Every finding on record at Center at Centerplace, LLC, The

Based on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature. Findings include:I. Facility policy and procedureThe Standardized Recipes policy, dated 2021, was provided by the nursing home administrator (NHA) on 4/23/26 at 5:06 p.m. It revealed in pertinent part, Standardized recipes will be used when preparing menu items. Standardized recipes (in appropriate portion sizes) for planned menu items will be maintained in the facility. Cooks/chefs are expected to use and follow the recipes provided. Cooks/chefs should discuss problems or concerns about recipes with the director of food and nutrition services so that issues can be resolved.II. Resident representative interview Resident #13's representative was interviewed on 4/20/25 at 1:17 p.m. The resident's representative said the resident had stayed at the facility several times and had no complaints about the food during previous stays. The representative said she complained about the food to the CNAs and staff responded that there had been turnover in the kitchen and whoever was in the building would took over that responsibility, and they did not have a cook at the moment.III. Resident group interviewA group interview was conducted on 4/21/26 at 1:30 p.m. with five alert and oriented residents (#46, #14, #41, #21, and #31) who were interviewable per the facility and assessment. The residents said the food was cold and did not taste good. The residents said the quality of the food was inconsistent. They said the chicken [NAME] served that day (4/21/26) was cold and tasted bland. The residents said they did not always receive what they ordered. They said they received a Coke even though they had ordered cranberry juice. They said they had ordered a pickle with their meal but they did not deliver it.IV. Additional resident interviewsResident #9 was interviewed on 4/20/26 at 1:36 p.m. Resident #9 said the food did not taste good and was bland with no salt. Resident #9 said on 4/19/26 at lunch he ordered meatloaf but received ham with side dishes of bland vegetables. Resident #9 said he asked for French fries and received mashed potatoes. Resident #9 said he told the staff and they said that was what the kitchen gave them. Resident #9 said he had a big problem getting coffee and that he loved coffee and drank it throughout the day. Resident #9 said he had a large mug he would like filled, but he received a small paper cup of coffee. Resident #9 said until 4/20/26, no one took his order or filled out a meal ticket to order from the kitchen.Resident #40 was interviewed on 4/20/26 at 2:16 p.m. Resident #40 said the food was cold, whether it was lunch or dinner. Resident #40 said the last time the food was cold was on 4/18/26. Resident #40 said she ordered one item and received something different. Resident #40 said she told the staff and they said they lost the meal tickets.V. Test trayA test tray for a regular diet was evaluated by four surveyors immediately after the last resident was served their room tray for lunch on 4/21/26 at 12:56 p.m. The test tray consisted of chicken fettuccine alfredo, garden salad and garlic bread. The following was observed:-The chicken fettuccine alfredo was bland in taste and lacked flavor;-The garlic bread was 113 degrees Fahrenheit (F) had a doughy texture, lacked garlic flavor and seasoning, and was bland; and,-The garden salad was 90 degrees F. It was served with no dressing. VI. Record reviewA review of the 1/30/26 resident council meeting revealed resident concerns related to food service. It revealed kitchen concerns included sandwich bread was too hard, stiff and cold, and chicken was overcooked. Breakfast meals were hard to bite or chew, including waffles and sausage. Drink portions were too small, items were missing on trays, including silverware, drinks and food items. There was a delay when requesting missing or extra items, and meals did not match what was on the tickets.The [NAME] chicken fettuccine recipe was provided by the cook (CK) #1 on 4/22/26 at 11:17 a.m. The recipe for [NAME] chicken fettuccine revealed the recipe yield was 50 portions. The ingredient list included salt with the instruction to add to taste. VII. Staff interviewsThe dietary manager (DM) was interviewed on 4/22/26 at 10:50 a.m. The DM said she monitored food quality through tray audits and food temperature checks to assess taste, texture and temperature. The DM said she checked temperatures at the start of service, ensured steam tables worked properly and completed spot checks during service. The DM said she ensured staff followed recipes to maintain taste, texture and quality. The DM said she corrected issues during service by reheating food that was not warm and adjusting items that did not meet quality standards, such as improving texture when food was dry. CK #1 was interviewed on 4/22/26 at 11:03 a.m. CK #1 said he received hands-on training when he started two months ago and brought one year of prior cooking experience. CK #1 said he received training on preparing different textures, including minced and moist diets, and added sauce as needed to achieve appropriate texture. CK #1 said he followed standardized recipes from a recipe book provided by Shamrock (food service distributor) and used them step by step to maintain consistency in taste and texture. CK #1 said he followed recipes for all menu items because not following them would affect taste and resident expectations. CK #1 said he reviewed the menu in advance and ordered ingredients if needed to ensure meals were prepared as planned. CK #1 said he used a thermometer and cut into food to check if it was cooked inside because it could look done on the outside but not be cooked inside. CK #1 said he tasted food before service to check seasoning and overall quality. CK #1 said he tasted the [NAME] chicken that day and said it was bland. CK #1 said the recipe included no salt or approximately half teaspoon of salt for 40 servings due to low sodium and heart-healthy diets. CK #1 said residents could add salt or pepper themselves if they wanted. CK #1 said the sour cream in the [NAME] made it taste bland. - However, a review of the [NAME] chicken fettuccine recipe revealed the ingredients and instructions directed salt to be added to taste and the recipe yielded 50 portions.VIII. Facility follow-upThe DON provided nursing staff an in-service on resident meal feedback on 4/23/26. Staff were to obtain resident meal feedback about taste and flavor of food, food temperature, texture appropriateness, portion size, accuracy of meal trays and overall meal satisfaction. Staff were to report urgent or significant concerns immediately to nursing and dietary leadership, including refusal to eat and repeated dissatisfaction.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of diseases and infection on two of two units.Specifically, the facility failed to:-Ensure staff wore the appropriate personal protective equipment (PPE) while providing care to Resident #4; and,-Ensure staff properly cleaned shared vital signs equipment between residents. Findings include: I. EBP failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), (4/2/24), retrieved on 4/27/26, from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central line,; urinary catheter, feeding tube, tracheostomy/ventilator; wound care: any skin opening requiring a dressing. B. Facility policy and procedure The Enhanced Barrier Precautions (EBP) policy, revised 1/29/25, was provided by the nursing home administrator (NHA) on 4/23/26. It read in pertinent part, Purpose: To reduce transmission of MDROs (multidrug-resistant organisms) by employing targeted gown and glove use during high-contact resident care activities. Per the CDC, EBP are recommended (when Contact Precautions do not otherwise apply) during high-contact care activities with residents who are at higher risk of acquiring or spreading an MDRO. EBP include use of gown and gloves during the high-contact patient care activities below: dressing; bathing/showering; transferring; when working with patients in the therapy gym that need mobility assistance and/or transfers that require a longer duration; providing hygiene, changing linens; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; and wound care. C. Observations and staff interviews On 4/21/2026 at 10:11 a.m. certified nurse aide (CNA) #1 was in Resident #4's room. Outside Resident #4's room in the hallway was a small white bin which contained EBP gowns. Resident #4's room had an EBP sign posted on the door to alert staff to use gowns and gloves for high-contact resident care activities. CNA #1 stood next to Resident #4's bed and helped Resident #4 get dressed. A hospital gown with fecal matter was in a trash bag on the floor. CNA #1 was wearing gloves. -CNA #1 failed to put on a gown. CNA #1 was interviewed in the hall after resident care had been completed. CNA #1 said Resident #4's colostomy leaked and got fecal matter onto Resident #4's hospital gown and abdomen. CNA #1 said Resident #4 needed assistance dressing herself. CNA #1 said she helped Resident #4 out of the dirty hospital gown and into a clean hospital gown. CNA #1 said she only wore gloves for the procedure. CNA #1 said she knew Resident #4 was on EBP, but staff only had to wear the PPE gown if they were providing catheter care to the resident. CNA #1 said she was dressing the resident, therefore did not have to wear the PPE gown. On 4/21/26 at 3:01 p.m. registered nurse (RN) #3 was providing education on EBP to an unnamed staff member. RN #3 had the staff member complete a return demonstration of gown donning and doffing. The staff member then signed an education sign-off sheet. RN #3 said he was having all staff complete the education. D. Additional staff interviews The director of nursing (DON) was interviewed on 4/22/26 at 1:44 p.m. The DON said she was the facility's infection preventionist (IP). The DON said CNA #1 should have worn a gown while providing care to Resident #4. The DON said she educated CNA #1 about proper EBP implementation and provided education to all direct care staff on EBP. II. Failure to clean vital signs equipment between residents A. Professional reference The CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), retrieved on 4/27/26 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly, read in pertinent part, Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin. B. Facility policy and procedure The Medical Devices/Equipment Disinfection policy and procedure, revised 8/29/22, was received from the NHA on 4/23/26 at 5:06 p.m. It read in pertinent part, The facility will follow the CDC guidelines for disinfection of medical devices/equipment. All non-dedicated, non-disposable medical equipment used for patient care is cleaned and disinfected with an environmental protection agency approved product per CDC guidelines and recommendations. C. Observations On 4/21/26 at 10:35 a.m. certified nurse aide (CNA) #5 left room [ROOM NUMBER] with vital sign equipment, entered room [ROOM NUMBER] and began assessing the resident residing in room [ROOM NUMBER]'s vital signs using the vitals equipment. room [ROOM NUMBER] was a single-occupancy resident room which had a sign for enhanced barrier precautions (EBP) on the door and a bin containing personal protective equipment just outside the door to the room. No cleaning wipes were available on the CNA's vital machine. -CNA #5 did not perform hand hygiene after leaving room [ROOM NUMBER] and did not wipe off the vital sign equipment prior to entering room [ROOM NUMBER]. At 10:36 a.m. CNA #5 left room [ROOM NUMBER], performed hand hygiene, and entered room [ROOM NUMBER] to begin assessing the resident's vitals. room [ROOM NUMBER] was a single-occupancy resident room which had a sign for EBP on the door and a bin containing personal protective equipment just outside the door to the room. -CNA #5 did not clean the vitals equipment after leaving room [ROOM NUMBER] or before entering room [ROOM NUMBER]. At 10:37 a.m. CNA #5 left room [ROOM NUMBER], performed hand hygiene, entered room [ROOM NUMBER] and began assessing the resident in room [ROOM NUMBER]'s vital signs. -CNA #5 did not clean the vitals equipment after leaving room [ROOM NUMBER] or before entering room [ROOM NUMBER]. At 10:41 a.m. CNA #5 left room [ROOM NUMBER], performed hand hygiene, entered room [ROOM NUMBER] and began assessing the resident in room [ROOM NUMBER]'s vitals. -CNA #5 did not clean the vitals equipment after leaving room [ROOM NUMBER] or before entering room [ROOM NUMBER]. C. Staff interview The DON who was also serving as the facility's infection preventionist (IP) was interviewed on 4/22/26 at 12:32 p.m. The DON said all vital signs equipment must be cleaned after use and between each resident. The DON said the vital signs equipment should be cleaned using purple top disinfecting wipes by the CNAs.

Based on observations and interviews, the facility failed to provide proper storage for medical supplies and supplements for two of three medication carts and two of two medication storage rooms. Specifically, the facility failed to:-Discard expired insulin;-Discard expired testing supplies; and,-Discard expired supplements. Findings include:I. Facility policy and procedureThe Storage of Medications policy, revised 2/9/26, was provided by the nursing home administrator (NHA) on 4/23/26 at 5:06 p.m. It read in pertinent part, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy as necessary, if a current order exists. Medication storage should be kept clean, well-lit, organized, and free of clutter.II. Observations and interviewsOn 4/21/26 at 9:25 a.m. the second-floor medication cart was observed with registered nurse (RN) #1. The following was observed:-An expired Insulin Lispro pen for Resident #21 with an expiration date of 4/18/26. On 4/21/26 at 9:33 a.m. the third-floor medication storage room was observed with RN #1. The following was observed:-An E-swab collection kit with an expiration date of 10/10/25-A urine collection kit with an expiration date of 3/31/26-Two expired boxes of safety winged blood collection kits.RN #1 said the e-swabs and urine collection system had expired and could not be used because they contained a preservative liquid. RN #1 said she would order new swabs and collection kits and discard the expired supplies. On 4/21/26 at 10:21 a.m. the third-floor medication cart was observed with licensed practical nurse (LPN) #1. The following was observed:-Four packets of Banatrol Plus (a supplement for the treatment of diarrhea) with an expiration date of 4/16/26.On 4/21/26 at 10:33 a.m. the third-floor medication storage room was observed with LPN #1. The following was observed:-Seventeen packets of Banatrol Plus with an expiration date of 4/16/26.IV. Additional staff interviewsThe director of nursing (DON) was interviewed on 4/22/26 at 9:15 a.m. The DON said expired medical supplies should be thrown out. The DON said using expired medical supplies, such as nasal swabs and urinary collection kits, could invalidate the results of any tests conducted from those supplies. The DON said the Banatrol was a food item and should not have been kept in the medication cart. The DON said she had prepared staff education and had begun teaching nursing staff on proper medication storage.V. Facility follow-upOn 4/23/26 at 4:53 p.m. the facility provided documentation which revealed the facility had conducted staff education and in-service training on the following;-Medication room and cart compliance, dated 4/22/26-Expired items and nutritional supplement storage, dated 4/23/26

Based on record review and interviews, the facility failed to ensure residents were free from any significant medication errors for two (#4 and #30) of five residents reviewed for medication errors out of 31 sample residents.Specifically, the facility failed to follow the physician's order parameters for Resident #4 and Resident #30's blood pressure medications. Findings include:I. Resident #4 A. Resident status Resident 4, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included hypertension and peripheral vascular disease.According to the 3/312/26 MDS assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Record review Review of Resident #4's April 2026 CPO revealed the following physician's orders:Amlodipine Besylate oral tablet 10 milligram (mg). Give 10 mg by mouth in the morning for hypertension. Hold if systolic blood pressure is less than 110 milliliters of mercury (mmHg). Ordered on 1/11/25. Losartan Potassium Oral Tablet 50 mg. Give 100 mg by mouth in the morning for hypertension. Hold if systolic blood pressure is less than 110 mmHg. Ordered on 1/22/2026. Review of vital signs record (3/1/26 to 4/20/26) revealed that resident's systolic blood pressure was below 110 mmHG on eight occasions, however the blood pressure medication was still administered. Review of Resident #4's EMR did not reveal supporting progress notes for the days above to clarify why the medications were still administered. II. Resident #30 A. Resident status Resident 30, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included hypertension and stage three kidney disease.According to the 3/12/26 MDS assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Record review Review of Resident #4's April 2026 CPO revealed the following physician's orders:Lisinopril Oral Tablet 10 mg. Give 20 mg by mouth in the morning for hypertension. Hold for systolic blood pressure less than 110 mmHg. Ordered on 3/12/26. -Review of the resident's EMR revealed: On 4/3/26 the resident's blood pressure was 108/58 mmHg and on 4/15/26 it was 103/65 mmHg. However, the lisinopril was still administered. Propranolol HCl Oral Tablet 20 mg. Give 20 mg by mouth two times a day for migraines. Hold for systolic blood pressure less than 100 mmHg or heart rate less than 60 beats per minute (BPM).-On 4/9/26 the resident's heart rate was 54 BPM. The medication was still administered. Review of Resident #30's EMR did not reveal supporting progress notes to clarify why medication was still administered. III. Staff interviews Registered nurse (RN) #1 was interviewed on 4/22/26 at 9:20 a.m. She said blood pressure medication should not be administered when blood pressure was below normal. She said blood pressure medications had specific physician's orders as to when to hold medication. She said it was the nurses responsibility to check the blood pressure and hold medication if blood pressure was below physician's documented parameters. RN #3 was interviewed on 4/22/26 at 9:41 a.m. He said if blood pressure medication had specific parameters defined by the physician, the medication must be held if it meets the parameters. He reviewed electronic records for Resident #4 and Resident #30, he said that unfortunately blood pressure medications were signed as given for both residents when it should have been held. He said administering blood pressure medications when blood pressure was already low could result in a medical emergency. The director of nursing (DON) was interviewed on 9/22/26 at 12:16 p.m. She said it was reported to her today that two residents received blood pressure medications when vitals signs indicated that it should have been held. She said she started immediate education to all nursing staff on duty to ensure that medications were given appropriately. She said nurses should always administer medications as ordered by the physician, and hold medication per physician ordered parameters. The pharmacy consultant was interviewed on 9/22/26 at 12:34 p.m. She said blood pressure medications should not be administered when blood pressure or heart rate were below recommended. She said it is a significant medication error because it could lead to very low blood pressure or below normal heart rate which could become a medical emergency.

