Every finding on record at Cedar Ridge Inn

Based on record review and interviews, the facility failed to ensure the environment was free of accident hazards for 1 (R #1) of 1 (R #1) resident, when the facility staff did not utilize safe resident handling techniques during a mechanical lift (a device designed to help staff move a resident from one place to another within a room or from one position to another) transfer. This deficient practice is likely to result in residents experiencing avoidable accidents and increases the risk of serious injury and harm.The findings are: A. Record review of the facility's safe resident handling and mobility policy, dated 2025, revealed staff were responsible for using resident handling equipment and transfer techniques in accordance with each resident's assessed needs to reduce the risk of injury to residents and staff. B. Record review of R #1's face sheet revealed R #1 was admitted on [DATE]. C. Record review of R #1's nursing progress notes, dated 05/12/26, revealed R #1's right leg became caught while staff positioned R #1 into a wheelchair during a two person mechanical lift transfer from the bed to the wheelchair. R #1 immediately cried out in pain during the transfer, nursing staff were notified, and staff completed an incident report. D. Record review of R #1's nursing progress notes, dated 05/13/26, revealed nursing staff assessed R #1 after the reported transfer incident. R #1 complained of right leg pain and rated the pain approximately 5 to 7 on a 10 point pain scale (a standardized scale in which 0 represents no pain and 10 represents the worst pain imaginable). Staff notified the provider, notified the responsible party and Director of Nursing (DON), administered acetaminophen (a medication used to treat pain and reduce fever), and initiated monitoring of R #1's right leg. E. Record review of R #1's nursing progress notes, dated 05/20/26 through 05/25/26, revealed the Nurse Practitioner (NP) evaluated R #1 for intermittent right leg pain and initiated treatment with Biofreeze (a topical analgesic used to temporarily relieve minor muscle and joint pain) and ibuprofen (a nonsteroidal anti-inflammatory drug used to reduce pain and inflammation) ordered as needed. Staff were instructed to continue monitoring R #1, and diagnostic imaging would be obtained if symptoms worsened or failed to improve. F. Record review of R #1's hospital records, dated 06/06/26, revealed diagnostic imaging identified a displaced right proximal femur fracture (a break occurring in the upper portion of the thigh bone near the hip joint), and R #1 underwent an open reduction internal fixation (ORIF; a surgical procedure used to realign and stabilize a fractured bone using internal hardware, such as plates, screws, or rods). G. Record review of R #1's comprehensive care plan, dated 06/17/26, revealed R #1 was dependent on staff for mobility assistance and required mechanical lift use for transfers. H. Record review of R #1's Discharge Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/29/26, revealed R #1 had diagnoses including multiple sclerosis (a chronic disease affecting the brain and spinal cord and disrupting communication between the brain and the body), a nondisplaced intertrochanteric fracture of the right femur with routine healing (a fracture of the upper portion of the right thigh bone healing as expected), and quadriplegia (paralysis affecting all four limbs and the trunk), which made R #1 dependent on facility staff for transfers. I. On 07/16/26 at 2:10 pm, during an interview, Certified Nursing Assistant (CNA) #1 stated she assisted with R #1's mechanical lift transfer on 05/12/26. CNA #1 stated R #1 instructed staff to push against her knees while positioning her into the wheelchair, rather than using the sling handles (a fabric harness used with a mechanical lift to safely transfer a person from one surface to another). CNA #1 stated R #1 immediately cried out in pain during the transfer, but she notified nursing staff. CNA #1 stated R #1 complained of pain during every subsequent transfer following the incident. J. On 07/16/26 at 2:27 pm, during an interview, CNA #2 stated she assisted with R #1's transfer on 05/12/26. CNA #2 stated R #1 frequently directed staff on how she wanted to be transferred. CNA #2 stated the sling handles were the safer method for positioning R #1, but R #1 instructed staff to push against her knees to guide her into the wheelchair. CNA #2 stated R #1 immediately screamed in pain during the transfer after her knees were pushed, nursing staff assessed R #1 after the incident, and staff became fearful of transferring R #1 afterward because of her continued complaints of pain. K. On 07/17/26 at 10:03 am, during an interview, the Administrator stated he was aware of the transfer incident involving R #1 on 05/12/26, and R #1 was later diagnosed with a hip fracture after discharging to the hospital. The Administrator stated staff were expected to use proper mechanical lift transfer techniques, even if a resident requested an alternate method, and this did not occur for R #1's mechanical lift transfer on 05/12/26. L. On 07/17/26 at 10:04 am, during an interview, the Director of Nursing (DON) stated staff were expected to perform proper mechanical lift transfer technique, even if a resident requested an alternate method. The DON stated staff were expected to use the safest transfer method available. The DON stated R #1 was evaluated by therapy and the Nurse Practitioner, and increased swelling prompted R #1's transfer to the hospital on [DATE]. M. On 07/17/26 at 10:20 am, during an interview, the Nurse Practitioner (NP) stated she evaluated R #1 after R #1 reported intermittent pain radiating from the mid thigh to the knee, which primarily occurred when staff repositioned R #1 onto the affected side. The NP stated her assessment did not reveal redness, swelling, guarding, or increased pain with manipulation of the extremity, and she initiated conservative treatment based on those findings.

Based on observation, record review, and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: Food items in the kitchen dry storage were not expired.Food items in the resident-use refrigerator (facility refrigerator designated for storing resident food and beverage items brought in from outside the facility) were not expired. The kitchen food preparation, food service, clean dishes storage, and ice machine areas were free from dust accumulation.This deficient practice is likely to affect all 82 residents identified on the resident census list provided by the Administrator on 06/01/26 and is likely lead to foodborne illnesses in residents if food is not being stored properly, and clean kitchen practices are not followed.The findings are:Expired Food Items:A. On 06/01/26 at 1:14 pm, during an observation, the main kitchen dry storage contained the following expired food items:One 24-ounce (oz) bag of French's crispy fried onions with an expiration date of 06/03/25.One 6-pound (lb) can of Monarch pineapple tidbits in natural juice with an expiration date of 06/22/25.Two 1-gallon containers of Heinz distilled white vinegar with an expiration date of 04/26/26.One 6-lb can of Libby's pure pumpkin with an expiration date of 04/2026. B. On 06/04/26 at 12:25 pm, during an observation, the resident-use refrigerator contained the following expired food items:One 30-oz jar of [NAME] Mayo with an expiration date of 02/14/25.One 15-fluid oz bottle of ReaLemon lemon juice with an expiration date of 09/28/25.One 15-oz container of Land O Lakes fresh buttery taste spread with an expiration date of 11/10/25.One 32-oz container of Santa [NAME] organic pure lemon juice with an expiration date of 12/03/25.One 19-oz container of Clover Valley strawberry squeezable spread with an expiration date of 01/06/26. C. On 06/04/26 at 12:35 pm, during an interview, the Dietary Director (DD) stated expired food items should not be present in the main kitchen dry storage or the resident-use refrigerator. The DD stated he was responsible for ensuring food items were monitored and removed before their expiration dates. The DD stated the dietary department maintained the kitchen dry storage and the resident-use refrigerator, and it was ultimately his responsibility to ensure it was cleaned and free of expired food items. The DD stated that expired foods posed food safety and potential health risks to residents. Dust Accumulation in Food Service Areas:D. Record review of Kitchen Cleaning logs, dated 02/23/26 through 05/25/26, revealed the following:The kitchen staff are responsible for cleaning walls, ceiling, and vents in the cooking areas.The kitchen staff did not document the cleaning of the walls, ceilings, and vents in the cooking areas during the weeks of 02/23/26, 03/01/26, 03/09/26, 03/16/26, 03/26/26, 04/02/26, 04/12/26, 04/20/26, and 04/27/26. The kitchen staff documented the walls, ceilings, and vents in the cooking areas were cleaned on all other dates. E. Record review of the facility's Ice Machine log, dated January 2026 through June 2026, revealed the ice machine and air filters were cleaned on 01/31/26 and 04/30/26. F. On 06/04/26 at 11:17 am, during an observation, the main kitchen had visible gray dust accumulation on the light fixtures and on the ceiling tiles located above the food preparation areas, the serving window, and the clean dish storage areas. The observation also revealed gray dust accumulation on the air filters of the kitchen's ice machine. G. On 06/04/26 at 12:35 pm, during an interview, the DD stated all food service areas and the ice machine air filters should be clean and free of dust accumulation. The DD stated the facility maintenance staff is responsible for cleaning those areas. The DD stated dust accumulation above food service areas and clean dish storage areas could fall into food and contaminate it, placing residents at risk for illness. H. On 06/04/26 at 12:45 pm, during an interview, the Maintenance Director (MD) stated there was dust accumulation above the food service areas in the kitchen and on the ice machine air filters. The MD stated the facility kitchen staff is responsible for ensuring the food service areas remained clean. The MD stated the maintenance staff is responsible for cleaning and maintaining the ice machine. The MD stated the ice machine received a deep cleaning every three months, and it is his expectation that the ice machine and air filters would be wiped down between deep cleanings.

