Every finding on record at Casa Del Sol Center

Based on observation, record review, and interview, the facility failed to maintain appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 59 residents (residents were identified by the resident census list provided by the Administrator on 06/22/26). This deficient practice could likely result in residents not receiving the care and service needed while in the facility. The findings are: A. Record review of the facility's Staffing Policy dated 05/15/26, revealed the following: 1. The center will provide qualified and appropriate staff levels to meet the needs of the patient population. 2. The staffing plan will include all shifts, seven (7) days per week. 3. Staffing problems occur that is beyond the charge nurse's or department supervisor's authority, or should a staffing problem occur that cannot be resolved, the charge nurse or supervisor must notify the DON and/or the Administrator/designee. B. On 06/22/26 at 12:53 PM, during an interview R #43 stated she has to wait a long time for staff to come and sometimes they don't come at all. R #43 stated especially at night by the time they get to her she is soaking wet. The sheets get wet and the staff have to change the bed. C. On 06/22/26 at 1:44 PM, during an interview R #4 stated that it takes the staff a long time to answer call lights. R #4 stated that there wasn't anyone on the floor to help him yesterday. D. On 06/23/26 at 9:56 AM, during an interview R #7 stated the staff don't like the 12-hour shifts they call in a lot. It takes up to 30 minutes to get his call light answered. E. 06/23/26 at 9:28 AM, during an interview R #14 stated that he has had diarrhea three times after eating the food. R #14 said that he put his call light on last night and no one came, and he had to change himself. R #14 said that nights are worse, and they never answer the call lights. F. On 06/23/26 at 10:48 AM, during an interview with R #47 stated he has long wait times for is roommate. R #47 stated it's up to three hour wait times if they are really short staffed. G. On 06/23/26 at 10:55 AM, during an observation R #29 waited over one hour to be assisted to go to bed. H. On 06/23/26 at 12:51 PM, during an observation and interview revealed the following: 1. R #3 was sitting in her wheelchair in the doorway of her room. 2. R #3 stated that she needed to be changed because she was wet. 3. R #3 stated she had been waiting for approximately 10 minutes already. 4. R #3 stated she doesn't want to press the call light because no one will come so she will wait in the hallway. 5. R #3 did press the call light and said she would wait in the hallway. 6. CNA #24 told R #3 that she is assigned to work in another hall, and she is only helping to pass out room trays and is unable to assist her at this time. 7. At 12:59 PM, CNA #25 turned light off in R #3's room. CNA #24 told R #3 that CNA #25 would help her. 8. CNA #26 told R #3 they will change her, but they are just busy at the moment. 9. At 1:02 PM, CNA #25 took R #3 into her room to assist her in changing. I. 06/23/2026 at 2:01 PM, during an interview with R #59 stated at night she has to wait a long time to be changed. R #59 stated it makes her feel aggravated when they don't come to help her. J. On 06/23/26 at 2:12 PM, during an interview with R #52 stated the facility is always short staffed on weekends. Sometimes more than half an hour wait times. K. On 06/24/26 at 11:39 AM, during an interview, with R #8 family member she stated, I think they don't have enough help, like when my sister needs to be toileted and they tell her to go in her brief instead of helping her. I understand they can't drop everything to go help her but maybe if they had more than one helper (CNA) they could help her be toileted. L. Record review of the facility's staffing timecard log dated 05/24/26-06/14/26 revealed the following: 1. On 05/26/26 for the shift 6:00 AM-6:00 PM there were three (3) CNA's working. 2. On 05/28/26 for the shift 6:00 AM-6:00 PM there were two (2) CNA's on the floor, 1 CNA was shadowing, and 1 CNA was providing one-on-one care for a resident. 3. On 06/04/26 for the shift 6:00 AM-6:00 PM there were two (2) CNA's working. 4. On 06/07/26 for the shift 6:00 AM-6:00 PM there were three (3) CNA's working. M. On 06/25/26 at 10:31 AM, during an interview with CNA #25 she stated she goes in early sometimes to help. The PPE that the DON has the staff wearing takes too much time, and residents get upset because they are already waiting for a while. The staff have to put on the PPE just to go in the room with EBP (Enhanced Barrier Precautions) doesn't make sense if they just passing meal trays or answering the call light. The nurses help when they can, but they are busy too. N. On 06/25/26 at 11:42 AM, during an interview with RN #24 she stated that they are short-staffed with CNA's. It's not all the time but when they are they feel it. Especially now that they have to put on PPE to go in residents' room with EBP. It takes time to put on if it's just for a remote or something simple. RN #24 stated she helps as much as she can but that when she's passing meds it's hard because she doesn't want to make a medication error. O. On 06/29/26 at 11:29 AM, during an interview with CNA #26 he stated there is not enough staff to take care of the residents. They pull the restorative CNA a lot to help, and sometimes there's only two of us and we need at least four staff. P. On 06/30/26 at 9:44 AM, during an interview the Scheduler stated she is in charge of Scheduling, Payroll, and Human Resources. The Scheduler stated she does not look at residents' needs just fills in where the holes are. It depends on the Census. The Scheduler stated she does not staff based on acuity (refers to the sharpness, severity, or intensity of a patient's condition or a sensory perception, guiding the level of care required). She stated she does not know how staff based on acuity. She was not trained. Q. On 06/30/26 at 9:44 AM, during an interview the Unit Manager stated the Scheduler needs training she was not trained on how to schedule staff per resident acuity. She does not know how to do it. Unit Manager's expectation is to have the Scheduler trained to understand resident acuity. R. On 06/30/26 at 11:06 AM, during an interview the DON confirmed the following: 1. The DON's expectation for staffing is to be fully staffed from 6:00 AM to 6:00 PM the staff needed are four (4) CNA's, one (1) CMA, one (1) Shower Aide, one (1) Restorative Aide, and two (2) nurses. 2. To be fully staffed from 6:00 PM to 6:00 AM the staff needed are three (3) CNA's and two (2) full nurses. One (1) Wound Nurse, one (1) Unit Manager Nurse.

Based on observation, record review and interview, the facility failed to provide clarification on Enhanced Barrier Precautions training (EBP) (is infection control measures using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms (MDROs) in nursing homes and long-term care facilities) for 4 (CNA #24, CNA #25, CNA #26, and CNA #27) of 4 (CNA #24, CNA #25, CNA #26, and CNA #27) staff sampled for staff training, when the facility failed to train staff on the new expectations to wear PPE for EBP above the training requirements causing confusion about when to wear PPE. This deficient practice could likely result in inadequate infection control, and can lead to increased spread of resistant organisms, and risk of infections among residents and staff if staff do not know what to do. The findings are: A. Record review of the facility's EBP policy, dated 11/14/25, revealed the following: 1. Infection control interventions designed to reduce the transmission of novel or multi-drug-resistant organisms. 2. EBP employs targeted personal protective equipment (PPE) during high contact patient activities. 3. All staff receive training on high-risk activities and organisms that require EBP. B. Record review of staff training records revealed the following: 1. CNA #24 completed EBP training on 04/08/26 online. 2. CNA #25 completed EBP training on 04/10/26 online. 3. CNA #26 completed EBP training on 04/08/26 online. 4. CNA #27 completed EBP training on 04/08/26 online. C. On 06/29/26 at 2:15 PM, during an interview for CNA #24 stated the following: 1. CNA #24 follows what the IP and DON tell him to for residents' who have a sign of EBP on their door. 2. CNA #24 uses PPE at all times when entering a resident room with EBP. 3. CNA #24 stated there are signs on the residents' doors before you enter to use EBP for higher care. 4. The DON wants all staff to were PPE for all residents with the sign EBP even if it's not higher contact care like dressing, showering, transferring, toileting, changing residents. D. On 06/23/26 at 10:41 AM, during an observation, and interview of hallway 100 revealed the following: 1. Laundry supervisor walked into a resident's room who had a sign of EBP on his door. 2. Laundry supervisor did not put PPE to pass laundry to the resident. 3. The DON stated to him he had to wear PPE for all residents' rooms who have EBP. 4. Laundry supervisor stated he just got back from leave and was not told anything about EBP. E. 06/23/26 at 12:27 PM, during an observation of hallway 100 revealed the following: 1. The room trays were being delivered to resident rooms. 2. Staff are putting PPE on to pass trays. 3. Staff took seven (7) minutes to don, doff, and use hand hygiene to pass one tray to R #7. F. On 06/29/26 at 2:36 PM, during an interview the RN #27 stated the following: 1. The DON and IP want the staff to use PPE in all EBP rooms regardless of the type of care staff are providing. 2. It takes time from actual resident care; had to wear during medication pass. 3. The CNA's have to wear when passing meal trays in residents' rooms who have EBP. G. On 06/29/26 at 1:52 PM, during an interview, the Infection Prevention Nurse (IPN) stated the following: 1. Everyone needs to use the PPE in all rooms that have signs of EBP at all times per the DON. 2. The DON wants IPN to get the staff used to putting PPE in every room with EBP even if they are not providing higher care. 3.The staff have not been trained on the DON's new expectations for EBP. H. On 07/01/26 at 10:20 AM, during an interview, the DON confirmed her expectation is that the staff use PPE in rooms with signs of EBP even if staff are not providing high contact care. I. On 07/01/26 at10:43 AM, during an interview with the Corporate Nurse Educator (CNE), stated she will have the EBP online for staff. Staff have not completed this curriculum. CNE stated she will implement this curriculum moving forward.

