out of the kitchen myself before. On 8/31/22 at 1:50 PM, V2, Director of Nursing/DON, was asked what the root cause analysis showed for this burn. V2 said, It's quite clear in (V6's) statement that it was an accident. V2 was asked if the hot liquid was at a cooler temperature could the burn have been prevented, and V2 replied in the affirmative. The facility's 7/07 Serving Hot Beverages and Soup Policy and Procedure showed The Food Service Department will monitor the temperature of all hot liquids being prepared to ensure that hot liquids are served at a temperature that will prevent [CONDITION(S)] if they should come into contact with skin. The coffee should be chilled to 120-130 degrees Fahrenheit before being served to residents. The Food Service Department is responsible for ensuring that all hot beverages leave the kitchen at the proper temperature. Use non-insulated cups and bowls to help dissipate the temperature of hot beverages and soups quickly. The Consumer Product Safety Commission publication 5098 1 2 showed most adults will suffer third degree [CONDITION(S)] if exposed to 150-degree water for two seconds. [CONDITION(S)] will also occur with a six second exposure to 140-degree water or with a thirty second exposure to 130-degree water. Even if the temperature is 120 degrees, a five-minute exposure could result in third-degree [CONDITION(S)]. The American Burn Association Scald Prevention Campaign showed the following time and temperature relationship to severe (third-degree) [CONDITION(S)]: Water Temperature Time for a third-degree burn 155F (Fahrenheit) 1 second 148F 2 seconds 140F 5 seconds 133F 15 seconds 127 F 1 minute 124F 3 minutes 120F 5 minutes 100F safe The Sciencing.com website showed Styrofoam is an excellent insulator. The material limits thermal transfer. Thus, a structure insulated with Styrofoam will maintain a comfortable temperature, regardless of the conditions on the outside. 2. R2's face sheet showed a [AGE] year-old female with diagnoses of a fractured right radius, Type 2 Diabetes, [CONDITION(S)], major depressive disorder, [CONDITION(S)], chronic kidney disease Stage 4, and a cardiac pacemaker. R2's 6/10/22 nurse note showed the nurse was notified by a CNA that there was a burn to R2's chest from spilling coffee. On 8/31/22 at 1:10 PM, R2 was in her room in a wheelchair. R2 was alert and oriented. R2 pulled the neck of her top down to reveal a healed wound to the left upper chest. The area was reddened and approximately three inches long and one inch wide. On 8/31/22 at 1:10 PM, R2 said, I was trying to drink my coffee and spilled it. It was in a Styrofoam cup. It was a bad burn. The skin was gone off it. I don't drink coffee anymore. 3. R3's face sheet showed a [AGE] year-old male with diagnosis of [CONDITION(S)], anxiety disorder, hypertension, chronic kidney disease Stage 3, and a cardiac pacemaker. R3's 7/31/22 10:07 PM progress note showed a large circular skin tear was visible on R3's left upper arm with a small amount of bleeding noted. On 8/31/22 at 1:03 PM, R3 was in his room. R3's left upper arm showed a raised, scabbed wound. R3 was alert and oriented. On 8/31/22 at 1:03 PM, R3 said he hit his arm on his walker recently and it cut his skin open. There was a nut or bolt sticking out and it caught my arm and 'skinned it'. This is not the same walker. R3 said V8, Certified Occupational Therapy Aide (COTA), or V9, Maintenance Assistant, got him a different walker after it happened. At 1:30 PM, V8 said he wasn't aware of any injury to R3. V8 said, About 3-4 weeks ago a bolt was missing from (R3's) walker handlebar and it was wobbly, so we fixed it. We secured another bolt in it and put tape around it. (R3) told me later the walker wasn't working too well so I gave him a different walker. At 1:35 PM, V8 showed this surveyor R3's previous walker in the north mechanical room. One side had a circular adjustment knob attached for loosening and tightening the handlebars. The opposite side's knob was absent. In the knob's place was a large nut and bolt. The end of the bolt protruded outward at least one inch. The head of the bolt was exposed. There was nothing to pad the hard surfaces. V9 was unavailable for interview. On 8/31/22 at 1:50 PM, V2, Director of Nursing (DON), provided a 7/31/22 9:00 PM incident report (not part of R3's medical record) which showed a skin tear measuring 5 centimeters (cm) X 4 cm X 0.5 cm. This report authored by V2 showed R3 said he almost fell and caught himself with his walker. The root cause attributed the injury to the resident action or internal risk factors. There was no mention of the altered walker.

Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Centers for Disease Control (CDC) for COVID-19 regarding the isolation of residents under investigation for COVID-19 and ensuring staff wore the appropriate PPE (Personal Protection Equipment) to prevent the spread of COVID-19. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This has the potential to affect all 68 residents residing in the facility. The Immediate Jeopardy began on March 15, 2021, when surveyors observed staff entering droplet isolation/PUI (Patients Under Investigation for COVID-19) rooms without wearing full PPE and observed a PUI resident (R214) out of his room, without a mask on. V1 (Administrator) was informed of the Immediate Jeopardy on March 17, 2021. This surveyor confirmed through observation, interview and record review that the Immediate Jeopardy was removed on March 17, 2021, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's Census Report dated March 15, 2021, showed 68 residents resided in the facility. The report also showed R213 and R214 were listed as a PUI residents (under investigation for COVID-19). 1. On March 15, 2021 at 11:02 AM, R214 was in the hallway of the PUI unit, without a mask on. R214 wheeled himself down the hallway in his electric wheelchair and into the unit lounge with V15 (Occupational Therapist/OT) walking behind him. On March 15, 2021 at 11:05 AM, V15 (OT) provided therapy services to R214 in the central lounge area of the PUI unit. On March 15, 2021 at 11:25 AM, V15 (OT) was seated in R214's room, directly across from R214 as he lay in bed. V15 did not have an isolation gown on but was wearing eye protection and an N-95 mask. A droplet isolation sign hung on 214's door with an isolation cart noted outside the door. On March 16, 2021 at 9:41 AM, V15 (OT) stated, I treat residents all over the building. My case load is currently 43 residents. For the PUI unit, I treat the PUI residents in their rooms and also pull some (PUI) residents out in the hallway for therapy if appropriate as long as they wear a mask. I don't treat my residents in clusters anymore. I used to treat my PUI residents at the end of the day but don't anymore because we are no longer in outbreak status. Now I do resident treatments throughout the facility as they are scheduled per day. 2. On March 15, 2021 at 10:10 AM, V13 (Nurse Practitioner/NP) and V14 (Nurse Practitioner Student) were standing in R213's room, directly next to R213's bed, speaking to R213. V14 (NP Student) did not have an isolation gown on but was wearing eye protection and an N-95 mask. V13 (NP) was wearing eye protection, an N-95 mask, and an isolation gown on backwards. V13's gown was open in the front, not tied, with her clothing exposed. A droplet isolation sign hung on R213's door with an isolation cart noted outside the door. On March 15, 2021 at 10:20 AM, V16 (Registered Nurse/RN) stated, (R213) is on droplet isolation due to her possible exposure to COVID-19. She is a new admit. All staff that enter her room must wear a gown that is tied in the back, an N-95 mask, eye protection, and gloves. 3. On March 16, 2021 at 9:28 AM, R214 was seated in his electric wheelchair outside of his room in the PUI hallway with no mask on. On March 16, 2021 at 9:05 AM, V2 (Director of Nursing/DON) stated, New admissions are admitted to the transition/PUI unit if their last hospital COVID-19 test was negative. These residents are placed under droplet isolation precautions for 14 days. We treat these residents as they have been exposed to COVID-19. Staff that enter these rooms must wear a face shield, gown that is tied in the back, an N-95 mask, and a face shield. These residents are not to come out of their rooms for therapy or for any reason. If they have to come out, they must wear a mask. On March 17, 2021, at 9:00 AM, V1 (Administrator) stated that as of March 17, 2021, 15.9 % of residents had been partially vaccinated, 13% had refused the vaccination, and 17.4% were of unknown vaccination status. V1 stated 12 residents residing on the PUI/transition unit are of unknown status as they are new admits to the facility. V1 stated the facility's last vaccination clinic for residents was February 23, 2020. The facility's COVID-19 Action Plan dated December 10, 2020, showed for residents on the transition/PUI unit, 2. Immediately place on droplet precautions. 