Based on record review and interview, the facility failed to meet professional standards of quality for 1 (R #49) of 2 (R #49 and #71) residents, when:The facility staff did not complete blood laboratory tests (tests and analyses conducted in a laboratory setting to help diagnose and monitor health conditions) as ordered by a physician for a resident who is prescribed an anticoagulant (blood thinner) medication. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: A. Record review of R #49's face sheet revealed an admission date of 07/18/24 and with the following diagnoses: Paroxysmal atrial fibrillation (an irregular heart rhythm that increases the risk of blood clots and stroke).Chronic diastolic congestive heart failure (a condition in which the heart has difficulty filling properly with blood).Pulmonary hypertension (high blood pressure in the arteries of the lungs).Hypertensive chronic kidney disease (long-term high blood pressure leads to kidney damage).Chronic kidney disease, Stage 4 (significant loss of kidney function). B. Record review of R #49's physician orders revealed the following: Dated 12/16/24, PT/INR (Prothrombin Time/International Normalized Ratio; a blood test that measures how long it takes for your blood to clot and standardizes this measurement across different laboratories) one time a day every Monday and Thursday. Dated 03/09/26, Warfarin Sodium Tablet (anticoagulant medication) 4 milligrams (MG). Give 1 tablet by mouth one time a day for treating and preventing blood clots. This medication was discontinued on 05/25/26. Dated 05/25/26, Warfarin Sodium Tablet 3 MG. Give 1 tablet by mouth one time a day for treating and preventing blood clots. This medication was discontinued on 06/04/26. C. Record review of R #49's care plan, dated 05/12/26, revealed R #49 receives a blood thinner to help prevent blood clots, and facility staff must complete blood laboratory tests as ordered. D. Record review of R #49's treatment administration record (TAR) located in the electronic health record (EHR), dated 04/01/26 through 04/30/26, revealed the facility staff completed R #49's PT/INR laboratory test 6 times out of 9 opportunities. E. Record review of R #49's TAR located in the EHR, dated 05/01/26 through 05/31/26, revealed the facility staff completed R #49's PT/INR laboratory test 5 times out of 8 opportunities. F. Record review of R #49's TAR located in the EHR, dated 06/01/26 through 06/04/26, revealed the facility staff completed R #49's PT/INR laboratory test 1 time out of 2 opportunities. G. On 06/05/26 at 5:02 PM, during an interview, the Director of Nursing (DON) stated it is his expectation that resident laboratory testing be completed as ordered by the physician. The DON stated a failure to obtain ordered laboratory tests could result in inadequate monitoring and treatment of the resident's condition. The DON stated R #49's PT/INR laboratory test should have been completed as ordered, but it was not.

Based on record review and interviews, the facility failed to develop and update a comprehensive, person-centered care plan for 2 (R #7 and R #8) of 2 (R #7 and R #8) residents reviewed for care planning, when staff failed to:Develop R #7's care plan to include a schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly) diagnosis. Develop R #8's care plan to include oxygen use. This deficient practice is likely to result in residents not having needs met, decreased quality of life, and avoidable decline in physical and psychosocial well-being. The findings are:A. Record review of the facility's comprehensive care plan policy, provided on 06/05/26, revealed the comprehensive care plan should describe services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy stated the comprehensive care plan should include measurable objectives and timeframes to meet the resident's identified needs, so staff responsible for carrying out interventions would be notified of their roles and responsibilities.R #7:B. Record review of R #7's face sheet revealed R #7 was initially admitted into the facility on [DATE] with the following diagnosis:Schizophrenia. C. Record review of R #7's active physician orders revealed the following:Dated 05/12/26, an order for Valproic Acid (anticonvulsant medication) 250 milligrams (mg) by mouth twice daily for the treatment of schizophrenia.Dated 06/01/26, an order for Benztropine Mesylate (medication used to treat movement disorders and side effects from antipsychotic medication use) 0.5 mg twice daily for the treatment of schizophrenia. D. Record review of R #7's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/23/26, revealed staff documented the resident has an active diagnosis of schizophrenia. E. Record review of R #7's care plan, dated 06/03/26, revealed the care plan did not include goals, a focus area, or interventions related to R #7's schizophrenia diagnosis. F. On 06/05/26 at 9:53 am, during an interview, the Licensed Practical Nurse (LPN) #1 stated R #7 has an active diagnosis of schizophrenia, and the facility nursing staff monitor R #7 for any reactions related to the medication he is taking for the schizophrenia diagnosis. G. On 06/05/26 at 11:00 am, during an interview, the Director of Nursing (DON) stated R #7 has an active diagnosis of schizophrenia. The DON stated that his expectation is for the R #7's schizophrenia diagnosis to be included in the care plan, but it was not. R #8:H. Record review of R #8's face sheet revealed R #8 was initially admitted into the facility on [DATE] with the following diagnosis:Chronic Obstructive Pulmonary Disease (COPD; lung disease). I. Record review of R #8's active physician orders, dated 05/08/26, revealed R #8 is prescribed continuous oxygen use at 2 liters per minute (LPM) via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). J. Record review of R #8's care plan, dated 06/02/26, revealed the care plan did not include goals, a focus area, or interventions related to R #8's oxygen use. K. On 06/01/26 at 2:34 pm, during an interview, R #8 stated she uses oxygen every night at 2 to 3 LPM. L. On 06/05/26 at 9:53 am, during an interview, the LPN #1 stated R #8 uses oxygen. M. On 06/05/26 at 11:00 am, during an interview, the DON stated residents receiving oxygen therapy are expected to have oxygen use included in their care plans. The DON stated R #8's oxygen use should be care planned, but it was not.

Based on record review and interviews, the facility failed to ensure staff revised the care plan for 1 (R #69) of 1 (R #69) resident reviewed, when:The facility staff failed update R #69's plan of care to include a newly obtained coccyx (tail bone) bruise and the related treatment interventions. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of the facility's comprehensive care plan policy, dated 2025, revealed the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The policy further revealed alternative interventions will be documented as needed. B. Record review of R #69's face sheet revealed R #69 was admitted into the facility on [DATE] with the following diagnoses:Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body following a stroke) affecting the left dominant side.History of falling.Need for assistance with personal care.Generalized muscle weakness.Unsteadiness on feet.Age-related osteoporosis (bones become extremely porous and are subject to fracture and slow healing) with current pathological fracture of the left femur (long bone that connects the hip to the knee) with delayed healing. C. Record review of R #69's skin and wound report, dated 05/26/26, revealed R #69 has a new in-house acquired (developed at the facility) bruise to the lower back. Documentation revealed R #69's bruise measured 7.55 centimeters (cm) in length and 6.62 cm in width. D. Record review of R #69's physician orders, dated 05/29/26, revealed an order to monitor R #69's coccyx bruise every shift and notify the wound treatment nurse of any changes. E. On 06/02/26 at 9:49 AM, during an interview, R #69 stated she has a bruise on her tailbone that has significantly increased in size over the previous week. R #69 stated the bruise causes her to experience pain, and the facility staff are aware of her bruise. F. Record review of R #69's comprehensive care plan, dated 06/04/26, revealed R #69's care plan was not revised to include the resident's coccyx bruise or related treatment interventions. G. On 06/04/26 at 5:00 PM, during an interview, the Director of Nursing (DON) stated R #69's care plan did not include the resident's coccyx bruise and should have. The DON stated the facility staff should have revised R #69's care plan to include the resident's coccyx bruise and related treatment interventions.

Based on observations and interviews, the facility failed to ensure the proper storage of medications and medical supplies located in the medication storage room, when: Multi dose medication vials stored in the medication refrigerator were not dated after being opened. Expired medical supplies were not removed from the medication storage room.This deficient practice has the potential to affect all 82 residents, as identified by the census provided by the Administrator on [DATE]. If the facility fails to ensure accurate medication labeling and the removal of expired medical equipment, then residents are at an increased risk of medication ineffectiveness and potential adverse (unwanted) resident outcomes.The findings are: A. On [DATE] at 8:45 a.m., during an observation of the locked medication storage room, a multi dose vial of Tuberculin Purified Protein Derivative (PPD; skin test used to determine if someone has developed an immune response to the bacterium that causes tuberculosis, TB) Mantoux Tubersol, five tuberculin units (TU)/0.1 milliliter (ml), was found in the medication refrigerator without a date indicating when it was first opened. Neither the vial nor the box was dated, and the manufacturer's expiration date was 02/2028. B. On [DATE] at 8:45 a.m., during an interview, the Director of Nursing (DON) stated the PPD Mantoux Tubersol vial and box were not dated, and they should have been. C. On [DATE] at 8:50 a.m., during an observation of the locked medication storage room, multiple unopened intravenous (IV; into the vein) catheters were found to be expired, with an expiration date of [DATE]. D. On [DATE] at 8:50 a.m., during an interview, the DON stated the IV catheters were expired and should have been removed from the medication storage room before reaching their expiration date.