Based on observation, interview, and record review, the facility failed to ensure residents and/or their representatives were informed in advance of medication changes and understood the reasons, risks, and benefits of the medications for 4 (R #3, R #7, R #8 and R #10) of 5 (R #3, R #7, R #8, R #9 and R #10) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding resident's care. The findings are: A. Record review of the Behaviors: Management of Symptoms Policy, revision date 09/15/25, revealed Obtain consent when medication is ordered for behavioral symptoms. R #3 B. Record review of R #3's Face sheet revealed the following: 1. An admission date of 05/16/26. 2. The following diagnosis: a. Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition characterized by a decline in cognitive function, such as memory loss and impaired reasoning, without a clearly identified cause or specific type of dementia (e.g., Alzheimer's disease, vascular dementia). b. Depression, unspecified (a diagnosis used when depressive symptoms cause significant distress or impairment but do not meet the full criteria for a specific depressive disorder). c. Anxiety disorder, unspecified (a diagnosis for clinically significant anxiety that causes distress or impairment but does not meet the full criteria for any specific anxiety disorder). d. Delirium due to known physiological condition (a serious change in mental abilities that develops rapidly, typically over hours to days, and is characterized by confused thinking, reduced awareness of the environment, disorientation, hallucinations, and fluctuating cognitive function such as attention, memory, and perception). C. On 06/22/26 at 8:35 AM, during an observation of R #3 she was lying in bed and was conversing about how good breakfast was. D. Record review of R #3 physician's orders revealed the following: 1. An order dated 05/17/26 for Risperidone (an antipsychotic medicine that works by changing the effects of chemicals in the brain) oral tablet 1 mg give 1 tablet by mouth one time a day for delirium due to known physiological condition. Order discontinued on 05/21/26. 2. An order dated 05/22/26 for Risperidone (an antipsychotic medicine that works by changing the effects of chemicals in the brain) oral tablet 1 mg give 1 tablet by mouth one time a day for delirium due to known physiological condition. Order discontinued on 06/08/26. E. Record review of R #3's MAR for May 2026 revealed the following: 1. R #3 received Risperidone oral tablet 1 mg 1 tablet for the following dates: a. 05/17/26, b. 05/18/26, c. 05/19/26, d. 05/20/26, e. 05/21/26, f. 05/22/26, g. 05/23/26, h. 05/24/26, i. 05/25/26, j. 05/26/26, k. 05/27/26, l. 05/28/26, m. 05/29/26, n. 05/30/26 o. 05/31/26. F. Record review of R #3's MAR for June 2026 revealed the following: 1. R #3 received Risperidone oral tablet 1 mg 1 tablet for the following dates: a. 06/01/26, b. 06/02/26, c. 06/03/26, d. 06/04/26, e. 06/05/26, f. 06/06/26, g. 06/07/26, h. 06/08/26. G. Record review of R #3's medical record revealed staff did not document a consent for R #3's Risperidone 1 mg. H. On 06/29/26 at 9:40 AM, during an interview the Unit Manager confirmed the following: 1. Staff did not complete R #3's consent form for Risperidone 1 mg. 2. Consent forms should have been signed within 7 days of R #3 being admitted to the facility. R #7 I. Record review of R #7's Administration Record, no date revealed the following: 1. An admission date of 06/17/25. 2. The following diagnosis: a. Post-Traumatic Stress Disorder, unspecified (a trauma-related anxiety disorder where symptoms of PTSD are present but do not fully meet the criteria for a specific PTSD diagnosis.) b. Other Psychoactive Substance Abuse, uncomplicated (refers to the misuse of psychoactive substances without significant physical or mental health complications). c. Anxiety disorder, unspecified (a diagnosis for clinically significant anxiety that causes distress or impairment but does not meet the full criteria for any specific anxiety disorder). d. Somatoform disorder, unspecified (a psychiatric condition characterized by physical symptoms that suggest a medical illness but cannot be fully explained by any known medical condition, substance use, or other mental disorder, causing significant distress or impairment). e. Schizophrenia, unspecified (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking). f. Bipolar disorder, unspecified (a characterized by significant mood changes that do not fully meet the criteria for other specific types of bipolar disorder yet still cause distress and impairment in daily functioning). J. On 06/22/26 at 9:17 AM, during an observation, R #7 was in his room walking around and talking to his roommate. K. Record review of R #7 physician's orders revealed the following: 1. An order dated 06/25/25 for Clonazepam (medication that treats seizures and also treats panic disorder) Oral tablet 1 mg give 1 tablet by mouth every 8 hours as needed for anxiety. 2. An order dated 05/21/26 for Lurasidone HCl (an atypical antipsychotic used to treat schizophrenia and bipolar depression) Oral Tablet 60 mg give 1 tablet by mouth one time a day for bipolar disorder. L. Record review of R #7's MAR for June 2026 revealed the following: 1. Staff documented that R #7 received Clonazepam Oral tablet 1 mg for the following dates: a. 06/16/26, b. 06/17/26, c. 06/18/26, d. 06/19/26, e. 06/20/26, f. 06/21/26, g. 06/23/26, h. 06/24/26. 2. Staff documented that R #7 received Lurasidone HCl 60 mg on the following dates: a. 06/01/26, b. 06/02/26, c. 06/03/26, d. 06/04/26, e. 06/05/26, f. 06/06/26, g. 06/07/26, h. 06/08/26. i. 06/09/26, j. 06/10/26, k. 06/11/26, l. 06/12/26, m. 06/13/26, n. 06/14/26, o. 06/15/26, p. 06/16/26, q. 06/17/26, r. 06/18/26, s. 06/19/26, t. 06/20/26, u. 06/21/26, v. 06/22/26, w. 06/23/26. M. Record review of R #7's medical record revealed staff did not document a consent for: 1. Clonazepam oral tablet 1 mg or 2. Lurasidone HCl oral Tablet 60 mg. N. On 06/29/26 at 9:47 AM, during an interview the Unit Manager confirmed the following: 1. Staff did not complete R #7's consent form for Lurasidone or Clonazepam. 2. Consent for medications is completed when residents are admitted to the facility, and when there are changes. O. On 06/30/26 at 11:54 AM, during an interview with the DON she stated her expectation is that the staff complete consent forms for medications. R #8 P. Record review of R #8's Face Sheet, no date revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8's diagnosis included the following: a. Unspecified dementia, unspecified severity (indicates that the specific type or cause of dementia has not been determined, and the severity is also not specified) with agitation (refers to an unpleasant state of extreme arousal, where a person may feel restless, irritable, nervous, or emotionally excited). b. Anxiety disorder unspecified (mental health diagnosis used when a person exhibits anxiety symptoms that cause significant distress or impairment in daily functioning, but these symptoms do not align completely with recognized disorders) Q. Record review of R #8's physician's orders revealed the following: 1. An order dated 05/13/26 for hydroxyzine (medication primarily used to treat anxiety disorders) give 50 mg by mouth every 8 hours as needed for increased anxiety. 2. An order dated 06/07/26 for lorazepam (medication primarily used to treat anxiety disorders) 0.5 mg give 1 tablet by mouth every 4 hours as needed for increased anxiety. 3. An order dated 06/13/26 for sertraline (medication primarily used to treat depression and anxiety disorders) give 100 mg by mouth in the morning for anxiety. Q. Record review of R #8's consent forms revealed staff did not document a consent form for hydroxyzine, lorazepam or sertraline. R. On 06/30/26 at 3:10 PM, during an interview with the Unit Manager the following was confirmed: 1. The nurse is supposed to complete the consent form. 2. The resident or their representative sign it before the medications are started. 3. R #8 did not have a consent form on file for hydroxyzine, lorazepam or sertraline. R #9 S. Record review of R #9's Administration Record, no date revealed the following: 1. An admission date of 06/30/22. 2. The following diagnosis: a. Type 2 Diabetes Mellitus without complications (a chronic disease characterized by high levels of sugar in the blood). b. Left bundle-branch block, unspecified (a cardiac conduction abnormality in which electrical impulses are delayed or blocked in the left bundle branch, causing the left ventricle to contract later than the right ventricle). c. Essential (primary) Hypertension (a chronically elevated blood pressure without a specific identifiable cause, typically developing gradually over time). d. Retention of urine, unspecified (a condition where the bladder does not empty completely or at all. This can be caused by various factors, including blockages, medications, or nerve issues). e. Chronic kidney disease, Stage 3 unspecified (a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). T. On 06/22/26 at 10:16 AM, during an observation of R #9 revealed he was wheeling himself in his wheelchair down the hallway. He was conversating about going to therapy. U. Record review of R #9 physician's orders revealed the following: 1. An order dated 06/25/25 for Mirtazapine (a medication used to treat major depressive disorder) oral tablet give 7.5 mg by mouth one time a day for Depression. V. Record review of R #9's MAR for April 2026 revealed the following: 1. Staff documented that R #9 received 1 tablet of Mirtazapine 7.5 mg at 8:00 AM every day from 04/01/26 -04/30/26. W. Record review of R #9's MAR for May 2026 revealed the following: 1. Staff documented that R #9 received 1 tablet of Mirtazapine 7.5 mg at 8:00 AM every day from 05/01/26 – 05/31/26. X. Record review of R #9's MAR for June 2026 revealed the following: 1. Staff documented that R #9 received 1 tablet of Mirtazapine 7.5 mg at 8:00 AM every day from 06/01/26 – 06/24/26. Y. On 06/29/26 at 10:01 AM, during an interview the Unit Manager confirmed that Staff did not complete R #9's consent form for Mirtazapine. R #10 Z. Record review of R #10's medical record revealed the following: 1. R #10 was admitted on [DATE] 2. R #10 had the following diagnosis: a. Anxiety. b. Major depressive disorder. c. Dementia AA. On 06/26/26 at 10:36 AM, during an observation of R #10's room, revealed R #10 to be blissfully unaware. BB. Record review of R #10's physician's orders revealed the following: 1. An order dated 06/20/26 for lorazepam (treat anxiety disorders, short-term anxiety symptoms, and anxiety-associated insomnia) oral concentrate 2 mg, give by mouth as needed for anxiety. 2. An order dated 06/20/26 for lorazepam oral concentrate 2 mg, give by mouth at bedtime for anxiety. CC. Record review of R #10's medical record no date revealed staff did not document a consent form for lorazepam. DD. On 06/30/26 at 1:16 PM, during an interview, the ADON could not provide a consent for R #10's lorazepam.

Based on observation, interview and record review, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 5 (R #3, R #7, R #8, R #9 and R #10) of 5 (R #3, R #7, R #8, R #9, and R #10) residents reviewed for unnecessary medications, when staff failed to: Complete Abnormal Involuntary Movement Scale (AIMS) for R #3, R #7, and R #9. Ensure that psychotropic medications ordered to be given as needed (PRN) were not prescribed for longer than 14 days without documentation of the rationale to extend beyond 14 days in the resident's medical record including an indication for the duration of the PRN order for R #8 and R #10. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of the Medication Monitoring Policy, dated 01/26, revealed PRN orders for psychotropic drugs are limited to 14 days unless a rationale is documented in the resident's medical record. B. Record review of the Behaviors: Management of Symptoms Policy, revision date 09/15/25, revealed the following: 1. Complete the Abnormal Involuntary Movement Scale (AIMS) for residents receiving antipsychotic medications. AIMS R #3 C. Record review of R #3's Administration Record revealed the following: 1. An admission date of 05/16/26. 2. The following diagnosis: a. Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition characterized by a decline in cognitive function, such as memory loss and impaired reasoning, without a clearly identified cause or specific type of dementia (e.g., Alzheimer's disease, vascular dementia). b. Depression, unspecified (a diagnosis used when depressive symptoms cause significant distress or impairment but do not meet the full criteria for a specific depressive disorder). c. Anxiety disorder, unspecified (a diagnosis for clinically significant anxiety that causes distress or impairment but does not meet the full criteria for any specific anxiety disorder). d. Delirium due to known physiological condition (a serious change in mental abilities that develops rapidly, typically over hours to days, and is characterized by confused thinking, reduced awareness of the environment, disorientation, hallucinations, and fluctuating cognitive function such as attention, memory, and perception). D. On 06/22/26 at 8:35 AM, during an observation of R #3 in her room revealed she was lying in bed. R #3 was conversing about breakfast. E. Record review of R #3 physician's orders revealed the following: 1. An order dated 05/17/26 for Risperidone (an antipsychotic medicine that works by changing the effects of chemicals in the brain) oral tablet 1 mg give 1 tablet by mouth one time a day for delirium due to known physiological condition. Order discontinued on 05/21/26. 2. An order dated 05/22/26 for Risperidone (an antipsychotic medicine that works by changing the effects of chemicals in the brain) oral tablet 1 mg give 1 tablet by mouth one time a day for delirium due to known physiological condition. Order discontinued on 06/08/26. F. Record review of R #3's medical record revealed staff did not document an AIMS review. G. On 06/29/26 at 9:40 AM, during an interview, the Unit Manager confirmed the following: 1. Staff did not complete an AIMS for R #3. 2. Her expectation is that the staff complete the required AIMS assessment every 3 months. R #7 H. Record review of R #7's Administration Record, no date revealed the following: 1. An admission date of 06/17/25. 2. The following diagnosis: a. Post-Traumatic Stress Disorder, unspecified (a trauma-related anxiety disorder where symptoms of PTSD are present but do not fully meet the criteria for a specific PTSD diagnosis.) b. Other Psychoactive Substance Abuse, uncomplicated (refers to the misuse of psychoactive substances without significant physical or mental health complications). c. Anxiety disorder, unspecified (a diagnosis for clinically significant anxiety that causes distress or impairment but does not meet the full criteria for any specific anxiety disorder). d. Somatoform disorder, unspecified (a psychiatric condition characterized by physical symptoms that suggest a medical illness but cannot be fully explained by any known medical condition, substance use, or other mental disorder, causing significant distress or impairment). e. Schizophrenia, unspecified (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking). f. Bipolar disorder, unspecified (a characterized by significant mood changes that do not fully meet the criteria for other specific types of bipolar disorder yet still cause distress and impairment in daily functioning). I. On 06/22/26 at 9:17 AM, during an observation, R #7 was in his room walking around. He was talking to his roommate. J. Record review of R #7 physician's orders revealed the following: 1. An order dated 06/25/25 for Clonazepam (a medication that treats seizures and also treat panic disorder) Oral tablet 1 mg give 1 tablet by mouth every 8 hours as needed for anxiety. K. Record review of R #7's AIMS dated 12/31/25 revealed staff completed the assessment. L. Record review of R #7's medical record revealed staff did not document any other AIMS. M. On 06/30/26 at 11:54 AM, during an interview the DON stated the AIMS assessment is to be completed by staff when there are changes to medications and completed quarterly thereafter. R #9 N. Record review of R #9's Administration Record, no date revealed the following: 1. An admission date of 06/30/22. 2. The following diagnosis: a. Type 2 Diabetes Mellitus without complications (a chronic disease characterized by high levels of sugar in the blood). b. Left bundle-branch block, unspecified (a cardiac conduction abnormality in which electrical impulses are delayed or blocked in the left bundle branch, causing the left ventricle to contract later than the right ventricle). c. Essential (primary) Hypertension (a chronically elevated blood pressure without a specific identifiable cause, typically developing gradually over time). d. Retention of urine, unspecified (a condition where the bladder does not empty completely or at all. This can be caused by various factors, including blockages, medications, or nerve issues). e. Chronic kidney disease, Stage 3 unspecified (a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). O. On 06/22/26 at 10:16 AM, during an observation of R #9 revealed he was wheeling himself in his wheelchair down the hallway. He was conversating about going the therapy. P. Record review of R #9 physicians orders revealed the following: 1. An order dated 06/25/25 for Mirtazapine (a medication used to treat major depressive disorder) oral tablet give 7.5 mg by mouth one time a day for Depression. Q. Record review of R #9's AIMS dated 03/02/26 revealed staff completed the assessment. R. Record review of R #9's medical record revealed staff did not document any other AIMS. S. On 06/29/26 at 10:01 AM, during an interview the Unit Manager stated that she didn't see R #9's record where the was an AIMS assessment done recently. AIMS should be done every 3 months and his last AIMS was 03/02/26. T. On 06/29/26 at 10:01 AM, during an interview the Unit Manager stated 1. Staff did not complete an AIMS for R #9. 2. Her expectation is that the staff complete the required AIMS assessment every 3 months. PRN psychotropic medications R #8 U. Record review of R #8's Face Sheet, no date revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8's diagnosis included the following: a. Unspecified dementia, unspecified severity (indicates that the specific type or cause of dementia has not been determined, and the severity is also not specified) with agitation (refers to an unpleasant state of extreme arousal, where a person may feel restless, irritable, nervous, or emotionally excited). b. Anxiety disorder unspecified (mental health diagnosis used when a person exhibits anxiety symptoms that cause significant distress or impairment in daily functioning, but these symptoms do not align completely with recognized disorders) V. On 06/26/26 at 2:20 PM R #8 was observed in the dining room listening to musical guest, R #8 appeared happy and was waving her arms around to the music. W. Record review of R #8's physician's orders revealed the following: 1. An order dated 05/13/26 for hydroxyzine (medication primarily used to treat anxiety) oral tablet, give 50 mg by mouth every eight hours as needed for increased anxiety, the order did not have an end date. 2. An order dated 06/13/26 for lorazepam (medication primarily used to treat anxiety) oral tablet 0.5 mg, give 1 tablet by mouth every four hours as needed for anxiety, the order did not have an end date. X. Record review of R #8's medical record, no date, revealed the record did not have any documentation regarding the duration or rationale for R #8's hydroxyzine and lorazepam PRN orders. Y. On 06/30/26 at 3:10 PM, during an interview, the Unit Manager confirmed the following: 1. R #8's orders for PRN hydroxyzine and lorazepam did not have an end date. 2. The orders should be entered for 14 days duration. 3. The provider did not document a rationale to extend beyond 14 days for R #8's PRN hydroxyzine and lorazepam orders. R #10 Z. Record review of R #10's admission record, no date revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 has the diagnosis of anxiety. AA. On 06/26/26 at 10:36 AM, during an observation of R #10's room, revealed R #10 to be blissfully unaware. BB. Record review of R #10's physician's order, dated 06/20/26, revealed an order for lorazepam oral concentrate 2 mg/ml, give 0.5 ml by mouth PRN for anxiety. CC. Record review of R #10's MAR, dated June 2026, revealed staff documented giving R #10 Lorazepam 0.5 mg PRN on 06/22/26 and 06/23/26. DD. Record review of R #10's medical record, no date, revealed staff did not document the following: 1. A rationale in R #10's medical record to extend the Lorazepam prn beyond 14 days. 2. The duration for the Lorazepam PRN. EE. On 06/24/26 at 3:06 PM, during an interview, the ADON confirmed that there was no end date for R #10's PRN lorazepam.