3. Isolation set up with gowns, facemasks with shield or goggles, gloves and door signage (N95 or higher-level respirator is required in this area) .14. Restrict resident to room as much as possible, except for medically necessary purposes. a) Resident will be provided with and encouraged to wear a mask at all times. b) Services provided should be with the room door closed. c) Not eligible for outdoor or indoor visitation, communal activity, communal dining, or communal therapy . The Centers for Disease Control Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated March 10, 2021 showed, Health care personnel (HCP) should continue to follow all current infection prevention and control recommendations, including addressing work restrictions, quarantine, testing, and use of personal protective equipment to protect themselves and others from [CONDITION(S)]-CoV-2 infection. The Immediate Jeopardy that began on March 15, 2021, was removed on March 17, 2021, when the facility took the following actions to remove the immediacy: 1. Staff education began on 3/16/21and will be completed by 3/17/21. Staff has been educated by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Nurse Management team regarding isolation of PUIs and wearing appropriate PPE while providing resident care to the PUIs to prevent the spread of COVID-19. Individual corrective action and education completed with the employee and collaborating providers identified by the survey team by their supervisors. Facility residents educated by ADON and Nurse Management team on measures to reduce spread of COVID-19. 2. The above staff education was completed prior to shift on 3/17/21. All remaining staff PRN/Casual will be educated via phone by the end of day 3/17/21. 100% of staff to be in-serviced as of 3/17/21. All employees and contracted employees that received education via telephone and verbally confirmed that they acknowledge the education and will be asked to sign the formal education tomorrow during all staff testing. 3. To ensure compliance, DON or designee will perform audits on isolation of PUIs and wearing appropriate PPE, 3 times a week for 4 weeks, and weekly thereafter to ensure policy and procedures are being followed. Any identified issues or concerns will be immediately addressed. 4. The QA committee will review this plan of correction until such time consistent substantial compliance has been met as determined by the QA committee. Audit findings will be discussed by the QA committee and monitoring will be adjusted as determined by the QA committee.

Based on interview and record review the facility failed to ensure a resident had non skid foot wear and a gait belt applied prior to transfer. These failures resulted in R1 slipping during a transfer and sustaining a fractured left arm. This applies to one of three residents (R1) reviewed for falls. The findings include: On 12/11/19 at 8:45 AM, R1 said V6 Certified Nursing Assistant (CNA) removed her shoes and attempted to transfer her from the recliner to the bed. R1 stated, V6 was holding my left arm and pants. My right foot slipped and V6 landed in the chair under and behind me. My left arm went over my head and hurt immediately. V6 called for help and another girl came to help. They discussed how to get me up and one CNA grabbed my legs and the other grabbed my upper body and they carried me to my bed. I had regular socks on, not the ones with skids. R1 further stated, The nurse didn't look at me until much later and it was days before they did anything. I thought they should have sent me out sooner. The worst part was being in pain for days. I complained of pain in the arm and they said they couldn't give me anything but Tylenol. I think they thought it was in my head. It made me feel better when I went to the hospital and found out it was fractured. I knew I wasn't overreacting. The fact that my shoes were off contributed to the fall. I had a stroke about a year ago and my left arm and leg are paralyzed. At 12:05 PM, V6 said she did attempt to transfer R1 without a gait belt and with her shoes off. V6 stated, R1 slipped and I held her and yelled for help. V7 (CNA) came in and we lowered R1 to the floor. Then we both lifted R1 from the floor and put her in bed. We told the nurse what happened right away. It was a new nurse who had only been there a couple weeks. This happened on Thanksgiving Day (11/28/19) after 6:00 PM. At 12:15 PM, V7 stated, V6 called for help from R1's room. I ran in to help and slipped in urine on the floor. R1's catheter was