Based on observations, record review and interviews the facility failed to ensure one (#15) of two residents reviewed for dialysis care out of 29 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to implement recommendations from the dialysis center for Resident #15 to be on a therapeutic diet and a fluid restriction. Findings include: I. Facility policy and procedure The Dialysis Contract, revised 8/5/22, was provided by the nursing home administrator (NHA) on 4/21/26 at 1:03 p.m. It revealed in pertinent part, Dialysis communication sheet will be given to the dialysis center with facility and patient information. Facility shall ensure appropriate information accompanies the resident to the dialysis center, including treatment presently being provided to the Designated Resident, including medications and any changes in a patient's condition (physical or mental), change of medication, diet or fluid intake. Any other information that will facilitate the adequate coordination of care, asreasonably determined by Center.II. Resident #15A. Resident statusResident #15, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included end stage renal disease (kidney failure), dependence on renal dialysis (blood filtration to remove waste), nutritional anemia (low blood count from poor nutrition), and type two diabetes. The 4/19/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She needed set-up assistance with eating, oral hygiene, substantial assistance with toileting and was dependent with showering/bathing. The MDS assessment indicated the resident was receiving dialysis and was on a therapeutic diet.B. Resident interviewResident #15 was interviewed on 4/20/26 at 10:46 a.m. and said she was on a liberal diet and was not receiving fresh fruits and vegetables with her meals.Resident #15 was interviewed again on 4/22/26 at 8:55 a.m. and said it is hard for the facility to follow dialysis center recommendations because they do not have fresh vegetables. She said she managed her own fluid intake.C. Record reviewA review of the April 2026 CPO revealed the resident was prescribed a liberal renal consistent carbohydrate diet (CCHO), regular texture and thin consistency, initiated 4/9/26.A review of the 4/13/26 dialysis communication form revealed a recommendation for a fluid restriction of 1.5 liters per day.A review of the 4/15/26 dialysis communication form revealed the resident must be on a high protein, low potassium, low sodium, renal and cardiac friendly diet.-Review of the resident's electronic medical record (EMR) did not reveal documentation that the facility followed up on, addressed or clarified the dialysis center recommendations.-Review of the April 2026 CPO did not include the dialysis center recommendation dated 4/13/26 for a fluid restriction of 1.5 liters per day.-Review of the April 2026 CPO did not include the dialysis center recommendation dated 4/15/26 for a high protein, low potassium, low sodium, renal and cardiac friendly diet.The dialysis care plan, initiated 4/19/26, documented the resident had potential for complications related to dialysis. Interventions included communicating with the dialysis center on scheduled dialysis days to report concerns, lab values, medications, weights and changes in condition and sending a dialysis form to dialysis appointments.The chronic kidney disease care plan, initiated 4/19/26, documented the resident had potential for complications from chronic kidney disease. Interventions included encouraging compliance with diet and fluid restrictions.A review of the 4/20/26 nutrition assessment revealed the resident's diet was documented as a liberal renal CCHO diet, and estimated fluid needs were documented as 2000 milliliters (ml) or per physician or dialysis recommendation.-However, the 4/13/26 dialysis communication form indicated the dialysis center recommended the resident to be on a 1.5 (1500 ml) fluid restriction and a high protein, low potassium, low sodium, renal and cardiac friendly diet.-A review of Resident #15's EMR revealed no documentation that the facility had contacted the dialysis center regarding the recommended diet changes, that the recommendations were unclear, that the physician was contacted, or that the dialysis center was contacted (see staff interviews below).III. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 4/22/26 at 9:10 a.m. CNA #3 said she had worked at the facility for six months and was familiar with Resident #15. CNA #3 said Resident #15 was on a liberal renal CCHO diet with regular texture. CNA #3 said she looked at meal tickets to determine what the resident could and could not eat and the nurses also informed her of any diet changes. CNA #3 said she had not seen any special recommendations from the dialysis center regarding Resident #15's diet. CNA #3 said the nurses would be informed of any diet changes and the nurses would inform the CNA and dietary aides. Registered nurse (RN) #2 was interviewed on 4/22/26 at 9:28 a.m. RN #2 said Resident #15 was on a liberal renal CCHO diet with regular texture. RN #2 said the last diet order update was on 4/9/26 to a CCHO diet. RN #2 said once Resident #15 returned from dialysis she reviewed the dialysis communication form, entered weights and any diet changes would be communicated with the physician. RN #2 said once the physician approved the new recommendations then she completed a diet communication form and placed it on the nurse's desk for the CNA to take to the kitchen. RN #2 said dialysis communication forms were placed in the medical record box and scanned daily.RN #2 said she received the dialysis communication form regarding Resident #15 on 4/15/26 and reviewed it and completed a diet communication form for the kitchen and did not follow up with the kitchen staff after she completed the form. RN #2 said she should have made herself a note to follow up with the dietary staff. RN #2 said when she completed a diet communication form, the CNAs were expected to take it to the kitchen. RN #2 said she did not contact the physician. The director of nursing (DON) was interviewed on 4/22/26 at 10:05 a.m. The DON said once the resident returned from the dialysis center with a dialysis communication form, the nurse reviewed the form and if there were any recommendations, the nurse contacted the physician and obtained orders. The DON said the nurses were responsible for and communicated with the interdisciplinary team (IDT) as well when the dialysis center made recommendations. The DON and RN #3 were interviewed together on 4/22/26 at 10:22 a.m. RN #3 said he was the unit manager. RN #3 said when the floor nurse received the dialysis communication form and if there were recommendations, the nurse would inform the physician and would get updated orders. RN #3 said once the physician approved the diet change then the nurse would complete a diet communication form and would notify the dietary staff. RN #3 said the floor nurse or the CNA would hand deliver the diet change form to the kitchen staff. RN #3 said the unit manager did not get involved in the process unless there was an issue, such as difficulty obtaining updated orders from the physician when there was disagreement and the nurse believed the diet change was necessary. RN #3 said the unit manager would be involved during IDT meetings.Cook (CK) #1 was interviewed on 4/22/26 at 10:29 a.m. CK #1 said the dietary manager (DM) handled nutrition and diet order communication forms. CK #1 said the DM was responsible for gathering diet change information from nurses and family. CK #1 said the dietary aides went upstairs to obtain meal tickets and picked up diet communication forms from the nurse station, and the DM reviewed the forms and adjusted meals accordingly.The DM was interviewed on 4/22/26 at 10:33 a.m. The DM said Resident #15 was on liberal renal CCHO diet with regular thin consistency. The DM said the last diet change for Resident #15 occurred on 4/10/26 to a liberal renal diet. The DM said she had not received any additional diet changes for Resident #15 since 4/10/26.The nurse practitioner (NP) was interviewed on 4/22/26 at 11:32 a.m. The NP said she was not aware of diet recommendations or fluid restrictions for Resident #15. The NP said she did not know anything regarding these recommendations because the nurses did not inform her. The NP said once the nurses informed her, she would follow up with the specialist. The NP said if changes were needed to Resident #15's diet, the nurses were responsible for informing her and she would then order the changes. The NP said she did not know why the dialysis center made diet recommendations on 4/15/26 and they did not send labs. The NP said when recommendations were unclear, the nurses would contact the dialysis center to clarify. The NP said she continued the resident to be on a liberal renal CCHO diet until she checked with nephrology and the dialysis team. The NP said it was important to follow up on dialysis recommendations because Resident #15 had multiple complex medical conditions, and for resident safety, the nurses needed to inform her so that she could make appropriate decisions.The DON and licensed practical nurse (LPN) #1 were interviewed together on 4/22/26 at 12:29 p.m. The DON said regarding fluid restrictions, it was her understanding that the nurses were responsible for reviewing the dialysis communication form and would inform the physician, then the physician documented it and once approved, entered orders. The DON said she was not aware of the fluid restriction that was made by the dialysis center regarding Resident #15 and there were no orders for it.LPN #1 said she had reviewed the 4/15/26 dialysis communication form and the diet recommendations were not clear. She said on 4/16/26 she contacted the dialysis center and the dialysis center told her that they would get back with the facility. She said it typically took about two weeks for the dialysis center to clarify that information. She said she had not heard back and the facility had not followed up again with the dialysis center. She said the only documentation of the contact was a sticky note indicating the dialysis center was contacted on 4/16/26. LPN #1 said in addition to the sticky note, she had a printout of the 4/15/26 dialysis communication form, which revealed that the NP had acknowledged reviewing it and had signed it on 4/16/26. The DON said the updated dialysis communication form, including the NP's acknowledgement had not been scanned into the resident's EMR because LPN #1 was working on obtaining clarification.-However, the NP earlier said she was not aware of the recommendations made by the dialysis center (see above).The medical director (MD) was interviewed by phone on 4/24/26 at 5:39 p.m. via phone after the survey. The MD said the physician at the facility made the decision that there was no need for the fluid or dietary restriction. The MD said he encouraged physicians to review the specialists' recommendations but ultimately decide what orders to implement for the resident.-However, there was no documentation indicating the MD physician had reviewed the fluid restriction recommendation.IV. Facility follow-upThe DON provided nursing staff an in-service on dialysis communication form processing on 4/21/26. The receiving nurse was to review all dialysis communication forms upon receipt, interpret the dialysis provider's recommendations, and contact the physician to obtain appropriate orders. The nurse was to enter physician orders accurately into the system, submit the orders to the nurse manager for review, and ensure orders were verified and validated. If the physician did not approve the dialysis recommendations, no changes were to be made to the resident's current orders.