Based on record review and interviews, the facility failed to ensure resident's medical records contained documentation regarding education, offering, or administration of the COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccination (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 1 (R #17) out of 5 (R #6, R #7, R #10, R #17, and R #72) residents reviewed. This deficient practice is likely to result in residents not being provided information regarding opportunity for vaccination, and further result in increased risk of infection.The findings are:A. Record review of the facility's Immunization and Vaccination policy, provided on 06/05/26, revealed the resident's medical record must include documentation that the resident or resident representative received education on the benefits and potential side effects of immunizations, and whether the resident received the immunization or did not receive it due to refusal or medical contraindication. B. Record review of R #17's face sheet revealed R #17 was initially admitted into the facility on [DATE]. C. Record review of R #17's electronic health record (EHR), dated 06/03/26, revealed the following:R #17's immunization record, dated 09/24/24, revealed R #17 refused the COVID-19 vaccine.A COVID-19 vaccination consent and/or refusal form was not present in R #17's EHR.The EHR did not contain documentation indicating that R #17 or R #17's representative received education regarding the benefits and potential side effects of the COVID-19 vaccine. D. On 06/03/26 at 9:19 am, during an interview, the Infection Preventionist (IP) stated the education for the COVID 19 vaccine was provided to residents or their representatives along with the vaccination consent and/or refusal form. The IP stated the vaccination consent and/or refusal form was the only location where this education was documented. The IP confirmed that R #17 did not have a COVID 19 vaccination consent and/or refusal form in her EHR. The IP stated she was responsible for ensuring that residents' vaccination forms were uploaded into their EHR. E. On 06/05/26 at 9:40 AM, during an interview, the Director of Nursing (DON) stated the COVID-19 vaccine education was only documented on the vaccination consent and refusal forms. The DON stated the completed vaccination consent and refusal forms should be scanned into the resident's EHR. The DON stated it is his expectation the vaccination consent and refusal forms would be current and available in the resident's EHR. The DON stated R #17 did not have a COVID-19 vaccination consent and/or refusal form completed but should have. The DON stated without documentation, residents may be at risk of being uninformed regarding whether to accept or decline vaccines.

Based on record review and interview, the facility failed to ensure advanced directives (documents providing an individual's wishes for emergency and lifesaving care) was available in the electronic health record (EHR) for 1 (R #18) of 1 (R #18) resident. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.The findings are: A. Record review of R #18's face sheet revealed an admission date of 05/19/2026 with R #18's code status (information that lets the resident's medical team know what they want and do not want in the event of a medical emergency such as their heart stopping) being a full code (lifesaving procedures desired). B. Record review of R #18's EHR, dated 06/03/2026, revealed a completed MOST form was not available for the resident. C. On 06/03/2026 at 1:34 PM, during an interview, the Licensed Practical Nurse (LPN) #2 stated she could not locate R #18's MOST form in the EHR. The LPN #2 stated it is her expectation that a resident's MOST form be present in the EHR. D. On 06/04/2026 at 9:45 AM, during an interview, the Director of Nursing (DON) stated R #18's MOST form should be available in the EHR, but it was not. E. On 06/05/2026 at 10:33 AM, during an interview, the Social Services Director (SSD) stated R #18's MOST form was completed on 05/20/2026, but it was not uploaded into the EHR and should have been. The SSD stated if a resident's MOST form is not available in the EHR, the resident's treatment preferences and code status may not be honored.

Based on record review and interview, the facility failed to submit the required incident summary report and the five-day follow-up investigation results to the State Agency (SA) for 1 (R #69) of 1 (R #69) resident reviewed for injuries of unknown origin. If the facility is not submitting the incident summary and the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Record review of the facility's abuse, neglect, exploitation, misappropriation of resident property and reporting policy, revised 2025, revealed an immediate investigation is required when there is a suspicion or report of abuse, neglect, or exploitation. The policy stated the investigations must include identifying and interviewing involved persons and witnesses, determining the extent and cause of the incident, and providing complete and thorough documentation of the investigation. B. Record review of R #69's face sheet revealed R #69 was admitted into the facility on [DATE] with the following diagnoses: Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body following a stroke) affecting the left dominant side.History of falling.Need for assistance with personal care.Generalized muscle weakness.Unsteadiness on feet.Age-related osteoporosis (bones become extremely porous and are subject to fracture and slow healing) with current pathological fracture of the left femur (long bone that connects the hip to the knee) with delayed healing. C. Record review of R #69's skin and wound report, dated 05/26/26, revealed R #69 has a new in-house acquired (developed at the facility) bruise to the lower back. Documentation revealed R #69's bruise measured 7.55 centimeters (cm) in length and 6.62 cm in width. D. Record review of R #69's physician orders, dated 05/29/26, revealed an order to monitor R #69's coccyx bruise every shift and notify the wound treatment nurse of any changes. E. On 06/04/26 at 3:50 PM, during an interview, the Certified Nursing Assistant (CNA) #9 stated they observed R #69's bruising when it first appeared. The CNA #9 stated they reported R #69's bruising to the nursing staff and R #69's bruising increased in size over several days. The CNA #9 stated R #69 denied falling and staff did not identify a fall as the cause of the bruising. F. On 06/04/26 at 4:00 PM, during an interview, the Director of Nursing (DON) stated he was unable to identify who discovered R #69's bruise and he could not determine a documented cause for the injury. The DON stated that if the source of a bruise is unknown, it is considered an injury of unknown origin. The DON stated the facility's expectation is to report an injury of unknown origin to the State Agency. The DON stated R #69's bruising incident summary report and the five-day follow-up investigation report was not completed and submitted to the State Agency and should have been.

Based on record review and interview, the facility failed to ensure a resident's Level 1 Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was reviewed for accuracy for 1 (R #8) out of 1 (R #8) resident reviewed. If the facility fails to review PASARR screenings for accuracy, then residents with serious mental illness or intellectual disability may receive inappropriate placement and care. The findings are:A. Record review of the facility's Coordination with PASARR Program policy, provided on 06/05/26, revealed all applicants would be screened for serious mental disorders, intellectual disabilities, and related conditions through the PASARR process. The policy stated the Social Services Director (SSD) was responsible for tracking each resident's PASARR screening status and making the appropriate referrals. B. Record review of R #8's face sheet revealed R #8 was initially admitted into the facility on [DATE] with the following diagnosis:Major depressive disorder (an episode of depression with mild symptoms that cause functional impairment). C. Record review of R #8's PASARR Level I Identification Screening, dated 02/03/26, revealed staff documented the resident did not have diagnoses such as depression. D. Record review of R #8's care plan, dated 02/16/26, revealed R #8 used antidepressant medication related to depression. E. On 06/05/26 at 10:37 AM, during an interview, the SSD stated R #8's PASARR, dated 02/03/26, was inaccurate because it did not include R #8's diagnosis of major depressive disorder. The SSD stated it is her responsibility to ensure PASARRs are accurate. The SSD stated an inaccurate PASARR could result in the facility missing recommended services or interventions for a resident.

Based on record review and interviews, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #18) of 1 (R #18) residents, when: R #18's baseline care plan was incomplete and inaccurate because it failed to include the resident's oxygen use.If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care). The findings are: A. Record review of the facility's baseline care plan policy, revised 01/2025, revealed the following:The baseline care plan must be developed within 48 hours of a resident's admission, and it must include the minimum healthcare information necessary to properly care for a resident, including physician orders. Interventions shall be initiated to address the resident's current needs, including any health and safety concerns. Any services and treatments to be administered by the facility shall be included in the baseline care plan. The admitting nurse or supervising nurse shall gather information from physician orders and the admission assessment when developing the baseline care plan. B. Record review of R #18's face sheet revealed an admission date of 05/19/2026 and the following diagnoses:Type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin).Hypoxemia (low levels of oxygen in the blood). Generalized muscle weakness.Localized edema (swelling caused by excess fluid).Hypertension (HTN; high blood pressure). C. Record review of R #18's physician orders, dated 05/19/2026, revealed an order for oxygen at 1 liter per minute (LPM) continuously via nasal cannula (NC; a small, flexible tube that delivers supplemental oxygen through soft prongs inserted into the nostrils). D. Record review of R #18's baseline care plan, dated 05/19/2026, revealed the baseline care plan did not include R #18's oxygen use. E. On 06/04/2026 at 9:32 AM, during an interview, the Director of Nursing (DON) stated care planning is part of the interdisciplinary team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident) process. The DON stated it is his expectation that R #18's oxygen use be included in R #18's baseline care plan, but it was not.

Based on observations, record review, and interviews, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #3) of 1 (R #3) resident reviewed for respiratory care, when the facility failed to: Administer oxygen therapy per physician orders for R #3.This deficient practice is likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions.The findings are: A. Record review of the facility's oxygen administration policy, dated 2025, revealed the following: Oxygen is administered to residents who need it, consistent with professional standards of practice, and is administered under physician orders. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them.Equipment needed for oxygen administration includes an oxygen source. B. Record review of R #3's face sheet revealed an admission date of 03/20/2026 and with the following diagnoses:Pulmonary Embolism (a blood clot in the lungs that can impair blood flow and oxygen exchange).Anemia (low red blood cell count)Fracture of upper end of right humerus (a break in the upper portion of the upper arm bone). C. Record review of R #3's physician orders, dated 03/20/2026, revealed R #3 is prescribed oxygen at 2 liters per minute (LPM) continuously (without interruption or gaps) with a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs) every day. D. On 06/02/2026 at 12:33 PM, during an observation and interview, R #3's portable oxygen tank gauge indicated the oxygen tank was empty. R #3 stated her portable oxygen tank was empty, and she was not receiving oxygen. E. On 06/02/2026 at 12:36 PM, during an observation, the Assistant Director of Nursing (ADON) replaced R #3's portable oxygen tank because it was empty. F. On 06/02/2026 at 12:37 PM, during an interview, the Licensed Practical Nurse (LPN) #1 stated it is her expectation that residents receiving oxygen therapy do not have empty portable oxygen tanks. The LPN #1 stated if a resident's portable oxygen tank is empty, the resident could become hypoxic (have low oxygen levels in the body's tissues). G. On 06/05/2026 at 10:33 AM, during an interview, the Director of Nursing (DON) stated it is his expectation that all residents receiving oxygen therapy do not have empty portable oxygen tanks. The DON stated if a portable oxygen tank is empty, the resident may not receive oxygen as ordered, increasing the risk of hypoxia and inadequate care.