leaking. We couldn't get R1 into the chair so we lowered her to the floor. Then, me and V6 lifted R1 into her bed. I carried her legs. We (V6 and V7) told V4 (Licensed Practical Nurse) about the incident. This incident happened 11/28/19. At 1:00 PM, V5 (R1's son) said he heard about the incident from his mother a day or two after it happened. V5 stated, I visited the weekend after Thanksgiving. R1 told me she slipped during a transfer and her left arm was extended upward. Mom said her arm was sore. The facility didn't call me until they wanted to do an x-ray. At 9:55 AM, V1 (Administrator) stated, There is no facility policy on transferring a resident. We do skills checks. V2 (Director of Nursing/DON) stated, I didn't know the incident occurred on Thanksgiving or that R1 was lifted to the bed by V6 and V7. I didn't know R1 was lowered to the floor. It is not safe or appropriate to transfer a resident paralyzed on one side without a gait belt. The lack of using the gait belt contributed to R1's fractured arm. V3 (R1's physician and facility Medical Director) stated, The improper transfer definitely caused R1's broken arm. V3 said he was not aware R1 was carried to her bed after the incident or that the incident occurred on 11/28/19. V3 said R1 would have been treated sooner if he was notified about it at the time of the occurrence. The facility's staff schedule for 11/28/19 showed V4, V6 and V7 worked the 3P-11P shift. The facility's investigative report dated 12/3/19 showed a written statement from V6 stating V6 transferred R1on Thanksgiving Day without shoes on. This statement showed R1 began to fall and V6 held her up under the arms and grabbing R1's pants. V6 admits in the written statement that a gait belt was not used and R1 said Oh my arm. V6's statement showed V6 notified the nurse. V7's written statement showed R1 lost her footing and believes R1 slipped on urine as R1's catheter was leaking. V7's statement showed V6 and V7 lowered R1 to the floor and then lifted her into bed. This statement showed V7 notified the nurse (V4). R1's care plan showed additional fall interventions were not implemented until 12/4/19. R1's face sheet dated 12/11/19 showed a [DIAGNOSES REDACTED]. R1's Fall Risk Data Collection dated 11/7/19 showed a low risk for fall. There was not an updated Fall Risk form in R1's electronic record since 11/7/19. An Occurrence Report for the 11/28/19 incident was not done until 12/3/19. This report showed the fall happened on 11/28/19. R1's Occupational Therapy note dated 11/8/19 showed R1 was seen for left upper extremity x-ray at hospital on [DATE] due to continued pain since incident occurring with nursing staff during transfer where patient had to be lowered to the floor. R1's CAT scan result dated 12/5/19 showed a displaced fracture involving the left humerus. V4's late progress note dated 11/28/19 showed V4 was aware of a transferring incident. R1's progress note dated 12/2/19 showed R1 reported increased left shoulder pain as a result of a transfer that did not go as smoothly and caused slight traction on the left upper extremity. This note showed a decrease in left shoulder shrug. V6's personnel file showed on 11-17-19 V6 was reeducated on gait belt use for all transfers and ambulation following a resident fall and on 9/13/19 corrective action was given for failure to follow safety rules. A facility policy for gait belt use was requested and none was received. The facility's Fall Prevention Policy dated (MONTH) 2014 showed following any falls, the facility staff completes an Occurrence Report. Details of the fall will be reported and potential causative factors identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's plan of care. The staff will review the resident's Fall Risk Data Collection. An update or change to the data collection form would be made only if the resident had previously been identified as low risk. All Occurrence Reports are reviewed at the daily QA (Quality Assurance) meeting to ensure that an intervention was immediately implemented, added to the plan of care and that the current intervention is appropriate. The facility's undated Significant Change & Notification Policy showed the policy's purpose was to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention; abnormal, unusual or new complaints of pain. When any of the above situations exist, the licensed nurse will contact the resident's representative and their medical practitioner.