Based on observations, record review and interviews, the facility failed to ensure one (#37) of two residents who required respiratory care received the care consistent with professional standards of practice out of 29 sample residents. Specifically the facility failed to:-Ensure a physician's order was in place for a bilevel positive airway pressure (BiPAP) machine (a type of non-invasive ventilation that helps people breathe by providing pressurized air through a mask or nasal plugs) for Resident #37 to use during the day; and,-Ensure a care plan was in place to clean, sanitize and store Resident #37's BiPAP mask. Findings include:I. Facility policy and procedureThe CPAP/BiPAP policy and procedure, revised 8/4/24, was provided by the nursing home administrator (NHA) on 4/23/26 at 5:06 p.m. It revealed in pertinent part, The patient will receive necessary respiratory care and services in accordance with professional standards of practice, the patient's care plan, and the patient's choice.Patient will have order that includes settings for CPAP/BiPAP and CPAP/BiPAP will be cleaned per manufacturer's guidelines.II. Resident #37A. Resident statusResident #37, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood), unspecified asthma, other disorders of the lung, and congestive heart failure.According to the 4/16/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial assistance with mobility, transfers, bathing, and moderate assistance with toileting and dressing. B. Resident interview and observationResident #37 was interviewed on 4/20/26 at 11:18 a.m. Resident #37 said since her admission [DATE]) the staff placed the BiPAP on the nightstand each morning after removing it. Resident #37 said no one had cleaned or washed the BiPAP, and she did not know if it needed to be cleaned. Resident #37 said she was recently in the hospital because she was diagnosed with pneumonia. During the interview, the BiPAP machine, with the mask attached to the tubing was on the nightstand next to the bed without a protective covering. Hair was on the exterior side of the BiPAP mask. Resident #37 said she had applied the BiPAP at night and only during the day if she napped. Resident #37 was interviewed again on 4/21/26 at 10:21 a.m. Resident #37 said she had required assistance with applying and removing the BiPAP. Resident #37 said the certified nurse aide (CNA) removed the BiPAP that morning and placed it inside the drawer of the nightstand. The drawer was halfway open without any other items inside the drawer. Resident #37 said she did not nap the previous day and they did not apply her BiPAP during the daytime. Resident #37 said if she did not nap during the day, then she did not need to apply the BiPAP. Resident #37 was wearing oxygen and said she wore oxygen throughout the day because her oxygen would drop. Resident #37 said during a previous admission to this facility she was missing parts of the BiPAP mask and was unable to wear it, which resulted in hospitalization for one week. Resident #37 said the hospital provided the missing parts and she was now able to use the BiPAP. C. Record reviewReview of Resident #37's April 2026 CPO, revealed the following physician's orders related to the resident's BiPAP machine: BiPAP at 12/5 with a flex of 2 (settings for BiPAP) using a Respironic DreamWear small nasal cushion and frame with 2 liters per minute of supplemental oxygen every shift. Initiate BiPAP at bedtime. Check placement of BiPAP mask every night shift, ordered on 4/12/26.Review of Resident #37's respiratory care plan, initiated 4/14/26 and revised 4/20/26, revealed the resident was at respiratory risk related to pulmonary function. Pertinent interventions included BiPAP use as per physician's orders with settings of 12/5 with a flex of 2 using a respironic dream wear small nasal cushion and frame with 2 liters per minute of supplemental oxygen.-The care plan failed to include cleaning, sanitizing and storage instructions for the BiPAP.The physician's progress note, dated 4/16/26, revealed the resident may require BiPAP use more frequently during the daytime due to a tendency to develop hypercapnia. The note revealed the resident's pulmonology instructed her to wear the BiPAP not only at night while sleeping but also for two to three hours during the day regardless of napping.-Review of the resident's electronic medical record (EMR) revealed the facility failed to implement the physician's order for the use of the BiPAP during the day until 4/22/26 (during the survey).-The care plan and CPO failed to include instructions for BiPAP use during daytime.III. Staff interviewsRegistered nurse (RN) #2 was interviewed on 4/21/26 at 3:56 p.m. RN #2 said there was an admissions checklist and the admitting nurse entered the medications, completed the assessment and did as much as possible. RN #2 said then the second nurse reviewed and the unit manager completed anything that the other two nurses were not able to.RN #2 said the physician ordered the BiPAP on 4/12/26 for nighttime use only. RN #2 said she was not aware that the resident was supposed to use the BiPAP during the day. RN #2 said she followed physician orders and there was no order for daytime use of the BiPAP. RN #2 said based on the 4/16/26 physician's progress note there should have been an order for daytime use to prevent carbon dioxide (CO2) retention and the physician should have entered an order after writing that progress note. RN #2 said the nurses generally reviewed progress notes and added or updated orders as needed. RN #2 said refusals were documented in the medication administration record (MAR) and there were no documented refusals for Resident #37 regarding BiPAP use. RN #2 said she would talk to the team and the resident to help coordinate therapy and other tasks to accommodate BiPAP use during the day. RN #2 said they monitored resident compliance during rounds, by checking if the resident was asleep.RN #2 said the BiPAP equipment should have been cleaned daily and rinsed with warm water and soap if needed. RN #2 said the person who removed the mask in the morning was responsible for cleaning it. RN #2 said after washing, the equipment should have been allowed to air dry, and once dried, it should have been placed in a plastic bag. RN #2 said the respiratory team came every two weeks to monitor the equipment and they checked the tubing and replaced it if needed.CNA #2 was interviewed on 4/21/26 at 4:23 p.m. CNA #2 said Resident #37 only wore the BiPAP during the night and the night shift helped put it back on her. CNA #2 said Resident #37 had not been prescribed BiPAP use during the day. CNA #2 said in the morning she made sure to help and took the mask off and ensured the mask and the hose were neatly placed on the nightstand. CNA #2 said if the mask needed to be cleaned, then she would use a little soap and a washcloth to wipe it and let it air dry. CNA #2 said she was not sure if she could use the purple disinfectant wipes to clean the mask. CNA #2 said she had not cleaned the mask and was not sure if it was cleaned since admission. The director of nursing (DON) was interviewed on 4/22/26 at 4:46 p.m. The DON said the facility should have followed the physician's order for BiPAP use during the day. The DON said the nurse manager and the DON were responsible for reviewing the 4/16/26 physician's progress note and ensuring the daytime BiPAP recommendation was implemented. The DON said if the physician did not enter an order for daytime BiPAP use, the facility would not implement it because nursing staff required a physician's order before initiating treatment. The DON said the use of BiPAP during the day was important because it would affect the resident's respiratory status. The DON said the BiPAP mask should have been cleaned according to manufacturer recommendations to ensure proper cleaning and infection prevention.The attending physician was interviewed by phone on 4/23/26 at 11:58 a.m. after the survey. The physician said Resident #37 went back to the hospital after her initial admission to the facility. The physician said there was no physician's order for BiPAP use during the daytime at the time of the initial admission. The physician said the recommendation for daytime BiPAP use was not made until after the second hospitalization. The physician said she spoke with Resident #37's nurses and they said they had been applying the BiPAP during the daytime. The physician said she also spoke with the resident, who said she had been wearing the BiPAP during the daytime except when she accidentally dozed off.IV. Facility follow-upThe DON provided nursing staff an in-service on BiPAP orders, cleaning, and storage on 4/23/26. The nurses were to perform hand hygiene before and after handling BiPAP equipment, use PPE, and clean equipment with facility-approved disinfectants. The nurse was to follow physician orders, the care plan, and manufacturer instructions for cleaning and allow the equipment to dry before reuse.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#6) of two residents reviewed for accident hazards out of 29 sample residents.Specifically, the facility failed to provide adequate supervision for Resident #6, who had previous falls, while showering. Findings include:I. Resident #6A. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the April 2026computerized physician orders (CPO), diagnoses included pneumonia, dementia with agitation and generalized muscle weakness.The 1/17/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) assessment score of 12 out of 15.The resident was required partial to maximal assistance from staff for most activities of daily living (ADL). The resident required maximal assistance from staff for most transfer activities.B. Resident interview and observationsResident #6 was interviewed on 4/21/26 at 10:53 a.m. Resident #6 said he had fallen the day prior (4/20/26) in the bathroom and was still feeling a bit woozy. Resident #6 said he slipped and fell in the shower and had hit his head on the shower wall and floor, and said the incident was scary. Resident #6 said there had been a staff member in the bathroom with him, but they had left the bathroom to go get towels. Resident #6 said he was washing his groin and went to reach for the grab bar in the shower when he slipped. Resident #6 said the CNA heard him yell, saw him on the ground and got the nurse to help him. Resident #6 said normally a staff member would stay with him the entire time during his shower, it just so happened the CNA left to go get something when he fell.Resident #6's bathroom door opened into the bathroom, and the shower was at a diagonal from the bathroom door approximately five feet away.C. Record reviewThe fall care plan, revised 4/20/26, revealed Resident #6 was at risk for falls due to impaired mobility secondary to weakness and debility and his drug regimen. The care plan documented Resident #6 had sustained two unwitnessed falls on 3/29/26 and 4/20/26. Pertinent interventions included wearing proper non-slip footwear and keeping the resident's call light within reach. On 4/20/26 an intervention was initiated for staff to provide supervised showering for Resident #6 with the resident remaining seated on the shower bench for all bathing tasks, using non-skid footwear, and staff providing direct assistance for all lower body hygiene.A fall risk evaluation, dated 1/16/26 at 10:22 p.m., revealed Resident #6 was at low risk for falls.A post-fall evaluation, dated 3/29/26, revealed Resident #6 reported to the staff he had fallen when he was adjusting his sheets and fell out of bed. The fall was unwitnessed and no injuries were identified. Resident #6 was assessed, neurological checks were initiated, and the resident's physician was notified.A progress note, dated 3/30/26 at 8:30 p.m., revealed Resident #6 reported an unwitnessed fall on 3/29/26 where he reported he had bumped his head. A root cause analysis indicated Resident #6 likely fell due to an unassisted transfer, impaired safety awareness and environmental weakness. The interdisciplinary team (IDT) reviewed the fall and implemented new interventions including increased observation/rounding, ensuring environment was well-lit and free of clutter, and reinforcing the use of Resident #6's call light.-Review of Resident #6's electronic medical record (EMR) did not reveal the resident's fall risk was re-assessed after his fall on 3/29/26 to evaluate any changes in the resident's fall risk.An IDT note, dated 4/14/26 at 11:40 a.m., revealed Resident #6 was reviewed by the IDT. Resident #6 was able to transfer with a two-wheeled walker and required moderate assistance for ADLs.Review of Resident #6's Kardex (staff directive tool), as of 4/18/26, revealed the following interventions:-Signs for resident to call, not fall placed in the resident's room to remind the resident to call for assistance-Staff to implement increased rounding/observation, ensure the environment is well-lit and free of clutter and reinforce use of call light.-Do not leave the resident alone in the bathroom.-Keep bed in low position while the resident is in bed.A progress note, dated 4/20/26 at 7:30 a.m., revealed a certified nurse aide (CNA) reported Resident #6 was taking a shower and was washing his groin when his feet slipped and the resident fell back onto his buttocks. Resident #6 reported he hit the back of his head, his right elbow and his back. Resident #6 was found sitting on the floor with his buttocks outside the shower and his legs in the shower. Resident #6 reported he was trying to wash his groin and his feet slipped out from under him. Resident #6 was assessed by the nurse and found to have a skin tear to the back of his right arm and a superficial abrasion to his mid-back. Resident #6 reported a pain of 4 on a scale from 1 to 10. Resident #6 was assisted to standing position by two staff members using a gait belt, seated on the shower bench and his shower was completed. Resident #6 reported feeling anxious from his fall. Resident #6's physician was notified and gave new orders to send the resident out to the emergency room due to the resident taking Warfarin (an anticoagulant medication). A post-fall evaluation, dated 4/20/26 at 11:02 a.m., revealed Resident #6 had an unwitnessed fall on 4/20/26 when the resident was in the shower and attempted to reach for the grab bar while standing but slipped. Resident #6 sustained a skin tear to his right upper arm and an abrasion to his mid-back. Resident #6 hit his head and neurological checks were initiated. A new recommendation to place a towel on the shower floor for traction was initiated. A progress note, dated 4/20/26 at 12:07 p.m., revealed Resident #6 was evaluated at the emergency room, his diagnostics did not reveal any injuries, and the resident would discharge back to the facility with no changes to his medications.An IDT note, dated 4/20/26 at 1:19 p.m., revealed Resident #6's fall that morning (4/20/26) was reviewed by the IDT. Resident #6 had an unwitnessed fall which occurred during a shower. The CNA involved in the incident reported Resident #6 was standing while washing his groin when his feet slipped despite his use of the grab bar resulting in him falling backwards. Resident #6 said he grabbed the grab bar in the shower and his feet slipped out from under him so he fell and hit his head on the cement. A root cause analysis was performed and determined the fall was related to Resident #6 standing during his shower with decreased traction on a wet surface and potential balance instability despite grab bar use. The IDT implemented a new intervention of supervised showering with Resident #6 remaining seated on the shower bench for the duration of the shower.A progress note, dated 4/20/26 at 6:55 p.m., revealed an update to a prior nursing note which documented Resident #6 was not left alone in the shower. The CNA was within reach and sight and leaned outside of the bathroom door to gather clothing items for Resident #6 during his shower when the resident slipped and fell. The CNA never left the bathroom, and was educated to gather needed supplies prior to assisting a resident in the shower to prevent reoccurrence.-However, an interview with CNA #3 revealed the CNA had left Resident #6 to retrieve his clothes which were placed outside the bathroom (see interviews below).Review of Resident #6's Kardex, as of 4/21/26, revealed a new intervention was added on 4/20/26 for staff to provide supervised showering with the resident and provide direct assistance for all lower body hygiene. Resident #6 was to remain seated on the shower bench for all bathing tasks and use non-slip footwear.-Review of Resident #6's EMR did not reveal the resident's fall risk was re-assessed after his fall on 4/20/26 to evaluate any changes in the resident's fall risk.III. Staff interviewsCNA #5 was interviewed on 4/21/26 at 3:36 p.m. CNA #5 said typically the CNAs assisted residents with their showers. CNA #5 said for stand-by assist residents she would typically get all the residents' items ready and stay with them in the bathroom while they showered. CNA #5 said she stayed in the room because if she left the resident could fall, and said she would never leave a resident who required stand-by assistance alone in the shower. CNA #5 said the therapy team came and updated residents' transfer statuses on the white boards in their room frequently. CNA #5 said residents' mobility needs and transfer statuses were written on the resident's whiteboard in their room and communicated during shift changes.CNA #5 said Resident #6 was not very stable while standing, so she would not leave him alone in the bathroom. CNA #5 said Resident #6 had recently had a fall, after which he needed to go out to the hospital. CNA #5 said another CNA, CNA #3, had been assisting Resident #6 in the shower and had thought the resident could wash himself because she had not previously worked with him. CNA #5 said CNA #3 usually worked on a different unit of the facility and was not familiar with Resident #6. CNA #5 said CNA #3 had left Resident #6 alone in the shower to go grab something and realized the resident had fallen when she heard him fall.CNA #4 was interviewed on 4/22/26 at 9:00 a.m. CNA #4 said when assisting residents with showering, she would assist the resident into the shower and ask the resident if they needed help. CNA #4 said if a resident was more independent she would give the resident privacy but make sure they had everything they needed within reach before leaving. CNA #4 said if a resident needed stand-by or moderate assistance she would stay with them in the bathroom. CNA #4 said she would not leave the bathroom while a resident showered unless she knew they were independent with showering.CNA #3 was interviewed on 4/22/26 at 9:19 a.m. CNA #3 said residents' transfer statuses and mobility needs were communicated through the nurse's daily report sheet, and said if she was not clear on what a resident was able to do she would clarify with the nurse. CNA #3 said when assisting residents with showering, for some residents she would just stay in the bathroom and help out as needed. CNA #3 said for residents who were more independent she would leave the bathroom but make sure the resident's call light was within reach and ensure there was a towel on the shower floor.CNA #3 said Resident #6 was fairly dependent on staff for ADLs, needed one staff member to assist him with getting up and getting dressed, but could sit up by himself. CNA #3 said Resident #6 had a fall the other day and she was the CNA who was assisting him with his shower. CNA #3 said she felt bad because she felt like Resident #6's fall was her fault. CNA #3 said she had just finished helping Resident #6 wash his body and asked the resident to wash his groin while she grabbed his clothes, which were sitting in his wheelchair outside the bathroom. CNA #3 said she had just grabbed his clothes when she heard a thunk noise and saw the resident had fallen. CNA #3 said she helped Resident #6 sit up and the resident reported he had tried to stand to wash his groin and had slipped. CNA #3 said Resident #6's nurse was just outside his room so she yelled for her to come and assist them. CNA #3 said she had since received education from the administration on not leaving the bathroom when residents were in the shower.Registered nurse (RN) #2 was interviewed on 4/22/26 at 9:53 a.m. RN #2 said residents' transfer statuses were communicated through the whiteboard in the resident's room and through nursing reports each day. RN #2 said the CNAs often floated between units, so the whiteboards in the residents' rooms were a failsafe. RN #2 said Resident #6 needed supervision from staff but was able to get up and go to the bathroom, and needed the assistance of one staff member for showering. RN #2 said she thought the CNAs stayed in the bathroom with residents while they showered both to help the resident as needed and prevent falls. RN #2 said she completed the initial comprehensive assessment but was not sure if or when she would otherwise complete a fall risk assessment.Licensed practical nurse (LPN) #2 was interviewed on 4/22/26 at 10:43 a.m. LPN #2 said residents' transfer statuses were communicated on the whiteboard in the resident's room and on the form the nurses gave the nursing staff each morning. LPN #2 said the nursing staff also gave each other verbal reports each shift to communicate any changes with the residents. LPN #2 said Resident #6 had sustained a few falls and was not steady at all on his feet. LPN #2 said Resident #6 was able to stand but was not safe for him to do so, so he generally used a wheelchair for mobility. LPN #2 said when a CNA assisted a resident with a shower the CNA should be in the bathroom throughout the entire shower and provide stand-by assistance to all residents. LPN #2 said after a resident sustained a fall, the nurse would assess the resident, have an RN complete a full assessment for the resident, talk with the resident and CNA to see what happened, assess the resident's vitals and notify the resident's physician. LPN #2 said she would then need to initiate neurological checks, do a fall evaluation and see what caused the fall and what intervention they needed to use going forward.LPN #2 said nurses needed to fill out a fall risk assessment after any falls or if there were any medication changes or other similar changes. LPN #2 said there was a post-fall checklist with everything they needed to do after a resident fell.RN #2 was interviewed a second time on 4/22/26 at 11:04 a.m. RN #2 said she was not sure what post-fall checklist LPN #2 was talking about because there were multiple, and was not sure where it would have been kept. RN #2 said she did not use a post-fall checklist because she knew what documentation needed to be completed after a resident sustained a fall. RN #2 said there were two or three different post-fall checklists which had been made by different nurse managers or directors of nursing over the last several months, with each list containing different items the nurses needed to complete. The director of nursing (DON) was interviewed on 4/22/26 at 2:49 p.m. The DON said fall risk assessments were completed on admission. The DON said after a resident sustained a fall, the nurses completed a fall evaluation to reassess the resident and ensure they did not miss any risk factors. The DON said the IDT had a process each morning where they discussed residents' falls. The DON said the nursing staff used the fall risk assessment to build the resident's fall care plan.The DON said during Resident #6's fall on 4/20/26 the CNA who was assisting him with his shower was in the bathroom with the resident during his shower and had cracked open the bathroom door to get his clothes which were outside the bathroom. The DON said the CNA (CNA #3) was able to slow Resident #6's fall in time. The DON said residents were generally not left alone in the shower unless the therapy department cleared them to be alone. The DON said she immediately provided CNA #3 with education on supervision during resident showers.IV. Facility follow-upOn 4/23/26 at 4:49 p.m. the NHA provided records of several staff in-services, including fall incident management for nurses (dated 4/20/26), updating a care plan and tasks after a fall (dated 4/20/26) and fall prevention (undated).