Based on observation, record review, and interviews, the facility failed to ensure a resident's documented dietary allergy was honored for 1 (R #34) of 1 (R #34) resident reviewed. This deficient practice is likely to result in food intolerance and/or an allergic reaction to the food served to residents.The findings are:A. Record review of the facility's Food Preparation Guidelines policy, dated 2026, revealed staff shall accommodate resident allergies, intolerances, and preferences by providing appropriate alternatives when needed. The policy stated resident preferences and allergies shall be obtained during the resident assessment process and added to the resident's dietary tray card. The policy stated staff shall offer residents appropriate alternatives when they choose not to consume food initially served. B. Record review of R #34's admission record revealed R #34 was admitted into the facility on [DATE] with documented dietary allergies to tomatoes and tomato-based products. C. Record review of R #34's active physician orders, dated 11/08/23, revealed R #34 is allergic to tomatoes and tomato-based products. D. Record review of R #34's care plan, dated 03/26/26, R #34 is allergic to tomatoes and tomato-based products. E. Record review of R #34's dietary tray ticket, dated 06/03/26, revealed R #34's dietary order was a regular diet with double portions and a documented tomato allergy. F. On 06/03/26 at 1:02 pm, during an observation, R #34's lunch tray contained ravioli with a red tomato-based sauce, green beans, a breadstick, and ranch dressing. The observation further revealed the dietary tray ticket accompanying the meal identified R #34's tomato allergy. G. On 06/03/26 at 1:15 pm, during an interview, R #34 stated he did not consume the meal served on his lunch tray because the facility staff served him food containing tomatoes. R #34 stated that if he consumes tomatoes or tomato-based products, bumps or sores will form in his mouth. H. On 06/03/26 at 1:16 pm, during an interview, Certified Nursing Assistant (CNA) #10 stated R #34 informed her that he could not eat the ravioli meal because of his tomato allergy. CNA #10 stated she obtained two peanut butter and jelly sandwiches from the kitchen and delivered them to R #34 as a replacement meal. I. On 06/03/26 at 2:25 pm, during an interview, the Dietary Manager (DM) stated the facility dietary staff identify food allergies through the tray ticket system. The DM stated the facility staff would provide an alternative meal when a menu item contained food to which a resident was allergic. The DM stated it is his expectation that a meal containing tomato products would not be served to a resident with a documented tomato allergy. J. On 06/03/26 at 2:45 pm, during an interview, Licensed Vocational Nurse (LVN) #1 stated R #34's tomato allergy included tomatoes and tomato-based products such as tomato sauce and ketchup. The LVN #1 stated she was unaware of any documentation indicating R #34 elected to consume tomato products despite the documented allergy. The LVN #1 stated R #34's tray ticket identified a tomato allergy. K. On 06/04/26 at 10:00 am, during an interview, the Director of Nursing (DON) stated it is her expectation that the facility staff do not serve residents foods listed on their documented allergy list. The DON stated the facility staff are expected to follow documented allergy information and not serve foods identified as allergens when a food allergy is documented.

Based on record review and interviews, the facility failed to ensure resident's medical records contained documentation regarding education, offering, or administration of the influenza (a highly contagious viral infection of the respiratory passages causing fever and severe aching) vaccination (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 1 (R #17) out of 5 (R #6, R #7, R #10, R #17, and R #72) residents reviewed. This deficient practice is likely to result in residents not being provided information regarding opportunity for vaccination, and further result in increased risk of infection.The findings are: A. Record review of the facility's Immunization and Vaccination policy, provided on 06/05/26, revealed that the resident's medical record must include documentation showing the resident or resident representative received education on the benefits and potential side effects of immunizations, and whether the resident received the immunization or did not receive it due to refusal or medical contraindication. B. Record review of R #17's face sheet revealed R #17 was initially admitted into the facility on [DATE]. C. Record review of R #17's electronic health record (EHR), dated 06/03/26, revealed the following:R #17's immunization record, dated 10/13/25, revealed R #17 refused the influenza vaccine.An influenza vaccination consent and/or refusal form was not present in R #17's EHR.The EHR did not contain documentation indicating that R #17 or R #17's representative received education regarding the benefits and potential side effects of the influenza vaccine. D. On 06/03/26 at 9:19 am, during an interview, the Infection Preventionist (IP) stated the education for the influenza vaccine was provided to residents or their representatives along with the vaccination consent and/or refusal form. The IP stated the vaccination consent and/or refusal form was the only location where this education was documented. The IP stated R #17 did not have an influenza vaccination consent and/or refusal form completed and should have. The IP stated she was responsible for ensuring that residents' vaccination forms were uploaded into their EHR. E. On 06/05/26 at 9:40 AM, during an interview, the Director of Nursing (DON) stated the facility staff documented influenza vaccine education only on the vaccination consent and refusal forms. The DON stated the staff should scan the completed vaccination consent and refusal forms into the resident's EHR. The DON stated he expected the vaccination consent and refusal forms to be current and available in each resident's EHR. The DON stated R #17 did not have a completed influenza vaccination consent or refusal form for 2025 but should have had one. The DON stated without documentation, residents may be at risk of being uninformed about whether to accept or decline vaccines.

Based on record review and interviews, the facility failed to provide quality care that meets professional standards for 1 (R #2) of 3 (R #2, #3, and #7) residents reviewed, when staff: Discontinued an eye drop medication without a physician's order and authorization. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider, and potential complications. The findings are: A. Record review of R #2's face sheet revealed an admission date of 07/01/23 with the following diagnoses:Cerebral infarction (the death of brain tissue due to lack of blood flow),Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life),Glaucoma (a group of eye conditions that can cause blindness). B. Record review of R #2's physician orders revealed the following: Start date of 02/23/26, Dorzolamide HCI-Timolol Maleate PF (eye drops used to treat high eye pressure caused by glaucoma), instill one drop in the right and left eye, one time per day in the morning. Physician order was discontinued on 03/04/26. Start date of 02/23/26, Dorzolamide HCI-Timolol Maleate, instill one drop in the right and left eye, one time per day in the evening. Physician order was discontinued on 03/04/26.Start date of 03/11/26, Dorzolamide HCI-Timolol Maleate, instill one drop in the right and left eye, one time per day in the evening. Physician order was discontinued on 04/08/26. Start date of 03/12/26, Dorzolamide HCI-Timolol Maleate, instill one drop in the right and left eye, one time per day at 5:00 am. Physician order was discontinued on 04/08/26. C. Record review of R #2's medication administration record (MAR), dated 03/01/26 through 03/31/26, revealed R #1 was not administered the Dorzolamide HCI-Timolol Maleate eye drops due to an active order no longer being available. D. Record review of R #2's nursing progress notes, dated 4/28/26, revealed the Dorzolamide HCI-Timolol Maleate eye drops were discontinued on 03/05/26 by the facility without a physician's order to discontinue the eye drops. E. On 04/28/26 at 12:50 pm, during an interview, the Administrator stated R #2's eye drops did get discontinued by accident. He stated R #2's daughter was informed of the missed medication and was upset about it. The Administrator stated R #2's eye drop medication should not have been discontinued without physician authorization. F. On 04/28/26 at 2:45 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated she accidently discontinued R #2's eye drops, and she did not realize the mistake for five days. The LPN #1 stated once she realized the error, she called the pharmacist, and they sent over new eye drops for R #2. G. On 04/28/26 at 1:02 pm, during an interview, the Director of Nursing (DON) stated R #2's eye drop medication should not have been discontinued by accident because there was no physician order to discontinue the medication.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident reviewed, when: The facility did not provide continuous oxygen (O2) per physician's orders due to O2 equipment failure. If the facility fails to provide O2 per physician orders, then residents may receive substandard care and treatment, placing them at risk for preventable harm.The findings are: A. Record review of R #1's face sheet revealed an admission date of [DATE] with the following diagnoses:Fracture left femur (long bone that connects the hip to the knee),Chronic obstructive pulmonary disease (COPD; lung disease),Acute respiratory failure (low oxygen levels in the blood and can damage vital organs),Pulmonary fibrosis (scarring of the lung). B. Record review of R #1's nursing progress notes, dated [DATE], indicated R #1 was sent to the emergency room (ER) due to R #1 having abnormal vital signs (body temperature, pulse rate, respiration [rate of breathing], oxygen saturation [amount of oxygen in the blood], and blood pressure). R #1 was admitted into the hospital due to her having a urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra). C. Record review of R #1's hospital notes, dated [DATE], revealed the following:R #1 was diagnosed by hospital staff with Pulmonary fibrosis, Sepsis (a serious condition in which the body responds improperly to an infection), and a urinary tract infection.The hospital recommended palliative care (relieve symptoms, stress and discomfort associated with serious or chronic illness).R #1 was discharged from the hospital and back to the facility on [DATE] at 3:55 pm. D. Record review of R #1's physician orders, dated [DATE], revealed an order for O2 at 2 liters per minute continuously with a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). E. Record review of R #1's nursing progress notes, dated [DATE], revealed the following:At 4:06 pm, R #1 arrived at the facility on a stretcher while wearing 2 liters of O2. R #1 was restless and grabbing at the air. R #1 was placed in bed and an O2 concentrator (a medical device that extracts oxygen from the surrounding air, providing patients with a continuous supply of oxygen-enriched air) was put into place. The facility nurse attempted a variety of connectors for the O2 concentrator. R #1 was placed on a portable oxygen tank with a mask because the O2 concentrator was ineffective. At 4:17 pm, the facility nurse received a report on R #1 from the hospital staff. R #1 had been admitted and treated for a UTI and sepsis. R #1 was discharged back to the facility on palliative care, and R #1 was orientated to person while being restless.At 5:55 pm, R #1 was pronounced deceased by the facility Nurse Practitioner (NP). R #1 was examined at the bedside and found to be unresponsive, and breathing respirations were not observed. R #1 did not have a heart rate present. F. On [DATE] at 3:54 pm, during an interview, R #1's daughter stated once the staff got her mother in bed, they took her off the portable O2 tank provided by the ambulance staff and provided O2 with the facilities O2 concentrator. The facility O2 concentrator was not working properly, and a facility nurse went to get another O2 concentrator. R #1's daughter stated it had been a while since R #1 was on O2 while the facility staff looked for another O2 concentrator. The facility nurse brought in another O2 concentrator, but that O2 concentrator was not working either. By the time the facility nurse returned with the portable O2 tank, the NP was present next to R #1 and stated R #1 did not need the O2 because she had died. R #1's daughter stated it took the facility nurse approximately 15 minutes to bring the portable O2 tank to R #1. G. On [DATE] at 11:43 am, during an interview, with Director of Nursing (DON) stated he was not there at the time R #1 came back to the facility on [DATE], but he was called after R #1 passed. He got report from a facility nurse that R #1's family was very upset. The DON stated he asked the staff why a portable O2 tank was not in place when R #1's O2 concentrators were not working, to keep R #1 on continuous O2 per physician orders. H. On [DATE] at 12:15 pm, during an interview, the NP stated R #1 was sent back to the facility from the hospital on comfort care measures (a distinct and compassionate approach within medical care, signifying a shift in focus from attempting to cure an illness to maximizing a person's quality of life). She stated R #1's death was not a surprise to anyone, and she recalled the family being very upset. She stated R #1 took her last breath when she arrived at R #1's room. She listened and checked R #1's pulse, and after a few minutes, she pronounced R #1's death. She stated R #1 was wearing O2 from a facility O2 concentrator when she saw her, but the O2 concentrator was not working properly. The NP stated she did not know how long R #1's O2 concentrator was not working, but even if R #1's O2 concentrator was working properly, it would not have changed the outcome because R #1's health was already declining.