Based on observation, record review and interview, the facility failed to ensure that the comprehensive care plans are reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for 4 (R #1, R #9, R #59 and R #66) of 9 (R #1, R #2, R #5, R #9, R #11, R #29, R #59, R #66 and R #88) residents reviewed for care plan accuracy and timing when staff failed to: 1. Revise R #1's and R #9's care plan with the most current resident information. 2. Ensure R #59's and R #66's interdisciplinary team care plan conference was held within seven days of the completion of the MDS. This deficient practice could likely result in staff being unaware of the actual needs of the residents', changes in care provided and residents not receiving the care related to their current health care status. The findings are: A. Record review of Care Plans Policy dated 09/15/25 revealed The center must develop and implement a person-centered care plan for each resident consistent with Residents Rights measurable objectives and timeframes to meet a residents' medical, nursing and mental, psychosocial needs and all services that meet professional standards of care. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Revisions R #1 B. Record review of R #1's Face Sheet no date revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1's diagnosis included hemiplegia (complete paralysis of one side of the body) and hemiparesis (indicates partial weakness on one side of the body) following cerebral infarction (stroke; which occurs due to blockage of blood flow to the brain) affecting right dominant side (affecting the side of a right-handed person). C. On 06/23/26 at 12:56 PM, during an interview and observation of R #1, the following was revealed: 1. R #1 stated she cannot move her right hand. 2. R #1 stated she is supposed to wear a splint on her right hand, but she has not worn it in a few months (cannot remember the exact timeframe) because she does not know where it is. 3. R #1's right hand was closed into a fist. She had to use her left hand to move her right hand and fingers. D. Record review of R #1's Occupational Therapy (OT; focuses on enabling people to engage in everyday occupations of life, which include self-care activities such as dressing, bathing, and preparing food) Evaluation dated 01/28/26 revealed the following: 1. Musculoskeletal system assessment (body's network of bones, muscles, tendons, essential for giving the human body its shape, maintaining stability, and enabling movement). a. Contracture (condition in which muscles, tendons, ligaments, or skin become permanently shortened and stiff, limiting joint movement and flexibility): functional limitations requiring orthotic (specialized external devices used to support, align, protect, or assist movement in a person's body) intervention: right wrist and hand. b. Current orthotic device: resting hand splint (designed to hold the hand, wrist, and fingers in a functional or neutral position, reducing pain, swelling, and abnormal muscle tone, particularly in neurological conditions like stroke). E. On 06/30/26 at 10:35 AM during an interview with CNA #1 the following was revealed: 1. R #1 did have a hand splint, but it has been missing for approximately 2 months. 2. R #1 was good at keeping the splint on, she did not complain about using it. F. On 06/30/26 at 1:54 PM and 2:22 PM during an interview with OT #1 the following was revealed: 1. R #1 did have a hand splint that was in place based on the OT evaluation dated 01/28/26. 2. He would prefer that the resident does wear the hand splint. 3. OT stated that staff had found R #1's hand splint in her room. 4. He will develop the therapy plan for R #1 to start using the splint again. G. Record review of R #1 care plan revision date 03/03/26 revealed that facility staff did not revise care plan to reflect application of R #1's hand splint. H. On 06/30/26 at 2:44 PM, during an interview with the Unit Manager the following was confirmed: 1. R #1 did have a splint that was being used for her right hand. 2. R #1's care plan should have been revised to include the use of the hand splint so that the nursing staff are aware. R #9 I. Record review of R #9's Face Sheet, no date revealed the following: 1. R #9 was admitted on [DATE]. 2. The following diagnosis: a. Type 2 Diabetes Mellitus without complications (a chronic disease characterized by high levels of sugar in the blood). b. Left bundle-branch block, unspecified (a cardiac conduction abnormality in which electrical impulses are delayed or blocked in the left bundle branch, causing the left ventricle to contract later than the right ventricle). c. Essential (primary) Hypertension (a chronically elevated blood pressure without a specific identifiable cause, typically developing gradually over time). d. Retention of urine, unspecified (a condition where the bladder does not empty completely or at all. This can be caused by various factors, including blockages, medications, or nerve issues). e. Chronic kidney disease, Stage 3 unspecified (a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). J. On 06/24/26 at 9:54 AM, during an interview and observation of the R #9's lower legs revealed the following: 1. R #9's lower legs were swollen from the knees to R #9's feet with no ace wraps or hose on his legs. 2. R #9 stated he doesn't take medication for his edema (a condition characterized by swelling in the legs due to fluid buildup in the tissues, often referred to as peripheral edema in his legs). 3. R #9 stated he did not like to use the ace wraps or hose. He refuses to wear them all the time. K. Record review of R #9 TAR for the month of June 2026, revealed an order dated 12/09/22 for may apply stockinette (a soft, loosely knitted stretch fabric, formerly used for making underwear and now used for cleaning, wrapping, or bandaging) then applying ace wraps from foot to 2-3 below the knee daily and off in the evening/night one time a day for lower legs and remove per schedule. L. Record review of R #9 care plan revision date 03/28/26 revealed the following: 1. Staff did not revise care plan to reflect application of stockinette then applying ace wraps from foot to 2-3 below the knee daily and off in the evening/night one time a day for lower legs and remove per schedule. 2. Staff did not revise care plan to reflect R #9's interventions for refusals when applying stockinette ace wraps on R #9. M. On 06/29/26 at 3:15 PM during an interview with the Unit Manager she stated the following: 1. R #9's refuses treatment often. 2. Staff did not document on R #9's care plan his refusal to wear the stockinettes and ace wraps. 3. Her expectation is that refusal and encouragement for treatment are inputted into the care plan. Timing R #59 N. Record review of R #59's Face Sheet, no date, revealed the following: 1. R #59 was admitted to the facility on [DATE]. 2. R #59 had the following diagnosis: a. Fibromyalgia. b. Morbid Obesity. c. Depression. d. Cognitive communication deficit. O. Record review of R #59's annual MDS, dated [DATE], revealed the MDS was completed on 06/02/26. P. On 06/23/2026 at 2:03 PM, during an interview and observation, R #59 stated they staff do not let her know when her care plan meetings are. Q. Record review of R #59's social services progress note, dated 05/21/26, revealed the SSD sent a care plan conference invitation to R #59's family. The SSD did not receive a response. R. On 06/30/26 at 2:03 PM, during an interview, the SSD stated that R #59 does not like to attend her care plan conferences. The SSD stated that he did not get a response from R #59's family regarding the scheduled conference. The SSD stated that he was planning on rescheduling the conference but had not scheduled it yet. The SSD confirmed that the care plan conference should be held within seven days of the MDS completion. The SSD confirmed that R #59's care plan conference was not completed within 7 days of the MDS completion. R #66 S. Record review of R #66 Face Sheet no date revealed the following: 1. R #66 was admitted to the facility on [DATE]. 2. R #66's primary diagnosis: displaced intertrochanteric fracture of the left femur (a common type of hip fracture that typically requires surgical intervention for proper healing and recovery). T. Record review of R #66's admission MDS, dated [DATE], revealed the MDS was completed (signed off by RN) on 06/19/26. U. On 06/23/26 at 9:50 AM, during an interview and observation, R #66 was lying in bed and stated that she has not had a meeting with the doctor or staff regarding her care plan and when she will go home. V. Record review of R #66's social services progress notes revealed staff did not document regarding R #66's care plan conference. W. On 06/30/26 at 11:03 AM, during an interview with the Social Services Director, he confirmed that R #66 had not had a care plan conference completed within 7 days of the completion of her admission MDS.

Based on observation, record review, and interview, the facility failed to follow professional standards of practice for not caring out physician's orders for 1 (R #11) of 2 (R #11 and R #66) residents reviewed for resident-to-resident interaction. This deficient practice could likely result in residents not receiving necessary care or worsening of their medical conditions. The findings are: A. Record review of facility's Physician/Advanced Practice Orders Policy dated 02/24/25, revealed the following: 1. Telephone orders are reviewed by phone and a practitioner who may or may not be in the center and are an adapted standard of practice. An order received by phone by a practitioner who is in the center is considered a telephone order. 2. Orders must be entered into the electronic or management system. All orders must be signed by an authorized, credential physician or other authorized practitioner in accordance with state regulations prescriptive privileges. B. Record review of R #11's Face Sheet, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 diagnosis included major depressive disorder recurrent severe with psychotic symptoms (a serious mental health condition characterized by repeated episodes of major depression accompanied by hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch and taste) or delusions delusion is a false belief or opinion, especially one held in resistance to strong evidence against it). C. On 06/24/26 at 10:47 AM, during an interview and observation of R #11 the following was revealed R #11 was sitting on her bed and was in good spirits. D. Record review of R #11's progress notes revealed the following: 1. A practitioner note dated 06/25/26: .pt (patient) took her last dose of antibiotics today, have requested repeat urine, cbc (complete blood count: lab work that evaluates the main components of your blood, red blood cells, white blood cells, and platelets), cmp (complete metabolic panel: lab work that measures 14 different substances in your blood, including enzymes, proteins, electrolytes, minerals, and waste products, giving a healthcare provider insight into your overall health and organ function) and ammonia level (blood work that measures the amount of ammonia in your blood to assess liver function and detect conditions that cause ammonia buildup). 2. Nursing Progress note dated 06/26/26 the nurse called the nurse practitioner and orders received to give lactulose 30 mg daily for 2 days then repeat ammonia level on 3rd day (06/29/26). 3. A practitioner note dated 06/29/26: . Patient had an elevated ammonia level of 56 she was given lactulose two doses pending re-evaluation and an ammonia level. E. Record review of R #11's physician's orders revealed staff did not enter an order to repeat the ammonia level on the 3rd day (06/29/26). F. Record review of R #11's laboratory results revealed the following: 1. Lab results dated 06/26/26: Ammonia level 55 micromoles/liter. 2. No ammonia level results for 06/29/26. G. On 07/01/26 at 10:11 AM, during an interview, the Unit Manager (UM) confirmed the following: 1. R #11's repeat ammonia level order was not entered due to issues with the laboratory and facilities ordering systems. 2. The order should have been entered so that a repeat ammonia level would have been collected 2 days ago on 06/29/26. 3. R #11's repeat ammonia level has not been collected yet and should have been. 4. The UM is not sure if any policy specifically covers entering orders, but a nurse should know that the order needs to be entered, it is common sense.

Based on observation, interview, and record review, the facility failed to ensure a resident with limited mobility receives appropriate services and assistance to maintain or improve mobility with maximum practicable independence for 1 (R #1) of 1 (R #1) residents reviewed for mobility and rehabilitation (specialized care provided to help residents recover from injuries, surgeries, or illnesses). This deficient practice could likely result in a decrease in the resident's functional mobility and could lead to feelings of despair. The findings are: A. Record review of Policy 13.2-Splints, Hand Rolls, Heel Protectors and other supportive/protective devices dated 12/01/06 revealed the following: 1. Residents are assisted as necessary by trained staff with the application and removal of preventive devices such as splints, hand rolls, heel protectors, or other supportive/protective devices as specified on the service plan. The measures/devices are provided in accordance with an order from the resident's physician. 2. Verify the order and the level of assistance required on the service plan, explain the procedure, answering all the resident's questions. 3. Encourage resident participation to the maximum extent possible. 4. Splints, braces, and other preventative/protective devices: a. Wash area with soap and water; dry with towel. b. Ensure that area to be covered is dry. c. Observe and monitor for correct placement of device and resident's comfort. d. Remove and replace device as outlined in the service plan. e. Observe the device for cleanliness and cleanse according to manufacturer's or resident/resident representative directions. f. Observe skin while applying and removing device; note any redness or other skin abnormalities. g. Record date, time applied, time removed, and any observed problems in logbook. B. Record review of R #1's Face Sheet no date revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1's diagnosis included hemiplegia (complete paralysis of one side of the body) and hemiparesis (indicates partial weakness on one side of the body) following cerebral infarction (stroke; which occurs due to blockage of blood flow to the brain) affecting right dominant side (affecting the side of a right-handed person). C. On 06/23/26 at 12:56 PM, during an interview and observation of R #1 the following was revealed: 1. R #1 stated she cannot move her right hand. 2. R #1 stated she is supposed to wear a splint on her right hand, but she has not worn it in a few months (cannot remember the exact timeframe) because she does not know where it is. 3. R #1's right hand was closed into a fist. She had to use her left hand to move her right hand and fingers. 4. He will develop the therapy plan for R #1 to start using the splint again. D. Record review of R #1's Occupational Therapy (OT; focuses on enabling people to engage in everyday occupations of life, which include self-care activities such as dressing, bathing, and preparing food) Evaluation dated 01/28/26 revealed the following: 1. Musculoskeletal system assessment (body's network of bones, muscles, tendons, essential for giving the human body its shape, maintaining stability, and enabling movement). a. Contracture (condition in which muscles, tendons, ligaments, or skin become permanently shortened and stiff, limiting joint movement and flexibility): functional limitations requiring orthotic (specialized external devices used to support, align, protect, or assist movement in a person's body) intervention: right wrist and hand. b. Current orthotic device: resting hand splint (designed to hold the hand, wrist, and fingers in a functional or neutral position, reducing pain, swelling, and abnormal muscle tone, particularly in neurological conditions like stroke). E. Record review of R #1's physician's orders revealed staff did not document an order for use of the splint to her right hand. F. On 06/30/26 at 10:35 AM during an interview with CNA #1 the following was revealed: 1. R #1 did have a hand splint, but it has been missing for approximately 2 months. 2. R #1 was good at keeping the splint on, she did not complain about using it. 3. Therapy starts the use of the splint then therapy teaches us how to put it on and take it off so it can be removed for showers or when the resident no longer wants it on. G. On 06/30/26 at 1:54 PM during an interview with OT #1 the following was revealed: 1. R #1 did have a hand splint that was in place based on the OT evaluation he completed on 01/28/26. 2. He would prefer that the resident does wear the hand splint. 3. Per OT visit documentation R #1 wore the hand splint on 02/02/26, 02/11/26, 02/19/26, 02/24/26, 03/31/26, 03/24/26 and 04/01/26. 4. OT stated that staff had found R #1's hand splint in her room. H. On 06/30/26 at 2:44 PM, during an interview with the Unit Manager the following was confirmed: 1. R #1 did have a splint that was being used for her right hand. 2. R #1 did not have an order in place for the splint. 3. If there is no order in place nursing staff are not aware that R #1 had a splint. The use of the splint does not show up on the treatment record for nursing staff to apply the splint.