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#1) of three residents reviewed for grievances out of 29 sample residents.Specifically, the facility failed to report, document and follow-up on a grievance reported by Resident #1 concerning a lost personal item. Findings include:I. Facility policy and procedureThe Grievance policy and procedure, revised 2/8/21, was received from the nursing home administrator (NHA) on 4/23/26 at 5:06 p.m. It read in pertinent part, Grievances can be communicated to a staff member either verbally or in writing. The facility will make every effort to promptly investigate and resolve any grievances. If a complaint is verbal, it is the responsibility of the staff member who received the complaint to properly complete the grievance form on behalf of the complainant. The completed form must be provided to the NHA or designee immediately. II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure, type 2 diabetes and acute pulmonary edema (an accumulation of fluid in the lungs).The 4/2/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required substantial or maximal assistance from staff for most activities of daily living (ADL).B. Resident interviewResident #1 was interviewed on 4/20/26 at 11:07 a.m. Resident #1 said she had a gecko stuffed animal, which had gone missing one to two weeks prior. Resident #1 said she had told the nursing staff it went missing. She said the nursing staff had helped her look all over her room but said they could not find it. Resident #1 said she was not sure if it had been taken with her bedding to the laundry room or if it had been accidentally thrown away. Resident #1 said she was upset the stuffed animal had gone missing because she had the stuffed animal for over a year prior.Resident #1 was interviewed a second time on 4/22/26 at 10:23 a.m. Resident #1 said a facility staff member had come in earlier to talk to her about her stuffed animal and said they were letting her look online to find another stuffed animal.C. Record reviewA behavior note, dated 4/4/26 at 9:50 p.m., revealed Resident #1 had a behavioral incident. Resident #1 was anxious and did not know where she had misplaced her green gecko toy. -However, no grievance form was completed at the time for her missing gecko toy.A grievance form, dated 4/21/26 (during the survey), was filed on behalf of Resident #1 by the social services director (SSD). The grievance form revealed Resident #1 said her green gecko stuffed animal was not able to be located after she returned to her room after receiving a shower. Resident #1 said this happened after the second shower she had after admission. Resident #1 said she had reported the item was missing to the nursing staff immediately after her shower.The grievance report summary revealed the SSD spoke with the nursing team members who said they were not aware of any missing items for Resident #1. The SSD spoke with Resident #1 who indicated she would like a new stuffed animal. The SSD documented she would order a new stuffed animal for Resident #1 per her preferences, and that the resident was happy and content with the plan going forward. The grievance was documented as being resolved on 4/21/26.-However, the grievance form was completed and resolved on 4/21/26, 17 days after Resident #1 reported her stuffed animal was missing.III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 4/21/26 at 3:36 p.m. CNA #5 said if a resident reported an item was missing, she would help the resident look for it then report the missing item to the nurse.CNA #4 was interviewed on 4/22/26 at 9:00 a.m. CNA #4 said if a resident said they were missing any items she would report the missing item to the nurse, the director of nursing (DON) and the housekeeping staff so they could look for it.CNA #3 was interviewed on 4/22/26 at 9:19 a.m. CNA #3 said if a resident said they were missing an item, she would ask the resident where they last saw the item, look through their room and their linens and fill out a grievance form for the resident.Licensed practical nurse (LPN) #2 was interviewed on 4/22/26 at 10:43 a.m. LPN #2 said if a resident said they were missing an item, she would help them look for it and try to check with other staff members or staff members on other shifts to see if they had seen the item. LPN #2 said she did not know if she would need to fill out a grievance form if a resident was not able to locate their personal items, but said she knew she would need to fill out a grievance form if a resident thought someone took something from them.The SSD was interviewed on 4/22/26 at 2:03 p.m. The SSD said any time a resident reported they are missing an item or if staff came to the SSD with concerns about a missing resident item they would fill out a grievance form. The SSD said the staff would first look for the item, then fill out a grievance form, and if they were not able to locate the item they would reimburse the resident or order a new item to replace it. The SSD said because the items can be very personal to the resident, the staff try to level with the resident and see how they can make the situation better. The SSD said the staff typically tried to look for the missing item and fill out a grievance form the same day the item was reported missing. The SSD said the facility did team meetings, at which she would remind the staff to fill out grievance forms for missing resident items so they could have documentation and ensure the grievance process was followed. The SSD said the usual timeline for reviewing and solving a grievance took 72 hours.-However, Resident #1's grievance regarding her missing stuffed animal did not have a grievance form associated with it and was not resolved for 17 days after it was first reported to be missing.The NHA was interviewed on 4/22/26 at 4:35 p.m. The NHA said staff members filled out a grievance form whenever a resident reported a personal item was missing. The NHA said missing personal items needed to be addressed immediately, but at most within a few days. The NHA said she had heard Resident #1 was missing a stuffed animal right before the beginning of the survey (on 4/20/26).-However, a grievance form was not filled out for Resident #1's missing stuffed animal until 4/21/26.

Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#1) out of three residents reviewed out of three sample residents. s out of three sample residents.Resident #1 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (lungs struggle to get enough oxygen into the blood), interstitial pulmonary disease (a condition that causes inflammation and scarring in the lungs), pulmonary hypertension (high blood pressure in the arteries connecting the heart to the lungs), chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of respiratory symptoms like shortness of breath and coughing), and pneumonia (a lung infection).The hospital referral information had conflicting information regarding the resident's cardio-pulmonary resuscitation (CPR) wishes. Upon admission, the resident's representative and a nurse practitioner (NP) signed the resident's Colorado Medical Orders for Scope and Treatment (MOST) form. The form indicated the resident's wishes were to have CPR. However, the facility failed to correctly transcribe the resident's wishes into the resident's electronic medical record (EMR). Progress notes, the care plan and the nurses' report sheet indicated the resident as do not resuscitate, which conflicted with the MOST form, signed by the resident's representative and the NP upon admission.On [DATE] at approximately 4:00 a.m. a certified nurse aide (CNA) found the resident deep in sleep. The CNA asked licensed practical nurse (LPN) #1 to check on the resident. LPN #1 promptly checked on the resident and found her without vital signs. LPN #1 called registered nurse (RN) #1 to assess the resident at approximately 4:25 a.m. RN #1 confirmed the resident did not have vital signs. The on-call physician was called and pronounced the death of the resident at 4:30 a.m. At no point, did the staff attempt to contact emergency medical services or initiate CPR.Serious harm to Resident #1 occurred due to the facility not having clear documentation of the resident's advanced directives. Specifically, the facility failed to ensure Resident #1's wishes of receiving CPR were initiated when the staff found the resident without vital signs. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE].I. Situation of serious [NAME] [DATE] at approximately 4:00 a.m., a CNA found the resident deep in sleep. The CNA asked LPN #1 to check on the resident. LPN #1 promptly checked on the resident and found her without vital signs. LPN #1 called RN #1 to assess the resident at approximately 4:25 a.m. RN #1 confirmed the resident did not have vital signs. The on-call physician was called and pronounced the death of the resident at 4:30 a.m. According to the MOST form Resident #1 wished to have CPR. However, the facility transcribed the resident's code status as DNR into the resident's EMR. The facility staff did not contact emergency medical services or initiate CPR when the resident was unresponsive. Due to the facility's failure to clarify Resident #1's advanced directives wish, the staff did not attempt to resuscitate the resident or contact emergency medical services once the resident was found to be non-responsive.II. Facility plan of correctionA. Immediate action:LPN #1 was suspended pending investigation and was immediately given education on correctly implementing MOST forms and referencing code status correctly.The in-service education document was provided by the director of nursing (DON) on [DATE] at 6:41 p.m. On [DATE] the facility held a nursing in-service which educated all relevant staff on CPR, code status and MOST form policies and procedures. The in-service informed staff that resident code status would no longer be listed on the report sheet. Staff were strictly to review code status according to the MOST form found in the MOST binder at each nurses' station. B. Identification of other residents On [DATE] an audit was initiated to identify all residents residing in the facility who were at risk for inconsistencies between MOST forms and the EMR. Audits were completed by the DON and the second floor unit manager. Audits compared MOST forms and EMRs to ensure completion and consistency between the two. For each resident, MOST forms were compared to care plans, physicians orders/MARs and the top of resident's charts to ensure code status was correct.C. Systemic changes and monitoringOn [DATE] audits were completed for each unit and MOST forms and EMRs were updated and accurate. Hospital referrals are no longer used as a resource to determine the code status of a new admission. Only hospital discharges will be used as a resource to determine the code status of a new admission. Upon admission, once a MOST form is completed, the facility will reference this form in emergency situations.D. MonitoringAudits will be conducted with any change in MOST form/code status and with new or returning admissions. The DON, MDS coordinator, and unit manager rotate on-call and are available at all times to complete MOST form audits. Audits will be completed with any new admissions, readmissions, or with changes to a MOST form.III. Facility policy and proceduresThe Cardio-Pulmonary Resuscitation (CPR) policy, revised [DATE], was provided by the DO) on [DATE] at 6:41 p.m. The policy read in pertinent part, The facility will be able to and will provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any patient requiring such care prior to the arrival of emergency medical personnel in accordance with related physician's orders, such as DNRs, and the patient's advance directives.The MOST Form policy, revised [DATE], was provided by the DON on [DATE] at 6:41 p.m. The policy read in pertinent part, Patients must sign the MOST form even if he/she can only sign with an 'X.' The MOST form can only be signed by someone other than the patient if there is a Medical Durable Power of Attorney (MDPOA) in place. (Name of facility) must have a record of the MDPOA and it must be in effect during stay at the facility. The nurse will go through the MOST form with the patient fully and completely. All sections of the MOST form MUST be completed, signed and dated by the patient. The patients attending Physician or Nurse Practitioner will review the form and also sign and date. Once the MD (physician)/NP (nurse practitioner) has signed, the MOST form will be scanned and uploaded into the patient's medical record. The original MOST form will be kept in the MOST form book (located at the nurse's station) and will be given to the patient upon discharge from the facility. If the patient is a readmission to the facility, the MOST form will be printed from the patient's medical record and reviewed with the patient. If there are no updates, the nurse will sign as the reviewer, date and provide the location of the review. The updated MOST form will be uploaded into the patient's medical record. If the patient wishes to make changes to the MOST form, a new form must be completed in its entirety and will be uploaded into the patient's medical record.IV. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia , interstitial pulmonary disease, pulmonary hypertension, chronic obstructive pulmonary disease with acute exacerbation and pneumonia.The [DATE] minimum data set (MDS) assessment identified Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #1 used a walker and was independent in indoor mobility. B. Resident #1's representative interview The resident's representative was interviewed on [DATE] at 11:52 a.m. The representative said the resident's wishes were to receive CPR and to be resuscitated as she had a full code status.C. Record reviewThe Colorado MOST form was signed by Resident #1's family member and the nurse practitioner on [DATE]. Review of the MOST form revealed Resident #1 agreed to the box marked Yes CPR, attempt to resuscitate. The hospital referral document, dated [DATE], identified Resident #1's code status as DNR. The hospital discharge document dated [DATE], identified Resident #1's code status as a full code.Resident #1's care plan, initiated [DATE], revealed Resident #1 was designated as a DNR. Resident #1's [DATE] medication administration (MAR) designated the resident as a DNR. The interdisciplinary progress note, dated [DATE] at 2:55 p.m., documented Resident #1 was a new admission. It further revealed Resident #1's code status was DNR.The social history progress note, dated [DATE] at 10:41 a.m., documented Resident #1 had a DNR.The NP progress note, dated [DATE] at 10:40 a.m., revealed Resident #1's code status was DNR.-However, according to the Colorado MOST form signed by the NP and the resident's representative, the resident wished to have CPR.The death note progress note, dated [DATE] at 5:28 a.m., revealed RN #1 was called to the third floor. Resident #1 was in her wheelchair unresponsive, with no pulse, no respirations and was cool to the touch. RN #1 was unable to hear a heart beat or respiratory rate. The note documented emergency medical services (EMS) was not called. The note identified Resident #1's code status as DNR. V. Staff interviews RN #2 was interviewed on [DATE] at 10:58 a.m. RN #2 said the nurses helped the residents fill out the MOST form when they were admitted to the facility. RN #2 said nurses updated the EMR with the most recent MOST form information. RN #2 said if she needed to find the code status of a resident she would reference the MOST form specifically and act accordingly afterwards. RN #2 said she was aware of the incident that occurred with Resident #1 and that staff had to complete training on MOST forms and CPR. RN #2 said nurses were no longer allowed to use their report sheets to reference code status. RN #1 was interviewed on [DATE] at 1:39 p.m. RN #1 said she received a phone call from LPN #1 at approximately 4:25 a.m. RN #1 aid LPN #1 requested assistance. RN #1 said LPN #1 verbally told RN #1 that Resident #1's code status was DNR. RN #1 said she did not use Resident #1's chart or MOST form binder to assess Resident #1's code status. RN #1 said she was not aware the resident was a full code status. RN #1 said when assessing the resident, she described the resident as dusky and grey. She said the resident had no vital signs. RN #1 said she went to Resident #1's room. She said Resident #1 was slumped forward in her wheelchair, was dusky grey colored and was cold to the touch. RN #1 said she listened for heart and lung sounds for a full minute, but did not hear anything. RN #1 said no vital signs were present.The medical director (MD) was interviewed on [DATE] at 2:03 p.m. The MD said the MOST form was the resource the nurses should have used to determine the code status of a resident. The MD said the staff should have called 911 when they found Resident #1 unresponsive.LPN #1 was interviewed on [DATE] at 2:25 p.m. LPN #1 said on [DATE] at approximately 4:00 a.m. a CNA had asked her if Resident #1 typically slept deeply. LPN #1 said she went right to Resident #1's room and checked on Resident #1. LPN #1 said the resident was in her wheelchair and was not responding. LPN #1 said she did a sternal rub and the resident did not respond. LPN #1 said the resident had no respirations or pulse and was mottling (blotchy skin due to poor circulation that is often seen at end of life). LPN #1 said she verified Resident #1's code status was DNR by referencing her report sheet. LPN #1 said she did not reference the MOST form binder. She said she referenced her nursing report sheet which identified the resident as DNR. LPN #1 said the sheet should have been updated with the correct code status when Resident #1 was admitted from the hospital. LPN #1 said she did not reference the MOST form binder or the EMR. LPN #1 said when she called the on-call physician service, she was told the physician would call the time of death at 4:30 p.m. LPN #1 said she received education on where to reference code status in the future and said she would directly reference the MOST form in the future.The DON was interviewed on [DATE] at 3:57 p.m. The DON said staff would no longer be able to look at the code status on report sheets. She said they discontinued that practice as it could lead to errors. The DON said the expectation was for the staff to reference the MOST form in the MOST form binder at each nurses' station. The DON said education was completed to ensure staff members were aware of this expectation. The nursing home administrator (NHA) was interviewed on [DATE] at 3:57 p.m. The NHA said there were MOST form binders on each floor at the nurses' station. She said staff should have referenced the MOST form to identify the code status of Resident #1.