Based on interview and record review, the facility failed to prevent the worsening of a pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin)for 1 (R #10) of 3 (R #10, #12 and #13) residents when staff failed to notify the physician when the resident's right gluteal fold (buttocks) wound worsened. If the facility does not recognize and notify the physician when a wound deteriorates, then the wound may worsen, become infected, and result in hospitalization. The findings are: A. Record review of R #10's face sheet revealed an initial admission date of 12/02/21 with a diagnosis of multiple sclerosis(MS; a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue). B. Record review of R #10's care plan, dated 09/09/24, revealed R #10 was dependent on staff assistance for all activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). C. Record review of R #10's wound assessment revealed the following: -On 07/17/25, an abrasion (partial thickness wound caused by damage to the skin) on R #10's right gluteal fold. Length (l) 0.82 centimeters (cm), width 0.6 cm. -On 07/31/25, an abrasion on R #10's right gluteal fold. Length 2.24 cm, width 1.19 cm, depth 1 cm. -On 08/06/25, an abrasion on R #10's right gluteal fold. Length 5.6 cm, width 3.12 cm. The wound was 70 percent (%) slough(yellow stringy tissue adhered to wound bed). - On 08/11/25, an abrasion on R #10's right gluteal fold. Length 3.7 cm, width 2.49 cm, depth 2.5 cm. The wound had a suspected infection and was 70% slough with increased drainage. - On 08/19/25, a stage III pressure sore (full thickness skin loss that extends into deeper tissue and fat but not into muscle, tendon, or bone)on R #10's right gluteal fold. Length 3.9 cm, width 3.17 cm, depth was 3.5 cm. The wound was debrided (medical removal of dead, damaged, or infected tissue) at the hospital, and a negative pressure wound therapy (NPWT; a treatment that uses suction to help wounds heal)was put into place. - On 08/25/25, a stage III pressure soreon R #10's right gluteal fold. Length 4.59 cm, width 3.31 cm, depth was 3.5 cm. The wound was 30 percent slough (yellow stringy tissue adhered to wound bed). D. Record review of R #10's physician orders revealed the following: - Monitor open area to right buttock for signs and symptoms of infection. Notify medical doctor (MD) for any changes every shift. Start 07/17/25 and end on 08/05/25. -Right buttock open area: Cleanse site with wound cleanser and apply foam dressing, daily every day shift for wound. Start date 07/18/25 and end on 07/31/25. -Right buttock open area: Cleanse site wound cleanser and apply skin prep to periwound. Apply collagen to wound bed and cover with mepilex (foam dressing for acute and chronic wounds). Change dressing as needed. May discontinue when resolved. Completeevery day shift for wound care. Start date 08/01/25 and end on 08/04/25. -Right buttock open area: Cleanse site wound cleanser, apply skin prep to peri wound, apply medihoney(wound and burn gel)to wound bed cover with mepilex. Start on 08/04/25 and end on 08/05/25. -Right gluteal (buttock) fold: Unstageable [a wound that has full thickness tissue loss but is covered with slough (dead tissue) or eschar (dark scab or falling away of dead skin) so that the true depth of the wound cannot be determined] pressure ulcer. Clean wound and dry with gauze. Apply a thin layer of Santyl (medication used to treat severe burn or skin ulcers by removing dead skin tissue and aid in wound healing)to wound bed. Cover with a foam bordereddressing. Start date 08/05/25 and end on 08/06/25. - Wound Care to right Gluteal fold unstageable PU: Clean wound and dry with gauze, apply skin prep to peri wound, apply a thin layer of Santyl to wound bed, cover with a foam bordered dressing. May change as needed if dressing is soiled. Every shift for wound care. Start date 08/08/25 0846 and end date 08/13/25. E. Record review of R #10's Medication Administration Record (MAR) dated 07/18/25 to 07/31/25, revealed the following: - Staff did not provide wound care to R #10 on 07/28/25. The record did not state why the wound care was not provided. - Staff did not provide wound care to R #10 on 07/29/25. The record did not state why the wound care was not provided. F. Record review of R #10's MAR, dated 08/01/25 to 08/06/25, revealed the following: - Staff did not provide wound care to R #10 on 08/01/25. The record did not state why the wound care was not provided. G. Record review of R #10's electronic health record revealed the following: -The record did not contain any progress notes indicating staff notified the physician of the resident's deteriorating wound from 07/17/25 to 08/05/25. -The record did not contain an order to send the resident out to the hospital. H. Record review of R #10's admission hospital record, dated 08/11/25, revealed R #10 had altered mental status (a change in mental function related to brain issues) at the facility and was picked up by an ambulance. The resident had evidence of urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra) and a pressure ulcer that was inflamed and hot. The R #10 had bacteremia (bacteria andinfectious organismsin your blood) with enterococcus faecalis (a bacteria found in the intestines that causes a serious infection) related to the right ischial pressure wound (right gluteal fold). I. Record review of R #10's hospital discharge record, dated 08/14/25, revealed the following: - Post debridement (medical procedure that involves the removal of dead, damaged, or infected tissue from a wound to promote healing): -Right ischium with full thickness wound (severe injury that extends through all layers of the skin). -Wound was malodorous (bad odor or smell). -Wound bed after debridement with liquifying necrotic tissue (process where dead tissue transforms into a liquid mass, often due to bacterial or fungal infections, or as a result of lack of blood supply). -Wound edges well defined. -Measurement: length 5 cm by width 4.6 cm by depth 1.8 cm. Undermining (erosion under the wound edges) from 3:00-9:00 (significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) with a depth of 1.5 cm. J. On 08/26/25 at 1:24 pm, during an interview, the Wound Care Nurse (WCN) stated the wound on R #10 was found on Friday, 07/18/25. She stated she put in an order for daily cleaning and to keep the wound covered on 07/18/25. She stated she planned to go to the facility on Monday, 07/21/25, to reassess the resident's wound, but she was out sick for at least one week. She stated she added collagen to the resident's wound care order on 08/01/25, and then she changed to medihoney for a day. She stated the Director of Nursing became involved on 08/06/25, and she called the physician and the wound care contract company to come take a look at the resident's wound. She stated new orders were put in for Santyl around 08/06/25. K. On 08/26/25 at 2:20 pm and 08/27/25 at 8:38 am, during an interview, Nurse #3 stated she provided wound care for R #10 and documented the care in the MAR. She stated the beginning of R #10's wound was just very tiny, but then she saw a larger dark area emerge. She stated she observed the resident's wound start to change, and she was alarmed by it. She stated she did not reach out to the physician, the WCN, or the DON. She stated she should have contacted them. L. On 08/26/25 at 3:45 pm, during an interview, the Director of Nursing (DON) stated she became aware of the resident's wound on 07/18/25. The DON stated she was not at the facility from 07/28/25 through 08/01/25. She stated she returned to the facility on [DATE]. The DON stated R #10's wife showed her pictures of the wound on 08/05/25, and she immediately called the physician. The DON stated the Wound Care Nurse Practitioner (WCNP) to come to the facility for a consult and to put in orders for Santyl on 08/05/25. The DON stated she was not aware of the deterioration of the wound prior to 08/05/25. The DON stated the Assistant Director of Nursing (ADON) was also not at the facility during the same time period. The DON stated the WCN should have called the physician to report the wound was getting worse. She stated the WCN should have notified her as well, even though she was out. The DON stated the resident's wound was red and hot when she saw it on 08/05/25, and she suspected the wound was infected. M. On 08/27/25 at 10:30 am, during an interview, the Medical Director (MD) stated he did not remember when he was notified of the wound for R #10, and he was usually in the building every week. The MD stated he was aware of the wound before R #10 went out to the hospital on [DATE]. He stated it was expected staff would notify him of any change in condition, to include worsening wounds. N. On 08/27/25 at 11:20 am, during an interview, Family Member #10 stated she was aware of the wound on 07/18/25. She stated she watched it get worse and talked to the facility nursing staff about it. She stated she went to the DON on 08/05/25 and showed her a picture of the wound. She stated the DON got a consult for R #10 on 08/05/25 and the orders were changed. Family member #10 stated R #10 was put on antibiotics (08/06/25), but he ended up in the hospital with an infection 08/11/25. O. On 08/27/25 at 11:36 am, during an interview, the WCNP stated the first time she saw the wound was on 08/07/25. She stated the wound was an unstageable pressure wound with 100% dry eschar. She stated the facility already ordered Santyl, and that was the treatment she would have put into place. The WCNP stated a wound culture could not be done due to the dry eschar. She stated she did not see R #10 again, because the resident went out to the hospital.