Based on interview and record review the facility failed to seek emergency medical treatment for [REDACTED]. This failure resulted in R15 being found unresponsive and requiring CPR (cardiopulmonary resuscitation). This applies to 1 of 15 residents (R15) reviewed for change of condition in the sample of 15. The findings include: The nurses note written by E16 Registered Nurse (RN) dated [DATE] for R15 shows, Upon arrival at 0700 (7:00AM) I got report from the night shift nurse who stated that R15 was not feeling well, her blood sugars had been lower than usual throughout the night but had stabilized at 93. I held her morning insulin and encouraged her to eat some breakfast which she ate some fruit and drank some orange juice and I would check her sugar before lunch. I checked on her again and she said she wasn't feeling well and she was tired. Her lungs sounded coarse and I could hear some secretions in her throat that she was attempting to cough up. At 1103 (11:03 AM) I checked her blood sugar and it was 83. I got her to sip some orange juice and I checked her oxygen saturations which were 87%, and I also asked her to state her name, the year, and where she was. She stated her name, that she was in rehab, but thought it was 2006 I bumped her oxygen up to 5L (5 liters). I called the doctor at this time and talked to the nurse who I reported all of her symptoms too. She stated she would have the doctor call back as soon as possible. At 1135 (11:35 AM) I went back in to check her again and her oxygen saturations had dropped to 73. I placed her on her [MEDICAL CONDITION] (continuous positive airway pressure). She continued to drop to 65. I placed her on a 15L (15 liter) non-rebreather. Her sats (oxygen saturations) came up to 93%. I attempted to give her a nebulizer treatment at this time which lasted 5 minutes before her oxygen saturations dropped again. And I put her back on the non-rebreather. I placed another call to the doctor at 1210 (12:10 PM). I reported further changes in condition including the fact that she was still confused, and her drop in oxygen requiring a non-rebreather. The nurse stated that the on call doc and the nurse practitioner were both in rooms and that as soon as she could get one of them I would receive a call back. At 1230 (12:30 PM) I went in to check on R15, she was still on her non-rebreather at 15L sating 92%. At 1255 (12:55 PM) I went back in to check on her and noticed her oxygen tank was getting low but she was looking at me and shaking her head yes, so I ran to grab a new oxygen tank, upon arriving back to her room at 1256 (12:56 PM) R15 was unresponsive. I checked for a pulse but could not find one. I ran and grabbed the closest nurse I could find and she checked for a pulse as well and could not find one. I ran to grab the crash cart and asked for someone to call 911 and for more help in the room. CPR (cardiopulmonary resuscitation) initiated at 1300 (1:00 PM) and continued until paramedics arrived at 1308 (1:08 PM). The doctor called back at 1310 (1:10 PM). On [DATE] at 8:30 AM, E16 RN stated, she came in at 7:00 AM and got report from the night shift nurse. She was told that R15 hadn't been doing well. She was seen the day before by the doctor. Her blood sugar was low. She checked on her and she was ok and responsive. She was doing morning medication pass and checked her blood sugar. It was in the 80's. She gave her some juice. The Certified Nursing Assistants (CNAs) came in to clean her up and turn her. She became short of breath. Her oxygen saturation was low. She went to talk to the Assistant Director of Nursing (ADON) and Director of Nursing (DON). They said to wait until the doctor called back. She continued the non-rebreather and called the doctor again to send her out to the hospital. She never got a call back. She went to check on her again, asked her a question, she nodded yes. She left to get a new oxygen tank and when she came back she didn't have a pulse. She started the code. She felt R15 needed to go to the hospital. I was told by the DON and ADON not to send her out because the doctor had seen her prior and to wait for them to call back. I finally did get a call back but the paramedics had already taken over. The nurse said to send her to the hospital. When I found her unresponsive, I left to get a nurse. I grabbed the first person I could, which was E15 Medicare Nurse Manager. It was not longer than 30 seconds when I left and grabbed E15. When we went back into the room, she confirmed R15 didn't have a pulse and started compressions while I left to get the crash