Based on record review and interviews, the facility failed to ensure one (#5) of five residents received the highest practicable treatment and care in accordance with professional standards of practice of five sample residents.Specifically, the facility failed to ensure:-All prescribed medications which were ordered upon Resident #5's admission, including medications to treat infections, were administered as ordered and when available; and,-Notify the physician when Resident #5 medications were not administered as ordered. Findings include:I. Facility policy and procedureThe IV (intravenous) Medication Administration policy, revised 10/12/22, was provided by the nursing home administrator (NHA) on 11/19/25 at 9:44 a.m. It read in pertinent part, It is the policy of this facility that IV medications are to be administered as prescribed by the attending physician. IV medication must be administered in accordance with the written orders of the attending physician.The Medication Administration policy, revised 8/22/22, was provided by the NHA on 11/19/25 at 10:58 a.m. It read in pertinent part, Medications must be administered in accordance with the written orders of the attending physician. Medications may not be set up in advance and must be administered within one hour before or after their prescribed time.II. Resident #5A. Resident statusResident #5. age less than 65, was admitted on [DATE]. According to the November 2025 computerized physician's orders (CPO), diagnoses included cellulitis (deep bacterial skin infection) of the right lower limb, pressure ulcer of the right hip, diabetes and respiratory failure.The 10/13/25 minimum data set (MDS) assessment revealed Resident #5 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required set up assistance with eating, supervision with personal hygiene and toileting and moderate assistance with showering.B. Resident #5 interviewResident #5 was interviewed on 11/18/25 at 11:45 a.m. Resident #5 said during his most recent admission to the facility, he did not initially receive all of his scheduled medications. Resident #5 said the facility had not missed medication doses since the day after he was admitted .C. Record reviewReview of the October 2025 CPO revealed the following physician's orders upon the resident's admission [DATE]):-Ceftriaxone sodium two gram (gm) IV, with instructions to give once daily for sepsis (infection).-Ferrous sulfate 325 milligrams (mg), with instructions to give once daily for iron deficiency.-Jardiance 10 mg, with instructions to give once daily for diabetes.-Allopurinol 300 mg, with instructions to give once daily for gout.-Bumetanide two mg, with instructions to give every morning for edema.-Potassium chloride ER (extended release) 20 mEq (milliequivalents, a unit for measuring potassium), with instructions to give three tablets once daily for low potassium.-Prednisone four mg, with instructions to give once daily for hypoxia (low oxygen level).-Sertraline 100 mg, with instructions to give once daily for antidepressant.-Tamsulosin 0.4 mg, with instructions to give once daily for BPH (benign prostatic hyperplasia, enlargement of prostate gland).-Apixaban 5 mg, with instructions to give twice daily for anticoagulant (blood thinner).-Carvedilol 12.5 mg, with instructions to give twice daily for hypertension (high blood pressure).-Gabapentin 300 mg, with instructions to give three times daily for diabetic neuropathy. Resident #5 was not administered the following ordered medications which were documented as not available: Ceftriaxone on 10/12/25 at 8:00 a.m.Ferrous sulfate on 10/12/25 at 8:00 a.m.Jardiance on 10/12/25 at 8:00 a.m.Allopurinol on 10/12/25 at 8:00 a.m.Bumetanide on 10/12/25 at 12:00 p.m.Potassium chloride on 10/12/25 at 8:00 a.m.Prednisone on 10/12/25 at 8:00 a.m.Sertraline on 10/12/25 at 8:00 a.m.Tamsulosin on 10/12/25 at 8:00 a.m.Apixaban on 10/12/25 at 8:00 a.m.Carvedilol on 10/12/25 at 8:00 a.m. Gabapentin on 10/12/25 at 8:00 a.m. and 2:00 p.m.The ordered doses of Resident #5's Allopurinol, Bumetanide, Potassium chloride, Prednisone, Sertraline, Tamsulosin, Apixaban, Carvedilol and Gabapentin were on facility's list of medications continuously available at the facility, which revealed they could have been administered on 10/12/25 as ordered by the physician.Review of the nursing progress notes from 10/12/25 did not reveal notification to the physician of the medications that were not administered.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 11/18/25 at 11:55 a.m. LPN #1 said the hospital usually forwarded the physician's orders to the facility prior to a resident's arrival. LPN #1 said when residents were admitted to the facility, the provider should be contacted to verify the orders. LPN #1 said the orders were then entered in the electronic medical record (EMR) and communicated to the pharmacy. LPN #1 said when medications did not arrive from the pharmacy by the scheduled time for administration, the medications could sometimes be obtained from the automated dispensing machine. Registered nurse (RN) #1 was interviewed on 11/18/25 at 12:15 p.m. RN #1 said when an antibiotic or other medications were not available to give at the time they were ordered for administration she would notify the physician and the physician would provide guidance for how to proceed. The pharmacist was interviewed on 11/18/25 at 1:22 p.m. The pharmacist said medications were delivered to the facility twice daily. She said if medications were ordered later in the day, they might not be delivered until the next day. The pharmacist said if the IV antibiotic could not be given on the start date, she would ideally expect the physician to be notified. The medical director (MD) was interviewed on 11/18/25 at 1:30 p.m. The MD said he expected nurses to use critical thinking skills to determine if a physician should be notified regarding a missed medication dose. The MD said if an IV antibiotic was scheduled early in the day and did not arrive later in the day from the pharmacy, the nurse should call to determine if the antibiotic should be given upon arrival. The MD said he would expect to have a conversation with the nurse if an IV antibiotic could not be given as scheduled.The DON was interviewed on 11/18/25 at 3:07 p.m. The DON said an antibiotic order might need to be extended if the first dose was not able to be administered as scheduled. The DON said she would contact the physician if an antibiotic were not able to be administered as scheduled. The pharmacist was interviewed on 11/18/25 at 3:52 p.m. The pharmacist said all of Resident #5's medications, including the IV Ceftriaxone were delivered to the facility on [DATE] at 3:30 p.m. The pharmacist said she would not expect there to be a delay in administration of an ordered IV antibiotic (such as the Ceftriaxone) once it was received by the facility.-However, the Ceftriaxone was not administered on 10/12/25 after receipt from the pharmacy (see record review above).The director of nursing (DON) and regional nurse consultant were interviewed together on 11/19/25 at 11:08 a.m. The DON said if medications could not be administered because they had not been delivered, the nurse could look in the automated dispensing system to determine if the medication was available at the facility for administration. The regional nurse consultant said the Ceftriaxone should have been administered on 10/12/25 upon delivery from the pharmacy, and not delayed until 10/13/25.LPN #2 was interviewed on 11/19/25 at 12:10 p.m. LPN #2 said if a medication was not available from the pharmacy, she would check the automated medication dispensing system to see if the medication was at the facility for administration. LPN #2 said if she could not administer the medication, she would contact the physician and possibly the pharmacy.The DON and the regional nurse consultant were interviewed again on 11/19/25 at 12:32 p.m. The regional nurse consultant said several of Resident #5's medications were available on 10/12/25 at 8:00 a.m. in the automated dispensing system at the facility and should have been administered to the resident at that time. The regional nurse consultant said there could be delayed healing or increased infection if multiple doses of antibiotics were missed.The DON said the facility was going to be collaborating with the pharmacy to ensure more IV antibiotics that were frequently ordered by physicians at admission would be available at the facility to use in the automated medication dispensing system in case the medication did not arrive from the pharmacy in time to be administered. The DON said the facility had provided reeducation to the nursing staff regarding medication availability.V. Facility follow-upThe DON provided a nursing staff education document titled Medication Availability for Admissions on 11/19/25 at 12:32 p.m. The document was dated 11/18/25 (during the survey), and was signed by 10 RN and LPNs. It read in pertinent part, When a medication has been ordered for admission from the discharge paperwork provided from a discharging facility, it is imperative that the patient begins their medications appropriately as ordered. If medications have not arrived from the pharmacy in time for the first dose, there are a couple of options available to pursue: check Nexsys to see if it is available, ask the family if they can bring in the medication from home, contact the pharmacy to request the medication and contact the ADON (assistant director of nursing) or DON for guidance. If the medication is not available, documentation is required, for example, what was done about it and who was contacted.