Based on observation, interview and record review the facility failed to secure an oxygen cylinder to prevent tipping and falling over for 1 (R #13) of 2 (R #13 and R #14) residents. If the oxygen container fell over, then the valve could break on the canister and cause the residual oxygen to leak or cause the oxygen cylinder to self-propel across the facility. The findings are: A. Record review of the facility's oxygen safety policy, last revised 2025, indicated oxygen cylinders will be properly chained or supported in racks or other fastenings (sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full or empty. B. On 08/26/25 at 10:35 am, an observation revealed R #13's oxygen tank sat unsecured next to her recliner. R #13 was not using the oxygen. C. On 08/26/25 at 10:35 am, during an interview, the Director of Nursing (DON) stated the portable oxygen container should not be in R #13's room. She stated oxygen cylinders should not be stored unsecured, because it could cause an accident.

Based on observation and interview, the facility failed to maintain the kitchen in a sanitary manner for all residents who received food or drinks in the facility when staff failed to: - Keep the kitchen dust and grime free. - Ensure the ice machine drained through an air gap. These failures had the potential to result in cross-contamination and foodborne illness which could affect all residents who ate food from the kitchen. The findings are: Dust A. On 02/17/25 at 12:25 pm, observation of the kitchen revealed the following: - The wall and ceiling above the food preparation area were visibly dusty. - The deep fry area had visible dust and grime on it. - Vents near the food preparation area had dust and grime. - The kitchen staff prepared the residents' lunches below the visibly dusty ceiling. B. On 02/21/25 at 10:08 am, during an interview, the Dietary Supervisor (DS) stated staff should wash down the walls and ceiling to make sure that there was not any contamination. The DS stated it was over a year since staff washed down the walls and ceiling. The DS stated the deep fry area should be cleaned daily, but it did not look like it was done. The DS stated maintenance staff was supposed to clean the ceiling vents, but the DS was unsure when they were done. C. On 02/21/25 at 10:10 am, during an interview, the Director of Maintenance (DOM) stated the last time he cleaned the vents in the kitchen was last year. The DOM stated he did not document when he cleaned the vents. Ice Machine D. On 02/19/25 at 3:52 pm, observation of the therapy kitchen revealed the ice machine did not drain through an air gap. The ice machine drained into a pump, and the pump drained directly into the waste water pipe. Further observation revealed the ice machine contained ice, and staff used the ice for the residents. E. On 02/19/25 at 3:55 pm during an interview, the Director of Maintenance stated the ice machines should drain through an air gap so the waste water did not backup into the ice machine drain pipes. He stated this could cause bacteria to grow into the pipe and contaminate the ice. The DOM stated he was aware the ice machine in the therapy kitchen did not drain through an air gap. He stated he thought this was okay since the ice machine drained into a pump. The DOM did not know if the pump had a backflow preventer, and he did not know if the pump prevented bacteria from entering the ice machine drain pipe. F. On 02/20/25 at 2:48 pm during an interview with the Administrator and the DOM, the Administrator stated the DOM was responsible to inspect and maintain the ice machines in the facility. The Administrator stated the DOM inspects the ice machines every three months to ensure there was not a buildup of scale and lime and to ensure the drain was clear. The Administrator and the DOM stated the ice machine should drain through an air gap to prevent the growth of bacteria.

Based on observation and interview, the facility failed to maintain a homelike environment for all residents who utilized the outdoor patio located outside the main dining room when staff failed to repair water damage to the building. Failure to make repairs to maintain a homelike environment could likely cause residents to feel like they do not matter. The findings are: A. On 02/19/25 at 12:41 pm, observation of the resident's outdoor patio, located off the main dining room, revealed the fascia (the exterior framing of the roof rafters) and soffit (the finish material visible beneath the roof's overhang on a building) located to the right (facing the door from the outside) was damage, with peeling paint and exposed wood with black substance. Further observation revealed the residents utilized the area for smoking, and the damage to the building was visible to the residents. B. On 02/19/25 at 12:25 pm, during an interview, the Maintenance Director stated he was responsible to inspect and maintain the building. The Maintenance Director stated he was aware of the condition of the fascia and soffit. He stated the damage was caused by water runoff. He said he made calls to an outside company about a year ago for repairs, but he did not follow up on it. C. On 02/20/25 at 2:48 pm, during an interview, the Administrator stated he was not aware of the water damage to the fascia and soffit in the residents' outside smoking area. The Administrator stated the Maintenance Director was responsible for inspecting and maintaining the building. He stated peeling paint and exposed wood would not be considered homelike, and the resident's should not have to see the building in that condition.

Based on interview and record review, the facility failed to properly care for a pressure ulcer (an injury that breaks the skin and underlying tissues) for 1 (R #195) of 6 (R #9, R #16, R #35, R #40, R #194, and R #195) residents randomly sampled for pressure ulcer, when they failed to do the following: 1. Monitor redness before it became a pressure wound. 2. Implement preventative interventions including pressure relieving devices 3. Delay in initiating wound care treatment for 11 days upon the discovery of (2) wounds. 4. Not consistently treating the wound with ointment as ordered. These deficient practices likely resulted in the development of unstageable wound with infection requiring hospitalization . The findings are: A. Record review of R #195's face sheet identified that he was admitted on [DATE] and had the following diagnosis: Flaccid Hemiplegia (paralysis affecting one half of the body), Muscle Weakness and need for assistance with personal care. These are not all inclusive. B. Record review of admission assessment dated [DATE], revealed R #195 had noted redness that was blanchable on the coccyx (tailbone) at the time of admission. C. Record review of care plan dated 09/29/23 for R #195 identified [Name of R #195] is at risk of skin impairment related to decreased mobility, incontinence and refusal of care. Interventions did not include any pressure relieving devices. D. Record review of weekly skin checks revealed: 1. On 10/06/23 identified red coccyx blanchable. No size identified. 2. On 10/13/23 identified a large pressure ulcer to the coccyx area, unstagable (are full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) and a smaller opening to the top of his right buttock, stage two (pressure injury that is partial-thickness skin loss, with loss of epidermis and subcutaneous tissue not exposed). E. Record review of R #195's physicians order, dated 10/24/23, revealed order for collagenase ointment (is an enzyme that breaks down collagen in damaged tissue and helps healthy tissue to grow. It may help wounds heal faster) 250 grams. Apply to the coccyx topically every shift for pressure ulcer. Clean wound with WW/NS (wound wash with normal saline to clean out the wound bed and around the wound), pat dry, apply ointments and place protective dressing over the wound twice a day. There were no other orders for wound treatment. F. Record review of R #195's Electronic Medication Administration Record (EMAR) revealed R #195 was ordered to receive wound care twice a day. The collagenase ointment was documented as not being available on the following dates and shifts. 1. 10/25/23 during the night shift. 2. 10/28/23 during the day shift. 3. 10/28/23 during the night shift. 4. 10/29/23 during the day shift. 5. 10/30/23 during the day shift. 6. 10/31/23 during the night shift. 7. 11/02/23 during the night shift. 8. 11/03/23 during the day shift. 9. 11/05/23 during the night shift. 10. 11/06/23 during the day shift. 11. 11/06/23 during the night shift. 12. 11/07/23 during the day shift. 13. 11/08/23 during the day shift. 14. 11/09/23 during the day shift. 15. 11/10/23 during the day shift. 16. 11/10/23 during the night shift. G. Record review of labs revealed a wound culture was obtained on 10/27/23 and Escherichia Coli (E. coli is a type of bacteria that normally lives in your intestines, but some strains can cause diarrhea, kidney failure, or urinary tract infections) was found to be growing in the coccyx wound. H. Record review of a nursing progress note dated 11/13/23, revealed the resident was sent out to the emergency room for evaluation and treatment of wound on his coccyx due to the wound declining. I. On 11/27/23 at 11:20 am, during an interview with new facility Administrator, she stated when R #195 came to the facility [on 11/15/23 from the hospital] I was told it [wound] was a pressure injury stage 2. When [Name of R #195] arrived, we had the nurse look at it and it was unstageable pressure injury. The wound was the size of a frisbee, and the smell was horrible. I have never seen a wound this big before. J. On 11/28/23 at 3:47 pm and 11/28/23 at 5:05 pm, during an interview with the Director of Nursing (DON), she stated the Wound Care Nurse (no longer employed at the facility) reported that R #195 would often refuse wound treatment. The DON was unable to identify the reason why wound treatment orders were started on 10/24/23 and not on 10/13/23 when the wound was identified. The DON confirmed that staff were changing the dressing but not applying collangenase ointment until it was delivered to the facility on [DATE]. K. On 11/29/23 at 9:09 am, during an interview with R #195, he identified that he was a retired Registered Nurse. Regarding the wound on his coccyx, he stated that nurses were changing the dressing but not applying any ointment. If I had a bowel movement (BM), I would go three days without a dressing [being put on]. 49196

