Every finding on record at Buena Vista Care Center

Based on observation, interview, medical record review, and facility P&P review, the facility failed to protect Resident 1's right to be free from physical abuse by another Resident (Resident 2), for one of three sampled residents reviewed for abuse. * During resident activities, a facility staff member witnessed Resident 2 hit Resident 1 on the chin, with a clenched fist. This failure to prevent physical abuse had the potential to result in serious injury and/or psychosocial harm to Resident 1. Findings: Review of the facility's P&P titled Identifying Types of Abuse revised 9/2022 showed abuse of any kind against residents is strictly prohibited. Abuse toward a resident can occur as resident-to-resident abuse. Physical abuse includes but is not limited to hitting or punching. Some situations of abuse do not result in an observable physical injury. The psychosocial effects of abuse may not be immediately apparent. 1. Medical record review for Resident 1 was initiated on 5/11/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was cognitively intact. Review of Resident 1's Change in Condition note dated 4/30/26, showed on 4/30/26 around 1440 hours, an incident occurred between two residents (Resident 1 and Resident 2) in the dining room. Per staff member, Resident 1 was backing his wheelchair out from the table and at the same time Resident 2 (also in his wheelchair) was attempting to leave the dining room. The residents bumped into each other. Resident 2 was angry and was seen hitting Resident 1 in the chin area. Both residents were immediately separated by staff. On 5/11/26 at 1331 hours, an interview was conducted with Resident 1. Resident 1 stated on 4/30/26 in the afternoon, he was seated in his wheelchair at a table in the dining room, during activities. Resident 1 stated Resident 2 was seated in a wheelchair and self-propelled himself into the dining room. Resident 1 stated Resident 2 wheeled himself to a table which contained prizes residents could purchase as a result of winning Bingo games. Resident 1 stated he told Resident 2 the prizes were for residents who participated in Bingo and Resident 2 had not participated. Resident 1 stated Resident 2 then self-propelled himself into Resident 1's wheelchair. Resident 1 stated he yelled, what are you doing! Resident 1 stated Resident 2 then hit him on the right side of his mouth with a clenched right fist. Resident 1 stated the force of the punch was a four out of 10. Resident 1 stated he felt pain in his mouth and rated his pain a three out of 10. Resident 1 stated he sustained an abrasion on the inside of his mouth, on the right side between his lips. Resident 1 stated after he was punched by Resident 2 he felt angry and wanted to retaliate. Resident 1 stated staff separated the residents and he did not retaliate. On 5/11/26 at 1402 hours, an interview was conducted with the IP. The IP stated on 4/30/26 in the afternoon, residents had gathered in the dining room for activities. The IP stated Resident 2 was seated in his wheelchair and self-propelled himself up to the activities table to view available resident prizes. The IP stated Resident 2 then self-propelled himself away from the table. The IP stated Resident 1 was seated in his wheelchair and was backing away from a table, at which time Resident 1 and Resident 2's wheelchairs bumped into each other. The IP stated Resident 2 became upset and started yelling at Resident 1. The IP stated she then saw Resident 2 hit Resident 1 on the area of his chin, with a right clenched fist. The IP stated staff then separated the residents. The IP stated Resident 1 was upset and stated he attempted to avoid Resident 2. 2. Medical record review for Resident 2 was initiated on 5/11/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's care plan for alteration in mood and pattern related to psychosis manifested by sudden angry outbursts initiated 2/25/25, showed goals including Resident 2's episodes of sudden angry outbursts will be reduced to zero from one episode per week. Review of Resident 1's MDS assessment dated [DATE], showed Resident 2 had moderately impaired cognition. On 5/11/26 at 1520 hours, Resident 2 was observed in the hallway seated in his wheelchair. Resident 2 was asked if he was involved in an incident with Resident 1 during activities on 4/30/26 in the afternoon. Resident 2 stated, no comment. On 5/11/26 at 1700 hours, an interview was conducted with the Administrator. The Administrator stated she was the facility's Abuse Coordinator. The Administrator stated the facility investigated the incident involving Resident 1 and Resident 2, with occurred on 4/30/26 in the dining room. The Administrator stated during the investigation that staff who witnessed the incident were interviewed. The Administrator stated the IP witnessed Resident 1 and Resident 2 bump into each other while seated in their wheelchairs. The Administrator stated the IP witnessed Resident 2 become upset and hit Resident 1 on the chin area. The Administrator was asked if Resident 1 and Resident 2 had been involved in any other altercations in the past. The Administrator stated in March of 2026, the facility investigated an alleged incident involving the residents. The facility investigated an allegation that Resident 2 had pushed Resident 1 from the back, at which time Resident 1 grabbed Resident 2 by the arm and Resident 1 then punched Resident 2's arm a couple of times. Cross reference F610.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse, for two of three residents (Residents 1 and 2) reviewed for abuse. * The facility failed to interview other residents present at the time of a physical altercation between Residents 1 and 2. The failure to interview all potential witnesses to an allegation of resident-to-resident physical abuse potentially inhibited the facility's ability to determine if resident abuse occurred and posed the risk for further abuse.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 9/2022 showed all reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. All allegations are thoroughly investigated. The Administrator initiates investigations. The individual conducting the investigation at a minimum interviews the residents and interviews any witnesses to the incident. Witness statements are obtained in writing, signed and dated. The witness may write their statement, or the investigator may obtain a statement. Medical record review for Resident 1 was initiated on 5/11/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was cognitively intact. On 5/11/26 at 1331 hours, an interview was conducted with Resident 1. Resident 1 stated on 4/30/26 in the afternoon, he was sitting in his wheelchair at a table in the dining room, during activities. Resident 1 stated Resident 2 was sitting in a wheelchair and self-propelled himself into the dining room. Resident 1 stated Resident 2 wheeled himself to a table which contained prizes residents could purchase as a result of winning Bingo games. Resident 1 stated he told Resident 2 the prizes were for residents who participated in Bingo and Resident 2 had not participated. Resident 1 stated Resident 2 then self-propelled himself into Resident 1's wheelchair. Resident 1 stated he yelled, what are you doing! Resident 1 stated Resident 2 then hit him on the right side of his mouth with a clenched right fist. Resident 1 stated the force of the punch was a four out of 10. Resident 1 stated he felt pain in his mouth and rated his pain a three out of 10. Resident 1 stated he sustained an abrasion on the inside of his mouth, on the right side between his lips. Resident 1 stated after he was punched by Resident 2, he felt angry and wanted to retaliate. Resident 1 stated staff separated the residents and he did not retaliate. Resident 1 was asked if anyone else had witnessed the incident. Resident 1 stated facility staff were present and Residents 3 and 4 were seated at the table with him. On 5/11/26 at 1402 hours, an interview was conducted with the IP. The IP stated on 4/30/26 in the afternoon, residents had gathered in the dining room for activities. The IP stated Resident 2 was seated in his wheelchair and self-propelled himself up to the activities table to view available resident prizes. The IP stated Resident 2 then self-propelled himself away from the table. The IP stated Resident 1 was seated in his wheelchair and was backing away from a table, at which time Resident 1 and Resident 2's wheelchairs bumped into each other. The IP stated Resident 2 became upset and started yelling at Resident 1. The IP stated she then saw Resident 2 hit Resident 1 on the area of his chin, with a right clenched fist. The IP stated staff then separated the residents. The IP stated Resident 1 was upset and stated he attempted to avoid Resident 2. The IP was asked if any other residents were seated at Resident 1's table. The IP stated Residents 3 and 4 were seated at Resident 1's table. On 5/11/26 at 1434 hours, an interview was conducted with Resident 3. Resident 3 was asked if she had witnessed an incident between Residents 1 and 2, which occurred on 4/30/26, during activities in the dining room. Resident 3 stated she had witnessed a physical altercation between Residents 1 and 2. Resident 3 stated she was seated at a table with Resident 1. Resident 3 stated Resident 1 was seated in his wheelchair at the table. Resident 3 stated she saw Resident 2 seated in his wheelchair at the Bingo prize table. Resident 3 stated she then saw Resident 2 for no reason, self-propel himself away from the prize table toward Resident 1 and hit Resident 1's wheelchair. Resident 3 stated she then saw Resident 2 punch Resident 1 in the mouth. On 5/11/26 at 1442 hours, an interview was conducted with Resident 4. Resident 4 reported having not witnessed the incident. On 5/11/26 at 1700 hours, an interview and concurrent facility document review, was conducted with the Administrator. The Administrator stated she was the facility's Abuse Coordinator. The Administrator stated the facility investigated the incident involving Resident 1 and Resident 2, with occurred on 4/30/26 in the dining room. Review of the facility's Investigative Summary dated 5/1/26, showed the Administrator conducted interviews with Residents 1 and 2. The Investigative Summary showed Resident 1 claimed Resident 2 hit him on the chin. Further review of the Investigative Summary also showed Resident 2 claimed Resident 1 hit him on the cheek. The Administrator verified during her interview with Resident 2, he claimed Resident 1 had hit him on the cheek. The Administrator was asked if any witnesses had corroborated Resident 2's claim he was hit by Resident 1. The Administrator stated no one had witnessed Resident 1 hit Resident 2. Review of the investigative interviews the facility conducted specific to the incident, failed to show documentation interviews were conducted with other residents, who were present at the time of the incident, who may have witnessed the incident. The Administrator was asked for the names of the residents who were present during the incident, and if these residents may have witnessed the incident. The Administrator stated she was uncertain and no interviews were conducted with other residents who were present during the incident, because staff had witnessed the incident. Cross reference F600.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the kitchen equipment was kept in sanitary condition. * The facility failed to ensure the kitchen equipment was cleaned properly. * The facility failed to ensure the hair restraints were worn. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medically vulnerable population of 87 residents who received food prepared in the kitchen. Findings: Review of the facility's Resident Matrix (list of all the residents currently in the facility and care areas triggered) received on 12/15/25, showed 87 of 89 residents consumed food prepared in the facility's kitchen. 1. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, for materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Review of the facility's P&P titled Sanitation revised 11/2022 showed the food service area is maintained in a clean and sanitary manner. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. On 12/16/2025 at 1022 hours, during an observation of the kitchen with the Dietary Supervisor (DS), a shelving unit was observed with peeling paint. The DS acknowledged the findings. 2. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Sanitation revised 11/2022 showed the food service area is maintained in a clean and sanitary manner. All utensil, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. On 12/16/2025 at 1022 hours, during an observation of the kitchen with the DS, two dishes that were stored with clean dishes had yellow food debris on the sides. The DS acknowledged the findings. 3. Review of the facility's P&P titled Preventing Foodborne Illness: Employee Hygiene and Sanitary practices revised 11/2022 showed food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Hair nets or caps and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. On 12/15/25 at 0853 hours, an observation was conducted in the kitchen. Dietary Aides 1 and 2 were observed with uncovered facial hair while working in the kitchen. On 12/15/2025 1011 hours, an interview was conducted in the kitchen with the DS. The DS was asked about the facility's policy regarding hair restraints. The DS stated facial hair should be covered. The DS was informed of Dietary Aides 1 and 2 with uncovered facial hair and the DS confirmed all facial hair should be covered with a hair restraint.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility's Infection Prevention and Control Surveillance Logs for 2025 were incomplete and inaccurate. * The facility's Infection Control Committee Meeting Minutes and data presented were inaccurate for 2025. * LVN 4 failed to ensure the GT syringe was properly cleaned prior to storage. * The facility failed to ensure N95 masks stored in Medication Cart C were not expired. * LVN 1 failed to perform hand hygiene during the blood glucose check monitoring for Residents 64 and 77. Additionally, LVN 3 failed to perform hand hygiene during the blood glucose check monitoring for Residents 1 and 43. * LVN 1 failed to properly sanitize insulin pen during insulin administration for Resident 77. * The facility failed to ensure the EBP signage was posted outside Resident 35's door. * Staff personal belongings were kept in the clean linen area in the laundry room. * The facility failed to ensure Resident 18's bed control remote was sanitized prior to use, when it was on the floor. Additionally, CNA 4 did not perform hand hygiene after picking up the remote and providing care to the resident. These failures posed the risk of not identifying the residents' infections and thereby preventing the implementation of interventions, and control the potential transmission of communicable diseases to other residents in the facility.Findings: Review of the facility's Policies and Practices – Infection Control P&P revised [DATE] showed objectives are to detect, investigate, and control infections in the facility. To maintain records of incidents and corrective actions related to infections. Review of the facility's Surveillance of Infections P&P revised [DATE] showed surveillance is used to identify cases and trends of significant organisms and HAI, to guide appropriate interventions, and prevent future infections. 1.a. Review of the facility's Infection Prevention and Control Surveillance Logs showed the following:- [DATE] showed for 15 residents with suspected infections, 10 residents did not meet McGeer's Criteria. - [DATE] showed for 24 residents with suspected infections, 15 residents' information were incomplete to show if the infections met McGeer's criteria. Nine were listed as HAI, and 15 as CAI. - February 2025 showed 21 residents with suspected infections, all 21 residents' information were incomplete to show if the infections met McGeer's criteria. All 21 were listed as CAI.- [DATE] showed 18 residents with suspected infections, all 18 residents' information were incomplete to show if the infections met McGeer's criteria. All 18 were listed as CAI.- [DATE] showed 18 residents with suspected infections, 16 residents' information were incomplete to show if the infections met McGeer's criteria. Two were listed as HAI, and 16 as CAI.