Based on observation, record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #66) of 2 (R #29 and R #66) residents reviewed for pain, when the facility failed to: 1. Ensure that physician ordered opioid pain medication was available for R #66. 2. Thoroughly document R #66's pain to include location of pain, interventions used to alleviate pain and the effectiveness of those interventions. 3. Administer medication for indicated pain level. This deficient practice could likely result in residents experiencing unnecessary pain causing residents to experience a decline in physical and emotional health. The findings are: A. Record review of Policy-NSG 227 Pain Management dated 03/24/25, revealed the following: 1. Staff will continually observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with professional standards of practice. 2. Assess and identify the presence of pain and need for pain management Assessment components include but are not limited to: a. pain location(s) b. pain level c. pain onset d. pain description(s) e. factors that worsen pain f. factors that improve pain 3. The nurse will notify the physician/advanced practice provider (APP) as appropriate and obtain treatment orders as indicated. 4. Patients receiving interventions for pain will be monitored for the effectiveness and/or side effects/adverse drug reactions (such as constipation and sedation). a. Staff will document non-pharmacological interventions and effectiveness. b. Staff will document effectiveness of as needed medications. 5. contact the physician/APP to report findings and obtain revised treatment orders as indicated. B. Record review of R #66 Face Sheet revealed the following: 1. R #66 was admitted to the facility on [DATE]. 2. R #66's primary diagnosis: displaced intertrochanteric fracture of the left femur (a common type of hip fracture that typically requires surgical intervention for proper healing and recovery). C. On 06/23/26 at 9:41 AM, during an interview and observation of R #66 revealed the following: 1. R #66 was sitting in bed, she grabbed her right thigh. 2. R #66 stated her pain can be very bad up to a 10 (pain scale where zero is no pain and 10 is the worst imaginable pain) because she broke her whole left leg when she fell at home at the beginning of the month. D. Record review of R #66's physician's orders revealed the following: 1. An order dated 06/05/26 for hydrocodone-acetaminophen 5-325 mg (combination opioid pain reliever used to relieve moderate to severe pain) give 1 tablet by mouth every 6 hours as needed for moderate pain levels of 4-10. 2. An order dated 06/05/26 acetaminophen (over the counter fever reducer and pain medication used to treat mild pain) Tablet 325 MG give 2 tablets by mouth every 6 hours as needed for temp of 100 Fahrenheit or above or pain level of 1-3. E. Record review of R #66's MAR dated June 2026 revealed the following: 1. R #66 was given acetaminophen 325 mg for a pain scale of 8 on 06/06/26 and 06/08/26. 2. R #66 was given acetaminophen 325 mg for a pain scale of 10 on 06/08/26. 3. R #66 was given acetaminophen 325 mg for a pain scale of 6 on 06/09/26. 4. R #66 was given hydrocodone-acetaminophen 5-325 mg for a pain scale of 10 on 06/10/26. F. Record review of R #66's progress notes revealed the following: 1. Staff did not document resident's pain location, non-pharmacological interventions and the effectiveness of any pain interventions. 2. Staff did not contact the facility provider to advise him that resident was reporting severe pain. 3. Staff did not contact the facility provider to advise him that R #66's had not received hydrocodone-acetaminophen 5-325 mg. G. On 06/30/26 at 2:27 PM, during an interview with the Unit Manager the following was confirmed: 1. Staff did not complete a thorough pain assessment, interventions and effectiveness of the interventions. 2. Her expectation is that staff complete and document a thorough pain assessment. 3. R #66 did not receive her hydrocodone-acetaminophen until 06/10/26 because the facility did not receive the medication from the pharmacy until that date. 4. The nursing staff should have contacted the provider to advise them that R #66 reported severe pain levels and did not have hydrocodone-acetaminophen available.

Based on record review, observation, and interview, the facility failed to ensure the nutritional needs and preferences were met for 1 (R #4) of 3 (R #4, R #11, and R #66) residents reviewed for choices by not following the menu. This deficient practice is likely to result in resident weight loss and frustration. The findings are: A. Record review of R #4's admission record, no date, revealed the following: 1. R #4 was admitted on [DATE]. 2. R #4 had the following diagnosis: a. Dysphagia. b. Muscle weekness. c. Gastro-esophageal reflux. B. On 06/22/26 at 1:47 PM, during an interview, R #4 stated that something is always missing from his food tray. R #4 stated that he doesn't always get everything that is on the meal ticket. C. On 06/29/26 at 12:33 PM, during an observation of R #4 in his room during lunch, revealed that the following was on R #4's food ticket (what the resident was served for that meal): 1. Bean and cheese burrito with flour tortilla. 2. Yogurt. 3. Fresh salsa. 4. Shredded lettuce and diced tomatoes with vinaigrette. 5. Tea. 6. Fortified milkshake. It was observed that the yogurt was not on the resident's lunch tray. D. On 06/29/26 at 12:35 PM, during an interview, CNA #6 confirmed the resident was missing the yogurt that was on his food ticket.

Based on observation, record review, and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #5) of 1 (R #5) residents reviewed for Preadmission Screening and Resident Review (PASRR, a mandatory federal program requiring Medicaid-certified nursing facilities to screen all applicants for serious mental illness and intellectual/developmental disabilities) included all mental health diagnosis. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: A. Record review of Policy-SS105 Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients dated 02/16/24 revealed the following: 1. Center Social Worker or designated staff will assure that all patients with Mental Disorders (MD) and/or Intellectual Disability (ID) receive appropriate pre-admission screenings according to federal and/or state regulations. 2. Ensure that all individuals are screened for a MD and/or ID prior to admission. 3. Ensure that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. B. Record review of R #5's Face Sheet, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5 diagnoses include: a. Anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). b. Bipolar disorder (mental health condition characterized by significant mood swings, including manic episodes [abnormally elevated mood] and depressive episodes) c. Other schizoaffective disorders (chronic mental health condition characterized by a combination of symptoms from schizophrenia and mood disorders, affecting how individuals think, feel, and behave). C. On 06/26/26 at 2:18 PM, during an observation and interview, revealed the following: 1. R #5 was observed sitting in bed. 2. R #5 stated she likes to stay in her room. D. Record review of R #5's PASRR dated 02/07/26 revealed that staff did not document R #5's bipolar and schizoaffective disorders diagnoses. E. On 06/30/26 at 11:08 AM during an interview with the social services staff, he confirmed the following: 1. R #5 has schizoaffective and bipolar disorders listed on her diagnosis list. 2. He missed those diagnoses and should have included them on the PASSAR.

Based on observation, record review, and interview, the facility failed to complete a Significant Change In Status (SCIS; major decline or improvement in the patient's health status) MDS assessment within 14 days after the facility determined that a resident was admitted to hospice (a specialized type of care focused on providing comfort, dignity, and support to individuals with terminal illnesses and their families during the end-of-life stage) providers for 2 (R #2 and R #8) of 2 (R #2 and R #8) residents reviewed for hospice care. This deficient practice could likely result in the residents not receiving the appropriate care and services that they need. The findings are: R #2 A. Record review of R #2's Face Sheet, no date revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2's diagnosis included Alzheimer's disease unspecified (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia). B. On 06/24/26 at 10:47 AM R #2 was observed lying in her bed with her eyes closed. C. Record review of R #2's hospice care plan revealed that R #2 began hospice services on 05/29/26. D. Record review of R #2's SCIS MDS assessment was completed (signed off by RN) on 06/15/26 (greater than 14 days of admission to hospice). R #8 E. Record review of R #8's Face Sheet, no date revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8's diagnosis included the following: a. Unspecified dementia, unspecified severity (indicates that the specific type or cause of dementia has not been determined, and the severity is also not specified) with agitation (refers to an unpleasant state of extreme arousal, where a person may feel restless, irritable, nervous, or emotionally excited). b. Anxiety disorder unspecified (mental health diagnosis used when a person exhibits anxiety symptoms that cause significant distress or impairment in daily functioning, but these symptoms do not align completely with recognized disorders) F. On 06/26/26 at 2:20 PM R #8 was observed in the dining room listening to musical guests, R #8 appeared happy and was waving her arms around to the music. G. Record review of R #8's physician's orders revealed an order dated 06/02/26 to admit to hospice. H. Record review of R #8's hospice care plan revealed that R #8 began hospice services on 06/02/26. I. Record review of R #8's SCIS MDS assessment was completed (signed off by RN) on 06/17/26 (greater than 14 days of admission to hospice). J. On 06/30/26 at 3:44 PM, during an interview with the MDS Coordinator, the following was confirmed: 1. R #2 was admitted to hospice on 05/29/26. 2. R #2's SCIS MDS was not signed off within 14 days of her admission to hospice. 3. R #8 was admitted to hospice on 06/02/26. 4. R #8's SCIS MDS was not signed off within 14 days of her admission to hospice.

Based on observation, record review, and interview, the facility failed to meet professional standards of practice for 1 (R #66) of 2 (R #29 and R #66) residents reviewed for pain management when staff failed to notify the provider that the resident was reporting moderate to severe pain (pain levels of 7-10 on a 0-10 scale where zero is no pain and 10 represents the most severe pain imaginable, often described as the worst pain a person has ever experienced). This deficient practice could likely lead to unnecessary pain causing residents to experience a decline in physical and emotional health. The findings are: A. Record review of NSG 227 Pain Management policy dated 03/24/25 revealed the following: 1. Patients receiving interventions for pain will be monitored for effectiveness and/or side effects/adverse drugs reactions (e.g. constipation, sedation). 2. Document ineffectiveness of routine and PRN medications including interventions, follow-up and physician/APP (advanced practice provider) notification. 3. Contact the physician/APP (advanced practice provider) to report findings and obtain revised treatment orders if indicated. B. Record review of R #66 Face Sheet revealed the following: 1. R #66 was admitted to the facility on [DATE]. 2. R #66's primary diagnosis: displaced intertrochanteric fracture of the left femur (a common type of hip fracture that typically requires surgical intervention for proper healing and recovery). C. Record review of R #66's physician's orders revealed an order dated 06/05/26 for hydrocodone-acetaminophen 5-325 mg (combination opioid pain reliever used to relieve moderate to severe pain) give 1 tablet by mouth every 6 hours as needed for moderate pain levels of 4 - 10. D. Record review of R #66's MAR dated June 2026 revealed the following: 1. R #66 was given acetaminophen 325 mg for a pain scale of 8 on 06/06/26 and 06/08/26. 2. R #66 was given acetaminophen 325 mg for a pain scale of 10 on 06/08/26. 3. R #66 was given acetaminophen 325 mg for a pain scale of 6 on 06/09/26. 4. R #66 was given hydrocodone-acetaminophen 5-325 mg for a pain scale of 10 on 06/10/26. E. Record review of R #66's progress notes revealed that staff did not document contacting the facility provider to advise him that R #66's had not received hydrocodone-acetaminophen 5-325 mg. F. On 06/30/26 at 2:27 PM, during an interview with the Unit Manager the following was confirmed: 1. R #66 did not receive her hydrocodone-acetaminophen until 06/10/26 because the facility did not receive the medication from the pharmacy until that date. 2. The nursing staff should have contacted the provider to advise them that R #66 reported severe pain levels of 6-10 and did not have hydrocodone-acetaminophen available.