Based on record review and interview, the facility failed to ensure that residents were free from neglect for 1 (R #101) of 1 (R #101) residents reviewed for death, by not intervening when R #101's family was observed feeding the resident peaches when she was on a pureed diet. This deficient practice likely resulted in R #101 choking, developing [MEDICAL CONDITION] (deprivation of oxygen to the brain) and possible aspiration pneumonia (lung infection when food/vomit goes into the lungs), leading to her death. The findings are: A. Record review of R #101's Face Sheet revealed, R #101 was admitted on [DATE] with a medical [DIAGNOSES REDACTED]. B. Record review of the Physician order [REDACTED]. C. Record review of the Nursing Progress Notes dated 09/13/17, revealed Call to resident's room around 2045 (8:45 pm) d/t (due to) choking. She (R #101) was passing air, but could not cough whatever it was up. Suctioned, and a piece of peach fell out. Resident was then able to state she was feeling alright and wanted to lay down. Checked on resident 15 minutes later and she was resting comfortably in bed, no distress. About 2115 (9:15 pm), again called to room, this time by daughter, d/t resident not responding to her. Upon entry in room, resident appeared dusky (darkish in color) and would not respond to nurse. Suctioned again and more fluid pulled out of throat, color started to return. Resident then opened her eyes and was responding to nurse. Family member upset that her mother didn't look like herself at all. Set of vitals received and O2 (oxygen saturation) was 75% (normal oxygen ranges from 95% to 100%) on RA (room air). O2 applied at 5+ LPM (five plus liters per minute). Sat (saturation) returned to 91%, decreased to 4 LPM, sats continued in low 90's. On call MD (medical doctor) was called during this time by the other nurse and okay given to send resident out. EMTs (emergency medical technicians) arrived about 2145 (9:45 pm), and resident left by ambulance at approximately (approx) 2200 (10:00 pm), with family to follow to hospital. On 09/22/17, R #101's daughter called facility stating she would be coming to gather her mothers belongings. At approx 2350 (11:50 pm) resident's daughter arrived at facility stating she would be collecting her mothers belongings as her mother had passesd away at the hospital. D. On 09/27/17 at 3:10 pm, during interview with Registered Nurse (RN) #1, she stated, I do remember there was an incident (on 09/13/17) involving her (R #101). We had to send her to the hospital because she had choked on something. RN #1 stated that she was called to R #101's room around 8:00 pm to assist (RN #2) because it was reported that R #101 was choking. RN #1 stated she brought the suction machine to R #101's room and saw her sitting at the edge of the bed covered in pink chunky stuff. RN #1 then stated that R #101 was trying to cough something up and RN #2 preceded to suction her. She stated that R #101 was doing better after suctioning, so RN #1 and RN #2 left the room. RN #1 stated that they were called to R #101's room again by a family member and that she stated R #101 was gray and not responding to her. RN #1 stated that RN #2 was suctioning R #101 again and she was bringing up more and more stuff. RN #1 stated they could not get R #101 to arouse and that she was looking dusky. RN #1 stated that RN #2 ran out of R #101's room to get the oxygen machine, because her oxygen sats were in the 70s. During the interview, RN #1 confirmed R #101's diet was pureed and stated that she observed R #101's daughter feeding R #101 peaches. When RN #1 was asked if she stopped the daughter, she stated I did not. It wasn't the appropriate time. It was the daughter making that choice for her mother. RN #1 was asked if peaches were appropriate on a pureed diet, she stated, No, what she gave her was not on the pureed diet. RN #1 further stated, No, I did not stop her. I was not the primary nurse at the time. RN #1 also confirmed that she did not report that she observed R #101's daughter feeding her peaches to the Administrator or to the Director of Nursing (DON). RN #1 confirmed she was the unit manager on 09/13/17. E. On 09/27/17 at 5:16 pm, during interview with RN #2, she stated that she went to R #101's room because she was choking. She stated, She was sitting on the side of the bed, her head was hung, it didn't look like she was breathing, at least deep. The family said she was eating so I attempted to suction. RN #2 stated that she suctioned about 25 to 30 cc's (cubic centimeters) of fluid out and then had the Certified Nursing Assistant (CNA) get her ready for bed. RN #2 stated that she went back into R #101's room after being called in by R #101's daughter and stated that she couldn't rouse R #101 and she tried suctioning her again and got the same amount of fluid out. RN #2 stated, I tried to arouse (sic) her, she wasn't responding verbally. I rubbed her chest, she wasn't responding. Her jaw was partially clenched and she wasn't responding to anything. I believe vitals were done right after she started choking (first time) and again after the second episode of choking. At that point we noticed her oxygen was low, it was in the 70s, so we put her on 4 liters of O2. RN #2 stated that when she suctioned R #101, a small piece of peach came out, but she didn't know if it came from her throat or her mouth. RN #2 stated that she saw the peach container in her room. RN #2 confirmed R #101 was on a pureed diet. F. On 09/27/17 at 3:38 pm, during interview with the DON, she stated that her expectation of a nurse observing a resident on a pureed diet eating solid food would be for patient safety we would take away whatever item was being given. The DON also stated that it would not matter if the nurse was not assigned to a particular hall or resident, stating, We are nurses for the facility not our halls. The DON stated that she asked how R #101 got a hold of peaches and staff stated that the family was giving them to her. The DON stated that RN #1 or RN #2 did not report seeing R #101's family feeding her peaches. The DON also confirmed that you would not feed peaches to a resident on a pureed diet. G. On 09/27/17 at 4:13 pm, during interview with the Administrator, she stated that her expectation of a nurse who observed family feeding a resident on a pureed diet solid food would be, To immediately tell the family that they shouldn't be having that and educate the family. The Administrator also confirmed it does not matter if the nurse is not assigned to that resident. H. On 09/28/17 at 11:26 am, during interview with the Administrator, she stated that she was not aware that RN #1 stated that she witnessed R #101's family feeding her peaches and did not stop them. The Administrator stated If (RN #1) was aware of the diet, I would ask why she didn't intervene for the resident's safety. The Administrator stated that she did write RN #1 up because on 09/11/17, RN #1 left early without telling her (Administrator) or the DON, so it was abandonment of shift and could be considered neglect on her part. The Administrator stated, I was actually going to turn her in to the board of nursing, due to her walking off shift and job abandonment. The Administrator verified that RN #1 had issues prior to her walking off shift on 09/11/17 and that there was an issue reported to the previous DON about RN #1's inappropriate behavior observed at the nurses station on 07/24/17. I. Record review of RN #1's Disciplinary Write-up dated 09/11/17, stated Incident: Employee (RN #1) left early on her shift without notifying her supervisors. She left an hour early off of her overnight shift on 09/10/17. This is considered walking off shift and abandonment. Employee must notify her supervisors of requests of leaving early, coming in late, or calling in. Not following the attendance policy results in disciplinary action. Action taken: Employee was educated on attendance policy and written up. J. Record review of RN #1's Disciplinary Write-Up dated 07/24/17, stated Incident: On around 07/24/17 a visitor witnessed the blond nurse at the nurses station yelling, swearing and generally being crazy out of control. Nurse was witnessed to be excessively disrespectful of the other employees, yelling at them. The nurse then turned to a resident that was asking for assistance and yelled at her. Witness states it was a very unprofessional display and they feared leaving their loved one. Acton taken: Written warning, professionalism and self control will be maintained. Any further display of unprofessional conduct will result in a Final Written Warning and Termination. K. Review of the facility Disciplinary Write-Up forms dated 01/21/11 to 08/02/14, revealed RN #1 had 6 (six) disciplinary write ups while working at the facility. L. Record review of the Abuse Prohibition/Resident Safety Policy (not dated), revealed It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse, and neglect. 'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect causes, or is likely to cause, harm to a person. M. Record review of the Hospital Neurology Consultation Report dated 09/14/17, revealed Per report the patient has been residing at a local nursing facility. When daughters came back yesterday they found the patient to be significantly obtunded (mental [MEDICATION NAME] with mild to moderate reduction in alertness and a diminished sensation of pain) and apparently over the course of a week or so had gone from being able to sit up on her own and speaking a few words responses to no longer speaking, severely obtunded and requiring additional support just to sit up thus prompting her admission. Also there is report that the patient was not safely swallowing over the last several days to week and have been given some food and tomato juice and began choking and/or vomiting significantly just prior to admission.