- [DATE] showed 26 residents with suspected infections, all 26 residents' information were incomplete to show if the infections met McGeer's criteria. All 26 were listed as CAI.- [DATE] showed 30 residents with suspected infections, 29 residents' information were incomplete to show if the infections met McGeer's criteria. One was listed as HAI, and 29 as CAI.- [DATE] showed 22 residents with suspected infections, all 22 residents' information were incomplete to show if the infections met McGeer's criteria. All 22 were listed as CAI.- [DATE] showed 28 residents with suspected infections, all 28 residents' information were incomplete to show if the infections met McGeer's criteria. All 28 were listed as CAI. - [DATE] showed 37 residents with suspected infections, all 37 residents' information were incomplete to show if the infections met McGeer's criteria. All 37 were listed as CAI. - [DATE] showed 29 residents with suspected infections, all 29 residents' information were incomplete to show if the infections met McGeer's criteria. All 28 were listed as CAI. - [DATE] showed 27 residents with suspected infections, 25 residents' information were incomplete to show if the infections met McGeer's criteria. Two were listed as HAI and 25 as CAI.- [DATE] showed 9 residents with suspected infections, seven residents' information were incomplete and two showed N/A to show if the infections met McGeer's criteria. Two were listed as HAI and seven as CAI. On [DATE] at 1012 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated she went to print 2025's Infection Prevention and Control Surveillance Logs earlier in the week and had technical issues resulting in lost data. The IP stated the residents' names and antibiotics were accurate since they auto populated. The IP stated the spreadsheet defaults to CAI if there was any missing data, which was why there were so many CAI's on the printed spreadsheets. The IP verified the log was incomplete and inaccurate for 2025. The IP stated some data was able to be retrieved, so any completed infections should be accurate (other than CAIs). b. On [DATE] at 1056 hours, an interview, medical record review, and concurrent facility document review was conducted with the IP. Review of the facility's [DATE]'s Infection Prevention and Control Surveillance Logs showed Resident 65 started antibiotics on [DATE], for a UTI. The IP stated she recalled the resident's infection meeting McGeer's Criteria even though the log was still incomplete. Review of Resident 65's medical record failed to show a clinical data to support the resident's infection met McGeer's Criteria. The IP verified the findings. c. On [DATE] at 1542 hours, an interview, medical record review and concurrent facility document review was conducted with the IP. Review of the facility's [DATE]'s Infection Prevention and Control Surveillance Logs showed Resident 46 started antibiotics on [DATE], for a UTI. The log showed it met McGeer's Criteria. Review of Resident 46's medical record failed to show clinical data to support the resident's infection met McGeer's Criteria. The IP verified the findings. d. On [DATE] at 1542 hours, an interview, medical record review and concurrent facility document review was conducted with the IP. Review of the facility's [DATE]'s Infection Prevention and Control Surveillance Logs showed Resident 47 started antibiotics on [DATE], for a UTI. The log failed to show if it met McGeer's Criteria. Review of Resident 47's medical record failed to show clinical data to support the resident's infection met McGeer's Criteria. The IP verified the findings. 2. Review of the facility's Infection Control Committee Meeting Minutes for 2025 showed the following:- dated [DATE], a total of 17 infections in January, with six HAI and 12 CAI. The minutes failed to show how many infections met McGeer's Criteria Infection Control Committee Meeting Minutes. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for [DATE] (15 infections, with 12 HAI and three CAI) or [DATE] (24 infections, with nine HAI and 15 CAI), as shown in 1.a. above. - dated [DATE], a total of 13 infections in February. The minutes failed to show how many infections met McGeer's Criteria and were HAI or CAI. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for January (24 infections, with nine HAI and 15 CAI) or February (21 infections, with 21 CAI) 2025, as shown in 1.a. above. - dated [DATE], a total of 13 infections, with four HAI and nine CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for February (21 infections, with 21 CAI) or March (18 infections, with 18 CAI) 2025, as shown in 1.a. above.- dated [DATE], a total of 16 infections, with two HAI and 16 CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for March (18 infections, with 18 CAI) or April (18 infections, with two HAI and16 CAI) 2025, as shown in 1.a. above.- dated [DATE], a total of 5 infections, with two HAI and three CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for April (18 infections, with two HAI and16 CAI) or May (26 infections, with 26 CAI) 2025, as shown in 1.a. above. - dated [DATE], a total of seven infections, with three HAI and four CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for May (26 infections, with 26 CAI) or June (30 infections, with one HAI and 29 CAI) 2025, as shown in 1.a. above. - dated [DATE], showed for the month of July there were 16 infections, with 14 HAI and two CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for June (30 infections, with one HAI and 29 CAI) or July (22 infections, with 22 CAI) 2025, as shown in 1.a. above. - dated [DATE], a total of 27 infections, with 19 HAI and 9 CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for July (22 infections, with 22 CAI) or August (28 infections, with 28 CAI) 2025, as shown in 1.a. above. - dated [DATE], for the month of September a total of 37 infections. The minutes failed to show how many infections were HAI/CAI and if they met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for August (28 infections, with 28 CAI) or September (37 infections, with 37 CAI) 2025, as shown in 1.a. above. - dated [DATE], for the month of October a total of 27 infections. The minutes failed to show how many infections were HAI/CAI and if they met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for September (37 infections, with 37 CAI) or October (29 infections, with 29 CAI) 2025, as shown in 1.a. above.- dated [DATE], a total of 25 infections, with two HAI and three CAI. The minutes failed to show how many infections were HAI/CAI and if they met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for October (29 infections, with 29 CAI) or November (27 infections, with 2 HAI and 25 CAI) 2025, as shown in 1.a. above.- dated [DATE], showed a total of 24 infections in November, with 16 HAI and 8 CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for November (27 infections, with 2 HAI and 25 CAI) 2025, as shown in 1.a. above. On [DATE] at 1043 hours, an interview was conducted with the Administrator. The Administrator stated the monthly Infection Control Committee Meetings review the previous month's data and should include all suspected infections as well as infections that did not meet McGeer's Criteria. On [DATE] at 1542 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated the data presented at the monthly Infection Control Committee Meetings is from the previous month, and any months where it showed the current month's data was being reviewed were incorrect. The IP stated for the monthly meeting, she reports all suspected infections with antibiotic use, not the infections that meet McGeer's Criteria. In addition, the IP verified the above findings and stated the data presented in all of 2025's monthly Infection Control Committee meetings did not match the data in the Infection Prevention and Control Surveillance Logs. 3. Review of the facility's P&P titled Handwashing/Hand Hygiene revised [DATE] showed the following: - This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. - Hand hygiene is indicated immediately before touching a resident, after touching a resident, after touching the resident's environment, and immediately after glove removal. On [DATE] at 0818 hours, a medication administration observation for Resident 2 was conducted with LVN 4. LVN 4 prepared and administered the following medications to Resident 2: - One tablet of amlodipine (calcium channel blocker) 5 mg tablet via GT one time a day; - One tablet of aspirin (NSAID) 81 mg tablet via GT one time a day; - One tablet of atenolol (beta-blocker) atenolol 50 mg tablet via g GT one time a day; - One tablet of cranberry (supplement) 450 mg tablet one time a day via GT; - Restasis ophthalmic emulsion 0.5% one drop in each eye every 12 hours; - One tablet of apixaban (anticoagulant) 2.5 mg tablet via GT two times a day; - One tablet of furosemide (diuretic) 20 mg tablet via GT one time a day; - One tablet of losartan (antihypertensive) 100 mg tablet via GT one time a day; - One tablet of magnesium oxide (mineral) 400 mg tablet via GT one time a day; - One tablet of meloxicam (NSAID) 15 mg tablet via GT one time a day; - One tablet of multivitamin with minerals tablet via GT one time a day; - One tablet of prednisone (corticosteroid) 5 mg tablet via GT one time a day; - Pro-stat (supplement) 30 ml liquid via GT one time a day; - Refresh tears ophthalmic solution 0.5% one drop in each eye four times a day; - One capsule of venlafaxine (antidepressant) 75 mg tablet via GT one time a day; and - One tablet of vitamin C 500 mg tablet via GT one time a day. LVN 4 prepared and administered the medications to Resident 2. However, following the medication administration, LVN 4 placed the syringe used for GT medication administration back in the storage bag without cleaning it. LVN 4 was asked to remove the syringe from the bag. Upon inspection, the syringe was found to have medication residue on the black rubber portion of the plunger. On [DATE] at 1457 hours, an interview was conducted with LVN 4. LVN 4 verified the above findings and stated the syringe should be cleaned in the sink when there was visible residue. 4. On [DATE] at 0839 hours, an inspection of Medication Cart C and concurrent interview was conducted with RN 2. During the inspection, a box of BYD Care N95 particulate respirators was found with an expiration date of [DATE]. There were twelve masks remaining of the twenty. RN 2 stated Medication Cart C was only used for storage of extra supplies and was not routinely checked. RN 2 stated supervisors and nurses have access to the supplies in Medication Cart C. RN 2 verified the N95 masks were expired and stated use of expired N95 masks can reduce the effectiveness of protecting the nurse. 5. a. On [DATE] at 1119 hours, an observation for Resident 64 was conducted with LVN 1. LVN 1 donned gloves after sanitizing her medication cart without performing hand hygiene first. LVN 1 performed the blood glucose check and removed gloves to prepare insulin, without performing hand hygiene. LVN 1 administered insulin to Resident 64, removed her gloves and did not perform hand hygiene. Medical record review for Resident 64 was initiated on [DATE]. Resident 64 was admitted to the facility on [DATE]. Review of Resident 64's H&P examination dated [DATE], showed Resident 64 was able to understand & make treatment decisions. Review of Resident 64's Order Summary Report dated [DATE], showed an order dated [DATE], to administer insulin regular human injection solution 100 unit/ml (insulin regular human) per sliding scale, subcutaneously before meals and at bedtime for DM using lancets and test strips. Rotate injection sites. b. On [DATE] at 1138 hours, an observation for Resident 77 was conducted with LVN 1. LVN 1 removed her gloves after sanitizing her cart, proceeded to prepare testing supplies, closed Resident 77's curtain, and donned gloves without performing hand hygiene. LVN 1 completed Resident 77's blood glucose check and removed gloves without performing hand hygiene. LVN 1 prepared Resident 77's insulin and donned a new pair of gloves to administer insulin to Resident 77. Medical record review for Resident 77 was initiated on [DATE]. Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's H&P examination dated [DATE], showed Resident 77 was able to make very simple decisions. Review of Resident 77's Order Summary Report dated [DATE], showed an order dated [DATE], to administer Humalog solution 100 unit/mL (insulin/lispro) per sliding scale subcutaneously before meals and at bedtime for DM. Finger stick AC and HS with lancet, test strips, rotate injection site. On [DATE] at 1144 hours, an interview was conducted with LVN 1. LVN 1 verified she was aware of the hand hygiene policy and should be washing her hands before and after performing resident care and when removing gloves. LVN 1 stated she failed to follow policy due to being nervous during the observation. c. On [DATE] at 1112 hours, an observation for Resident 1 was conducted with LVN 3. LVN 3 completed the blood glucose check and removed the gloves without performing hand hygiene immediately after removing the gloves. Medical record review for Resident 1 was initiated on [DATE]. Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated [DATE], showed Resident 1 was unable to understand and make treatment decisions due to dementia. Review of Resident 1's Order Summary Report showed an order dated [DATE], to administer insulin regular human injection solution 100 unit/mL (insulin regular/human) per sliding scale subcutaneously every six hours for DM using lancets and test strips. Rotate injection sites. d. On [DATE] at 1130 hours, an observation for Resident 43 was conducted with LVN 3. LVN 3 completed the blood glucose check and removed the gloves without performing hand hygiene immediately after removing gloves. Medical record review for Resident 43 was initiated on [DATE]. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's H&P examination dated [DATE], showed Resident 43 was noncompetent. Review of Resident 43's Order Summary Report dated [DATE], showed an order dated [DATE], to administer insulin regular human injection solution pen-injector 100 unit/mL (insulin regular/human) inject as per sliding scale subcutaneously before meals and at bedtime for DM. Finger stick AC meals and HS, with test strips, lancet, and rotate injection site. On [DATE] at 1052 hours, an interview was conducted with LVN 3. LVN 3 verified he was aware of the hand hygiene policy and should be washing his hands before and after performing resident care and when removing gloves. 6. Medical record review for Resident 77 was initiated on [DATE]. Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's Order Summary Report dated [DATE], showed an order dated [DATE], to administer Humalog solution 100 unit/mL (insulin/lispro). Inject as per sliding scale: if 0 - 60 mg/dl = 0 Units, less than 60 mg/dl call MD; 61 - 150 mg/dl = 0 Units; 151 - 200 mg/dl = 2 Units; 201 - 250 mg/dl = 4 Units; 251 - 300 mg/dl = 6 Units; 301 - 350 mg/dl = 8 Units; 351 - 400 mg/dl = 10 Units; 401 - 999 mg/dl call MD, subcutaneously before meals and at bedtime for DM. Finger stick before meals and nightly with lancet, test trips, rotate injection site, call MD if blood glucose less than 70 mg/dl or greater than 400 mg/dl. Review of Resident 77's H&P examination dated [DATE], showed Resident 77 was able to make very simple decisions. On [DATE] at 1138 hours, an observation of Resident 77 was conducted with LVN 1. LVN 1 performed a blood glucose check on Resident 77. The result was 202 and based on the sliding scale, Resident 77 needed four units of insulin. LVN 1 removed Resident 77's insulin pen KwikPen from her cart. LVN 1 removed the cap of the kwikPen and attached it to a sterile needle. LVN 1 did not clean the top of the KwikPen with an alcohol swab prior to attaching it to the sterile needle. LVN 1 proceeded to administer four units of insulin to Resident 77. On [DATE] at 1144 hours, an interview was conducted with LVN 1. LVN 1 verified she was aware she should have cleaned the top of the KwikPen with alcohol prior to attaching it to the sterile needle but missed that step. On [DATE] at 1125 hours, an interview was conducted with the DON. The DON verified the nurses should be cleaning the syringe in the sink if the final flush of water does not remove the residue. The DON also verified there should not be expired masks available for use. The DON also verified nurses should be performing hand hygiene before and after resident care and when they remove their gloves. The DON also verified the nurses should be cleaning the top of the KwikPen with alcohol prior to attaching the sterile needle. 