Based on observation, interview, and record review, the facility failed to ensure there was a system in place for the nursing staff to immediately determine code status [the residents choice as to whether or not they would like to be provided cardio- pulmonary resuscitation (CPR) in the event that they stopped breathing and/or their heart stopped] for 1 (R #58) of 3 (R #3, R #8, and R #58) residents reviewed for code status, when they failed document R #58's code status in her medical record. This deficient practice could likely lead to a delay in potentially lifesaving measures if staff are not immediately aware of residents' preferences for resuscitation. The findings are:A. Record review of the Code Status Orders Policy, dated [DATE], revealed upon admission/re-admission a code status order is required as soon as possible in the resident's medical record. B. Record review of R #58's admission Record, no date, revealed the following: 1. R #58 was admitted to the facility on [DATE]. 2. R #58 went to the hospital [DATE]. 3. R #10 had the following diagnosis: a. Anxiety. b. Major depressive disorder. c. Dementia C. On [DATE] at 10:49 AM during an interview and observation of R #58 revealed she went to the hospital on [DATE] because she fell. D. Record review of R #58's MOST (Medical Orders for Scope of Treatment), dated [DATE], revealed full code status. E. Record review of R #58's physicians orders, no date, revealed staff did not document an order for R #58's full code. F. Record review of R #58's medical record, no date, revealed staff did not document R #58's code status. G. On [DATE] at 11:02 AM, during an interview, the ADON confirmed the following: 1. That there was not a code status document for R #58. 2. R #58's code status was deleted when she went to the hospital on [DATE]. 3. Resident's code status should be reviewed when resident's return from the hospital and it should be documented in the resident's medical record.

Based on interview, record review, and observation, the facility failed to promote and facilitate a resident's right to choose for 1 (R #29) of 1 (R #29) residents reviewed for choices when the facility failed to assist R #29 into bed when she requested assistance to lie down. This deficient practice could likely result in residents becoming depressed, anxious, or feel like their wishes are not important because their right to choose is not being honored. The findings are: A. Record review of Resident's Rights Under Federal Law Policy dated 11/28/16 revealed the following: 1. The resident has a right to a dignified existence, self-determination (free choice of one's own acts), and communication with and access to persons and services inside and outside the facility. 2. The facility must ensure that the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. B. On 06/23/26 at 9:30 AM, during an interview, R #29 stated that she had eaten breakfast and was waiting to lie down. C. On 06/23/26 at 10:00 AM, during an observation of R #29's room, revealed R #29 was still sitting in her wheelchair and her call light was on. The MDS nurse went into her room, turned off the call light. She told R #29 she would find someone to help lie her down. D. On 06/23/26 at 10:32 AM, during an observation and interview, R #29 was observed sitting in her wheelchair. Her head was leaning forward, and she had her eyes closed. R #29 stated that she was falling asleep and wanted to lie down in bed. R #29 pressed her call light again. E. On 06/23/26 at 10:46 AM, during an observation R #29 was observed lying in bed with her eyes closed. F. On 06/30/26 at 10:18 AM, during an interview and an observation, R #29 stated that she was cold and tired and was waiting to lie down. R #29 was in her wheelchair next to her bed. R #29 pressed her call light. G. On 06/30/26 at 10:20 AM, during an observation and interview, revealed the following: 1. CNA #1 walked into R #29's room, did not speak to R #29. 2. CNA #1 turned off the call light. 3. CNA #1 stated he did not assist her to bed because R #29's daughter does not want R #29 to be assisted into bed until after she eats lunch. H. On 06/30/26 at 12:46 PM, during an observation R #29 was observed sitting in her wheelchair with her bedside table in front of her. R #29's head was resting on the bedside table. R #29 had pushed her lunch wrappers (food wrappers from local fast-food restaurant) onto the floor to lay her head down on the bedside table. I. On 06/30/26 at 3:19 PM, during an interview, the Unit Manager confirmed that staff should communicate with R #29 when turning off her call light. Staff should honor R #29's request to be assisted to lie down in bed.

Based on record review, observation, and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 2 (R #28, and R #58) of 8 (R #2, R #3, R #5, R #8, R #28, R #29, R #43 and R #58) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: R #28 A. Record review of the Individual Program Planning policy, dated 08/07/23, revealed the Activity Director (AD) will identify individuals who are not able to tolerate or prefer not to participate in group or independent leisure opportunities and would benefit from individualized attention. B. Record review of R #28's admission Record, no date, revealed the following: 1. R #28 was admitted to the facility on [DATE]. 2. R #28 has the following diagnosis: a. Cerebral Infarction (occurs when a blood vessel in the brain is blocked). b. Symptoms and signs involving cognitive functions (any disruption in the brain's ability to process, store, or retrieve information). c. Guillain-Barre Syndrome (a rare, life-threatening autoimmune disorder where your immune system mistakenly attacks your peripheral nerves). d. Cognitive communication deficit (an impairment in communication caused by disrupted brain functions like attention, memory, and executive functioning, rather than a primary speech or language disorder) C. Record review of R #28's annual MDS, dated [DATE], revealed R #28 has a BIMS score of 7 (0 to 7: Severe problems with thinking and memory). D. On 06/24/26 at 9:49 AM, during an observation of R #28's room, it was revealed that R #28 was in his bed sleeping. E. On 06/25/26 at 10:29 AM, during an observation of R #28's room, it was revealed that R #28 was in his bed with the tv on. F. On 06/29/26 at 2:50 PM, during an interview, the AD stated she does shopping for R #28 every month. The AD stated that she also turns on the tv for R #28 and talks to him. The AD stated R #28 doesn't get out of bed often. The AD stated that she does not provide ongoing one on one activities for R #28. R #58 G. Record review of R #58's admission Record, no date, revealed the following: 1. R #58 was admitted to the facility on [DATE]. 2. R #58 has the following diagnosis: a. Muscle weakness. b. Cognitive communication deficit. H. On 06/23/26 at 10:32 AM, during an interview and observation, R #58 stated that she could not go to activities anymore due to her decline in health. R #58 stated that staff do not provide one on one activities for her. I. On 06/29/26 at 2:58 PM, during an interview, the AD stated that R #58 used to go to group activities, but she did not attend them anymore. The AD stated that she invites R #58 to group activities but R #58 declines. The AD stated that she did not focus on the residents that are able to participate in group activities if they wanted to. The AD stated she does not provide one on one activities for R #58.

Based on record review, observation, and interview, the facility failed to provide quality of care for 1 (R #9) of 4 (R #9, R #14, R #58, and R #59) resident reviewed for quality of care, when they failed to: 1. Ensure staff applied R #9's stockinette (the most basic and common knitted fabric) and ace wraps to his legs. 2. Accurately documented that they applied R #9's stockinette and ace wraps to his legs.This deficient practice could likely lead to worsening of resident's condition. The findings are: A. Record review of facility's Physician/Advanced Practice Orders Policy dated 02/24/25, revealed the following: 1. To ensure all Physician orders are received from a credentialed practitioner before implementing. 2. Telephone orders are reviewed by phone and a practitioner who may or may not be in the center and are an adapted standard of practice. An order received by phone by a practitioner who is in the center is considered a telephone order. 3. Verbal orders are given face-to-face to a nurse by a practitioner who is in the center. Verbal orders are not an accepted standard of practice and only be used in an emergency. 4. Orders must be entered into the electronic or management system. All orders must be signed by an authorized, credential physician or other authorized practitioner in accordance with state regulations prescriptive privileges. B. Record review of R #9's Administration Record, no date revealed the following: 1. An admission date of 06/30/22. 2. The following diagnosis: a. Type 2 Diabetes Mellitus without complications (a chronic disease characterized by high levels of sugar in the blood). b. Left bundle-branch block, unspecified (a cardiac conduction abnormality in which electrical impulses are delayed or blocked in the left bundle branch, causing the left ventricle to contract later than the right ventricle). c. Essential (primary) Hypertension (a chronically elevated blood pressure without a specific identifiable cause, typically developing gradually over time). d. Retention of urine, unspecified (a condition where the bladder does not empty completely or at all. This can be caused by various factors, including blockages, medications, or nerve issues). e. Chronic kidney disease, Stage 3 unspecified (a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). C. Record review of R #9's physician's order dated 12/09/22 for may apply stockinette then applying ace wraps from foot to 2-3 below the knee daily and off in the evening/night one time a day for lower legs and remove per schedule. D. On 06/24/26 at 9:54 AM, during an interview and observation of the R #9's lower legs revealed the following: 1. R #9's lower legs were swollen from the knees to R #9's feet with no ace wraps or hose on his legs. 2. R #9 stated he doesn't take medication for his edema in his legs. 3. R #9 stated he did not like to use the ace wraps or hose. 4. R #9 stated he refuses to wear them all the time. E. Record review of R #9 TAR for the month of June 2026, revealed the following: 1. An order to May apply stockinette then applying ace wraps from foot to 2-3 below the knee daily Off in the evening/night one time a day for lower legs and remove per schedule. a. Staff documented on 06/1/26: apply at 10:00 AM and removed at 8:00 PM. b. Staff documented on 06/2/26: apply at 10:00 AM and removed at 8:00 PM. c. Staff documented on 06/3/26: apply at 10:00 AM and removed at 8:00 PM. d. Staff documented on 06/4/26: apply at 10:00 AM and removed at 8:00 PM. e. Staff documented on 06/5/26: refusal at 10:00 AM and removed at 8:00 PM. f. Staff documented on 06/6/26: apply at 10:00 AM and removed at 8:00 PM. g. Staff documented on 06/7/26: apply at 10:00 AM and removed at 8:00 PM. h. Staff documented on 06/8/26: apply at 10:00 AM and removed at 8:00 PM. I. Staff documented on 06/9/26: refusal at 10:00 AM and removed at 8:00 PM. j. Staff documented on 06/10/26: apply at 10:00 AM and removed at 8:00 PM. k. Staff documented on 06/11/26: apply at 10:00 AM and removed at 8:00 PM. l. Staff documented on 06/12/26: refusal at 10:00 AM and removed at 8:00 PM. m. Staff documented on 06/13/26: apply at 10:00 AM and removed at 8:00 PM. n. Staff documented on 06/14/26: apply at 10:00 AM and removed at 8:00 PM. o. Staff documented on 06/15/26: apply at 10:00 AM and removed at 8:00 PM. p. Staff documented on 06/16/26: apply at 10:00 AM and removed at 8:00 PM. q. Staff documented on 06/17/26: apply at 10:00 AM and removed at 8:00 PM. r. Staff documented on 06/18/26: apply at 10:00 AM and removed at 8:00 PM. s. Staff documented on 06/19/26: apply at 10:00 AM and removed at 8:00 PM. t. Staff documented on 06/20/26: apply at 10:00 AM and removed at 8:00 PM. u. Staff documented on 06/21/26: refusal at 10:00 AM and removed at 8:00 PM. v. Staff documented on 06/22/26: apply at 10:00 AM and removed at 8:00 PM. w. Staff documented on 06/23/26: apply at 10:00 AM and removed at 8:00 PM. F. On 06/29/26 at 3:00 PM, during a dual interview with RN #26 and RN #27 revealed the following: 1. RN #26 and RN #27 stated they have not been applying R #9's stockinette or ace wrap to his lower legs. 2. RN #26 and RN #27 stated they thought that the Wound Care Nurse (WCN) was supposed to apply R #9's stockinette and ace wrap. 3. They will do it when the WCN is off. G. On 06/29/26 at 3:08 PM, during an interview the WCN stated she does not do R #9's stockinette and ace wrap because it is not a wound order. WCN stated she only does wound care treatments, and the floor nurses should be doing that care for R #9. H. On 06/29/26 at 3:15 PM, during an interview with the Nurse Manager, she stated the following: 1. R #9's refuses staff applying the stockinette and ace wrap often. 2. Staff did not follow R #9's order for applying the stockinette and ace wraps. 3. Staff were documenting applying the stockinette and ace wrap but were not. 4. Staff should have been documenting R #9's refusal to have staff apply the stockinette and ace wrap. 5. Her expectation is that orders are to be followed.

Based on record review and interview the facility failed to promote and facilitate resident's right to choose, when the facility failed to:Allow residents to eat breakfast in the dining room for all 49 resident who eat in the dining room (residents were identified by the Resident Matrix provided by the Administrator on 03/09/26).Allow R #5 to continue to smoke after a new smoking agreement and procedure was implemented at the facility.This deficient practice could likely result in residents becoming depressed and anxious because their right to choose is not being honored. The findings are:Dining RoomA. On 03/09/26 at 11:28 am, during an interview, R #6 stated that on Saturday 03/07/26 residents could not eat in the dining room. R #6 stated that they were told there was not enough staff for residents to eat in the dining room because one of the CNAs called out. R #6 stated that the residents had to eat in their rooms. B. Record review of the employee timecards for 03/07/26 revealed three CNAs were working the day shift (6:00 am - 6:00 pm). C. On 03/09/26 at 3:14 pm, during an interview, the DON stated that the facility was supposed to have four CNAs, but they only had three. The DON confirmed that residents did have to eat in their room and not in the dining room. The DON stated that she found out about it in the afternoon of 03/07/26. The DON also confirmed that there was no reason for it have happened. Residents should have been able to eat breakfast in the dining room. R #5D. Record review of R #5's face sheet no date revealed he was admitted on [DATE]. E. On 03/10/26 at 3:06 pm, during an interview R #5 stated that his smoking privileges were taken away. R #5 stated that he has been on 1 to 1 care (a single caregiver is assigned to one individual) because staff said he was smoking in the bathroom. R #5 denies smoking in the bathroom. R #5 stated that he signed that smoking agreement and procedure after he was admitted . R #5 stated he wants to smoke. F. Record review of Smoking Agreement and Procedures dated 12/22/25 revealed the following: Failure to comply with designated location and times and other smoking rules could result in termination of smoking privileges.R #5's signature.Witnessed by Social Services. G. Record review of R #5's progress notes revealed the following:01/16/26 Roommate [name of roommate] said that [name of R #5] has been smoking in the bathroom.His smoking privileges are revoked.02/12/25 Notified [Name of the ombudsman], Ombudsman, that the resident was non-compliant with the smoking policy. The roommate reported [Name of R #5] was smoking in the bathroom and has been going in and out of the center daily. He is currently placed on 1:1 supervision. H. On 03/10/26 at 3:32 pm, during an interview, the Administrator confirmed the following:R #5 had his smoking privileges taken away because his roommate had said he was smoking in the bathroom.Staff never caught him but could smell him.R #5 also liked to keep his smoking materials and not hand them over to staff.R #5 has been on 1 to 1 care since for safety.The Administrator confirmed that the facility had started a new smoking agreement and procedure after R #5 was admitted .