Based on record review and interviews, the facility failed to ensure residents received treatment and care consistent with professional standards of practice. This affected five (#1, #2, #5, #6 and #7) of six residents out of eight total sample residents. RESIDENT #1 Resident #1 was admitted to the facility from the hospital on [DATE]. His diagnoses included long-term use of anticoagulants (blood thinner). Orders included the anticoagulant Lovenox by injection, started [DATE] and discontinued [DATE], and Apixaban (Eliquis) an oral anticoagulant for deep vein thrombosis, started [DATE], discontinued [DATE], and ordered again on [DATE] to [DATE]. A review of the treatment administration record (TAR) revealed the November orders, starting [DATE], read in part, Anti-coagulation medication monitoring: monitor every shift for signs and symptoms of bleeding (black tarry stools, increased or new bleeding of gums, blood in urine, etc). If complications notify MD . -However, this order was discontinued on [DATE], and there was no documentation of anticoagulant monitoring on the resident's TAR from [DATE] to [DATE] - 26 shifts over 13 days. There was no documentation explaining why monitoring was discontinued and, the resident's care plan did not address anticoagulant therapy - the risks, signs/symptoms of bleeding, or monitoring expectations found on the TAR. In addition, the resident's record did not contain consent for the use of the anticoagulant medication Eliquis. On [DATE] at around 6:00 p.m., a certified nurse aide (CNA) found the resident with coffee-colored emesis and a dark bowel movement. The CNA reported the findings to the licensed practical nurse (LPN #1) who worked the night of [DATE] and the early morning of [DATE]. In an interview, the LPN stated Resident #1 had not previously had a dark bowel movement or coffee-colored emesis. The LPN called the assistant director of nursing (ADON) (the interim DON at the time). The ADON requested the registered nurse (RN) do a full assessment. After receiving the RN's report, the ADON contacted the physician around 10:30 p.m. and a decision was made to monitor the resident. -However, there was no documentation of the RN's full assessment in the electronic medical record or a change of condition assessment form. Per the nursing home administrator (NHA), no RN assessment note was completed. Further, there was no documentation explaining why the resident was not sent to the hospital which was the expectation for evidence of a new bleed per the ADON. Moreover, although the resident's primary care physician (PCP) documented the resident's MOST form (Medical Orders for Scope of Treatment) was revised on [DATE] and record review revealed an order entered that day for do not resuscitate (DNR), the revised MOST form could not be located during the survey, and the resident's care plan still read full code, initiated [DATE]. Resident #1 expired at the facility early in the morning on [DATE]. According to a note dated [DATE] at 4:47 a.m., the resident was checked at 4:00 a.m. and found without respirations or heart tones. The cause of death, according to the death certificate, was a presumed gastrointestinal bleed. RESIDENTS #2, #5, #6, AND #7 Record review and interviews revealed the facility failed to complete a change in condition assessment form when Resident #2 experienced low oxygen levels and was unresponsive; failed to care plan Resident #5, #6, and #7's anticoagulant use, and failed to have physician orders monitoring their anticoagulant use. Further, the facility failed to have documentation that consent was obtained for Resident #6's anticoagulant medication. SUMMARY The facility failed to properly address Resident #1's significant change of condition when the resident, who was receiving anticoagulant medication, began bleeding internally. The facility's failure to assess and monitor the resident's anticoagulant medication use and change in condition, failure to document changes, and failure to seek medical treatment, contributed to serious harm for Resident #1. The failures also created the potential for further serious resident harm if the facility's system for assessing, monitoring, and communicating changes was not immediately corrected. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy A review of Resident #1's anticoagulant use, monitoring records, and staff interviews revealed the facility failed to take steps, consistent with professional standards of practice, to promote Resident #1's well-being both before and upon the discovery of the resident's coffee-colored emesis and dark bowel movement on [DATE]. There was no evidence the facility thoroughly investigated the [DATE] incident to uncover and address why the nurses did not recognize the resident's change in condition, complete accurate assessments, and seek appropriate treatment. -Record review revealed no documentation of anticoagulant monitoring on Resident #1's treatment administration record (TAR) from [DATE] to [DATE] - 26 shifts over 13 days. Further, the resident's care plan did not address anticoagulant therapy - the risks, signs/symptoms of bleeding, or monitoring expectations found on the TAR. -Record review revealed no documentation of the RN's full assessment in the electronic medical record or a change of condition assessment form. Per the nursing home administrator (NHA), no RN assessment note was completed. There was no documentation explaining why the resident was not sent to the hospital which was the expectation for evidence of a new bleed per the assistant director of nursing (ADON). The facility's failure to implement an immediate and comprehensive review of the facility's system of anticoagulation management and of response to resident changes in condition, including the response to Resident #1's coffee-colored emesis and dark bowel movement, placed residents at risk for serious harm if the situation was not immediately corrected. B. Facility notice of immediate jeopardy On [DATE] at 4:30 p.m., the NHA, chief operating officer (COO), and director of nursing (DON) were notified that the facility's failure to identify and respond to Resident #1 change in condition created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On [DATE] at 11:04 a.m. the facility submitted a final plan for removal of the immediate jeopardy situation. The plan read: The facility immediately completed the following: 1. Resident-centered care plan was created on [DATE] for all residents who currently received anticoagulant medications and will be completed by [DATE]. 2. Orders for on-going monitoring for anticoagulant medications were obtained from the providers on all residents who do not have orders on [DATE]. 3. An in-service was completed on [DATE] by the DON/designee to all licensed nursing staff who were in the building (phone call education for staff who were not in the building) to ensure that the facility performs adequate physical assessments for change of conditions, recognize changes and how to accurately and timely communicate the assessment findings to the physician on call. 4. An in-service was completed on [DATE] by the DON/designee to all licensed nursing who were in the building (phone call education for staff who were not in the building) to ensure that they analyze the situations for when to send residents to the hospital, with background information, assessments and recommendations with a timely, consistent and accurate process. 5. Education will be provided to all nursing staff prior to the start of their shift. All residents have the potential to be affected by this alleged deficiency. All residents in the building were reviewed for change of condition and none of the other residents were affected by this deficient practice. The DON or their designee will oversee the compliance with the resident-centered care plan and ensure continuous monitoring of anticoagulant therapy. This monitoring will include staff performance of thorough physical assessments for changes in resident conditions, timely recognition of these changes, and the accurate and prompt communication of assessment findings to the on-call physician. Additionally, the monitoring process will ensure that nursing staff appropriately analyze situations where hospitalization may be necessary, including completing timely and accurate background information, assessments, and recommendations. Monitoring will start on [DATE] and will follow the schedule below: Daily for one week, Weekly for four weeks, Monthly for two months, or until substantial compliance is achieved. D. Removal of immediate jeopardy Based on the facility's plan above and evidence of its implementation, the immediate jeopardy situation was removed on [DATE] at 12:40 p.m. However, the deficient practice remained at a G level, isolated actual harm. II. Professional references and facility expectations A. Professional references - Anticoagulant risks 1. The National Library of Medicine, Anticoagulant Safety, updated [DATE], retrieved on [DATE] at Amaraneni A, Chippa V, [NAME] J, et al. Anticoagulation Safety. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519025/, read in pertinent part: Millions of patients rely on oral anticoagulants to decrease the risk of ischemic stroke and other thromboembolic events, underscoring the importance of understanding their safety profiles. However, these medications rank among the leading causes of emergency department visits and hospital admissions among older adults, prompting classification as high-alert medications by the Institute of Safe Medication Practices and a focus on harm reduction in The Joint Commission's National Patient Safety Goals. Still, the benefits outweigh the overall risks for most patients. The initial weeks of oral anticoagulant use pose the highest risk of adverse effects, particularly during transitions from hospital to home care, necessitating careful management as patients recuperate. Despite their efficacy in preventing and treating thromboembolism, all anticoagulants elevate the risk of bleeding. Clinicians must carefully assess each agent's risks and benefits, tailoring medication choices accordingly. Adverse effects often stem from concurrent use of antiplatelet medications, dosing errors, or inadequate monitoring, underscoring the importance of healthcare professionals' knowledge about potential complications like intracranial and gastrointestinal bleeding, hematoma formation, and available reversal agents. Accurate assessment of bleeding risks and prescribing appropriate doses is essential for maximizing clinical benefit. Symptoms of significant bleeding vary by site, and early symptoms include epistaxis, gum bleeding, heavy menstrual bleeding, or excessive bruising. Airway-related hematomas may cause sore throat, painful or difficult swallowing, nosebleeds, shortness of breath, or hemoptysis. Extremity involvement may manifest as pain, swelling, weakness, or limited motion. Intraabdominal bleeding can lead to pain and distension, while intracranial bleeds may cause severe headaches, vomiting, dizziness, or seizures. Ocular bleeding may result in vision changes. Gastrointestinal bleeding may present as melena, hematochezia, or hematemesis. Gastrointestinal signs: Patients may have evidence of hypovolemia manifesting as tachycardia and hypotension, visible or occult blood in the stool, and pain on abdominal examination. Healthcare professionals must swiftly determine the severity and location when assessing bleeding complications in patients taking oral anticoagulants. A comprehensive history and medication review are crucial, documenting the anticoagulant regimen, last dose timing, and potential overdose risk. In addition, exploring the history of renal or hepatic disease, bleeding disorders, thrombocytopenia, and medications affecting hemostasis is necessary. Understanding the anticoagulation indication and thrombosis risk aids treatment decisions. Enhancing patient-centered care, outcomes, safety, and team performance in anticoagulation management requires a multifaceted approach involving physicians, advanced practitioners, nurses, pharmacists, and other healthcare professionals. Physicians and advanced practitioners should demonstrate strong clinical skills in risk assessment, medication selection, and dosage determination while effectively communicating with patients to involve them in treatment decisions. Nurses play a crucial role in monitoring patients, educating them about adherence and lifestyle changes, and promptly recognizing and managing complications. Pharmacists contribute by conducting medication reviews, assessing drug interactions, and ensuring appropriate care transitions. Effective interprofessional communication, supported by clear documentation, is essential for coordinating care and minimizing errors. Care coordination involves developing standardized protocols, guidelines, and pathways for anticoagulation management across various settings, ensuring seamless transitions and optimizing patient outcomes. By leveraging their skills, communication, and coordination, healthcare teams can collectively enhance anticoagulation safety and improve patient care and outcomes. 2. Eliquis package insert ([DATE]) was retrieved on [DATE] from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/,d+[DATE]s034lbl.pdf. It revealed in pertinent part, Eliquis increases the risk of bleeding and can cause serious, potentially fatal bleeding. Advise patients of signs and symptoms of blood loss and to report them immediately or go to an emergency room . B. Facility expectations The facility's Change of Condition policy, reviewed [DATE], was provided by the NHA on [DATE] at 12:36 p.m. It read in pertinent part: As part of the evaluation the nurse will help identify individuals for having any changes of condition during their stay or if a patient has a fall. In addition, the nurse shall evaluate and document/report the following: Vital signs; Difficulty speaking; Difficulty understand(ing) speech; neurological abnormalities; recent labs; all active diagnoses; cognitive and emotional status; change in mental status and LOC (level of consciousness). Direct care staff to notify nurse if they notice subtle, but significant changes in the patient: For example: Decrease in food intake; Increase confusion/agitation; Change in vital signs etc; Change in balance; Injury from fall; Change in neuro's (neurological findings). The nursing staff will notify the physician if any of the above signs and symptoms are identified. The physician will indicate if patient requires additional evaluation/ treatment at the facility or if patient needs to be sent out to the hospital. Nurse to also notify family if requested by patient or family is listed to contact in case of an emergency. III. Resident #1 A. Resident status Resident #1, age 68, was admitted on [DATE] and discharged on [DATE] due to death. According to the [DATE] computerized physician orders (CPO), diagnoses included encephalopathy, cerebral infarction, acute pancreatitis, type 2 diabetes mellitus, chronic kidney disease, and long-term and current use of anticoagulants (blood thinners). The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 6 out of 15. He was dependent on assistance with eating, bathing, upper and lower body dressing, personal hygiene, bed mobility, and transfers. The record revealed no documented discussion with the resident/resident representative concerning hospice or palliative care. Further record review revealed no Medical Orders for Scope of Treatment (MOST) form, identifying the type of treatments and interventions the resident/representative wanted but may be unable to express. However, the care plan read Full code (life-saving measures if respiratory/cardiac arrest), initiated [DATE]. Orders revealed the resident was administered anticoagulants. A review of a [DATE] physician note revealed Resident #1 was started on Lovenox (an anticoagulant) by injection at the hospital and continued after admission until [DATE] when, per the [DATE] CPO, Lovenox was discontinued due to a site reaction to the injections. The anticoagulant Apixaban (Eliquis) an oral anticoagulant, 2.5 MG (milligram) was ordered for administration by mouth two times a day for DVT (deep vein thrombosis). This order was discontinued on [DATE] at 8:12 a.m., and Apixaban oral tablet 2.5 MG by mouth two times a day for DVT was ordered (start date site of [DATE] at 9:00 p.m.). A review of the TAR revealed an order for anti-coagulation medication monitoring: monitor every shift for signs and symptoms of bleeding (black tarry stools, increased or new bleeding of gums, blood in urine, etc). If complications notify MD. P = Problems, 0 = No Problems. Start date [DATE], and discontinued date [DATE]. B. Change in status/goals after admission 1. Record review revealed documentation of the resident's primary care provider (PCP) follow-up visit to discuss goals of care on [DATE] at 8:45 a.m. It read in part: -Resident #1's hospitalization history: admitted to the hospital on [DATE] with global weakness and dysarthria. The patient was then discharged from the hospital to the skilled nursing facility on [DATE]. The patient transferred to the emergency room (ER) on [DATE] for concerns of developing sepsis, diagnosed with COVID, and sent back to the facility. The resident transferred to theER on [DATE] for liver function testing, increasing lethargy, and worsening pulmonary symptoms. Urinary tract infection (UTI) diagnosed in the ED (emergency department). The resident was transferred to theER on [DATE] and [DATE] due to feeding tube issues. The feeding tube was unclogged and the patient was sent back to the facility. -Goals of care discussion held [DATE] with the resident and his wife through an interpreter over the phone who speaks Chuukese (arranged per facility administration). Explained in detail numerous medical issues that the patient was currently dealing with. Explained in detail that given the multitude of issues as well as progressive worsening in weakness and failure to improve with therapy that it was unlikely that patient will improve from a therapeutic standpoint in regards to his stroke. Explained that he will likely never swallow again, he will likely never walk again, and will be dependent on others for the remainder of his life. Also explained given the multitude of issues affecting multiple organ systems that further worsening of such is likely to occur and that rehospitalization was certain in his future. -We discussed CPR (cardiopulmonary resuscitation) at length, what it entails, what that would look like for Resident #1 and possible outcomes of such. After answering questions, the wife decided that CPR/intubation would not likely be in the patient's best interest and instead DNR would be more appropriate. New MOST form filled out and filed. A bedside nurse was present in the room for the entire discussion. All questions answered. 