7. Review of the facility's P&P titled Enhanced Barrier Precautions dated 8/2022 showed the EBPs were utilized to prevent the spread of MDROs to the residents. The EBPs are indicated for residents with wounds regardless of MDRO colonization. Signs are posted on the door or wall outside of the resident room indicating the type of precaution and PPE required. On [DATE] at 0959 hours and 1134 hours, Resident 35 was observed laying on his bed, in his room. There was no EBP signage posted in his room nor by the door. Medical record review for Resident 35 was initiated on [DATE]. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 35 had a diagnosis of a stage 4 pressure ulcer of the sacral region. Review of Resident 35's Care Plan Report dated [DATE], showed a care plan for EBP related to the resident's wound infection with interventions including placing the EBP signage at the resident's door entry. Review of Resident 35's Order Summary Report showed a physician's order dated [DATE], for EBP due to Resident 35's wound. On [DATE] at 1138 hours, an observation, interview and concurrent medical record review for Resident 35 was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 stated Resident 35 had the EBP due to his wound and the EBP signage should have been posted by the resident's door to inform the staff members. On [DATE] at 1447 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings. 8. On [DATE] at 1033 hours, an inspection of the facility's clean laundry room was conducted with the Laundry Aide. A facility staff member's personal backpack, lunch bag, and tumbler were sitting inside of a rolling clothing rack and touching the residents' clean clothing. The Laundry Aide stated she should not have put her personal items touching the residents' clean clothing. The Laundry Aide verified the above findings. On [DATE] at 1114 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the laundry staff were meant to keep their personal belongings in the facility's lockers. The Maintenance Supervisor stated the Laundry Aides should not have their personal items where the residents clean clothing is kept. The Maintenance Supervisor acknowledged the above findings. 9. Review of the facility P&P titled Handwashing/Hand Hygiene revised 10/2023 showed this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated: after contact with blood, body fluids, or contaminated surfaces. On [DATE] at 1118 hours, during initial tour of the facility, CNA 3 was taking care of Resident 18. Resident 18's bed control remote was on the floor. CNA 3 picked up the bed control remote from the floor with gloves, and used the remote to lower the head and foot of the bed. CNA 3 gave the bed control remote to the resident without sanitizing the remote. CNA 3 then changed Resident 18 without changing the gloves. On [DATE] at 1125 hours, an interview was conducted with CNA 3. CNA 3 acknowledged he did not disinfect the bed control and used the same gloves when changing Resident 18's diaper. On [DATE] at 0755 hours, an interview was conducted with the DSD. The DSD stated the CNA should have disinfected the bed control before using it. The DSD further stated that CNA should have washed his hands and changed gloves before changing Resident 18 diaper to prevent infection. On [DATE] at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to follow up with the physician regarding the residents on the antibiotic therapy who did not have true infections based on the McGeer's criteria listed in the Infection Prevention and Control Surveillance Logs for 2025 and for three nonsampled residents (Residents 46, 47, and 65) * Residents 46, 47, and 65's physicians' were not notified to reevaluate their antibiotics when their infections did not meet the McGeer's criteria. In addition, the facility's Infection Prevention and Control Surveillance Logs were incomplete and failed to show the dates/times when the IP followed up with the physicians for other residents who were prescribed antibiotics whose infections did not meet the McGeer's criteria. These failures had the potential for the residents to receive unnecessary antibiotic therapy and put them at risk for MDROs. Findings: 1. Review of the facility's Antibiotic Stewardship P&P revised 4/2025 showed the laboratory results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. a. Review of the facility's Infection Prevention and Control Surveillance Logs for 2025 showed the following:- January, showed comments that four infections did not meet McGeer's criteria, the physician was notified and ordered to continue the antibiotics. - February, failed to show if any of the 21 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- March, failed to show if any of the 18 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- April, failed to show if 16 of 18 infections failed to meet the McGeer's criteria, including one comment that culture results showed multiple organisms and MD ordered to continue antibiotics. - May, failed to show if any of the 26 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- June, failed to show if 29 of 30 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- July, failed to show if any of the 22 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- August, failed to show if any of the 28 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- September, failed to show if any of the 37 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- October, failed to show if any of the 29 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- November, failed to show if 25 of the 27 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- December, failed to show if five of the nine infections were reviewed timely and if they met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.A random review of the residents' medical record failed to show the physicians' orders were obtained to continue the antibiotic therapy after not meeting the McGeer's criteria. On 12/17/25 at 1012 hours, an interview and concurrent record review was conducted with the IP. The IP stated when infections did not meet the McGeer's criteria for infections, she called the physician and documented the outcome in the comment section of the surveillance log. The IP stated she did not document anywhere else, including the residents' medical record. The IP stated for the comments where she notified the physician/MD, and they ordered to continue the treatment, she did not actually obtain a physician's order and simply meant she notified the physician, and the physician wanted to continue with the antibiotics. The IP stated she did not document her discussion with the physician anywhere else, and did not have dates/times for her log's comments when she followed-up with the physician. The IP also stated she had technical issues and lost data for all of the 2025's surveillance logs. b. On 12/17/25 at 1056 hours, a follow-up interview and record review was conducted with the IP. Review of the December 2025 facility's Infection Prevention and Control Surveillance Logs showed Resident 65 started antibiotics on 12/5/25, for a UTI. The IP stated she recalled the resident's infection meeting the McGeer's criteria even though the log was still incomplete, and therefore she did not need to call the physician to follow up on their antibiotic use. Review of Resident 65's medical record failed to show a clinical data to support the resident's infection met the McGeer's criteria. The IP verified the findings and stated she should have notified the physician to reevaluate the antibiotic use. c. On 12/17/25 at 1542 hours, a follow up interview and concurrent record review was conducted with the IP. Review of January 2025 facility's Infection Prevention and Control Surveillance Logs showed Resident 46 started antibiotics on 1/1/25, for a UTI. The log showed it met McGeer's Criteria. Review of Resident 46's medical record failed to show clinical data to support the resident's infection met the McGeer's criteria. The IP verified the findings and stated she should have followed up with the physician to reevaluate the antibiotic use. d. On 12/17/25 at 1542 hours, a follow up interview and concurrent record review was conducted with the IP. Review of November 2025 facility's Infection Prevention and Control Surveillance Logs showed Resident 47 started antibiotics on 11/17/25, for a UTI. The log failed to show if it met the McGeer's criteria. Review of Resident 47's medical record failed to show clinical data to support the resident's infection met the McGeer's criteria. The IP verified the findings and stated she should have followed up with the physician to reevaluate the antibiotic use.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for one final sampled resident (Resident 2) and two nonsampled residents (Residents 5 and 7) reviewed for unnecessary medications. * The facility failed to document the nonpharmacological interventions to be attempted prior to administering Resident 2's alprazolam (antianxiety) medication. * The facility failed to document the nonpharmacological interventions to be attempted prior to administering Resident 5's trazodone medication. * The facility failed to implement the nonpharmacological interventions prior to administering the trazodone (antidepressant medication) to Resident 7. In addition, the facility failed to ensure Resident 7's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the olanzapine (antipsychotic medication). These failures had the potential for adverse effects from the psychotropic medications, not providing the correct data to the prescriber to adjust the dosage of the medications and to negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Antipsychotic Medication Use revised July 2022 showed: - A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior including, anti-psychotics, anti-depressants, anti-anxiety medications and hypnotics. Residents will not receive medications that are not clinically indicated to treat a specific condition. - Nonpharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. - Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: Cardiovascular; orthostatic hypotension. The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. 1. a. Medical record review for Resident 7 was initiated on 12/16/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's H&P examination dated 10/30/25, showed the resident was non-competent. Review of Resident 7's MDS assessment dated [DATE], showed a BIMS score of 7, indicating severe cognitive impairment. Review of Resident 7's Order Summary Report dated 12/18/25, showed the following physician's orders: - dated 10/16/25, to administer trazodone hydrochloride 50 mg by mouth at bedtime for depression manifested by inability to sleep. However, further review of Resident 7's medical record failed to show a physician's order or documented evidence the nonpharmacological interventions were implemented for Resident 7's use of a routine antidepressant. On 12/18/25 at 1125 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked about the nonpharmacological interventions provided for the use of Resident 7's antidepressant medication. The DON stated the facility did not provide the nonpharmacological interventions for the residents who were on routine antidepressant medications, but only with antidepressant medications prescribed as needed. b. Review of Resident 7's Order Summary Report showed the following physician's orders: - dated 10/16/25, to administer olanzapine 2.5 mg by mouth one time a day for schizoaffective disorder manifested by verbalization that people are going to steal her clothes; - dated 10/16/25, to monitor the orthostatic B/P (lying ) every day shift every on Saturdays for the olanzapine medication use. Review of Resident 7's MAR dated 12/17/25, showed the following: -on 12/6/25, the BP reading for the lying position was 132/60 mmHg; and -on 12/13/25, the BP reading for the lying position was 146/60 mmHg. However, further review of Resident 7's medical record failed to show a physician's order or documented evidence the orthostatic blood pressure for the sitting and standing positions were being monitored. On 12/18/25 at 1415 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated the facility was monitoring Resident 7 for orthostatic hypotension with sitting, standing, and lying positions prior to Resident 7 transferring to the acute care hospital in October 2025, however, since Resident 7 returned from the acute care hospital on [DATE], the facility had only been monitoring for one position (lying). On 12/18/25 at 1125 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no physician's order to monitor Resident 7's orthostatic BP in the sitting and standing position after Resident 7 was readmitted from the acute care hospital on [DATE]. 2. Medical record review for Resident 5 was initiated on 12/15/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 9/26/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's Order Summary Report dated 9/16/25, showed a physician's order to administer trazodone HCl 50 mg one tablet by mouth at bedtime for depression manifested by inability to sleep. Review of Resident 5's MDS assessment dated [DATE], under Section I, showed Resident 5 had a diagnosis of depression. However, further review of Resident 5's medical record failed to show the nonpharmacological interventions attempted prior to the administration of Resident 5's trazodone medication. On 12/17/25 at 1419 hours, an interview and concurrent medical record review for Resident 5 was conducted with LVN 3. When asked about Resident 5's trazodone medication use, LVN 3 stated Resident 5 was taking the trazodone medication for their inability to sleep. When asked there were documented evidence to show the nonpharmacological interventions provided to Resident 5 prior to the use of the trazadone medication, LVN 3 stated no. LVN 3 verified the above findings. On 12/17/25 at 1459 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 2. RN 2 verified the above findings. RN 2 stated Resident 5 had a physician's order for the risperidone (anti-psychotic medication) medication and a physician's order for the nonpharmacological interventions for the use of the risperidone medication. However, RN 2 further stated the risperidone and trazodone medications should have different nonpharmacological interventions because the two medications were two different medication classes and had different targeted behaviors. On 12/18/25 at 1447 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings. 3. Medical record review for Resident 2 was initiated on 12/15/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 11/26/25, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Order Summary Report dated 12/18/25, showed Resident 2 had a physician's order dated 12/15/25, to administer alprazolam 0.5 mg one tablet every 12 hours as needed for agitation/fidgeting in bed causing distress via GT for 14 days. However, further review of Resident 2's medical record failed to show the nonpharmacological interventions attempted prior to the administration of Resident 2's alprazolam medication. On 12/17/25 at 1155 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 2. When asked about Resident 2's alprazolam medication use, RN 2 stated Resident 2 was taking the alprazolam medication for agitation/fidgeting in bed causing distress. When asked about the documented evidence to show the nonpharmacological interventions attempted prior to the administration of the alprazolam medication, RN 2 verified there was no documented evidence in the resident's medical record. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to develop the resident-centered care plans to reflect the individual care needs of two of 19 final sampled residents (Residents 8 and 52). * The facility failed to develop a care plan for a new diagnosis of a UTI [a common bacterial infection in the urinary system (kidneys, bladder, ureters, urethra)] for Resident 8 when the resident returned from the acute care hospital. * The facility failed to develop a comprehensive individualized care plan to address Resident 52's weight loss of 21 lbs. in six months. These failures posed the risk of not providing appropriate and individualized care to Residents 8 and 52 to meet their highest practicable mental health and well-being.Findings: Review of the facility's P&P titled Care Plan, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person -centered care plan: - describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. - reflects currently recognized standards of practice for problem areas and conditions. Review of facility's P&P titled Weight Assessment and Intervention revised 3/2022 showed the residents' weights are monitored for undesirable or unintended weight loss or gain. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. One month – 5% weight loss is significant; greater than 5% is severe; b. Three months – 7.5% weight loss is significant; greater than7. 5% is severe; and c. Six months - 10% weight loss is significant; greater than 10% is severe. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Timeframes and parameter for monitoring and reassessment. 1. Medical record review for Resident 52 was initiated on 12/15/25. Resident 52 was admitted to the facility on [DATE]. and readmitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 7/28/25, showed Resident 52 had no capacity to understand and make decisions due to dementia. Review of Resident 52's Weight Summary showed the following dates and weights: - on 6/1/25, the resident had a weight of 165 lbs; - on 7/2/25, the resident had a weight of 163 lbs; - on 8/2/25, the resident had a weight of 147 lbs; - on 9/3/25, the resident had a weight of 150 lbs; - on 10/1/25, the resident had a weight of 143 lbs; - on 11/1/25, the resident had a weight of 143 lbs; and - on 12/2/25, the resident had a weight of 144 lbs. (a loss of 21 lbs./12.7% in six months} Review of Resident 52's Order Summary Report showed a physician's order dated 8/13/25, for fortified/high protein/consistent-carbohydrate-no added salt diet, with pureed texture and mildly thick consistency. Review of Resident 52's Care Plan Report showed a care plan revised 8/22/25, addressing the resident's impaired nutritional and hydration status related to dysphagia and mechanically altered diet. The goal included the residents to not exhibit signs and symptoms of dehydration and will not have significant weight change. However, further review of the resident's plan of care failed to show documented evidence a care plan problem was developed to address the resident's weight loss of 21 lbs. in six months. On 12/17/25 at 1130 hours, an interview and concurrent medical record review was conducted with the RD. The RD stated she was not involved in the resident's care planning and stated the DON was responsible for the nutrition care plan for the residents. On 12/17/25 at 1626 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above findings. RN 2 stated the Dietary Department should address the resident's weight loss. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 8 was initiated on 12/17/25. Resident 8 was admitted on [DATE], and readmitted on [DATE]. Review of Resident 8's progress note dated 10/13/25 at 2239 hours, showed Resident 8 was readmitted to the facility with a new diagnosis of a UTI. Review of Resident 8's COC documentation dated 10/19/25 at 1715 hours, showed Resident 8 with increased weakness and decline in ADL function. The MD was notified and had ordered Resident 8 to be sent to the acute care hospital. Review of Resident 8's MAR for October 2025 showed a physician's order to administer triaxone (antibiotic) sodium injection solution reconstituted 1 gm at 100 ml/hr intravenously every 24 hours for UTI for seven days. However, further review of Resident 8's plan of care, there was no documented evidence the facility developed and implemented a comprehensive person-centered care plan to address Resident 8's UTI diagnosis. On 12/17/25 at 1057 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated when a resident returned from the acute care hospital, the RN supervisor updated the resident's care plan. LVN 1 stated when a resident was admitted with a new diagnosis, the care plan should include the goals and interventions addressing the new diagnosis. LVN 1 was informed and verified the above findings. LVN 1 stated the importance of having the diagnosis on the resident's care plan was to know what interventions were being provided, if the interventions were effective, and if the physician's orders were up to date. LVN 1 further stated the importance of a care plan was to keep track of what was being done and monitoring the resident's care. On 12/17/25 at 1111 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 8's care plan did not reflect the new diagnosis of a UTI. RN 1 stated there should be a UTI care plan along with the interventions in the resident's medical record. On 12/18/25 at 1001 hours, an interview and concurrent medical record review as conducted with the DON. The DON stated when a resident returned from the acute care hospital with new orders, the facility carried out the new orders and modified the care plan to address the diagnosis. The DON stated the importance of developing the resident's care plan was to ensure the interventions were being carried out, to monitor the effectiveness of the interventions, and to inform the MD of the residents' care. On 12/18/25 at 1245 hours, an interview was conducted with the Administrator, DON and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of three final sampled residents (Resident 67) reviewed for activities. * The facility failed to provide room visits for Resident 67 as per the activities plan of care. This failure had the potential for the resident to experience feelings of social isolation.Findings: Review of the facility's P&P titled Individual Activities and Room Visit Program revised 6/2018 showed the following:- Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them.- It is recommended that resident with in-room activity programs receive, at a minimum, three in room visits per week. A typical in-room visit is ten-fifteen minutes in length, but may be longer if appropriate for the resident. On 12/15/25 at 1017 hours, during the initial tour of the facility, Resident 67 was observed lying in bed. The television was observed to be off and there was no other sensory stimulation observed. Medical record review for Resident 67 was initiated on 12/15/25. Resident 67 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 67 's plan of care showed a care plan problem dated 11/14/24, addressing the resident's little or no activity involvement related to immobility and physical limitation. The care plan further showed Resident 67 would be provided with sensory stimulation such as music therapy, and hand massage, listening to music (Spanish), family visits and visiting the patio on occasion. The Activity staff would continue to provide room visit three times per week or as necessary. The interventions included to modify the resident's daily schedule treatment plan as needed to accommodate activity participation. Review of Resident 67's MDS Quarterly assessment dated [DATE], showed Resident 67 had severe cognitive impairment and needed substantial/maximal assistance from the facility staff for mobility. Further review of Resident 67's medical record failed to showed documentation sensory stimulation activities and/or room visits were provided to Resident 67. On 12/16/25 at 1031 hours, observed Resident 67 was lying in bed awake. The television was observed to be off. On 12/16/25 at 1134 hours, an observation and concurrent interview for Resident 67 was conducted with CNA 4. CNA 4 stated Resident 67 did not attend any activities and only got Resident 67 out of bed during shower days. On 12/16/25 at 1515 hours, an interview and concurrent medical record review was conducted with Activity Assistant. When asked what activities were provided to Resident 67, the Activity Assistant stated the activity staff provided room visits. When asked to review any documentation to show the activities provided to Resident 67 during the room visits, the Activity Assistant failed to show documentation of the activities provided during the room visits. On 12/16/25 at 1528 hours, an interview and concurrent medical record review was conducted with Activity Director. The Activity Director verified the facility had no activity notes when the activity staff provided the room visit for the residents. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one final sampled resident (Resident 64) and two nonsampled residents (Residents 66 and 77) observed for blood glucose monitoring. * LVN 1 failed to discard the first drop of blood during the blood glucose check for Residents 64, 66 and 77. * LVN 1 failed to rotate the injection site when administering the insulin (medication to help lower blood sugar) to Resident 64. These failures had the potential for the residents not to receive the necessary care and services to maintain their highest physical well-being.Findings: Review of the facility's P&P titled Obtaining a Fingerstick Glucose Level revised October 2011 showed the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Obtain a blood sample by using a sterile lancet. Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. 1.a. Medical record review for Resident 64 was initiated on 12/15/25. Resident 64 was admitted to the facility on [DATE]. Review of Resident 64's H&P examination dated 12/3/25, showed Resident 64 was able to understand and make treatment decisions. Review of Resident 64's Order Summary Report dated 12/15/25, showed the following physician's orders:- dated 11/26/25, to administer insulin regular human injection solution 100 unit/ml (insulin regular human) subcutaneously per sliding scale before meals and at bedtime for DM. Rotate the injection sites. On 12/15/25 at 1119 hours, LVN 1 was observed performing a blood glucose check on Resident 64. LVN 1 was observed cleaning Resident 64's finger with an alcohol pad. LVN 1 then obtained a blood sample using a sterile lancet. However, LVN 1 did not waste the first drop of blood and used the first drop of blood for the test sample. b. Medical record review for Resident 66 was initiated on 12/15/25. Resident 66 was admitted to the facility on [DATE]. Review of Resident 66's H&P examination dated 11/7/25, showed Resident 66 was able to make decisions. Review of Resident 66's Order Summary Report dated 12/15/25, showed the following physician's order dated 11/6/25, to administer insulin regular human injection solution pen-injector 100 unit/ml (insulin regular human) subcutaneously per sliding scale before meals and at bedtime for DM. On 12/15/25 at 1202 hours, LVN 1 was observed performing a blood glucose check on Resident 66. LVN 1 was observed cleaning Resident 66's finger with an alcohol pad. LVN 1 then obtained a blood sample using a sterile lancet. However, LVN 1 did not waste the first drop of blood and used the first drop of blood for the test sample. c. Medical record review for Resident 77 was initiated on 12/15/25. Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's H&P examination dated 1/20/25, showed Resident 77 was able to make very simple decisions. Review of Resident 77's Order Summary Report dated 12/15/25, showed the following physician's order dated 9/7/25, to administer Humalog solution 100 unit/mL (insulin/lispro) subcutaneously per sliding scale before meals and at bedtime for DM. On 12/15/25 at 1138 hours, LVN 1 was observed performing a blood glucose check on Resident 77. LVN 1 was observed cleaning Resident 64's finger with an alcohol pad. LVN 1 then obtained a blood sample using a sterile lancet. However, LVN 1 did not waste the first drop of blood and used the first drop of blood for the test sample. 2. Review of the facility document titled Competency Assessment titled Obtaining a Fingerstick Glucose Level dated 4/3/25, and authorized by the DON on 4/3/25, showed LVN 1 was competent in all categories of obtaining a fingerstick glucose level. On 12/15/25 at 1119 hours, LVN 1 was observed administering insulin to Resident 64. During the insulin administration, LVN 1 asked Resident 64 where the resident wanted the insulin injected. Resident 64 wanted the insulin injection in the right arm. However, LVN 1 did not verify the previous insulin injection sites. On 12/16/25 at 1144 hours, an interview was conducted with LVN 1. LVN 1 verified she was aware of the facility's policy to discard the first drop of blood during a blood glucose test but failed to do so for Residents 64, 66, and 77. LVN 1 also stated she was aware of the physician's order to rotate insulin injection sites for Resident 64. On 12/18/25 at 1125 hours, an interview was conducted with the DON. The DON was unaware of the facility's policy to waste the first drop of blood when obtaining a blood sample for the blood glucose monitoring. However, the DON verified the licensed nurses should be rotating the injection sites when administering insulin. On 12/18/25 at 1458 hours, an interview was conducted with the DSD. The DSD stated the competency for obtaining a fingerstick glucose level was conducted by the DON. The DSD further stated the licensed nurses were required to perform the task on a resident to be checked off for the competency and if there were any identified issues, the DON had the license nurse repeat the test.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries (damage to the skin and underlying tissue from prolonged pressure, often over bony areas) for one of two final sampled residents (Resident 69) reviewed for pressure injuries. * The facility failed to ensure Resident 69 had weekly assessments documented for a Stage 2 pressure injury (partial-thickness skin loss where the epidermis and part of the dermis are damaged) to the coccyx. This had the potential for Resident 69's Stage 2 pressure injury to worsen and not provided appropriate care.Findings: Review of the facility's P&P titled Pressure Injuries Overview revised February 2024 showed a Stage 2 pressure injury is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-intact blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage including continence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (skin tears, burns, abrasions). Review of the facility's P&P titled Charting and Documentation revised July 2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting. Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol revised April 2018 showed the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status' current treatments, including support surfaces, and all active diagnoses. Medical record review for Resident 69 was initiated on 12/16/25. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Admission/readmission Data Tool dated 11/12/25 at 1651 hours, showed the resident had a sacrococcyx Stage 2 pressure injury, measuring 4.0 cm by 2.0 cm by x 0.1cm. The description showed the pressure injury was a shallow open wound with red wound bed, no drainage and no signs and symptoms of infection. Review of Resident 69's progress note dated 12/14/25, showed the MD was notified regarding the evaluation on the sacrococcyx Stage 2 pressure injury's improvement with no signs and symptoms of infection. The progress note showed Resident 69 had denied pain or discomfort during wound treatment and a new order from the physician was obtained to continue the current treatment to the sacrococcyx Stage 2 pressure injury as follows: to cleanse with normal saline, pat dry, apply zinc oxide cream (over the counter skin protectant) and cover with foam dressing daily for 30 days. However, further review of Resident 69's progress note dated 12/14/25, failed to show documented assessment of the pressure injury, including the measurements for length, width and depth, presence of exudates or necrotic tissue as per the facility's P&P. On 12/17/25 at 1402 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated the facility was providing wound treatment for Resident 69's sacrococcyx Stage 2 pressure ulcer injury. LVN 2 verified Resident 69's initial assessment for the pressure injury was documented on the resident's Admission/readmission Data Tool dated 11/12/25, and the reevaluation assessment was done on 12/14/25. LVN 1 verified the reassessment documentation failed to show thorough documentation, including the measurements/size of the wound and only showed the pressure injury was improving. On 12/18/25 at 1022 hours, an interview was conducted with the DON. The DON stated an assessment of a pressure injury was completed at the time of the resident's admission and then weekly assessments were completed. The DON was informed of the incomplete wound assessments and documentation for Resident 69's sacrococcyx Stage 2 pressure injury as per the facility's P&P and verified above the findings.