cart and get more help. I saw a CNA and told her to call 911 and get more help. I knew she was a full code because I had checked earlier in the day. I felt like I couldn't properly do my job. My judgment was to send her out to the hospital. I thought I could get into trouble or lose my job if I sent her out. On [DATE] at 9:22 AM, E15 Medicare Nurse Manager stated, I was down by the nursing station when E15 came and grabbed me. She said, I don't think R15 has a pulse. I confirmed she wasn't breathing and had no pulse. I asked E15 what R15's code status was and she said she was a full code. I immediately started compressions. On [DATE] at 9:36 AM, E2 Director of Nursing stated, R15 had severe [MEDICAL CONDITIONS] and was morbidly obese. She was in and out of the hospital because of [MEDICAL CONDITION] and chronic respiratory issues. She started with shortness of breath. She was still responding and put on a non-rebreather. The nurse called the doctor and made several attempts with no response back from the doctor. The nurse went to get another oxygen tank and when she came back she found her unresponsive. She initiated CPR. E15 had updated me about what was going on, told her to update the doctor. I also went and talked with R15, she stated, I just don't feel good. I told E15 to keep an eye on her. I actually spoke with E15 after the incident and told her that if a patient is declining rapidly she can send by 911. I wanted the nurses to be aware even off hours if interventions are not helping and the doctor is not responding, they can send the patient out without an order from the doctor. A lot of the nurses didn't know that. On [DATE] at 1:16 PM, Z1 R15's physician stated, if she thought she was in imminent danger, I would expect them to send her (to the hospital). R15's electronic medical record lists her [DIAGNOSES REDACTED]. The EMR shows R15's oxygen saturation on [DATE] at 11:28 AM was 63% with oxygen via nasal cannula. The facility's significant condition change and notification policy (no date) shows, A significant change in the resident's physical, mental or psychosocial states. (See below for examples). Sudden onset of shortness of breath; Significant change in/or unstable vital signs. When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner .The medical practitioner will be contacted immediately for any emergencies regardless of the time of day .If the medical practitioner cannot be reached, the director of nursing or the charge nurse can make arrangements for transportation to the emergency department.

Based on interview and record review the facility failed to provide necessary care and services by not conducting a comprehensive assessment including vital signs. The facility failed to seek emergency treatment for [REDACTED]. These failures contributed to R1 showing signs and symptoms of shock. This applies to 1 of 4 residents (R1) reviewed for care abd services in the sample of 4. The findings include: The August 2013 Physician order [REDACTED]. R1's Plan of Care (updated 9/4/13) states, "The resident is on Anticoagulant therapy; Monitor/document/report to Nurse/Dr. s/sx (signs/symptoms) of anticoagulation complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (Short of Breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs)..." On 11/26/13 at 1:30 PM, Z3 (R1's Power of Attorney for Healthcare) stated, "When we went to the facility there were multiple gowns with blood on them. Her (R1's) roommate said she had been bleeding for several days." On 10/24/13 at 2:00 PM, E4 (Transport CNA, Certified Nursing Assistant) said between 8:00 and 9:00 AM, The nurse (E3,Registered Nurse) told me R1 was having some vaginal bleeding. E3 stated R1 needed to be transported for an ultrasound (requested by Gynecologist) and then to her Gynecologist appointment. E4 continued. "I spoke with (R1) before leaving for the ultrasound. She looked sick; she had a spit pan and tissues. She looked tired, and had no energy... At the hospital, the condition of (R1) declined. During the ultrasound (R1's) breathing increased; it was a big difference... We got back (to the facility) around lunchtime... I told the nurse immediately, there was something wrong with (R1's) breathing, (R1's) color had changed. She (R1) was cold, clammy, and had wet skin. I took (R1) to her room (at 12:00 PM) and she (R1) was by herself (until we left for her Gynecologist appointment at 1:00 PM)'. On 10/25/13 at 10:20 AM, E3 (RN) stated, "I saw (R1) about 7:45 AM (on the 9/3/13). (R1) was in her bathroom. One of her aides had called me to her (R1's) room for bleeding. I observed the blood; (there was a) fairly large amount (of blood). It covered the wheelchair, and there were many clots. There was about 500 ml of blood; there was a lot of blood... (R1) declined any pain. I looked at her perineum (area between the vagina and anus) and R1 was trickling blood... I couldn't identify the source. I called (Z1) physician and told him she (R1) was not feeling well and complained of nausea...I explained there was a lot of blood. I had no further communication with (Z1) that day... R1 left for the (ultrasound) at approximately 10:40 AM. She (R1) returned at 12:15 PM, I put pulse ox (pulse oximertry), and it was normal. I listened to her lungs. She was a little cold. It was reported to me (R1's) breathing was off... I remember her (R1) being a little bit wet. I didn't think at that time the change was significant. Vitals were not taken (after R1 returned from ultrasound)". E3 stated she did not call R1's primary physician after R1 returned from the ultrasound. E3 said she never took R1's vitals; That day R1's vitals were taken once, by a CNA before R1 left for her ultrasound appointment at 10:40 AM. On 10/24/13 at 2:00 PM, E3 continued, We left shortly after 1:00 PM. The nurse at the Gynecologist's office took R1's blood pressure and it was 90/50. R1's nursing note dated 9/3/13 at 3:41 PM, states, "Upon shift change nurse (at 7:00 AM) was called into resident's (R1) room to inspect bleeding from perineum area, nausea and vomiting. Nurse witnessed blood with numerous clots on residents wheelchair. Vitals taken at 1040 AM... MD (Z1, Primary Care Physician) notified and ordered for resident to be refereed to OB/GYN, due to bleeding being a chronic issue. OB/GYN called and required pelvic X-ray before he (Z2, Gynecologist) could see resident (R1). MD office (Z1) notified and agreed to order pelvic exam. When resident returned from pelvic exam at 1215 PM, the nurse called OB/GYN (Z2's office) to schedule appt. (appointment). Appt was made for 1:15 PM, Resident left facility at 1:00 PM." On 10/25/13 at 9:15 AM, E2 (Director of Nursing) was asked when staff report to the nurse that a resident has a change in breathing, color, and is cold/clammy, or wet, how should the nurse respond. E2 stated, "I would expect the nurse assess the patient ASAP (As soon as possible). The nurse should go directly to assess the patient, and provide any treatment we could... Vital signs and a symptom specific assessment should be completed, and the primary (care physician) should be called to report the change in condition." On 10/25/13 at 10:45 AM, Z1 (Primary Physician) stated, "I was called because (R1) was having vaginal bleeding. (At that time), (R1) had normal vital signs." Z1 continued, when it was reported that R1 had become cold, clammy, and pale in color, "The nurse should have checked (R1's) heart rate and blood pressure. If R1's blood pressure was low or if (R1) she showed signs of a change in condition, (The nurse) should have called me again. This didn't happen suddenly. I don't know if the lack of assessment contributed to the incident. I don't think it was Hypovolemic (low-blood volume) Shock". On 10/25/13 at 11:30 AM, Z2 (Gynecologist) stated, R1 "was in awful shape when (she) arrived. She was clammy, pale, and dying. 911 was called before I walked into the room (to examine R1)." The facilty should have taken vitals. It could have been an acute (sudden) change after R1 left the facility (between 12:45 PM and 1:00 PM. Z2's progress note dated 9/3/13 documents, "Pt (R1) found to be agonal (near death), very pale... Paramedics called. Son called... Pt (R1) taken to (local hospital emergency room ). Pt (R1) without HR (heart rate) in ambulance as it (the ambulance) was leaving." emergency room progress note dated 9/3/13 states, "This patient was brought to the emergency department via (local) EMS (Emergency Medical Services). She (R1) was DOA (Dead on Arrival) at a local physician's office. This writer notified notified coroner of body's arrival and the events leading to her (R1's) arrival..." R1's certification of death record dated 9/3/13 states, "Cause of Death - Shock, [MEDICAL CONDITION], Vaginal Bleeding." The manufacture guidelines (dated 8/2013) states, "(Warnings and Precautions) Risk of bleeding: XARELTO can cause serious and fatal bleeding. Promptly evaluate signs and symptoms of blood loss." and "Promptly evaluate any signs or symptoms of blood loss and consider the need for blood replacement. Discontinue XARELTO in patients with active pathological hemorrhage." (p 1-3)