2. Events [DATE] and [DATE] An [DATE] nursing progress note revealed Resident #1 was changed at the beginning of the shift (6:00 p.m.) by a certified nurse aide (CNA). When Resident #1 was rolled to his right side, the resident had vomited coffee ground emesis. Resident #1 was cleaned up and the nurse was notified. Resident #1's brief was changed and found to have a dark bowel movement. A call was made to the DON. A full assessment was completed by the registered nurse (RN) in the building and notified the DON of the results. The DON called the provider and he gave the following orders: One time order of 30ML of first-lansoprazole oral suspension 3 MG/ML (Lansoprazole) (a medication that reduces acid in the stomach). Vital signs every four hours and if systolic blood pressure was less than 100 or heart rate greater than 100 to call the provider. The [DATE] at 4:47 a.m. death note revealed the DON had called the provider at approximately 10:30 p.m. and he gave the following orders: One time order of 30ML of First-Lansoprazole Oral Suspension 3 MG/ML (Lansoprazole.) Vital signs every four hours. If Systolic is less than 100 or HR (heart rate) is greater than 100 call the provider. Vitals just after midnight: Blood pressure ,d+[DATE], Temperature 98.1, Pulse 100, Respirations 19, O2 (oxygen saturation) 90%. The resident was checked on at 2:00 a.m. and had no changes to note. At 4:10 a.m. the staff went in to check on the resident and complete vital signs and the patient had no respirations or heart tones. Eyes were fixed and dilated. RN assessed patient for the final outcome. The patient was a DNR. Time of pronouncement of death: 4:10 a.m. per on-call physician. Body not sent anywhere at this time. Wife in room and would gather belongings. Skin condition upon death: intact. Responsible party notification: Wife in attendance in room. MD Notification: On-call notified at 4:20 a.m. C. Record review and interviews revealed the facility failed to ensure Resident #1 received treatment and care consistent with professional standards of practice. The DON was interviewed on [DATE] at 5:28 p.m. The technician at the local county coroner's office was interviewed on [DATE] at 10:08 a.m. Resident #1's PCP was interviewed on [DATE] at 10:19 a.m. The ADON was interviewed on [DATE] at 1:11 p.m. The NHA was interviewed on [DATE] at 2:47 p.m. and LPN #1 was interviewed on [DATE] at 5:42 p.m. 1. Failure to properly manage Resident #1's anticoagulant therapy a. Record review Although the resident's TAR revealed an order for anti-coagulation medication monitoring every shift for signs and symptoms of bleeding (see above), this order was discontinued on [DATE]. There was no explanation for discontinuing monitoring for evidence of bleeding, and a review of the TAR and the resident's electronic medical record revealed no documentation of anticoagulant monitoring from [DATE] to [DATE] - 26 shifts over 13 days. Although there are significant risks to resident safety from anticoagulants (see references above), a review of the resident's care plan revealed it did not address anticoagulant therapy - the risks, signs/symptoms of bleeding, or monitoring expectations found on the TAR. Finally, the resident's record did not contain consent for the use of the anticoagulant medication Eliquis. b. Interview ADON: The assistant director of nursing (ADON) said if a resident is on an anticoagulant, the nurses should be monitoring for signs and symptoms of bleeding, evaluating the resident if signs of bleeding are reported by staff, and documenting the evaluation. The ADON said it was important to monitor if a resident uses anticoagulant medication for the very reason with Resident #1 of a gastrointestinal bleed. The ADON said without monitoring, there could be abnormal labs, leading up to and including death. The ADON said there should be a care plan for all residents using an anticoagulant medication so that staff providing care were aware. PCP: The PCP said if a resident was on an anticoagulant medication such as Eliquis, there should be monitoring and documentation of symptoms of bleeding. The PCP said it went without saying how important it was because healthcare providers worry about the ongoing risk of hemorrhage. 2. Failure to properly manage Resident #1 change of condition a. Interviews DON: The DON, who assumed her position on [DATE], said she did not know why Resident #1 was not sent to the hospital when he had signs and symptoms of a gastrointestinal bleed. ADON: The ADON said she was the nurse on-call and acting as the interim DON during the evening on [DATE] and early morning on [DATE]. She said it was her understanding that Resident #1's bleeding was not new and that he had gone to the hospital multiple times with the same issue. She said this was reported to her from the staff that evening. She said on the night of [DATE], she got a call from LPN #1 and she spoke to the RN in charge who made it sound like, and confirmed, that the resident had gone out to the hospital multiple times for the same issue (coffee ground emesis and dark stool) and it sounded like a recurrent issue in the way it was presented. She said typically, if it was a new bleed, the resident would be sent out immediately and per protocol, a change of condition assessment form completed. The ADON confirmed she did not have an RN assessment for Resident #1 or a completed change of condition assessment form. The ADON said she called the on-call physician and told him it was reported the resident had abdominal distension, that the resident had received both doses of his anticoagulant, and that the resident had coffee-ground emesis and dark-colored bowel movement. She said the physician was made aware of the bleeding, but told it was a frequent event, not a new event. He was informed the resident's status had changed to DNR, the wife was at the bedside and it was reported to her the wife did not push to send the resident to the hospital but did not say either way. The ADON said the action decided on by the physician was to give Prevacid (a medication that reduces acid in the stomach), check vitals every four hours with parameters of when to notify the provider, and ordered a CBC but not stat (right now). It was not obtained before the resident expired. The ADON said at the time of the incident she agreed with the provider, but with what she knew now, that the bleeding was a new issue, her decision would have been different and she would have recommended sending Resident #1 to the hospital. PCP: The PCP said if there was a change in condition, such as increased bleeding, nose bleeds, vomiting blood, or gastrointestinal bleeding, she would want to be notified. The PCP said the facility should know to contact her or call 911. The PCP said if there was no documentation stating otherwise, a resident with new significant bleeding should be sent to the hospital for further monitoring and evaluation. The PCP said she saw Resident #1 on [DATE] before taking time off. When she returned to work, she asked what happened in reference to the resident's death. The PCP said she thought Resident #1 should have been sent to the hospital. She said that although she was not the provider who was covering that day, whenever she heard about a gastrointestinal bleed and the resident was on an anticoagulant medication, they should go to the hospital. NHA: The NHA said Resident #1 spoke a rare language, Chuukese (a language spoken in the Federated States of Micronesia). The NHA said the resident had been sent out to the hospital a couple of times in [DATE]. The NHA said his understanding about what had occurred with Resident #1 was that the resident's wife had said no - the resident did not want to be sent out. He said the ADON called and told him the resident's clinical indicators were decreasing and told him they were going to send the resident out but the wife said no. The NHA said an interpreter was not present. The resident's wife spoke some English; however, he acknowledged there was no documentation of the resident's wife saying no to hospitalization . He said he found out that Resident #1 had passed away the next morning. LPN #1: LPN #1 said she had worked at the facility for one year and was the nurse who was working on the night of [DATE] and early morning of [DATE] with Resident #1. LPN #1 said that Resident #1 had a lot going on and the doctor during the day came in and that was the report she got. LPN #1 said Resident #1 had a lot of congestion going on and breathing was loud. LPN #1 said when she first checked on him, his tube feeding was going and he was sitting up. LPN #1 said the CNA told her of Resident #1's dark bowel movement and coffee-colored emesis but the CNA did not show it to her. LPN #1 said Resident #1 had not had a dark bowel movement or coffee-colored emesis before. LPN #1 said the RN had come up to the third floor from the second floor to assess him. LPN #1 said the bleeding was new as far as she was concerned. LPN #1 said she did not speak to the doctor. She called the ADON (interim DON at the time) who said to have the RN do a full assessment and call her back and then she (ADON) would call the doctor. LPN #1 said after that, the RN called the ADON back to give her a report. LPN #1 said she did not remember what the RN said after the assessment. LPN #1 said basically, the RN found nothing wrong and she asked the RN if she thought Resident #1 should be sent out and the RN said no, that she had talked with the ADON. LPN #1 said she was told to call the ADON with any change of condition, and before calling a provider or sending a resident out to the hospital. LPN #1 said she had tried to call the daughter but she had not answered. LPN #1 said she felt that Resident #1 should have gone to the hospital but she deferred to the RN and ADON (interim DON at that time). County coroner technician (CCT): The technician at the local county coroner's office said Resident #1's actual cause of death as listed on the death certificate was presumed gastrointestinal bleed caused by gastric ulcers as recorded by Resident #1's PCP. b. Record review There was no documentation of the RN's full assessment on [DATE] in the electronic medical record or a change of condition assessment form, and, per the NHA, no RN assessment note was completed. There was no documentation why the resident was not sent to the hospital, which was the expectation for a new bleed per the ADON. On [DATE] at 12:21 p.m., the RN assessment for the [DATE] event was requested. On [DATE] at 1:50 p.m., the NHA responded that an RN assessment note was not completed and the RN had been terminated. The Change of Condition policy (see above) was not reviewed or revised following the events on [DATE] that revealed nursing staff failed to fully evaluate, document, and report Resident #1's change in condition. A review of the policy revealed it was last reviewed [DATE], per the Change of Condition document provided by the NHA. Printed on the Change of Condition policy document was the issuing date ([DATE]), a revised date ([DATE]), a revised date ([DATE]), and a reviewed date ([DATE]). (Department of Nursing) A review of the electronic medical record revealed there were no physician orders to send Resident #1 to the hospital. 3. Failure to take steps to clarify Resident #1 and their representative's goals for care to ensure a response consistent with their goals. a. Record review The [DATE] PCP follow-up visit to discuss goals of care (see above) indicated a new MOST form that documented Resident #1 would be a DNR (do not resuscitate) was filled out and filed. Further, the resident's record revealed an order was written with a start date of [DATE] that read Resident #1 was a DNR (do not resuscitate)/No code. -Notwithstanding the PCP note and order above, the new MOST form (or copy), requested from the NHA on [DATE] at 4:22 p.m., could not be located as of [DATE] according to the NHA. -Notwithstanding the PCP note and order above, a review of Resident #1 care plan was not updated and read the resident was a full code, initiated on [DATE]. b. Interviews DON: The DON said she did not recall anything about Resident #1's MOST form. However, she said it should have been scanned into t[TRUNCATED]

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of care by not sending a resident to the hospital when indicated that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) policy, revised 2/11/25 (during the survey), was provided by the nursing home administrator (NHA) on 2/13/25 at 1:17 p.m. It read in pertinent part, It is the policy of the facility to develop a QAPI plan in accordance with Federal guidelines to describe how the facility will address clinical care, residents' quality of life and residents' choice and is based on the scope and complexity of services defined by the facility assessment. Objective of the QAPI improvement policy: The objective of this requirement is the completion and implementation of the QAPI plan to identify the high risk, problem prone and high volume areas to evaluate for improvement and identify, collect and use data relevant to the unique characteristics and needs of the residents. II. Cross-reference citation Cross-reference F684: The facility failed to provide quality care by not sending a resident to the hospital when indicated, resulting in the death of the resident. The facility's failure to provide quality of care put residents in a situation where a serious outcome occurred and created an immediate jeopardy situation. III. Staff interviews The medical director (MD) was interviewed on 2/12/25 at 3:53 p.m. The MD said he was not informed of the immediate jeopardy. However he said the NHA was out of the facility last night and today (2/11/25 and 2/12/25). The MD said he was in the facility at least two times per month. The MD said he attended QAPI committee meetings regularly. The MD said he had been the medical director since the facility was initially built. The MD said he was not aware there was a quality of care issue by not sending residents to the hospital when indicated, resulting in a death due to a GI (gastro-intestinal) bleed. Nor was he aware of any quality of care problems related to anticoagulant monitoring, care plans or obtaining consents for anticoagulant use. The MD said the prior administrators may have discussed the issues before, however he said it had not been discussed in QAPI recently. The MD said he was frustrated with the high turnover rate with staff and leadership at the facility and felt more stability would improve the quality of care for residents. The NHA was interviewed on 2/13/25 at 1:49 p.m. The NHA said the QAPI committee met monthly and included every department. The NHA said he was new to the facility as of October 2024. The NHA said he established a pre-QAPI preparation to talk about follow up from previous QAPI meetings. He said all departments discussed what was going on, such as falls, wounds, grievances, resident council and staffing concerns. The NHA said the QAPI committee included more than all the required members and they all knew if a corrective action had been implemented. The NHA said quality of care with change of condition documentation and when decisions were made to send to the hospital would be discussed moving forward and added to QAPI.

Based on record review and interviews, the facility failed to honor resident choices for one (#7) of three residents reviewed out of eight sample residents. Specifically, the facility failed to provide Resident #7 a shower schedule based on her preferences. Findings include: I. Facility policy and procedure The Showers policy and procedure, revised 2/9/23, was received from the nursing home administrator (NHA) on 2/14/25 at 3:13 p.m. It documented in pertinent part, Patient preferences must be initiated and complied with. Showers are to be completed on the designated shower schedule or patient modified shower schedule. Patient refusals must be progress noted, educated, family notified if indicated and care planned. II. Resident #7 A. Resident status Resident #7, age 79, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included pneumonia (infection in the lungs), respiratory failure, muscle weakness and atrial fibrillation (abnormal heart rhythm). The 2/3/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The resident required maximal assistance with toileting and dressing and partial assistance for transfers. B. Resident interview Resident #7 was interviewed on 2/11/25 at 3:05 p.m. She said she had been at the facility for a couple weeks and was only getting one shower a week. She said showers made her feel refreshed. She said she mentioned to a staff member that she would like to shower more often, but nobody followed up. She said she would like a shower at least twice a week. C. Record review Resident #7's shower care plan, revised 2/9/25, identified that she preferred showers and her bathing frequency was twice weekly on Tuesdays and Fridays during day shift. The shower documentation from 1/15/25 to 2/12/25 revealed Resident #7 did not receive a shower on her scheduled shower days on 1/28/25, 1/31/25, 2/7/25 and 2/11/25. She received a shower on four out of eight opportunities. D. Staff interviews Occupational therapist (OT) #1 was interviewed on 2/13/25 at 11:09 a.m. She said sometimes the occupational therapy department gave residents their showers. She said the occupational therapy department had not given Resident #7 any of her showers. She said physical therapy did not give resident showers. The assistant director of nursing (ADON) and the regional clinical director (RCD) were interviewed on 2/13/25 at 11:38 a.m. The ADON said the facility tried to accommodate the resident's shower preferences as best as they could. She said the facility assigned showers on the residents preferred shower days under tasks for the certified nurse aides (CNA). She said if a shower was not given, the nursing staff needed to reproach the resident later in the day and offer the shower again. She said if the resident refused or was out of the building, the staff should offer a shower the next day. She said it was expected to be charted if a shower was given or missed. CNA #2 was interviewed on 2/13/25 at 1:45 p.m. CNA #2 said if a resident refused a shower and the staff were not able to give the resident a shower, she would talk to the resident and try to convince them to take the shower. She said if the resident still refused, she said she would tell the nurse and the nurse would provide education to the resident. She said she would chart that the resident refused a shower.