Based on interview and medical record review, the facility failed to ensure the necessary care and services were provided for one of one final sampled resident (Resident 1) reviewed for accident hazards. * The facility failed to timely monitor and document the neurological assessments for Resident 1's unwitnessed fall incident on 5/1/25. This failure had the potential to place the resident at risk for serious injury.Findings: Medical record review for Resident 1 was initiated on 12/15/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 5/1/25 at 0310 hours, showed Resident 1 had an unwitnessed fall and was found sitting on the floor beside his bed. Resident 1 was noted to have a small amount of blood and a small bump at the right temporal area (near the temples of the head) of his head. Resident 1 was on an anticoagulant (blood thinner) medication but Resident 1 refused an acute care hospital transfer. Resident 1's responsible party was made aware of the fall incident. Review of Resident 1's Neuro Check Flowsheet - V 4 dated 5/1/25, showed under Section 3 every one hour four times. The first assessment for every hour monitoring was obtained on 5/1/25 at 0730 hours. However, the second assessment for every hour monitoring was obtained on 5/1/25 at 1132 hours (four hours after the first assessment) and the third assessment for every hour monitoring was obtained on 5/1/25 at 1530 hours (four hours after the second assessment). Review of Resident 1's H&P examination dated 8/18/25, showed Resident 1 was unable to understand and make treatment decisions due to dementia. On 12/17/25 at 0951 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 3. LVN 3 stated the neurological assessments were obtained after a fall incident to monitor the resident's level of consciousness. LVN 3 verified the above findings. LVN 3 stated the neurological assessment was not completed in a timely manner because the assessment should have been obtained every hour for four hours for Resident 1. On 12/18/25 at 1447 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of the medications. * The facility failed to ensure the oral and IV emergency medication kits were replaced timely. * The facility failed to ensure the administration of the controlled medications for Residents 53 and 81 were documented in the MAR. * LVN 4 failed to administer the full dose of the cranberry supplement via GT for Resident 2. These failures had the potential for diversion of the controlled medication, medication administration error, and negative residents outcomes.Findings: Review of the facility's P&P titled Administering Medications revised April 2023 showed:- Medications are administered in a safe and timely manner, and as prescribed.- The individual administering the medication initials the resident's MAR on the appropriate line or EMAR after giving each medication and before administering the next ones. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised January 2025 showed:- When an emergency dose of medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. An entry is made in the emergency logbook containing all required information.- As soon as possible, the nurse records the medication use on the medication order form and notified the pharmacy for replacement of the emergency drug supply by faxing a request utilizing the prescription refill sticker.- If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. 1. On 12/15/25 at 1512 hours, an interview and concurrent inspection of Medication Room A was conducted with RN 2. The oral and IV emergency kits were observed to be sealed with yellow locks. RN 2 stated the yellow locks indicated the emergency kits were previously opened and waiting to be replaced by the pharmacy. RN 2 was asked to open both emergency kits. Review of the emergency kit pharmacy log for the oral emergency kit indicated the kit was opened on 12/10/25. Review of the emergency kit pharmacy log for the IV emergency kit indicated it was opened on 11/30/25. RN 2 stated she called the pharmacy to follow up on the replacement of the emergency kits but verified the emergency kits were past the facility's 72-hour policy. On 12/18/25 at 1125 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 2. On 12/16/25 at 1013 hours, an inspection of Medication Cart D was conducted with LVN 4. During the inspection of Medication Cart D, a random inspection of the controlled medications was conducted. Review of Medication Cart D's Antibiotic or Controlled Drug Record showed the following:a. Resident 53's Antibiotic or Controlled Drug Record for the oxycodone/APAP (narcotic pain medication) 7.5-325 mg medication showed one tablet of the oxycodone/APAP 7.5-325 mg tablet was removed on 12/9/25 at 1545 hours. Review of Resident 53's MAR for December 2025 was conducted with LVN 4 and the MAR failed to show the oxydodone/APAP 7.5-325 mg medication was administered on 12/9/25 at 1545 hours to Resident 53. b. Review of Resident 81's Antibiotic or Controlled Drug Record for the hydrocod/APAP (narcotic pain medication) 10-325 mg medication showed one tablet of the hydrocod/APAP 10-325 mg tablet was removed on 12/9/25 at 2050 hours. Review of Resident 81's MAR for December 2025 was conducted with LVN 4 and the MAR failed to show the hydrocode/APAP 10-325 mg medication was administered on 12/9/25 at 2050 hours to Resident 81. LVN 4 verified the MAR entries for Residents 53 and 81 were missing and stated all the medications should be documented in the resident's MAR upon administration. On 12/18/25 at 1125 hours, an interview was conducted with the DON. The DON verified all controlled drug administration should be documented in the MAR. 3. Medical record review for Resident 2 was initiated on 12/15/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 11/26/25, showed Resident 2 was able to understand and make treatment decisions. An addendum note was added on 12/16/25, which showed Resident 2 was unable to understand and make treatment decisions due to dementia and encephalopathy (any disease or disorder that alters brain function or structure). Review of Resident 2's Order Summary Report dated 12/15/25, showed a physician's order dated 11/25/25, to administer cranberry (supplement) oral tablet 450 mg via GT one day a day for UTI prophylaxis. On 12/15/25 at 0818 hours, a medication administration observation for Resident 2 was conducted with LVN 4. LVN 4 was observed crushing the cranberry supplement tablet and administering the supplement to Resident 2 via GT. However, upon completion of the administration, there was significant tablet residue in the medication cup, which was not administered to Resident 2. On 12/15/25 at 1457 hours, an interview was conducted with LVN 4. LVN 4 verified the above findings and stated leaving the medication residue in the medication cups resulted in the resident not receiving the correct dose.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.08% (for six medication errors out of 26 total opportunities). One of six licensed nurses (LVN 4) who were observed during medication administration was found to have errors. * LVN 4 failed to ensure all the medication residual was administered via GT to Resident 2 for six of 14 medications administered. This failure had the risk for the resident to have potential side effects or complications related to the medications.Findings: On 12/15/25 at 0818 hours, a medication administration observation for Resident 2 was conducted with LVN 4. LVN 4 prepared and administered the following medications to Resident 2:- One tablet of amlodipine (used to treat high blood pressure) 5 mg;- One tablet of aspirin (used to relieve pain, fever and inflammation; acts as a blood thinner) 81 mg;- One tablet of atenolol (used to treat high blood pressure) 50 mg;- One tablet of cranberry 450 mg;- Restasis (used to treat chronic dry eyes) eye drops 0.5%;- One tablet of apixaban (blood thinner) 2.5 mg;- One tablet of furosemide (diuretic) 20 mg;- One tablet of losartan 9(used to treat high blood pressure) 100 mg;- One tablet of magnesium oxide (supplement) 400 mg;- One tablet of meloxicam (used to relieve pain, swelling and stiffness) 15 mg;- One tablet of multivitamin with minerals (supplement);- One tablet of prednisone (used to reduce inflammation and suppress the immune system) 5 mg;- 30 ml of Pro-stat (supplement) liquid;- Refresh tears (used to treat dry eyes) eye drops.- One capsule of venlafaxine (antidepressant) 75 mg; and- One tablet of vitamin C (supplement) 500 mg.LVN 4 prepared and administered the above medications to Resident 2. However, following the medication administration, six medication cups were found to have significant medication residue in them. LVN 4 verified the medication residue in the cups. The medications observed with residue were: - aspirin 81 mg;- magnesium oxide 400 mg;- multivitamin with minerals- prednisone 5 mg;- venlafaxine 75 mg; and- vitamin C 500 mg. Medical record review for Resident 2 was initiated on 12/15/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 11/26/25, showed Resident 2 was able to understand and make treatment decisions. An addendum note was added on 12/16/25, which showed Resident 2 was unable to understand and make treatment decisions due to dementia and encephalopathy. Review of Resident 2's Order Summary Report dated 12/15/25 ,showed the following physician's orders dated 11/25/25:- To administer amlodipine 5 mg tablet via GT one time a day;- To administer aspirin 81 mg tablet via GT one time a day;- To administer atenolol 50 mg tablet via g GT one time a day;- To administer cranberry (supplement) 450 mg tablet one time a day;- To administer Restasis ophthalmic emulsion 0.5% one drop in each eye every 12 hours;- To administer apixaban 2.5 mg tablet via GT two times a day;- To administer furosemide 20 mg tablet via GT one time a day;- To administer losartan 100 mg tablet via GT one time a day;- To administer magnesium oxide 400 mg tablet via GT one time a day;- To administer meloxicam 15 mg tablet via GT one time a day;- To administer multivitamin with minerals tablet via GT one time a day;-To administer prednisone 5 mg tablet via GT one time a day;-To administer Pro-stat (supplement) 30 ml liquid via GT one time a day;-To administer Refresh tears ophthalmic solution 0.5% one drop in each eye four times a day;-To administer venlafaxine 75 mg tablet via GT one time a day; and-To administer vitamin C 500 mg tablet via GT one time a day. On 12/15/25 at 1457 hours, an interview was conducted with LVN 4. LVN 4 verified the above findings and stated leaving medication residue in cups resulted in the resident not receiving the correct doses. On 12/18/25 at 1125 hours, an interview was conducted with the DON. The DON verified the licensed nurses should be administering the complete dose of the medications and stated the failure to administer the full doses of the medications could result in the resident not getting the full effect of the medication.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for two of 87 Residents (Residents 53 and 81) who received food prepared in the kitchen. * Resident 53 and 81's meals were delivered and served cold. * Resident 53's beef was tough to cut with a knife and difficult to chew. These failures had the potential for decreased meal intake which could result in weight loss, decreased nutritive value, and negatively impact the residents' quality of life for all 87 residents who received food prepared in the kitchen. Findings: Review of the facility's Resident Matrix (list of all the residents currently in the facility and care areas triggered) received on 12/15/25, showed 87 out of 89 residents consumed food prepared in the kitchen. Review of the facility's policy titled Food Preparation and Service revised 11/2022 showed under Food Preparation, Cooking and Holding Time/Temperatures (1) The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. (3) . danger zone the greater the risk for growth of harmful pathogens.maintained at or below 41 F or at or above 135 F. (7) Fresh, . fruits and vegetables are cooked to a holding temperature of 135 F. 1. On 12/15/25 at 1035 hours, an interview was conducted with Resident 53. Resident 53 stated that the food was always cold and lacked taste. Medical record review for Resident 53 was initiated on 12/15/25. Resident 53 was admitted to the facility on [DATE], and was readmitted on [DATE]. On 12/16/25 at 1230 hours, an interview and concurrent trayline observation was conducted with the DS. The DS stated they did not have a warming element on the residents' trays to keep the plates warm. On 12/16/25 at 1250 hours, during lunch observation, two test trays were placed on the final meal cart (a Regular diet and a Pureed texture diet). On 12/16/25 at 1300 hours, after the last tray was served to the residents, the two test trays were removed from the meal cart. The food items tested included Roast Beef, Baked Potato, and Seasoned [NAME] Beans. The foods on the regular diet tray did not hold temperatures above 114 degrees Fahrenheit for beef, potato, and vegetables. The beef was tough to cut with a knife and difficult to chew. The DS acknowledged the findings. 2. On 12/17/25 at 0945 hours, an interview was conducted with Resident 81. Resident 81 stated the steak and pork were too tough, hard to eat, and the breakfast eggs in the morning were sometimes cold. Medical record review for Resident 81 was initiated on 12/15/25. Resident 81 was admitted to the facility on [DATE], and was readmitted on [DATE]. On 12/17/25 at 1130 hours, an interview was conducted with the Dietary Supervisor (DS). The DS stated anything above 110 degrees for food service was acceptable. A weekly test tray was done; however, there were not specific parameters on the test tray audit for the acceptable temperatures. The DS acknowledged the findings.

Based on observation, interview, facility P&P review, and document review, the facility failed to ensure the facility's P&P on Foods Brought by Family/Visitors was followed. * The facility failed to ensure the safe food handling practices of outside food were explained to family/visitors in a language and format they understood. This failure had the potential to cause foodborne illness to the medically vulnerable resident population who consumed food [NAME] from outside resources.Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents had the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Foods Brought by Family/ Visitors revised 8/2024 showed the food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of the residents. Safe food handling practices are explained to family/visitors in a language and format that they understand. On 12/16/2025 at 0926 hours, an interview was conducted with LVN 4. LVN 4 stated she informed the families who brought in food from home of the resident's diet. The food can be kept in the refrigerator for two days then discarded. The food can be warmed up by the staff. LVN 4 added she had received an in-service regarding food brought to the facility from the family and visitors. When asked who gave the families information on safe food handling, LVN 4 stated, it was the role of the Director of Staff Development (DSD). On 12/16/2025 at 0945 hours, an interview and concurrent record review was conducted with the DSD. The facility record conducted to the staff by the DSD titled Education Program Lesson Plan for Food Brought in by Family/ Visitors dated 3/20/25, was reviewed with the DSD. When asked about the in-services/ education provided to the staff regarding safe food handling practices, the DSD stated it was the role of the nurses on the floor and the admissions department to provide information on safe food handling to the family and visitors. The education program's lesson plan did not include safe food handling information for the family and visitors. On 12/16/2025 at 1000 hours, an interview was conducted with the Admissions Director. The Admissions Director stated the residents received an admission packet which included the policy and procedure on food brought in by the family and visitors. When asked if it included education on safe food handling, the Admissions Director responded, no. On 12/16/2025 at 1010 hours, an interview was conducted with the Administrator. The Administrator stated there was a poster on the wall near the nursing station that educated the families and visitors regarding safe food handling.