Based on record review and interview, the facility failed to ensure that residents were free from neglect for 1 (R #1) of 5 (R #s ,[DATE]) residents reviewed for falls, wounds and diabetes. This deficient practice likely resulted in delayed identification of R #1's wound and infection and may have contributed to the resident's death. The findings are: A. Record review of R #1's nursing facility medical record indicated an admission date of [DATE] and a discharge date of [DATE]. B. Record review of a Therapy Progress Note indicated the following: 1. [DATE]: Res (resident's) sister was concerned about res skin and appearance to rectal area stating 'it's got blood on it (rectal area).' This PTA (Physical Therapy Assistant) told res sister that we will ask the nurse to come and check it. Explained to res sister that res has had diarrhea for at least 2 days. Nurse from yesterday was also aware. Med (Medication Aide) Aide reports that CNA (Certified Nursing Assistant) communicated that resident has been using the toilet by himself and is not changing his depend (adult brief) when it's soiled and instead, keeps using the soiled one until CNA saw and had res change (it). 2. [DATE]: Pt (patient) stated that he did not want to do therapy today because he is not feeling well and he is in pain. When asked where, he said it (the pain) is when he sits and that he cannot sit for long. Pt supine (laying flat on one's back) in room with sister who stated that he is having very bad pain in his sacral (lower back/buttock) region which is not because of the wound. Pt unable to tolerate sitting. Wound in between gluteal checks sore and inflamed, palpation of area anterior (near the front) to wound, the skin felt solid. Informed nurse that pt had a wound on sacral region in between gluteal cheeks. Nurse stated it was inflammation of the skin due to the constant diarrhea .informed sister and the pt that information was relayed to (Name of Registered Nurse (RN) #1). (Name of RN #1) stated that she wrote a note to the doctor informing him of the wound and solidity of area on bottom. C. Record review of R #1's medical record revealed no documentation to indicate that R #1's physician had been notified of R #1's wound in between the buttocks or the hardened area on the left gluteus (any of three muscles in each buttock that move the thigh) per the therapy progress note dated [DATE]. D. Record review of Nursing Progress Notes indicated the following: 1. [DATE]-[DATE]: Nursing notes did not mention any skin concerns other than slight excoriation (skin abrasion) on the peri (perineal) area (area between genitals and anus). 2. [DATE] at 9:32 am, written by (Name of RN #1): Excoriation on peri area has improved greatly. Resident has hardness noted on R (right) side of glut max (gluteus maximus, buttocks). He is unable to sit comfortably even with cushion. 3. [DATE] at 10:56 am, written by (Name of RN #1): Skin is W/D/I (warm, dry, intact), some excoriation noted in peri area, hardness noted on right glut. Resident reports some pain/discomfort. 4. [DATE] at 8:03 am, written by (Name of RN #2): .This am, resident had redness from his thighs to his knees and the areas were firm and warm to the touch. We turned him to his right side and noted right buttocks was dark brown skin and hard to the touch and warm. The open wound to the lower sacrum and perianal area looks like an ulcer that was about 2 inches long and has a very foul odor and his scrotum is swollen and firm and warm to the touch. His outer thighs were red and firm and warm to the touch. This nurse decided to call (Name of Doctor #1) to get an order to send him to the hospital. E. Record review of the Wound Assessments indicated the following: 1. [DATE]: No open wounds. 2. [DATE]: Wound type: Irritation/excoriation. Wound Location: Coccyx (tail bone area). Date wound identified [DATE]. Present on admission? No. Describe skin irritation/excoriation: red or darker pink, moderate irritation. F. Record review of Transfer Summary dated [DATE] indicated the following: Resident appears to have a severe [MEDICAL CONDITION] (a potentially serious bacterial skin infection which appears as a swollen, red area of skin that feels hot and tender) from hip to knees bilaterally (on both sides) including to groin. Also an anal wound that is open and has a foul odor to it. Transferred to the hospital. G. Record review of facility Incident Report dated [DATE] indicated the following: 1. [DATE]: Therapist evaluated skin and found wound in between gluteal cheeks to be sore and inflamed, area felt solid to the touch. Reported finding to (Name of RN #1) who stated it was excoriation r/t (related to) diarrhea and she left a note for the physician (this administrator can find no note for the doctor). 2. ,[DATE]: RN #1 charts that resident's excoriation is greatly improved. 3. (Name of RN #1) had no explanation for why she did not document (how she followed up on R #1's complaints and information given to her by other staff members). (Name of RN #1) stated, 'I can see I need to improve my documentation.' (Name of RN #1) terminated from employment on [DATE]. H. On [DATE] at 3:18 pm, during interview with the Administrator, she stated that R #1 initially had some excoriation to his sacral area as a result of loose stools. She stated that the PTA was the staff member who discovered the hardening of the gluteal area and notified the nurse. The Administrator stated that during her investigation which included resident and staff interviews and documentation review, she didn't feel that RN #1 tended to the residents needs and she (RN #1) failed to go in and assess what was reported to her by the therapist and she blew it (concerns about R #1's wounds and pain) off as previous excoriation from the diarrhea. The Administrator stated that she could find no documentation to indicate that the nurse appropriately responded to the report from the PTA regarding the wound in between the buttocks and the hardening to the gluteus and resulting pain that R #1 had been reporting. I. On [DATE] at 3:20 pm, during interview with the Corporate Nurse/Acting DON (Director of Nursing), she stated that RN #1's employment was terminated because she failed to provide care based on the standards of practice. The Corporate Nurse stated that RN #1 was unable to provide documentation to indicate that care was provided, that she'd followed up on R #1's complaints of pain and that she'd notified the physician of these concerns. J. On [DATE] at 3:56 pm, during interview with PTA, she stated that on [DATE], she went into R #1's room several times as he'd been refusing to participate in therapy due to his pain. PTA stated that R #1 and his sister informed her that he was having a lot of pain in his buttock area in addition to a wound in between the buttocks. PTA stated that at this time, she assessed the buttock and anus area and noted a hardened area between R #1's anus and testicles. PTA stated that she informed the resident and his sister that they should speak to the physician about these concerns. PTA stated that the sister asked her to inform the nurse about these concerns as, when the sister informed RN #1, she (the sister) didn't feel that RN #1 was appropriately responding to the concerns when she had been notified of them previously by R #1 and his sister. PTA stated that, as soon as she left R #1's room, she notified RN #1 of the concerns and RN #1 stated that she was already aware of the concerns and had left a note for the physician. PTA stated that when she spoke to RN #1, RN #1 did not seem very concerned and she (PTA) was concerned about whether she would follow through and address R #1's complaints. K. On [DATE] at 11:50 am, during interview with RN #1, she stated that she was one of the nurses who cared for R #1. RN #1 stated that shortly after R #1 was admitted , his sister who had been his caregiver informed her that he had some redness to his bottom and that she had been using Vaseline on this area. RN #1 stated that during R #1's stay at the facility, she never noted the red, excoriated area to be an open wound and that the area just appeared to be irritated due to frequent diarrhea. RN #1 stated that when she left for the day on [DATE], R #1's buttock area still appeared to just be irritated. She stated that she never noted a foul odor coming from the excoriated area and that she did not note any reddened, hard area from R #1's hip to knee area. She was unable to indicate how, over the course of one day, the wound would have gone from slight irritation to a 2 inch open wound with foul odor or how the reddened, hard area could have extended to the knees when it was only a small hardened area of the buttock the day before. RN #1 verified that she was terminated after management conducted an investigation and determined that she did not provide adequate care and that the night nurse who cared for R #1 after RN #1 did note a lot of redness and swelling in addition to the open wound of the buttock and perineal area. RN #1 stated that she was not sure if she notified R #1's physician of the skin concerns but that the facility procedure was that any time a physician was notified, this was documented in the nursing progress notes. L. Record review of (Name of Hospital) Medical Record indicated the following: 1. Physician History and Physical dated [DATE]: The patient presents with a complaint of low blood sugar, skin infection. Location of the complaint is generalized, left buttock. The onset is unknown. Clinically septic (bacteria in the bloodstream). 11:48 am: After lengthy conversation with family, they elected no further CPR at this time. Time of death: 11:36 am. Preliminary cause of death: [MEDICAL CONDITION] (bacteria in the bloodstream). 2. Blood culture dated [DATE] indicated a positive result for [MEDICAL CONDITION]. M. Record review of Disciplinary Action for RN #1 dated [DATE] indicated the following: Failure to appropriately assess a resident. Failure to ensure resident received appropriate intervention resulting in negative outcome. Failure to follow facility protocol for incident reporting and follow up. Poor attitude towards co-workers and families. Action Taken: termination .