Based on record review and interview, the facility failed to have medical record complete and accurate for 2 (R #2 and R #3) of 3 (R #2, R #3, and R #4) resident sampled for foley catheters, when staff failed to have physician's orders for R #2's and R #3's foley catheters. This deficient practice could likely result in staff being unaware of the residents' needs and foley catheter care not being performed. The findings are:A. Record review of R #2's face sheet no date revealed she was admitted on [DATE]. B. Record review of R #2's care plan dated 03/03/26 revealed R #2 had a foley catheter. C. Record review of R #2's physician's orders no date revealed staff did not document an order for R #2's foley catheter. D. Record review of R #3's face sheet no date revealed he was admitted on [DATE]. E. Record review of R #3's care plan dated 02/09/26 revealed R #2 had a foley catheter. F. Record review of R #3's physician's orders no date revealed staff did not document an order for R #3's foley catheter. G. On 03/09/26 at 2:28 pm, during an interview, the Unit Manager (UM) confirmed staff did not document an order for foley catheters for R #2 and R #3. The UM confirmed that staff should have entered the order into R #2 and R #3 medical records.

Based on record review and interview, the facility failed to provide quality of care in accordance with professional standards of practice for 1 (R #1) of 3 (R #1, R #7, and R #8) residents sampled for hospitalization, when staff failed to send R #1 to the hospital for several hours after receiving an order to send her. This deficient practice could likely result in resident's condition worsening and cause impairment or death. The findings are:A. Record review of R #1's medical record revealed:R #1 was admitted on [DATE].R #1 was sent to the hospital on [DATE]. B. Record review of the facility's 5 day follow up report 01/22/26 revealed the following:On 01/14/26 at approximately 11:00 pm, R #1's provider orders that she go to the hospital due to her recent lab results.RN #1 failed to send out R #1 until after 6:30 am on 01/15/26.RN #1 stated that she did not send R #1 to the hospital because she was unable to print the documents for transfer to hospital.RN #1 and LPN #1 (the LPN working the nightshift with RN #1) received education and disciplinary action. C. On 03/10/26 at 11:53 am, during an attempted interview RN #1 did not answer the phone call. She did not return the phone call. D. On 03/10/26 at 11:59 am, during an interview LPN #1 stated that the printer had not been working for a little while at the beginning of the year. LPN #1 stated that he did not receive any education on transferring residents to hospital or disciplinary action. F. On 03/10/26 at 12:17 pm, during an interview the Unit Manger (UM) confirmed that on night of 01/14/26 R #1's provider ordered that she go to the hospital due to her recent lab results. When the UM arrived at the facility on the morning of 01/15/26, R #1 had not been sent to the hospital. The UM confirmed that they sent R #1 to the hospital at that time. The UM stated that they had given education and disciplinary action to RN #1 and LPN #1 about sending residents to the hospital. The UM stated that the education was verbal. G. On 03/10/26 at 4:31 pm, during an interview the UM confirmed she had reviewed RN #1's and LPN #1's personnel file and that no disciplinary action was actually given to RN #1 or LPN #1.

Based on observation, interview, and record review the facility failed to have an accurate MDS assessment for 1 (R #4) of 3 (R #2, R #3, and R #4) resident sampled for foley catheters, when staff failed to accurately assess that R #4 did not have a foley catheter. This deficient practice could likely result in staff being unaware of the residents' needs. The findings are:A. Record review of R #4's face sheet no date revealed he was admitted on [DATE]. B. Record review of the admission MDS dated [DATE] revealed resident had a Foley catheter. C. On 03/09/26 at 2:15 pm, during an observation of R #4 revealed no foley catheter. D. On 03/09/26 at 2:28 pm, during an interview the Unit Manager (UM) confirmed R #4 did not have a foley catheter. The UM confirmed that R #4's MDS did have foley catheter marked in error.

Based on observation, record review, and interview, the facility failed to: 1) maintain a resident's usual body weight for 1 (R #30) of 1 (R #30) sampled residents for weights loss. R #30 lost 20 pounds between 12/06/17 and 01/02/17. This would be a weight loss percentage of 8.21%. (CMS considers a weight loss of greater then 5% in one month to be severe weight loss.) The facility failed to ensure acceptable parameters of nutritional status (11% weight loss in 6 months) for 1(R #14) of 2 (R #14 and R #41) reviewed for nutrition, of while misidentifying the focus of the nutritional risk (relating to dentures when the resident does not have dentures), not care planning to alert all staff resident was no longer feeding herself, and not notifying the physician the resident was no longer feeding herself. ice can result in lack of identifying resident needs concerning nutrition and implementing appropriate interventions. The findings are: R #30 A. Record review of R #30's Care Plan dated 12/26/17 revealed R #30 was admitted on [DATE] with the [DIAGNOSES REDACTED]. B. Record review of a Registered Dietitian (RD) note dated 11/20/17 revealed this resident only eats between 25-75% of her meals. C. Record review of a RD note dated 11/21/17 revealed that the doctor ordered the [MEDICATION NAME] (medication to spur appetites) was increased to spur the appetite and House Supplement (usually a liquid supplement to increase a resident's protein and calorie intake) was ordered between meal for weight maintenance. D. Record review of a RD note dated 12/10/17 revealed the resident lost 14 pounds (6%) in one month with a normal intake of less than 25% of her meals. E. Record review of the Speech Therapy note dated 12/12/17 read, Recommend trial puree consistency and nectar (thickened) liquids . (The resident) is easily agitated and refusing to eat. CNA reported that when I left the room, (the) patient refused to eat more. F. Record review of a RD note dated 12/15/17 revealed the resident lost approximately 10 pounds in one week due to poor intake. The note confirmed the new puree texture diet. Further, (The resident) requires 1:1 (one-to-one) feeding assistance. G. Record review of the resident's weights indicated the following: 1. On 12/06/17, the resident weighed 234 pounds. 2. On 01/02/17, the resident weighed 214 pounds. H. Record review of a RD note dated 01/11/18 revealed, (The) rsd (resident) with significant wt (weight) loss of 8% (20# (pounds)) . This occurred in one month. The diet was changed to Regular consistency with thin liquids and the intake improved to 75% of meals. [MEDICATION NAME] and House Supplement continued to be ordered. I. Record review of the Care Plan, updated on 12/28/17, revealed the change in the diet and the [MEDICATION NAME] and House Supplement orders, but there was no mention of the 1:1 feeding assistance. J. On 01/10/18 at 8:35 am, during observation and interview, R#30 was given a plate of puréed pancakes, sausage, and eggs. The staff delivered the meal and then left the room to deliver another tray. No staff came to assist the resident with eating. The resident took and small bite of each item and made a face like she did not like the taste after each bite. When asked what her thoughts were regarding the food, R #30 stated that she did not like the texture and the food was bland. She was also asked if staff stayed to encourage her to eat. She stated that they do not. K. On 01/10/18 at 3:20 pm, during an interview, the Speech Therapist stated that R #30 was uncooperative and decided that because of her dementia, she could be forgetting to swallow. When asked, she stated that she has yet to follow up to see how she is doing since the texture change. L. On 01/11/18 at 8:23 am, during an observation, R #30 was sitting in the main dining room at a table with a CNA encouraging her to eat. The resident seemed to enjoy the meal without coughing up each bite. (This indicated she did not have trouble eating a regular diet and did not need pureed food.) M. On 01/11/18 at 10:30 am, during an interview, the Dietary Manager stated the resident did get regular food and did well (no signs of dysphasia (difficulties in swallowing food and drink)). The resident ate more at this meal than since the puree order. R #14 N. Record review of the medical record for R #14 revealed the following weights indicating a significant weight loss of 11% in 6 months. 01/2/2018 15:04 123.2 Lbs 12/6/2017 13:29 126.4 Lbs 11/8/2017 14:49 128.4 Lbs 10/4/2017 13:20 130.2 Lbs 9/1/2017 14:12 134.6 Lbs 8/2/2017 14:30 139.0 Lbs O. Record review of the care plan for R #14 dated as initiated 10/25/17 and revised 10/25/17 revealed: Focus: Resident is at nutritional risk, related to having dentures. Goal: Resident will maintain a stabilized weight during this assessment period review process. Target Date 11/14/17 Interventions: Regular Liberalized Dysphasia (difficult swallowing) Puree (food this is a smooth, thick paste) Diet with Fortified Food TID (three times a day), Revised 10/09/17 House Supplement two times a day for 30 days, Created 11/06/17 Evaluated for proper consistency of diet. Prefers chopped meat related to chewing difficulty. Encourage resident to chew and swallow each bite. Prefers chopped meat. Weight monthly and alert dietician and physician to any significant loss of gain. Supervise/cue/assist as needed with meals, Date initiated 06/13/17 P. On 01/10/18 at 10:20 am, during an interview with CNA #2 she stated, (Name of R #14) is dependent, we do everything for her. I feed her, she doesn't feed herself. She does not have dentures. Q. On 01/10/18 at 12:35 pm, during dining observation, R#14 was sitting at table being fed by a CNA. R#14's arms remain at her side and the CNA is feeding her a puree diet with a spoon, and offering sips of liquid from a small glass. R. On 01/11/18 at 11:03 am, during an interview with the MDS (Minimum Data Set) Coordinator, and the MDS Assistant, the MDS Coordinator stated, I see (Name R #14) is on weight review list and is still going down in weight. I did not know she was not feeding herself. S. On 01/11/18 at 08:32 am, during an interview with CNA #3 when asked about the care plan indicating nutrition risk due to dentures, CNA #3 stated, (Name of R #14) does not have dentures, I have never seen her with dentures and I feed her all the time. T. On 01/11/18 at 09:16 am, during an interview with the DM (Dietary Manager), she stated, She (R #14) has declined a lot in her weight. She (R #14) usually eats good in breakfast, less at lunch and dinner. We had put her on a nutritional supplements for 30 days but it did not help. She is not on the supplements any more. U. On 01/11/18 at 11:03 am, during an interview with the MDS Coordinator, and the MDS Assistant, the MDS Coordinator stated, I see (Name of R #14) is on weight review list and is still going down in weight. I did not know she was not feeding herself. The MDS Assistant stated, The care plan should have been revised for needing to be fed. We did not get the MDS correct, it says she has dentures, but she does not, she has her own teeth. V. On 01/11/18 at 03:20 pm, during an interview with the RD stated, She (R #14) keeps losing weight. Her intake is good. It is time for her physicians to look at something possibly metabolic (the processes of the body working together to create energy. W. On 01/16/18 at 10:19 am, during an interview with the NP (Nurse Practitioner), she stated, The staff has not specifically addressed the weight loss with me. On 11/09/17, I ordered to check her [MEDICAL CONDITION] and I stopped the [MEDICATION NAME] deconate (an anti-psychotic medication that can influence weight). The not feeding herself is new to me. X. On 01/16/18 at 10:37 am, during an interview, LPN #1 stated, (Name of R #14) has always fed herself. I will have to ask the CNAs how long this has been going on. I did not know she was not feeding herself. Y. On 01/17/18 at 11:58 am, during an interview with the UM (Unit Manager), she stated, She (R #14) might need more assessment for the weight loss. The care plan was not right about weight loss due to dentures.