Based on observation, interview, and facility P&P review, the facility failed to maintain the essential equipment in a clean, sanitary, and safe operating condition for one of two washing machines inspected (Washing Machine 1). * Washing Machine 1 was observed with dark red, green, and white build up on the inner door window. In addition, the rubber lining of the inside of the washing machine door was observed with thick brown and white build up. These failures had the potential for the essential equipment to not function in the way it was intended and expose the residents to unsafe practices.Findings: Review of the facility's P&P titled Maintenance Service revised 12/2009 showed the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 1. On 12/15/25 at 1046 hours, an interview and concurrent observation of Washing Machine 1 was conducted with the Laundry Aide. During the observation, the washing machine's inner door window was observed to have a dark red, green, and white build up. When the Laundry Aide was asked about the facility's process in cleaning the identified part of the washing machine's door, the Laundry Aide stated she was unable to clean the part of the door which was noted with dark red, green, and white build up since it was meant to be sealed off. The Laundry Aide stated they had no cleaning log for the washing machines. On 12/15/25 at 1510 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the Laundry Aides were responsible for cleaning the two washing machines in the facility. The Maintenance Supervisor further stated if the cleaning needed to be done was more technical, he will have his assistant help clean it, or he will call a vendor to have them clean or fix the washing machine. The Maintenance Supervisor stated the washing machines were cleaned weekly with bleach. When asked if there was a log for cleaning the washing machines, the Maintenance Supervisor stated the laundry aides did not fill out a log when the washing machines have been cleaned. When the Maintenance Supervisor was asked about the washing machine's inner door window with the dark red, green, and white build up that was observed, he stated he noticed the buildup on the washing machine's inner door window and stated stated he brought it up to the management. When asked if he had documentation to show he addressed the issue with the management, the Maintenance Supervisor stated he did not have documentation to show he addressed the buildup observed from Washing Machine 1. On 12/16/25 at 0820 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the dark red, green, and white buildup should not have been there. The Maintenance Supervisor verified the above findings. 2. On 12/15/25 at 1048 hours an interview and concurrent observation of Washing Machine 1 was conducted with the Laundry Aide. During the observation, the Laundry Aide was asked to open the washing machine door. Once the door was opened, a thick brown and white build up was observed on the rubber lining of the inside of the washing machine door. The Laundry Aide was asked about the facility's process in cleaning the identified part of the washing machine's door, she stated she cleaned the washing machine every week, and the last time she cleaned it was last Friday. When asked if there was a log for cleaning the washing machines, the Laundry Aide stated they did not have a log for cleaning the washing machines. On 12/15/25 at 1510 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the Laundry Aides were responsible for cleaning the washing machines, and they should be cleaned every week. When asked if there was a log for cleaning the washing machines, he stated the laundry aides did not fill out a log when they have cleaned them. The Maintenance Supervisor was made aware and acknowledged the above findings. The Maintenance Supervisor stated the rubber lining inside Washing Machine 1 should have been cleaned. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and the Regional Nurse Resource acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to facilitate the resident's preferences and choices for shaving for one of 19 final sampled residents (Resident 41). * The facility failed to assist Resident 41 with her hygiene preferences in regard to shaving her facial hair and underarms. This failure posed the risk of the resident not being able to choose their hygiene preferences. Findings: Review of the facility's P&P for Shaving the Resident revised February 2018 showed the purpose of this procedure is to promote cleanliness and to provide skin care. Under the Preparation section, showed to review the resident's care plan to assess any special needs of the resident. On 12/15/25 at 1438 hours, an interview was conducted with Resident 41. Resident 41 stated that she was not allowed to shave her facial hair and underarms at the facility. Resident 41 stated she needed to shave her underarms but was informed by the facility staff that the facility did not have the supplies and could not assist her with shaving her underarms. Medical record review for Resident 41 was initiated on 12/15/25. Resident 41 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 41's H&P examination dated 9/15/25, showed Resident 41 was able to understand and make treatment decisions. Review of Resident 41's plan of care showed a care plan problem dated 2/9/25, addressing the resident's self-care deficit. The care plan problem showed the resident required assistance or was dependent on personal hygiene. The interventions included to provide assistance with care and ADL. On 12/17/25 at 1142 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 41 was independent, however, Resident 41still needed to be supervised due to her blindness. CNA 1 stated the residents who requested to shave their facial hair and underarms were assisted by the facility staff. CNA 1 further stated the facility provided the shaving supplies to the residents. On 12/17/25 at 1157 hours, an interview was conducted with LVN 1. LVN 1 stated the residents could be assisted to shave their underarms. LVN 1 stated the facility provided shaving razors to the residents who requested to shave. LVN 1 stated Resident 41 did need assistance with shaving since she was blind. LVN 1 further stated the facility staff would try to be accommodating to the resident's hygiene choices. On 12/17/25 at 1345 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 41 had requested to shave her underarms. CNA 2 stated she informed Resident 41 the facility staff was not allowed to shave the residents' underarms. CNA 2 stated the facility provided the shaving razors and supplies needed for shaving. On 12/18/25 at 1016 hours, an interview was conducted with the DON. The DON stated if a resident who was alert and had a preference of wanting to shave their underarms, they should be able to. The DON stated the CNA could assist with shaving the resident's underarms. On 12/18/25 at 1042 hours, an interview was conducted with the DSD. The DSD stated the CNAs' competency check list included shaving as one of the skills listed and checked. The DSD stated this skill was assessed at the time of hire and annually. The DSD stated the CNAs could assist with shaving the residents' underarms, along with shaving their face, legs, and arms. On 12/18/25 at 1109 hours, facility document review was conducted with the DSD. The DSD showed the competency check list titled Certified Nursing Assistant Skills Evaluation/Orientation Checklist for CNA 2 dated 8/4/25. Review of the skills checklist showed CNA 2 was signed off as satisfactory for shaving, which included underarms as verified by the DSD. On 12/18/25 at 1109 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for two of 19 final sampled residents (Residents 9 and 13) were complete and accurately documented. * The facility failed to ensure Resident 9's blood pressure (BP) access site was accurately documented in the resident's medical record. *The facility failed to ensure Resident 13's POLST Section D was completed and the social services' documentation was accurate. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate. Findings: Review of the facility's P&P titled Hemodialysis Catheters - Access and Care of, revised 2/2023 showed to prevent infection and/or clotting do not use the access site arm to take blood samples, administer IV fluids, or give injections. Do not use the access arm to take blood pressure. 1. Medical Record Review for Resident 9 was initiated on 12/15/25. Resident 9 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 9's Plan of Care dated 7/22/25, showed a care plan problem with Focus Impaired Renal Function End Stage Renal Disease, on hemodialysis. The care plan included an intervention for no BP check or blood draw on the left arm. Review of Resident 9's Order Summary Report showed a physician's order dated 10/20/25, for no BP check or blood draw on the left upper arm. Review of Residents 9's MDS quarterly assessment dated [DATE], showed a BIMS score of 12, meaning moderately cognitively impaired. Review of Resident 9's documentation of BP showed: - On 11/30/25 at 1200 hours, a BP reading of 132/76 mmHg on the left arm; - On 12/3/25 at 0939 hours, a BP reading of 136/70 mmHg on the left arm; - On 12/4/25 at 1323 hours, a BP reading of 130/70 mmHg on the left arm; - On 12/5/25 at 0837 hours, a BP reading of 130/78 mmHg on the left arm; - On 12/5/25 at 1350 hours, a BP reading of 136/70 mmHg on the left arm; - On 12/5/25 at 1535 hours, a BP reading of 130/74 mmHg on the left arm; - On 12/6/25 at 0859 hours, a BP reading of 138/78 mmHg on the left arm; - On 12/6/25 at 1528 hours, a BP reading of 130/74 mmHg on the left arm; - On 12/8/25 at 1138 hours, a BP reading of 138/84 mmHg on the left arm; - On 12/12/25 at 0851 hours, a BP reading of 138/70 mmHg on the left arm; - On 12/13/25 at 0724 hours, a BP reading of 136/72 mmHg on the left arm; - On 12/13/25 at 1316 hours, a BP reading of 134/70 mmHg on the left arm; - On 12/14/25 at 0912 hours, a BP reading of 126/70 mmHg on the left arm; - On 12/14/25 at 1314 hours, a BP reading of 130/76 mmHg on the left arm; - On 12/15/25 at 0745 hours, a BP reading of 132/74 mmHg on the left arm; - On 12/15/25 at 1024 hours, a BP reading of 128/70 mmHg on the left arm; and - On 12/16/25 at 0638 hours, a BP reading of 138/80 mmHg on the left arm. On 12/16/25 at 1220 hours, an interview and concurrent medical record review for Resident 9 was conducted with LVN 4. LVN 4 verified Resident 9 had an AV shunt on the left arm, and the licensed nurses' documentation of the Resident 9's was on the left arm. On 12/16/25 at 1307 hours, an interview was conducted with Resident 9. Resident 9 stated that he never allowed the licensed nurses to take his BP on the left upper arm. On 12/17/25 at 1556 hours, an interview for Resident 9 was conducted with RN 2. RN 2 verified the findings and stated the BP should not be taken on the left upper arm to prevent infection and risk for blood clot. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P titled POLST (undated), showed the POLST is a physician order form that complements an advance directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make decisions) by converting an individual's wishes regarding life-sustaining treatment and resuscitation into physician's orders. Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective, complete, and accurate. Medical record review for Resident 13 was initiated on 12/15/25. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's POLST dated 10/12/20, showed Section D for the advance directive was not completed. Furthermore, review of Resident 13's Social Service Review v1 – v3 dated 1/24/25, Section A, showed Resident 13 had issued an advance directive about her care and treatment. Review of Resident 13's H&P examination dated 1/25/25, showed Resident 13 had no capacity to make decisions. On 12/17/25 at 1030 hours, an interview and concurrent medical record review for Resident 13 was conducted with the SSD. The SSD verified the above findings. The SSD stated Section D of Resident 13's POLST was left blank and should have been completed. In addition, the SSD stated Resident 13 had no advanced directive and verified the Social Service Review document was inaccurate. Furthermore, the SSD showed documented evidence of Resident 13's Multidisciplinary Care Conference v2 dated 5/13/24, that the resident's responsible party declined to create an advanced directive. On 12/18/25 at 1447 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to conduct a thorough abuse investigation for one of five sampled residents (Resident 1) as evidenced by: * The facility did not interview the other resident, Resident 3 who was mentioned on interview to have caused distress to Resident 1. This failure posed the risk of not identifying if other residents were affected by the reported abuse allegation.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 9/2022 showed all allegations are thoroughly investigated. Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse form dated 8/7/25, showed Resident 1 reported having problems with the other residents in the facility, including verbal abuse and physical altercations, such as being hit twice. Resident 1 reported he would sometimes miss breakfast due to conflicts with his roommate, who was described as rude and disruptive. Resident 1 expressed frustration with these living conditions and the behavior of others around him. Review of the facility's 5-day investigation summary dated 8/8/25, showed the following investigation was completed:- the Administrator and DON interviewed Resident 1. Resident 1 mentioned having issues with Resident 3 in the past, but not anymore. Resident 1 was offered and refused a room change. - the SSD interviewed Resident 4. Resident 4 denied concerns with Residents 1 and 3 and denied abuse or care concerns. Review of the facility's abuse allegation investigation showed only two residents were interviewed (Residents 1 and 4). Resident 3 was not interviewed regarding the alleged abuse. On 8/12/25 at 1335 hours, an interview and concurrent facility document review was conducted with the SSD. The SSD stated Resident 1 reported not being compatible with Resident 3 two times in the past. The SSD verified she participated in the investigation for Resident 1's allegation of abuse and was the designated staff to conduct resident interviews. The SSD stated she only interviewed Resident 4 to ask him if there were any issues or concerns between Residents 1 and 3. The SSD stated she did not interview Resident 3 because the Administrator instructed her to only interview Resident 4. The SSD reviewed Resident 1's interview with the Administrator and DON. The SSD verified Resident 3 should have been included in the resident interviews. On 8/12/25 at 1426 hours, an interview was conducted with the Administrator regarding the investigation of Resident 1's abuse allegation. The Administrator stated both she and the DON interviewed Resident 1 and the SSD interviewed Resident 4. The Administrator stated during the interview with Resident 1, Resident 1 brought up concerns with Resident 3, and stated Resident 1 had ongoing concerns with Resident 3 in the past, and brought it up again. The Administrator stated they have talked to Resident 3 in the past for roommate compatibility issues. The Administrator stated they overlooked interviewing Resident 3 because they had talked to him in the past.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for one of five sampled residents (Resident 5). * The facility failed to provide the wound care treatments for Resident 5's left foot wounds as ordered by the physician. This failure had the potential for Resident 5 to not receive the appropriate care and services to treat his left foot wounds. Finding: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown- Clinical Protocol dated 4/2018 showed the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. Medical record review for Resident 5 was initiated on 12/19/24. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 7/22/24, showed Resident 5 had no capacity to understand and make decisions and had a diagnosis of Type 2 Diabetes Mellitus with other diabetic kidney complications. Review of Resident 5's Plan of Care showed the care plan problems initiated on 10/13/24, addressing the following: - Resident 5's altered skin integrity for the left 5th metatarsal. The interventions included to administer the treatment as ordered. - Resident 5's altered skin integrity for the left mid lateral foot. The interventions included to administer the treatment as ordered. Review of Resident 5's TAR for December 2024 showed a physician's order dated 12/18/24, for the following: - for the left mid to lateral foot diabetic ulcer, to cleanse with normal saline, pat dry, apply Betadine external solution 10% topically (antiseptic solution), apply an ABD pad (a highly absorbent sterile dressing), wrap with a kerlix roll of gauze, and secure with tape, every day during the day shifts for 14 days. - for the left 5th metatarsal head diabetic ulcer, to cleanse with normal saline, pat dry, apply Betadine external solution 10% topically, apply an ABD pad, wrap with a kerlix roll or gauze, and secure with tape every day during the day shifts for 14 days. On 12/23/24 at 1015 hours, a wound care observation for Resident 5 was conducted with LVN 1. LVN 1 was observed cleansing Resident 5's left foot wounds with the Gentell wound cleanser spray (a no rinse wound cleanser) and a gauze. On 12/23/24 at 1040 hours, a concurrent interview and medical record review for Resident 5 was conducted with LVN 1. LVN 1 reviewed Resident 2's treatment orders for the left foot and stated the physician's order was to cleanse Resident 5's left foot diabetic wounds with normal saline. When asked about the wound cleansers, LVN 1 stated the normal saline and Gentellwound cleanser were not the same. LVN 1 verified she used the Gentell dermal wound cleanser to cleanse Resident 5's left foot wounds. LVN 1 further stated the wound treatments should be administered to the residents as ordered by the physician. On 12/23/24 at 1338 hours, an interview as conducted with the DON. The DON stated the licensed nurses were expected to administer the wound treatments as ordered by the physician, to accurately reflect the resident's care. The DON further stated the Gentell wound cleanser and normal saline were not the same, and if the treatment nurse was using something other than what was ordered, the nurse should clarify the order with the physician. On 12/23/24 at 1715 hours, the DON was informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure ulcers to one of two sampled residents (Resident 1). Resident 1 was admitted to the facility with an unstageable pressure ulcer. * The facility failed to assess, measure, obtain a wound treatment order, and implement the necessary interventions to prevent further skin breakdown of Resident 1's Stage 4 pressure ulcer on the sacrococcyx. This resulted in Resident 1's Stage 4 pressure ulcer on the sacrococcyx deteriorating. Resident 1 was transferred to the acute care hospital for infection of the Stage 4 sacrococcyx pressure ulcer on 9/30/19. * Resident 1 was readmitted to the facility on [DATE]. The peri-wound (skin around the wound) of Resident 1's Stage 4 pressure ulcer on the sacrococcyx had breakdown and was irritated starting 11/25/19. The facility failed to assess, measure, obtain wound treatment orders, and implement the necessary interventions to prevent further skin breakdown. This resulted in the peri-wound of the Stage 4 sacrococcyx pressure ulcer further deteriorating and developing deep tissue injury, which extended to the bilateral buttocks. Resident 1 was transferred to the acute care hospital with an infected Stage 4 pressure ulcer. In addition, the wound assessments by the licensed nurses did not match the assessments completed by the Wound Technician. * The physician's orders [REDACTED]. These failures resulted in worsening of Resident 1's pressure ulcer requiring another hospitalization . Findings: The National Pressure Ulcer Advisory Panel released definitions of pressure ulcers on (MONTH) 13, (YEAR). They are as follows: - Stage 3: full-thickness loss of skin, in which adipose (fat tissue) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible. - Stage 4: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are exposed. - Unstageable: full thickness skin and tissue loss in which the extent of tissue damage within the ulcer, cannot be confirmed because it is obscured by slough or eschar. - Deep tissue injury (DTI): intact or non-intact skin with localized area of persistent non-blanchable, deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Medical record review for Resident 1 was initiated on 12/9/19. Resident 1 was admitted to the facility on [DATE], and readmitted on ,[DATE] and 12/5/19. Review of the MDS dated [DATE], showed Resident 1 was cognitively intact. a. Review of the Admission/Readmission Nursing Data Tool dated 7/29/19, under section XIV - Pressure Ulcer Assessment showed Resident 1 was not at risk for developing a skin/pressure injury. Review of the Wound Evaluation Flow Sheet showed the date first observed was 7/30/19. The date of the first assessment was 7/31/19. This assessment showed Resident 1 had a Stage 4 sacrococcyx pressure ulcer with 5% granulation (new tissue), 5% yellow slough, and 90% necrotic tissue, measuring 8.5 cm (length) x 10 cm (width) x UTD (unable to determine) (depth). The depth was obstructed by necrosis, there was no undermining, there was a small amount of serosanguineous exudate (bloody serous fluid), and the skin color surrounding the wound was pink or normal. Review of Resident 1's Treatment Administration Record for (MONTH) 2019 showed a physician's orders [REDACTED]. Review of the Wound Evaluation Flow Sheet dated 8/19/19, showed Resident 1's sacrococcyx pressure ulcer was a Stage 4 with 10% granulation tissue, 50% yellow slough, and 40% necrotic tissue, measuring 8.5 cm x 10 cm x UTD. Review of the Wound Technician's Visit Report dated 8/19/19 at 1759 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer measured 8.5 cm x 10 cm x 0.1 cm. The Assessment Notes showed the wound was the same as the observation on 8/12/19, with 25% granulation tissue, 25% yellow slough, 25% eschar (necrotic tissue), and the Wound Technician would request a longer bed for Resident 1. Review of the Wound Technician's Visit Report dated 8/21/19 at 1908 hours, under Assessment Notes showed Resident 1's Stage 4 sacrococcyx pressure ulcer had a mild odor. The physician started an antibiotic and the wound was debrided (the dead tissue was cut away). The Assessment Notes showed Resident 1 required a Roho cushion (Roho cushion is a soft pressure relief cushion to sit on). Review of the Wound Evaluation Flow Sheet dated 9/16, 9/23, and 9/30/19, showed Resident 1 had a Stage 4 sacrococcyx pressure ulcer with 10-20% granular tissue, 30-40% yellow slough, and 50-60% necrotic tissue, measuring 8.5 cm x 9 cm x UTD. The depth of the wound was obstructed by necrosis, no undermining, there was a small amount of serosanguineous exudate, and the skin color surrounding the wound was pink or normal. Review of the Wound Technician's Visit Reports dated 9/16, 9/18, 9/23, and 9/30/19, showed Resident 1's Unstageable sacrococcyx pressure ulcer measured 8.5 cm x 9 cm x 0.1 cm with 1-25% granulation tissue, 1-25% yellow slough, and 76-100% eschar. The Assessment Notes showed the following treatment orders and recommendations for Resident 1's Unstageable sacrococcyx pressure ulcer: - On 9/9/19, Resident 1's wound had a foul odor. The Dakin's solution (treats skin/wound infections) was used and the [MEDICATION NAME] (antibiotic) topical would be added to the wound treatment; - On 9/11/19, the [MEDICATION NAME] topical would be added to the wound treatment. Resident 1 still had not received the Clinitron bed (a Clinitron bed is an air fluidized therapy bed which minimized pressure that cause tissue breakdown) and a Roho cushion; - On 9/16/19 at 1723 hours, Resident 1's wound culture was positive [MEDICAL CONDITION], and Resident 1 was on [MEDICATION NAME] (antibiotic). Resident 1's Unstageable sacrococcyx pressure ulcer had an odor, and the peri-wound had redness. [MEDICATION NAME] (treatment and prevention of skin irritation) would be added. The Treatment Notes for Stage III/IV pressure injury - Necrotic Tissues showed to apply appropriate primary cover dressing using [MEDICATION NAME] ointment, and Santyl ointment. The Wound Orders showed Resident 1 needed a wheelchair cushion (Roho cushion) and a long Clinitron bed for Resident 1's Unstageable sacrococcyx pressure ulcer. Resident 1 was unable to off load the pressure due to the right shoulder bursitis (a painful inflammation); - On 9/23/19 at 1646 hours, the Notes showed Resident 1's peri-wound treatment with antifungal cream, and the Assessment Notes showed Resident 1 was still waiting for the Clinitron bed; - On 9/30/19 at 1706 hours, the Assessment Notes showed Resident 1's sacrococcyx pressure ulcer with necrotic tissue and a foul odor that was much different than the previous odor, resident was non-compliant with turning every two hours, and Resident 1 now had a new bed. The wet necrotic tissue of Resident 1's sacrococcyx pressure ulcer was debrided, and the bone was exposed. The physician was notified, and Resident 1 was recommended to be transferred to the acute care hospital for surgical debridement and evaluation of the wound. Review of the Progress Notes showed a Skin/Wound Note entry dated 9/16/19 at 1306 hours, showing Resident 1 was seen and examined by the Wound Technician with no new order noted. Review of the Progress Notes showed a Skin/Wound Note entry dated 9/23/19 at 1137 hours, showing Resident 1 was seen and examined by the Wound Technician with no new order noted, and the peri-wound was slightly [DIAGNOSES REDACTED]tous (reddened associated with irritation). Review of the Wound Technician's Visit Notes showed the date the facility received the Wound Technician's Visit Notes as follows: - The Wound Technician saw Resident 1 and signed the Visit Note on 9/16/19 at 1723 hours; the facility received the Visit Note on 9/28/19 at 1736 hours; - The Wound Technician saw Resident 1 on 9/23/19, and signed the Visit Note on 9/25/19 at 1646 hours. The facility received the Visit Note on 10/21/19 at 1658 hours; - The Wound Technician saw Resident 1 and signed the Visit Note on 9/30/19 at 1707 hours. The facility received the Visit Note on 10/16/19 at 0940 hours. Review of Resident 1's medical record failed to show Resident 1's pressure ulcer treatment was discussed between the Wound Technician and treatment nurses, and failed to show the above recommendations for [MEDICATION NAME] ointment, [MEDICATION NAME] ointment, and antifungal cream were ordered for Resident 1's Stage 4 sacrococcyx pressure ulcer and skin area around the wound (peri-wound). Review of Resident 1's care plan failed to show the facility addressed the resident's right shoulder bursitis and the inability to offload due to pain in the right shoulder. The care plan problems addressing the resident's pressure ulcers and pain concerns showed generic interventions to identify and treat existing conditions which might increase pain and discomfort, and turn and reposition every two hours or PRN. There were no specifics regarding how to turn and reposition Resident 1 in view of the right shoulder bursitis, or how frequently the turn schedule should be changed considering the resident's right shoulder pain. Review of the acute care hospital's medical record showed Resident 1 was transferred to the acute care hospital with an infected Stage 4 sacral decubitus ulcer on 9/30/19. b. Review of the medical record showed Resident 1 was readmitted to the facility on [DATE]. Review of the Wound Evaluation Flow Sheet dated 11/13/19, showed an initial examination of Resident 1's Stage 4 sacrococcyx pressure ulcer with 80% granulation, and 20% yellow slough, measuring 8 cm x 9 cm x 5 cm. The skin color surrounding the wound was bright red, and/or blanched to the touch. Review of the Wound Evaluation Flow Sheet dated 12/2/19, showed Resident 1's Stage 4 sacrococcyx pressure ulcer measured 8 cm x 9 cm x 5 cm, and the skin color surrounding the wound was bright red, and/or blanched to touch. Review of the Wound Technician's Visit Report dated 11/20/19 at 1901 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer measured 8 cm x 9 cm x 3 cm. The Assessment Notes showed the wound had 80% granulation tissue, 20% slough, and the wound was treated with a wound vac. Under the Treatment Notes showed Sacral - Peri-wound Impaired or Altered Skin Protocol included: - If red apply appropriate product using zinc ointment; - If macerate (soft, wet, or soggy skin often associated with improper wound care) apply appropriate product using zinc ointment; - If fungus/yeast apply antifungal agents using antifungal cream; - If denuded (surface area of skin is missing) apply appropriate product using skin prep; - If dry apply appropriate product using A&D ointment. The Notes showed a Roho and longer LAL (mattress) were ordered, and the Wound Technician spoke with the case manager of the insurance company. Review of the Wound Technician's Visit Report dated 11/25/19 at 1757 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer was granulating well, some peri-wound skin irritation, would treat with skin prep and antifungal powder. The Notes showed to continue with wound vac and apply skin prep and antifungal powder to peri-wound. Review of the Wound Technician's Visit Report dated 11/27/19 at 1757 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer was debrided and the wound vac was reapplied. The Notes showed to apply appropriate primary of filler dressing using [MEDICATION NAME] gel (promotes a moisture-balanced environment conducive to wound healing). Review of the Wound Tech Multi Wound Chart Details dated 12/2/19 at 1835 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer measured 12 cm x 15 cm x 3.2 cm. The wound had 1-25% granulation, 1-25 % yellow slough, and 51-75% moist black eschar. The Assessment Notes showed the wound was worse with necrosis, increase in size and a foul odor. The resident was reported to have been in bed and had not been offloaded for two days. The bone in the wound bed was exposed, and Resident 1 was to be transferred to the acute care hospital due to wound worsening and resident was non-compliant. The Treatment Notes - Stage III/IV Pressure Injury/Moderate Drainage showed to apply appropriate primary or filler dressing using [MEDICATION NAME] gel. Review of the Wound Technician's Visit Notes showed the date the facility received the Wound Technician's Visit Notes as follows: - The Wound Technician saw Resident 1 and signed the Visit Note on 11/20/19 at 1901 hours. The facility received the Visit Note on 11/28/19 at 0925 hours; - The Wound Technician saw Resident 1 and signed the Visit Note on 11/25/19 at 1757 hours. The facility received the Visit Note on 12/2/19 at 0626 hours; - The Wound Technician saw Resident 1 on 11/27/19, and signed the Visit Note on 11/27/19 at 1846 hours. The facility received the Visit Note on 12/2/19 at 0815 hours. Review of the Progress Notes showed Skin/Wound Note entries dated 11/25 at 1837 hours, and 11/27/19 at 1615 hours, showing Resident 1 was seen and examined by the Wound Technician with no new orders. Review of the Progress Notes showed a Discharge Summary dated 12/2/19 at 1210 hours, showing Resident 1's Stage 4 sacrococcyx pressure injury's peri-wound had eschar and [DIAGNOSES REDACTED]. Resident 1 was admitted to the hospital for a recurrent infected Stage 4 sacrococcyx pressure ulcer on 12/2/19. Review of the acute care hospital's Emergency Department Record, under assessment dated [DATE] at 1445 hours, showed a large sacral pressure ulcer with a foul smell, surrounding [DIAGNOSES REDACTED], and a large amount of necrotic tissue. Review of the acute care hospital's Daily Assessment Inquiry dated 12/2/19 at 1657 hours, showed Resident 1 had a sacrum pressure ulcer Stage 4, measuring 7 cm x 6 cm x 4 cm, a right ischium (bottom of the buttock) DTI measuring 7 cm x 6 cm x UTD, and a left ischium DTI measuring 7 cm x 5 cm x UTD. Review of the acute care hospital's Daily Assessment Inquiry dated 12/5/19 at 1630 hours, showed Resident 1's Stage 4 sacrum pressure ulcer measured 7 cm x 6 cm x 4 cm, the right ischium DTI measured 7 cm x 6 cm x UTD, and the left ischium DTI measured 7 cm x 5 cm x UTD. On 12/5/19, Resident 1 was readmitted to the facility. Review of the Wound Evaluation Flow Sheet dated 12/5/19, showing an initial examination of Resident 1's Stage 4 sacrococcyx pressure ulcer showed 10% granulation, 40% yellow slough, and 50% necrotic tissue, and measuring 15 cm x 16 cm x 5.5 cm. Review of the Wound Technician's Visit Report dated 12/9/19 at 1835 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer had 26-50% granulation, 1-25 % yellow slough, and 1-25% necrotic tissue, measuring 12 cm x 15 cm x 3.2 cm. Under Treatment Notes - Stage III/IV Pressure Injury/Moderate Drainage showed to apply appropriate primary or filler dressing using Calcium Alginate, foam dressing and [MEDICATION NAME] gel. On 12/11/19 at 1135 hours, an observation and concurrent interview concerning Resident 1's sacrococcyx pressure ulcer was conducted with the Treatment Nurse. Resident 1 was observed laying on his left side. No Roho cushion was observed on Resident 1's wheelchair. The Treatment nurse was asked how she measured the wounds. The Treatment Nurse stated she measured the sacrococcyx pressure ulcer, left and right buttock skin breakdown area as one big wound. Resident 1's pressure ulcer measured 15 cm x 16 cm x 5.2 cm. Resident 1's lower sacrococcyx and left and right ischium wounds were observed with three separate wounds with three clearly distinct wound edges. The