Based on record review and interview, the facility failed to ensure residents were provided with care and services in accordance with the written plan of care for 3 (R #4, R #49, & R #78) of 6 (R #4, R #6, R #16, R #46, R #49 and R #78) residents reviewed for unnecessary medications and turning and repositioning when they failed: 1) to monitor and document behaviors to justify the use of anti-psychotic medication and 2) failed to turn and reposition R #49 while in bed. This deficient practice could result in residents receiving medications unnecessarily, experiencing adverse side effects and worsening pressure ulcers due to not turning and repositioning. The findings are: Behavior Monitoring R #4 A. Record review of R #4's Face Sheet dated 01/26/17 revealed the following Diagnoses: [REDACTED]. B. Record review of Medication Administration Records (MAR) for R #4 dated 01/01/17 indicate the following [MEDICAL CONDITION] medications; [MEDICATION NAME] (antidepressant medication), 10 mg (milligram, an unit of measurement), give one tablet one time a day for depression, active since 09/16/14; [MEDICATION NAME] (anti-anxiety medication) 0.25 MG, 1 tablet every 8 hr for anxiety-prn (as needed), active since 09/16/14; [MEDICATION NAME] (used to treat mild to moderate dementia) tablet 10 mg, give 1 tablet by mouth at bedtime for Dementia, active since 09/15/14; [MEDICATION NAME] (sedative/ hypnotic to treat [MEDICAL CONDITION]), 1 mg tablet at bed for [MEDICAL CONDITION], active since 10/22/15. C. Record review of R #4's care plan dated 01/11/17 revealed the following: 1) Focus: (Name of R #4) exhibits and is at risk for distressed/fluctuating mood symptoms (sx) related to Dementia, confusion memory loss; Date initiated: 01/17/17; Interventions included: monitor for pain, monitor for signs of [MEDICAL CONDITION], monitor for signs/sx of worsening sadness/depression, monitor for signs/sx of worsening anxiety/fear, monitor for for signs/sx of worsening anger/agitation, evaluate need for psych/behavioral health consultation. 2) Focus: (Name of R #4) is at risk for alterations in comfort related to chronic pain. Intervention; Date initiated: 11/21/14, revised on 01/21/17; Interventions included: Evaluate pain characteristic; quality, severity, location, precipitating/relieving factors, utilize pain scale; Monitor for non-verbal signs/sx of pain and medicate as ordered and monitor for change in mood or mental status: 3) Focus: (Name of R #4) is at risk for complications related to use of [MEDICAL CONDITION] drugs, date initiated: 11/21/14, revision on: 01/12/15; Goal: (Name of R #4) will have the smallest most effective dose without side effects; Interventions included: Monitor for changes in mental status and functional level and report to MD (Medical Doctor) as indicated, monitor for side effects and consult physician and /or pharmacist as needed, obtain psych evaluation as ordered. D. Record review of Suspected Medication Side Effects sheet for the months of January 2017 and December 2016 were blank. E. Record review of Behavioral Monitoring and Interventions for months of January 2017 and December 2016 were blank. F. Record review of progress notes from 05/01/16 through 01/13/17 revealed the following: 1) On 01/11/17, 01/10/17, and 01/09/17 verbal abuse towards staff. 2) Care plan meeting note dated 01/13/17: Resident sleeps a lot; charge nurse stated resident usually gets up an go to the dining room for meals, but she gets sleepy when she gets medicated with [MEDICATION NAME] (sic, should have been [MEDICATION NAME]), which is schedule when resident has behaviors. 3) No progress notes for the following interventions except after a change in condition related to a fall on 12/24/16 (no changes noted and no medications given): monitoring of pain, monitoring for signs of [MEDICAL CONDITION], monitoring for signs/sx of worsening sadness/depression, monitoring for signs/sx of worsening anxiety/fear, monitoring for for signs/sx of worsening anger/agitation, monitoring for continued need for medications as related to behavior and mood, monitoring for non-verbal signs/sx of pain, no evaluating need for psychological/behavioral health consultation. G. On 01/26/17 at 8:53 am during an interview, when LPN #3 revealed R #4 takes the following medications: [REDACTED]. LPN #3 stated, (Name of R #4) has not had any changes; she has been on the same stuff forever. When asked how the facility monitors side effects and behaviors, LPN #3 stated, Documentation would be in the notes; we don't have monitor sheets. LPN #3 looked in records for R #4 and confirmed, In the notes, there is nothing. When asked what interventions were used when R #4 is displaying behaviors, LPN #3 stated, That is when we give her the [MEDICATION NAME]. H. On 01/26/17 at 11:25 am during an interview, when RN #2 was shown R #4's care plan and asked where monitoring is documented, RN #2 stated, Nothing is documented unless they (residents) do something; I didn't know that was in her care plan. I. There was no documentation in R #4's file of a medication or psychological consultation. J. On 01/26/17 at 12:17 pm, during an interview, Medical Records Director (MRD) revealed the last time R #4 was seen the doctor for medication consult, was last February (2016?). R #78 K. Record review of R #78's Face Sheet dated 01/26/17 revealed the following Diagnoses: [REDACTED]. L. Record review of R #78's Medication Review Report dated 01/27/17 revealed the following psychotherapeutic medications: [REDACTED]. M. Record review of R #78's care plan dated 10/09/15 revealed the following: 1) Focus: (Name of R #78) exhibits and is at risk for and/or exhibits symptoms (sx) of [MEDICAL CONDITION]; date initiated 10/09/15, revision 10/26/15; Goal: R #78 will consistently retain current level of motor activity through out review, R #78 will be free of signs/sx of [MEDICAL CONDITION] with no unexplained or rapid changes in mental status, mood and behavior or communication through review, target date: 04/12/17 ; Interventions: Address underlying triggers/causes. 2) Focus: (Name of R #78) is at risk for complications related to use of [MEDICAL CONDITION] drugs, date initiated: 10/09/15, revision 10/26/15; Goal: (Name of R #78) will have the smallest most effective dose without side effects x (for) 90 days, target date 04/12/17; Interventions included: Complete behavior monitoring flow sheet, Monitor for changes in mental status and functional level and report to doctor (MD) as indicated, monitor for side effects and consult physician and /or pharmacist as needed, obtain psych evaluation as ordered. N. Record review of Suspected Medication Side Effects sheet for the months of January 2017 and December 2016 were blank. O. Record review of Behavioral Monitoring and Interventions for months of January 2017 and December 2016 were blank. P. Record review revealed no change in medication since admission on 10/09/15. Q. On 01/26/17 at 12:15 pm, during interview, Unit Manger (UM) confirmed R #78 behavioral sheets and Suspected Medication Side Effect sheets were blank. Turning and Repositioning: R #49 R. Record review of the Admission record for R #49 revealed he was admitted to the facility on [DATE] with an unstageable pressure ulcer on his sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). S. Record review of a Care Plan for R #49 dated 05/22/16 revealed: Focus: Resident is at risk for further skin breakdown as evidenced by nutritional concerns, shear/friction risks, limited mobility, incontinence. Interventions: Assist resident in repositioning every 2 hours. T. Record review of Skin Integrity Report dated 12/18/15 to 01/24/17 revealed the following: 1) 12/18/15, Unstageable pressure ulcer on sacrum measuring 5 x (by) 3 cm (centimeter). No tunneling or undermining (Undermining is deep tissue (subcutaneous fat and muscle) damage around the wound margin). 2) 01/13/16, Unstageable pressure ulcer on sacrum measuring 5.2 x 3.2 x 0.5 cm. In the section for tunneling or undermining, it was not specified whether the ulcer had undermining or tunneling but it measured at 12 o'clock at 0 cm; 3 o'clock 0.5 cm depth; 6 o'clock 0.3 cm depth and 9 o'clock 0.5 cm depth. 3) 02/10/16, Unstageable pressure ulcer on sacrum measuring 4.5 x 2.8 x 0.5 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 1.5 cm depth; 6 o'clock 1.2 cm depth; 9 o'clock 1.5 cm depth. 3 o'clock is not noted. 4) 04/22/16, Unstageable pressure ulcer on sacrum measuring 1.7 x 1.0 x 1.0 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 3.7 cm depth; 3 o'clock 2.2 cm depth; 6 o'clock 2.8 cm depth and 9 o'clock 0.3 cm depth. 5) 06/13/16, Stage IV pressure ulcer on sacrum measuring 2.5 x 2.0 x 2.2 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 3.0 cm depth; 3 o'clock 2.1 cm depth; 6 o'clock 2.8 cm depth and 9 o'clock 0.8 cm depth. 6) 08/26/16, Stage IV pressure ulcer on sacrum measuring 2.0 x 0.3 x 2.0 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 0.0 cm depth; 3 o'clock 1.0 cm depth; 5 o'clock 2.0; 6 o'clock 1.0 cm depth and 9 o'clock 0.0 cm depth. 7) 10/19/16, Stage IV pressure ulcer on sacrum measuring 0.5 x 0.5 x 1.8 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 0.0 cm depth; 3 o'clock 0.8 cm depth; 6 o'clock 2.5 cm depth; and 9 o'clock 0.0 cm depth. 8) 12/08/16, Stage IV pressure ulcer on sacrum measuring 0.5 x 0.5 x 1.8 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 0.0 cm depth; 3 o'clock 0.5 cm depth; 6 o'clock 0.0 cm depth; and 9 o'clock 2.0 cm depth. 9) 01/24/17, Stage IV pressure ulcer on sacrum measuring 0.5 x 0.6 x 1.2 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 1.2 cm depth; 3 o'clock 1.2 cm depth; 6 o'clock 1.8 cm depth; and 9 o'clock 1.6 cm depth. U. Observations of the resident in bed during the survey revealed the following: 1) 01/23/07: 11:45 am, R #49 laying on back; 2:25 pm resident laying on back; 3:30 pm resident laying back 2) 01/24/17: 11:45 am R #49 laying on right side; 1:45 pm laying on right side; 2:45 pm laying on right side; 3:30 pm laying on right side. 3) 01/25/17: 9:45 am resident lay on back; 11:45 am resident laying on back; 1:20 pm resident laying on back. V. On 01/25/17 at 1:20 pm during an interview with R #49, he was asked if the CNA's had assisted him to change positions on this day. The resident blinked once, indicating No. W. On 01/26/17 at 9:49 am, during an interview with the Unit Manager, she was asked about the development and increase in size of the tunneling/undermining of R #49's wound. She stated that not turning him would add to the possibility of the wound increasing in size. She also stated The CNA's should follow the care plan and turn him every 2 hours. X. On 01/26/17 at 11:30 am, during an interview with the Clinical Quality Specialist, she stated, Not turning and repositioning any resident would lead to more wound breakdown and possibly worsening.

Based on observation, record review, and interview, the facility failed to assess and prevent pain during wound dressing changes for 1 (R #49) of 1 (R #49) residents sampled for pressure ulcers. The failed practice could likely result in the resident suffering physical pain as well as mental anguish during the dressing changes. The findings are: A. Record review of the Admission record for R #49 revealed he was admitted to the facility on [DATE] with an unstageable pressure ulcer on his sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). B. On 01/24/17 at 10:00 am, Licensed Practical Nurse (LPN) #1 was asked to perform wound care for R #49. The resident was heard to moan softly while the dressing change was being done. After the dressing change was complete, the LPN was asked about pain management for R #49. He stated, I know my residents pretty well. He (R #49) had a [MEDICATION NAME] (Nerve pain medication and anticonvulsant) this morning. His family does not want any narcotics to be given. C. On 01/24/17 at 3:30 pm, during an interview, Certified Nursing Assistant (CNA) #2 stated, I think he was in pain during the dressing change. He doesn't have the same complaints when I provide incontinence care for him. D. Record review of a Order Summary Report dated 01/01/17 to 01/31/17 revealed the following: 1) [MEDICATION NAME] (medication is used to relieve moderate to severe pain) 5-325 mg (milligram). Give 1 tablet via [DEVICE] (tube inserted through the abdomen directly to the stomach) as needed for pain BID (twice a day) PRN (as needed) for pain. 2) Tylenol Tablet 325 mg. Give 325 mg via [DEVICE] every 4 hours as needed for pain or temperature greater than 100. 3) No entry for [MEDICATION NAME] (used in adults to treat nerve pain and [MEDICAL CONDITION] in adults) was found. E. Record review of a facility Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. F. Record review of the facility MAR indicated [REDACTED]? If no, indicate response through chart codes every shift. The form revealed no positive entry for pain 01/01/17 through 01/25/17 in the am. G. Record review of a facility PRN Pain Management Flow Sheet dated January 2017 revealed the form was blank with no entries. H. On 01/25/17 at 11:40 am, during an interview with R #49 and his wife, she was asked if she would ask her husband if the dressing changes hurt. He blinked twice indicating Yes. R #49's wife was asked to affirm the yes response and she stated He blinks twice for yes and once for no. I. On 01/26/17 at 9:30 am, during an interview with R #49, he was asked if he was hurting during the dressing change. He blinked twice. He was asked if he had any pain medication before the dressing change and he blinked once. J. On 01/26/17 at 9:35 am, during an interview with CNA # 4, she stated I think it hurt him. I've watched the changes about 10 times. He was moaning very softly. K. On 01/26/17 at 9:20 am, Registered Nurse (RN) #1 was asked to perform wound care for R #49. During the dressing change , the resident could be been to flinch when the wound was flushed and he moaned when the wound was packed. The RN was asked if she had pre-medicated the resident for pain and she stated No. L. On 01/26/17 at 11:30 am, during an interview with the Clinical Quality Specialist, she stated, If the resident says they are in pain, then they are in pain. He (R #49) should have been pre-medicated or at least assessed for pain.

Based on record review, observation, and interview, the facility failed to prevent a Stage IV pressure ulcer from worsening for 1 (R #49) of 1 (R #49) residents sampled for pressure ulcers. The facility failed to turn and reposition the resident per the care plan resulting in a pressure ulcer that has tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). This failed practice could result in the wound worsening and developing an abscess (pocket of pus that collects in tissues, organs, or spaces inside the body) possibly resulting in surgery. The findings are: A. Record review of the Admission record for R #49 revealed he was admitted to the facility on [DATE] with an unstageable pressure ulcer on his sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). B. Record review of a Care Plan for R #49 dated 05/22/16 revealed: Focus: Resident is at risk for further skin breakdown as evidenced by nutritional concerns, shear/friction risks, limited mobility, incontinence. Interventions: Assist resident in repositioning every 2 hours. C. Record review of Skin Integrity Report dated 12/18/15 to 01/24/17 revealed the following: 1) 12/18/15, Unstageable pressure ulcer on sacrum measuring 5 x (by) 3 cm (centimeter). No tunneling or undermining (Undermining is deep tissue (subcutaneous fat and muscle) damage around the wound margin). 2) 01/13/16, Unstageable pressure ulcer on sacrum measuring 5.2 x 3.2 x 0.5 cm. In the section for tunneling or undermining, it was not specified whether the ulcer had undermining or tunneling but it measured at 12 o'clock at 0 cm; 3 o'clock 0.5 cm depth; 6 o'clock 0.3 cm depth and 9 o'clock 0.5 cm depth. 3) 02/10/16, Unstageable pressure ulcer on sacrum measuring 4.5 x 2.8 x 0.5 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 1.5 cm depth; 6 o'clock 1.2 cm depth; 9 o'clock 1.5 cm depth. 3 o'clock is not noted. 4) 04/22/16, Unstageable pressure ulcer on sacrum measuring 1.7 x 1.0 x 1.0 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 3.7 cm depth; 3 o'clock 2.2 cm depth; 6 o'clock 2.8 cm depth and 9 o'clock 0.3 cm depth. 5) 06/13/16, Stage IV pressure ulcer on sacrum measuring 2.5 x 2.0 x 2.2 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 3.0 cm depth; 3 o'clock 2.1 cm depth; 6 o'clock 2.8 cm depth and 9 o'clock 0.8 cm depth. 6) 08/26/16, Stage IV pressure ulcer on sacrum measuring 2.0 x 0.3 x 2.0 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 0.0 cm depth; 3 o'clock 1.0 cm depth; 5 o'clock 2.0; 6 o'clock 1.0 cm depth and 9 o'clock 0.0 cm depth. 7) 10/19/16, Stage IV pressure ulcer on sacrum measuring 0.5 x 0.5 x 1.8 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 0.0 cm depth; 3 o'clock 0.8 cm depth; 6 o'clock 2.5 cm depth; and 9 o'clock 0.0 cm depth. 8) 12/08/16, Stage IV pressure ulcer on sacrum measuring 0.5 x 0.5 x 1.8 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 0.0 cm depth; 3 o'clock 0.5 cm depth; 6 o'clock 0.0 cm depth; and 9 o'clock 2.0 cm depth. 9) 01/24/17, Stage IV pressure ulcer on sacrum measuring 0.5 x 0.6 x 1.2 cm. In the section for tunneling or undermining, it was not specified which it was but it measured at 12 o'clock 1.2 cm depth; 3 o'clock 1.2 cm depth; 6 o'clock 1.8 cm depth; and 9 o'clock 1.6 cm depth. D. Observations of the resident in bed during the survey revealed the following: 1) 01/23/07: 11:45 am, R #49 laying on back; 2:25 pm resident laying on back; 3:30 pm resident laying back 2) 01/24/17: 11:45 am R #49 laying on right side; 1:45 pm laying on right side; 2:45 pm laying on right side; 3:30 pm laying on right side. 3) 01/25/17: 9:45 am resident lay on back; 11:45 am resident laying on back; 1:20 pm resident laying on back. E. On 01/25/17 at 1:20 pm during an interview with R #49, he was asked if the CNA's (certified nursing assistant) had assisted him to change positions on this day. The resident blinked once, indicating No. F. On 01/26/17 at 9:49 am, during an interview with the Unit Manager, she was asked about the development and increase in size of the tunneling/undermining of R #49's wound. She stated that not turning him would add to the possibility of the wound increasing in size. She also stated The CNA's should follow the care plan and turn him every 2 hours. G. On 01/26/17 at 11:30 am, during an interview with the Clinical Quality Specialist, she stated Not turning and repositioning any resident would lead to more wound breakdown and possibly worsening.

Based on observation, interview, and record review, the facility failed to enure staff followed accepted standards of practice to follow physician's orders [REDACTED].#1, R #2, and R #3) of 3 (R#1, #2, and #3) sampled for Urinary Tract Infections [MEDICAL CONDITION] and pressure ulcers. The facility failed to 1) follow physician's orders [REDACTED].#1, 2) follow physician's orders [REDACTED].#1, 3) follow physician's orders [REDACTED].#1, 4) follow physicians's orders for R #2 pressure relieving boot, 5) follow physician's orders [REDACTED].#3's wound to the air. This deficient practice resulted in residents not receiving the appropriate care as outlined by their provider for their current conditions resulting in illness and infection. Findings are: R #1 Specialist Follow Up A. Record review of physician orders [REDACTED]. B. On 12/06/16 at 8:40 am, during an interview, the MR (medical records staff) confirmed that it is his job to make appointments for residents with outside providers after he receives a written order. He stated R #1's admission date of [DATE] was before he began to work here. He further stated, I have checked all the appointments in the log from 10/20/16 to 11/31/16 and there are no appointments for (Name of R #1) to see (Name of wound care specialist). C. On 12/06/16 at 12:09, during an interview with the Wound Care Clinic scheduler, she indicated there were no appointments scheduled for R #1. R #1 had an appointment on October 4 (before admission to the facility), and the patient did not show up for the appointment, and they had no further appointments scheduled. D. On 12/06/16 at 1:30 pm, during an interview, the DON (Director of Nurses) stated, No, the doctor's orders were not followed and we have no documentation of a followup visit scheduled. R #1 Foley Catheter E. Record Review of the Physician order [REDACTED]. F. Record review of Skilled Nurses' notes for November 2016 revealed no documentation of the foley catheter being discontinued, or any mention of the order. G. On 12/05/06 at 3:40 pm, during an interview, the ADON (Assistant Director of Nurses) stated, Looks like the foley (catheter) was not discontinued. There is no documentation in the notes. They (nurses) should have charted if it was discontinued and called results to the office. H. On 12/06/16 at 9:50 am, during an interview, the DON stated, There is no documentation. When asked about the possible outcome to the resident, the DON stated, She might have developed a foley related UTI. I. Record review of the medical record for R #1, dated 11/06/16, from a local hospital revealed: admitted with a [DIAGNOSES REDACTED]. R #1 Skin Checks J. Record Review of the physician's orders [REDACTED]. K. Skin Integrity Report dated 10/20/16 1. No location listed, but illustration has circle in area of right upper buttock/sacrum: 10/20/16 Stage II, 1 cm (centimeter) x 1 cm x 0 cm, 11/04/16 1 cm x .8 x 0 cm. 2. Left foot (graft area): 10/20/16 4 cm x 3 cm 3. Left foot (graft area): 10/20/16 1 cm x 1 cm 4. No location listed, but illustration has a circle in the area of the right shin: 10/20/16 (graft area) 15 cm x 10 cm 5. No location listed, but illustration has a circle in the area of the left elbow: Stage II, 1 cm x 1 cm x 0 cm L. On 12/06/16 at 12:30 pm, during an interview with the the DON, when asked about lack of documentation of skin assessments on 10/27/16 and 11/03/16; he stated, It looks like we missed some of the skin reports. They should have been done weekly. R #2 M. Record review of the Nursing Admission assessment dated [DATE] revealed R #2 was admitted with a Stage III pressure ulcer to his left heel. N. Record review of Discharge Instructions Details from a local hospital dated 10/17/16, revealed, Off-Loading (used as a preventative or healing measure in wounds). Keep weight off affected area/limb at all times - Prevalon boot (heel protecting boot) to left foot at all times except for hygiene and for Physical Therapy. O. Record review of a physician order [REDACTED]. Dx: (diagnosis) pressure ulcer. P. Record review of a Physician order [REDACTED]. Keep weight off. Prevalon boot to left foot at all times except for hygiene and Physical Therapy. The order is noted and signed by Registered Nurse (RN) #1 on 11/16/16. Q. On 12/05/16 at 4:30 pm, R #2 was observed to be sitting at the nurse's station. Further observation revealed he was wearing a pair of gray socks. He did not have the Prevalon boot on his left foot. R. On 12/05/16 at 4:35 pm, during an interview, RN #1 was asked about the Prevalon boot. The RN #1 verified that the resident was not wearing his boot. The nurse stated I wasn't aware he had to have the boot on when he is out of bed. RN #1 checked the physician orders [REDACTED]. He's supposed to wear it all of the time. I was not aware of this. S. On 12/05/15 at 4:45 pm, during an interview, ADON stated, The CNA's are responsible for putting the boot on. The nurse is responsible for making sure the CNA puts the boot on. When asked what the possible outcome for the resident is for not having the boot on, she replied, Worsening of the wound. T. On 12/06/16 at 8:10 am, during an interview, CNA #2 stated, The boot is new for me. Today was the first day for me. I had never put it on him before. The nurse is supposed to tell us of new orders. No one told me about the boot. When asked how long she had been working with R #2, she replied, For a long time. I was here when he came here in September. U. On 12/06/16 at 8:20 am, during an interview, the DON stated, The boot should be on when he is up. It's to relieve pressure on his Stage III ulcer. The possible negative outcome to the resident is the wound worsening. R #2 UA V. Record review of the medical record for R #2 revealed an order dated 09/20/16 for a UA (Urine Analysis) with reflex CX (test to determine organism) stat (immediately). W. Record review of a laboratory report dated 10/21/16 revealed a Urinalysis was completed. X. On 12/05/16 at 1:15 pm during an interview, the ADON stated I don't know why the UA wasn't done when it was ordered on [DATE]. Y. On 12/06/16 at 8:20 am, during an interview, the DON stated, The UA was ordered but not done until a month later. The possible outcome for the resident is further re-infection. R #2 Failure to Notify Physician Z. Record review of a progress note for R #2 dated 09/28/16 written by LPN #3 revealed, Resident resting in bed, BS (blood sugar) 46, skin clammy, cold to touch, unresponsive with verbal orders for sternum (the breastbone) rub, administered [MEDICATION NAME] (increases in blood sugar levels) 1 mg (milligram), treatment effective. BS increased to 115. Will continue to monitor. AA. Record review of Convalescent Care Orders dated 09/02/06 from a local hospital revealed Facility to notify MD is BS < (less than) 60 and > (greater than) 200. BB. Record review of the medical record for R #2 did not reveal any entry that the nurse notified the physician or the family. CC. On 12/05/16 at 1:15 pm, during an interview, the ADON stated, The physician and the family should have been notified of the low blood sugar. I cannot find any documentation that the nurse did that. DD. On 12/06/16 at 8:20 pm, during an interview, the DON stated, I was informed yesterday of the low blood glucose. The nurse should have notified the physician of the low blood glucose. EE. On 12/06/15 at 10:00 am, during a phone interview with LPN #3, he stated, I remember he was cold and clammy. I did a finger stick and his blood glucose was very low. The CNA was doing rounds and discovered him. She came to get me right away. I tried to give him some orange juice but he couldn't drink. I gave him the [MEDICATION NAME] injection. I stayed with him until his blood glucose was in the 90's. I may have called the doctor but I don't remember if I documented it. FF. Record review of the facility protocol on [DIAGNOSES REDACTED] (low blood sugar) revealed Documentation: Physician notification and response. GG. Record review of a facility policy for NSG122 Change in Condition: Notification of dated 11/28/18 revealed Policy: A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker, where there is: A significant change in the patient's physical mental or psychosocial status. R #3 HH. Record review of the physician's orders [REDACTED]. II. On 12/06/16 at 12:00 pm, during an interview, LPN #1 stated that R #3's order to expose the wound is still Active . but we don't follow it. JJ. On 12/06/16 at 12:05 pm, during an interview, the DON stated that exposing the wound to air that long could be an infection control issue. It is our decision not follow exposing the wound for 4 hours . We did follow it for a month but have not since. The DON was asked If the facility was not following the order, why was it not discontinued?; the DON responded that the MD (medical doctor) was sometimes not willing to change the orders they recommended. KK. On 12/06/16 at 12:17 pm, during an interview, the Administrator stated that he was unaware that R #3's order was not being followed. The Administrator did agree that this could be an infection control issue. The Administrator confirmed that if the Medical Doctor did not want to change the orders, per the facilities recommendations, then the Facility Medical Director should have been involved to help resolve the issue. LL. Review of Sandra M. Nettina, MSN, ANP-BC, ed. 2014 Lippincott Manual of Nursing Practice - 10th Ed. Philadelphia, PA. Lippincott Williams & Wilkins. ISBN-10: 1-4511-7354-7, ISBN-13: 978-1-4511-7354-3. STAT!Ref Online Electronic Medical Library. <http://online.statref.com/Document.aspx?fxId=485&docId=7>. 12/13/2016 4:31:58 PM CST (UTC -06:00) revealed: Common Departures from the Standards of Nursing Care: Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, communicate information about the patient . adhere to facility policy or procedure.

Based on record review and interview, the facility failed 1)to ensure a foley catheter (indwelling catheter used to drain the bladder) was removed in compliance with a physician order [REDACTED]., the tube draining urine from the bladder) to the rectum was done completely for 1 (R #3) of 1 (R #3) resident sampled for perineal care when they failed to clean R #3 thoroughly.These deficient practices could likely result in the residents being placed at a higher risk for urinary tract infection,[MEDICAL CONDITION] (an overwhelming bacterial infection), and death from septic shock. The findings are: R #1 Foley Catheter A. Record Review of the Physician order [REDACTED]. B. Record review of Skilled Nurses' notes for November 2016 revealed no documentation of the foley catheter being discontinued, or any mention of the order. C. On 12/05/06 at 3:40 pm, during an interview, the ADON stated, Looks like the foley (catheter) was not discontinued. There is no documentation in the notes. They (the nurses) should have charted if it was discontinued and called results to the office. D. On 12/06/16 at 9:50 am, during an interview, the DON stated, There is no documentation. When asked about the possible outcome to the resident, the DON stated, She might have developed a foley related UTI. E. Record review of the medical record for R #1, dated 11/06/16 from a local hospital revealed: admitted with a [DIAGNOSES REDACTED]. R #3 Perineal Care F. On 12/06/16 at 10:30 am, during observation of perineal care by CNA #1, revealed: CNA #1 turned the resident to his side and cleansed stool from the rectum. She used several disposable wipes to remove stool. There was still stool on the wipes when she turned the resident back and told him, We are done. G. On 12/06/16 at 11:05 am, during an interview, CNA #1 was asked, Do you think that resident was clean when there was still that much color on the wipes? CNA #1 stated, Not really. I should have wiped him until there was no color. H. On 12/06/16 at 12:30 pm, during an interview, the DON stated, The CNA should have gotten him clean. That can result in a resident getting a UTI (urinary tract infection), or having bacteria close to the open wound (pressure sore) and possibly causing infection.