Treatment Nurse was asked to measure the three separate wounds. Resident 1's sacrococcyx Stage 4 measured 10 cm x 8 cm x 5.2 cm. The wound bed was observed with 40% granulation, 20% eschar and 40% slough. The skin area surrounding the wound was observed with [DIAGNOSES REDACTED]. Resident 1's left ischium wound measured 7 cm x 5 cm with 20% eschar, and 80% yellow and red tissue. The skin area surrounding the wound was observed macerated, with [DIAGNOSES REDACTED], and denuded. The right ischium wound measured 9 cm x 5 cm, the wound bed was observed with 100% red and yellow tissue with a small amount of yellow drainage. On 12/11/19 at 1200 hours, an interview and concurrent medical record review was conducted with the Treatment Nurse regarding Resident 1's sacrococcyx pressure ulcer and the left and right ischium DTIs. The Treatment Nurse stated she measured the wound area including the sacrococcyx, and the left and right ischium wounds together to get the total wound measurement of 15 cm x 16 cm x 5.5 cm after Resident 1's readmission from the acute care hospital on [DATE]. When the Treatment Nurse was asked about the wound assessment when Resident 1 was transferred to the hospital on [DATE], with the Stage 4 sacrococcyx measuring 8 cm x 8 cm x 5 cm, the Treatment Nurse stated she measured the sacrococcyx wound only; she did not see or might have overlooked the right and the left ischium wounds. The Treatment Nurse stated she thought the area on the right and left ischium wounds were just macerated skin, and the wound vac was on top of the wound. The Treatment Nurse was asked when she observed the skin area surrounding the wound was deteriorated. The Treatment Nurse stated she observed the peri-wound was deteriorated on Monday 12/2/19, when Resident 1 was transferred to the hospital. The Treatment Nurse stated the Wound Technician was with her when they assessed Resident 1's pressure ulcer. On 12/11/19 at 1518 hours, an interview and concurrent medical record review was conducted with RN 1 regarding Resident 1's sacrococcyx pressure ulcer. RN 1 stated she assessed Resident 1 before transferring the resident to the hospital. RN 1 stated Resident 1's Stage 4 sacrococcyx pressure ulcer with the skin area surrounding the wound extended to both buttocks, and the skin had [DIAGNOSES REDACTED] with eschar. RN 1 stated she did not measure the wound. On 12/12/19 at 1330 hours, a telephone interview and concurrent medical record review was conducted with the DON regarding the wound assessment and documentation. The DON stated the wound assessment should include the wound measurement, appearance, correct classification of the wound, accurate description of the wound, signs or symptoms of infection, whether the wound improved, physician notification of the wound, any discharge, any smell from the wound, and pain. The DON was asked how she measured the wound. The DON stated the peri-wound measurement was not included in the measurement of the wound; the peri-wound description should be under the comment section. After reviewing the Wound Technician's Visit Report and the Treatment Nurse's Wound Evaluation Flow Sheets for the months of August, September, November, and (MONTH) 2019, the DON verified the discrepancies in the wound assessments by the Wound Technician and the Treatment Nurse. The DON verified Resident 1's Wound Evaluation Flow Sheets for the months of August, September, November, and (MONTH) 2019 failed to show the peri-wound was deteriorated and when it occurred. The DON was asked how the Wound Technician ordered the wound treatment after assessing the resident. The DON stated the Wound Technician should have given the wound treatment orders after she saw the resident, and sent the Visit Report. On 12/12/19 at 1405 hours, a telephone interview and concurrent medical record review was conducted with the DON and the Treatment Nurse. The DON verified the recommendations for [MEDICATION NAME] ointment on 9/6/19, [MEDICATION NAME] on 9/11, and the antifungal on 9/25/19, had not been ordered for the resident. The Treatment Nurse was asked about the recommendations for wound treatment in the Visit Reports dated 11/25/19, and 11/27/19. The Treatment Nurse stated the Wound Technician sent the Visit Reports late, and the Wound Technician's orders or recommendations were not communicated to her; therefore, she was not aware the recommendations and the treatment orders were not changed. The DON verified the findings and stated the treatment nurse was supposed to read and verify the recommendations in the Visit Report completed by the Wound Technician, and call the physician to get the orders for wound treatment. On 12/16/19 at 0935 hours, a telephone interview and concurrent medical record review was conducted with the Wound Technician. The Wound Technician was asked about her orders and recommendations in her Visit Notes dated 8/19 and 9/19/19. The Wound Technician stated she discussed with the treatment nurse on the day she saw the resident, and put the orders in her visit notes. The Wound Technician stated the treatment nurse was supposed to call the physician to get the treatment orders, and the treatment nurse could read the visit notes and request the treatment orders for the resident. After review of Resident 1's Visit Notes dated 11/25, 11/27, and 12/2/19, and the wound photos taken by the Wound Technician on 11/25 and 12/2/19, the Wound Technician verified the skin area surrounding the wound was not measured and specifically described. The Wound Technician confirmed the wound assessments dated 11/25 and 12/2/19, had a discrepancy when it showed Resident 1 had three separate wounds, the sacrococcyx, and the left and right ischiums; however, she measured the whole skin break down area as one wound. The Wound Technician was asked if the peri-wound treatment recommendations in (MONTH) 2019 were discussed with the facility's treatment nurses. The Wound Technician stated it was the PRN order, it was not written in the physician's orders [REDACTED]. Review of all wound technician Visit Notes showed the facility did not receive the Visit Notes via fax for a week or more. The Wound Technician verified the findings and stated she dictated her Visit Note the same day she saw the resident, and her company was supposed to fax the visit notes to the facility. The Wound Technician stated he did not know why the visit notes took a long time to reach the facility. c. Review of Resident 1's Order Summary Report dated 9/27/19, showed a physician's orders [REDACTED]. Review of the medical record failed to show the order for a Roho cushion was carried out by the facility staff. On 12/19/19 at 1136 hours, a telephone interview was conducted with Resident 1. When asked about turning and repositioning in bed, Resident 1 stated he had pain to his right shoulder and could not lay long on the right side; however, he was able to stay on the left side for one hour. Resident 1 stated that was the reason he refused to turn sometimes, but he did his best to reposition. Resident 1 stated he wanted his wounds healed, he did not want to return to the acute care hospital. Resident 1 stated he got up one hour a day and had a special mattress but had a regular cushion for the wheelchair, not a gel cushion or Roho cushion. On 12/19/19 at 1323 hours, a telephone interview and concurrent medical record review was conducted with the DON. When asked about the recommendation and order for the Roho cushion, the DON stated the Wound Technician had a contract with the insurance company. The Wound Technician contacted the insurance company to get the approval for the Roho cushion for Resident 1. On 12/23/19 at 1126 hours, a telephone interview was conducted with the Wound Technician. When asked about the order and recommendation for the Roho cushion, the Wound Technician stated the Roho cushion was pending approval. The Wound Technician was asked if there was any other cushion to replace the Roho cushion. The Wound Technician stated the Roho cushion was an ultimate treatment device for the resident. The Wound Technician stated the facility did not have a case manager to follow up, and she called the insurance company herself.

Based on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services after a hip surgery for [REDACTED]. The facility failed to provide necessary hip precautions to Resident 1 when she was readmitted to the facility after a hip surgery, which resulted in a dislocation of her left hip prosthesis. This failure caused Resident 1 to be readmitted to the acute care hospital for close reduction of the left hip dislocation. In addition, the facility failed to promptly carry out a physician's orders [REDACTED]. Findings: According to the Foundations and Adult Health Nursing, fifth edition, nursing interventions after a surgery of a [MEDICAL CONDITION] included the following: - Avoid elevating the affected extremity when sitting. - The head of the patient's bed is to be elevated at maximum of 45 degrees to avoid flexion of the hip and strain on the fixation device. - Do not allow patient to cross their legs because this could adduct (cross body part over the midline) which can dislocate the hip. - Do not allow patient to abduct their legs by using an abductor pillow for 7 to 10 days following surgery to prevent dislocation of the prosthesis. Medical record review for Resident 1 was initiated on 11/8/17. Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the history and physical examination [REDACTED]. Review of the Admission/Readmission Nursing Data Tool showed Resident 1 arrived at the facility on 10/17/17 at 1800 hours, via ambulance. The entry for Musculoskeletal assessment under the section for Musculoskeletal Limitations showed none identified was checked off. The admission assessment showed Resident 1 was anxious and restless. Review of the Physician's Admitting Order form dated 10/17/17, showed an order for [REDACTED]. Review of the nurses' notes dated 10/17/17 at 1800 hours, failed to show any documentation of the hip precautions or interventions in place following the resident's left hip surgery. Review of the nurses' notes dated 10/17/17, for the night shift (2100 to 0700 hours) failed to show any hip precautions or interventions were implemented . Review of Resident 1's plan of care developed on admission failed to show any care plan problems or interventions to address any hip precautions following the resident's left hip surgery. On 11/8/17 at 1359 hours, an interview was conducted with CNA 1. CNA 1 stated she provided total assistance of one person (herself) to Resident 1 for bed mobility. CNA 1 stated Resident 1 could not understand or follow instructions. On 11/8/17 at 1417 hours, an interview was conducted with CNA 2. CNA 2 stated she did not receive any instructions regarding Resident 1 after care limitation for hip precautions. CNA 2 stated she would only turn Resident 1 to her right side. When asked how she would turn Resident 1, CNA 2 stated she would stand on Resident 1's left side and hold the resident left shoulder and lower thigh or knee area and turn the resident and then place a pillow behind her back. On 11/8/17 at 1430 hours, an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated she evaluated Resident 1 on 10/18/17 (one day after admission), and noticed Resident 1's legs were uneven (one leg was shorter than the other), and Resident 1 was screaming in pain when she was touched. The Director of Rehabilitation stated the residents who underwent this type of hip surgery should have hip precautions in place. When asked what the hip precautions were, the Director of Rehab stated the resident's affected leg should not be externally rotated, the resident could not cross their affected leg over the other or bend their hips more than 90 degrees. In addition, for the residents with poor safety awareness like Resident 1, they needed to use an abductor pillow (a wedge that is placed between the resident's legs) to prevent the resident from crossing their leg over the other to maintain proper alignment. On 11/8/17 at 1504 hours, an interview was conducted with the OT Assistant. The OT Assistant stated he was approached by the ADON on 10/18/17, regarding Resident 1's leg discrepancy. The OT Assistant stated he provided Resident 1 with an abductor pillow because Resident 1 was not compliant with the hip precautions due to poor safety awareness. The OT was asked how the staff should have turned or positioned Resident 1 in bed. The OT Assistant stated when the staff needed to turn Resident 1, they should stand on the resident's right side of the bed and log roll her (turn her trunk and legs to maintain alignment to prevent her left leg crossing over). On 11/8/17 at 1532 hours, an interview was conducted with the ADON. The ADON stated she did the admission assessment for Resident 1 on 10/17/17. The ADON stated she did not receive any instructions regarding the use of an abductor pillow and could not remember if Resident 1 had one on admission. The ADON also stated the morning of 10/18/17, when she went to administer the intravenous medication to Resident 1, she noticed the resident's leg discrepancy. The ADON stated she notified physical therapy staff right away. The ADON also stated there was no abductor pillow in between Resident 1's legs at that time. On 11/9/17 at 1134 hours, a follow-up telephone interview was conducted with the ADON. The ADON stated she was aware Resident 1 had a hip surgery; however, there were no instructions from the acute care hospital regarding hip precautions. The ADON stated the evening of 10/17/17, when Resident 1 was readmitted to the facility, she was not able to review all of the resident's discharge instructions from the acute care hospital because she was working on two admissions. The ADON stated she could not remember if she gave the instructions to the CNA to keep a pillow in between Resident 1's legs. The ADON verified there was no care plan or interventions developed to address the hip precautions. When asked if she contacted the physician to clarify or obtain an order for [REDACTED]. Review of the Physical Therapy Plan of Care dated 10/18/17, showed a discrepancy of a half an inch in length for Resident 1's left leg. The interventions included strict hip precautions. There was an entry showing a nurse to call the physician for recommended hip x-ray to rule out dislocation. Review of the Pain Assessment Flow Sheets showed Resident 1 was given [MEDICATION NAME]-[MEDICATION NAME] as needed on the following dates: - On 10/18/17 at 1600 hours, for a pain level of 7 out of 10 on the left hip. - On 10/18/17 at 2100 hours, for a pain level of 7 out of 10 on the left hip. - On 10/19/17 at 1000 hours, for a pain level of 6 out of 10 on the left hip. - On 10/20/17 at 0930 hours, for a pain level of 6 out of 10 on the left hip. - On 10/23/17 at 0000 hours, for a pain level of 6 out of 10 on the left hip. - On 10/23/17 at 1600 hours, for a pain level of 7 out of 10 on the left hip. Additional review of Resident 1's plan of care showed a care plan problem dated 10/20/17, to address a dislocation of the left hip arthroplasty. The approaches included to perform the x-ray as ordered, monitor for increased pain, log roll the resident to prevent any further dislocation and provide an appointment STAT with the orthopedic surgeon. Review of the Physician and Telephone Orders dated 10/18/17, showed an order to have a follow up appointment with the orthopedic surgeon in one week and perform the x-ray of the left hip prior to the orthopedic appointment. Review of the nurses' notes dated 10/18/17 at 1900 hours, showed x-ray of the left hip was scheduled to be done on 10/20/17 (two days later). Review of the left hip x-ray result dated 10/20/17, showed Resident 1's left hip arthroplasty was dislocated. Review of the Change of Condition form dated 10/20/17, showed the result of the x-ray taken on 10/20/17 was relayed to Resident 1's PCP; and the staff had received an order to get a STAT appointment with the orthopedic surgeon to see what kind of interventions would be necessary to repair Resident 1's left hip dislocation. Review of the Physician and Telephone Orders dated 10/20/17, showed an order for [REDACTED].>On 12/20/17 at 1422 hours, a telephone interview was conducted with the DON. The DON verified the physician's orders [REDACTED]. When asked what a STAT order meant, the DON stated it should be done right away, and if the licensed nurse could not get a STAT appointment, the resident should have been sent to the acute care hospital emergency department. The DON verified Resident 1 was not seen by the orthopedic surgeon until 10/24/17 (four days after), and from the orthopedic surgeon's office, Resident 1 was sent straight to the acute care hospital for surgical repair. Review of the acute care hospital Discharge Summary dated 11/9/17, showed Resident 1 was admitted to the acute care hospital on [DATE], and discharged back to the facility to 10/27/17, with [DIAGNOSES REDACTED].