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure a process was in place which enabled staff to identify residents who were on enhanced barrier precautions (EBP) when a sign was not posted outside the residents' rooms; -Ensure staff donned (put on) appropriate personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP); -Ensure staff followed appropriate infection control procedures while administering a medication intravenously; and, -Ensure staff donned appropriate PPE and performed hand hygiene during medication administration. Findings include: I. Ensure staff followed proper infection control procedures for residents on enhanced barrier precautions (EBP) A. Facility policy and procedure The Enhanced Barrier Precautions policy and procedure, dated 3/27/24 (to be implemented by 4/5/24), was provided by the nursing home administrator (NHA) on 4/29/23 at 10:53 a.m. The policy read in pertinent part, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Per the Centers for Disease Control and Prevention (CDC), EBP are recommended (when Contact Precautions do not otherwise apply) during high-contact care activities with residents who are at higher risk of acquiring or spreading a multidrug resistant organism (MDRO). EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Enhanced barrier precautions involve staff utilizing gown and gloves during specified high-contact activities with the patient. Enhanced barrier precautions include use of gown and gloves during the high-contact patient care activities below: Dressing, bathing/showering, transferring when working with patients in the therapy gym that need mobility assistance and/or transfers that require a longer duration, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. B. Resident status Resident #140, age 74, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included fournier gangrene (infection of the genital and perineal areas), morbid obesity and diabetes mellitus type II. The 4/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was dependent for bathing, toileting hygiene, lower body dressing and putting on footwear, all transfers and mobility in bed. He required supervision or touching assistance with personal hygiene, upper body dressing and oral hygiene, and set up help with eating. The assessment documented Resident #140 had an indwelling catheter and received some medications through a central intravenous line. C. Observations On 4/22/24 and 4/23/24 Resident #140's room did not have a sign on the door to his room notifying staff the resident had orders for enhanced barrier precautions. -However, Resident #140's MAR documented the EBP signage on the door to his room was in place on 4/22/24 and 4/23/24 during the survey (see record review below). On 4/23/24 at 10:39 a.m. Resident #140 was assisted to his room by two staff members. A contact precautions sign was posted on Resident #140's door. An unidentified staff member pushed Resident #140 through the hallway in his wheelchair and into Resident #140's room.A second staff member followed them into the room. Both staff members entered Resident #140's room and failed to don the appropriate PPE of a gown and gloves. One of the two staff members in Resident #140's room asked him if he preferred to get into bed. While in Resident #140's room, Resident #140 was assisted into bed. -On 4/24/24 at 10:39 a.m. the contact precautions sign on Resident #140's door was removed and replaced with an EBP sign. D. Physician orders and care plan The physician orders documented an order starting 4/13/24 for enhanced barrier precautions and personal protective equipment (PPE) with high contact care activities due to numerous wounds and to ensure signage was in place every shift for Resident #140. Review of Resident #140's medication administration record (MAR) from 4/13/24 through 4/23/24 (during the survey) revealed staff was documenting that an EBP sign was in place outside the resident's room. -However, observations revealed Resident #140 did not have any EBP signage in place on 4/22/24 and 4/23/24 but did have a contact precautions sign on his door on 4/23/24 (see observations above). -Resident #140's care plan for EBP due to wounds and his PICC line was initiated on 4/22/24 (during the survey). Pertinent interventions included staff were to wear PPE during high contact resident care and designated precautions signs were to be placed outside the door. E. Staff interviews The rehabilitation aide (RA) was interviewed on 4/25/24 at 2:30 p.m. The RA said she received various types of training on enhanced barrier precautions that included videos and in person training. The RA said she was trained how to don and doff (remove) PPE and PPE should be used to transfer a resident on EBP in their room. The RA said she did not have a way to know if a resident was on enhanced barrier precautions unless there was a sign posted on the resident's door. Licensed practical nurse (LPN) #4 was interviewed on 4/25/24 at 2:45 p.m. LPN #4 said nurses were to do a complete visual inspection to ensure the sign for enhanced barrier precautions was posted on a resident's door before marking the order complete in the resident's MAR. She said staff were trained annually on infection control practices and when a resident was admitted with precautions. She said the training included why the resident was on a specific precaution. LPN #4 said the training did provide instructions for donning and doffing PPE. LPN #4 said a resident who needed to be transferred with the assistance of one or two people should wear PPE if the resident was on EBP. The director of nursing (DON) was interviewed on 4/25/24 at The DON said a staff member informed her a contact precautions sign was posted on a resident's doors when an EBP sign should be posted instead. The DON said she was not aware the sign on Resident #140's door was incorrect. The DON said the sign had been changed from a contact precautions sign to an EBP sign on the afternoon of 4/23/24 (during the survey). The DON said staff were to ensure the correct sign was posted before marking the task complete in the resident's MAR. The DON said the facility staff should put on a gown and gloves for any transfers with contact with a resident on EBP. 50219 II. Resident #188 A. Resident status Resident #188, age 73, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included cystitis (an infection of the bladder), bacteremia (presence of bacteria in the blood), and discitis (an infection of the intervertebral disc space). The 4/20/24 MDS assessment revealed that the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The assessment documented the resident was receiving intravenous (IV) medications. B. Observations On 4/22/24 at 11:03 a.m. no sign was observed on Resident #188's door. On 4/22/24 at 2:29 p.m. registered nurse (RN) #1 entered Resident #188's room and donned gloves prior to IV medications to the resident via his PICC line. RN #1 did not don a gown at any point during the medication administration. On 4/23/24 at 10:32 a.m. no sign was observed on Resident #188's door. On 4/24/24 at 9:52 a.m. no sign was observed on Resident #188's door. On 4/25/24 at 10:00 a.m. an EBP sign was observed on Resident #188's door and drawers containing PPE were placed outside his room. C. Record review A review of the April 2024 CPO revealed the following physician orders: -Cefazolin sodium solution 2 grams intravenously three times a day, ordered 4/13/24, discontinued 4/16/24, and re-ordered 4/16/24; -Normal saline flush 10 milliliters after each IV medication administration, ordered 4/14/24; and, -EBP and PPE with high contact care activities due to the resident's PICC line, ordered 4/24/24 (during the survey). D. Staff interviews LPN #2 was interviewed on 4/25/24 at 10:07 a.m. LPN #2 said nursing staff needed to wear gloves and a gown to maintain infection control when entering a room that was on EBP. LPN #2 said any time nursing staff were touching or working with an indwelling line, such as a PICC, it required EBP. The DON and the regional clinical resource (RCR) were interviewed on 4/25/24 at 12:18 p.m. The DON said nursing staff needed to wear gloves and a gown when administering IV medications to residents with PICC lines. The RCR said she was unsure if the staff needed to wear a gown too. 37166 III. Failure to wear proper PPE during blood glucose checks and complete proper hand hygiene. A. Observations On 4/23/24 at 12:08 p.m. LPN #1 was administering medications to Resident #140. The sign on Resident #140's door read contact precautions. LPN #1 entered the room, put gloves on without washing her hands, approached the resident and tested his blood glucose prior to exiting the resident's room. -LPN #1 did not don a gown, which was indicated it was required on the contact precautions sign hanging on the resident's door. -LPN #1 did not perform hand hygiene prior to putting on gloves. In a few minutes, LPN #1 returned to Resident #140's room to administer insulin. LPN #1 donned clean gloves without performing hand hygiene and administered the insulin to the resident. -LPN #1 did not don a gown and did not sanitize her hands prior to administering the insulin. At 12:18 p.m. LPN # 1 was administering medications to Resident #191. The sign on the door read enhanced barrier precautions. LPN #1 entered the room, put gloves on without performing hand hygiene, approached the resident and tested his blood glucose prior to exiting the resident's room. -LPN #1 did not don a gown, which was indicated it was required on the enhanced barrier precautions sign hanging on the resident's door. -LPN #1 did not perform hand hygiene prior to putting on gloves. In a few minutes, she returned to the room to administer insulin to Resident #191. LPN #1 donned clean gloves without performing hand hygiene and administered the insulin. -LPN #1 did not don a gown and did not sanitize her hands prior to administering the insulin. At 12:26 p.m. LPN #1 was administering medications to Resident #195. The sign on the door read contact precautions. LPN #1 entered the room, put gloves on without performing hand hygiene, approached the resident and tested her blood glucose prior to exiting the resident's room. -LPN #1 did not don a gown, which was indicated it was required on the enhanced barrier precautions sign hanging on the resident's door. -LPN #1 did not perform hand hygiene prior to putting on gloves. In a few minutes, she returned to the room to administer insulin to Resident #195. LPN #1 donned clean gloves without washing her hands and administered the insulin. -LPN #1 did not don a gown and did not sanitize her hands prior to administering the insulin. On 4/25/24 at 10:00 a.m. LPN #3, was administering medications to Resident #18. Upon entering the room, the resident was observed sitting in a wheelchair and leaning over with his hand touching the floor. LPN #3 repositioned the resident by moving his hands to the table. She did not offer hand hygiene to the resident. She poured the medications into the resident's palm and the resident took the medications by licking them off his palm. B. Staff interviews LPN #1 was interviewed on 4/23/24 at 12:40 p.m. LPN #1 said a gown was not required for glucose checks and insulin administration. LPN #3 was interviewed on 4/25/24 at 10:15 a.m. LPN #3 said she should have offered resident hand hygiene to Resident #18 but forgot to do so. The DON was interviewed on 4/25/24 at 11:40 a.m. The DON said Resident #140, #191 and #195 were on enhanced barrier precautions. She said gown and gloves must be worn during blood glucose checks and insulin administration. She said nurses were in close contact with resident's clothes and body fluids when doing injections and therefore should have followed enhanced barrier precautions by wearing a gown and gloves. She said Resident #18 should have been offered hand hygiene prior to medication administration.

Based on observations, record review and staff interviews, the facility failed to maintain accurate minimum data set (MDS) assessment for one (#18) of five residents out of 22 sample residents. Specifically, the facility failed to accurately complete the minimum data set (MDS) assessment and submit a timely assessment for Resident #18. Findings include: I. Resident status Resident #18, age 68, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease, psychotic disorder with hallucinations, major depressive disorder and neuropathy (damage to the nerves outside the spinal cord and brain). The 2/29/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. II. Record review A review of Resident #18's electronic medical record (EMR) revealed the following: Resident #18's admission note documented he was admitted to the facility on [DATE] with an admitting diagnosis of hospice and Parkinson's disease for a long term stay. A review of Resident #18's previously submitted MDS assessments revealed the following: The 11/9/23 admission assessment did not indicate that Resident #18 was receiving hospice care. -However, Resident #18 was admitted to the facility on hospice care services. -The quarterly assessment with a target date of 2/9/24 was not submitted until 3/21/2024. which was greater than the required 92 day submission timeframe for a quarterly assessment. -The functional abilities section of Resident #18's 11/9/23 admission assessment and the 2/9/24 quarterly assessment were incomplete. III. Staff interviews The nursing home administrator (NHA) was interviewed on 4/25/24 at 11:30 a.m The NHA said the MDS assessments for Resident #18 should have been completed for functional abilities and hospice. The MDS coordinator (MDSC) was interviewed on 4/25/24 at 12:20 p.m. The MDSC said she was told if the resident did not receive therapy, the functional abilities section of the resident's MDS should not be completed. The MDSC said she submitted Resident #18's quarterly assessment late. -However, a 12/19/23 note written in Resident #18's EMR at 6:03 p.m. documented the following skilled services were being provided: management/evaluation of the resident, observation/assessment of resident, and teaching/training to manage and monitor fluid intake to prevent dehydration therapy (physical therapy, occupational therapy, speech therapy). Additional information included the resident participated in therapy.

Based on observations, record review and interviews, the facility failed to ensure two (#12 and #138) of five residents who required respiratory care received the care consistent with professional standards of practice out of 22 sample residents. Specifically, the facility failed to: -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine for Resident #12 and Resident #138; -Implement a routine cleaning schedule for the care of Resident #12 and Resident #138's CPAP machines; -Ensure the distilled water was used in Resident #138's CPAP machine instead of tap water; and, -Ensure a care plan was in place and implemented for Resident #12 and Resident #138's CPAP machines to include route of administration, oxygen supplementation, storage, cleaning and machine settings. Findings include: I. Professional reference The Controlling Legionella in Other Devices (2/3/21), was retrieved on 4/29/24 from https://www.cdc.gov/legionella/wmp/control-toolkit/index.html, and read in pertinent part, In the absence of control, Legionella can grow in almost any system or equipment containing non sterile water, such as tap water, at temperatures favorable to Legionella growth. Devices that may grow Legionella in the absence of control include the following: Dental and medical equipment such as scalers, CPAP, bronchoscopes, and heater-cooler units. Dental and medical equipment should be cleaned regularly per manufacturer recommendations; and use distilled water in respiratory equipment such as CPAP machines, heater-cooler units, and bronchoscopes. II. Facility policy and procedure The CPAP/BiPAP policy and procedure, revised 2/8/21, was provided by the nursing home administrator (NHA) on 4/29/24 at 10:53 a.m. The policy read in pertinent part, Continuous positive airway pressure (CPAP) is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure. The patient will receive necessary respiratory care and services in accordance with professional standards of practice, the patient's care plan, and the patient's choice. The patient will have an order that includes settings for CPAP/BiPAP and the CPAP/BiPAP will be cleaned per the manufacturer's guidelines. -The manufacturer's guidelines for cleaning the CPAP machines was requested and not provided by the end of the survey on 4/25/24. III. Resident#12 A. Resident status Resident #12, age 77, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included a compression fracture of the second lumbar vertebrae, repeated falls, osteomyelitis, weakness, obstructive sleep apnea and dependence on other enabling machines and devices. The 3/25/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was dependent with care for showering and putting on and taking off footwear, he needed substantial assistance with toileting hygiene, partial assistance with dressing and set up help only with eating and oral hygiene. The assessment documented the resident used a CPAP machine. B. Resident interview and observation Resident #12 was interviewed on 4/22/24 at 11:00 a.m. Resident #12 said his CPAP machine did not get cleaned at the facility and he used his CPAP every night. Resident #12's CPAP mask and tubing was on his bed during the interview on 4/22/24. C. Record review A review of the nurse practitioner progress notes for Resident #12 revealed the nurse practitioner documented that Resident #12 had obstructive sleep apnea (OSA)-CPAP on 3/25/24, 4/1/24, 4/8/24, 4/15/24 and 4/22/24. -However, further review of the resident's electronic medical record (EMR) revealed Resident #12 did not have a physician's order for the use of a CPAP or a physician's order that included the route of administration, frequency, oxygen supplementation, storage and/or settings of the device. -The use of a CPAP was not on Resident #12's care plan as an active problem area, and the care plan did not have goals and interventions listed for the CPAP to include route of administration, frequency, oxygen supplementation, storage and/or settings and a cleaning schedule. IV. Resident #138 A. Resident status Resident #138, age 77, under age 65 was admitted on [DATE] and discharged home on 4/23/24. According to the April 2024 CPO, diagnoses included enterocolitis (colon inflammation) due to clostridium difficile (a bacteria), type II diabetes mellitus, chronic kidney disease, morbid obesity, adjustment disorder with anxiety and depression. The resident's BIMS score had not been completed at the time of the survey. The resident's care plan documented the resident was confused at times. The 4/10/24 daily skilled nursing note documented Resident #138 was independent with oral hygiene, toileting hygiene, transfers and eating. B. Resident interview and observation Resident #138 was interviewed on 4/22/24 at 2:15 p.m. Resident #138 said the facility was out of distilled water for her CPAP machine and instead had used regular tap water in her CPAP machine for two days. Resident #138 said a certified nurse aide (CNA) told her facility staff looked for distilled water in the facility but were unable to locate distilled water for the CPAP. She said the CNA told her the facility would order distilled water but was unsure when the distilled water would be delivered. Resident #138's CPAP mask was observed on the nightstand by her bed during the interview. C. Record review Resident #138's respiratory care plan, initiated 4/8/24 and revised 4/25/24 (during the survey), documented she was at respiratory risk related to respiratory conditions and/or deficiencies and abnormalities in pulmonary function. Interventions included to administer and provide respiratory therapy and respiratory treatment interventions as per physician's orders, wash mask with CPAP cleanser and warm water, and place on a paper towel to air dry and use the CPAP per physician's orders (initiated 4/8/24 and revised on 4/25/24). -However, further review of the resident's EMR revealed Resident #138 did not have a physician's order for the use of a CPAP or an order that included the route of administration, frequency, oxygen supplementation, storage and/or settings of the device and a cleaning schedule. V. Staff interviews The director of nursing (DON) and the NHA were interviewed on 4/25/24 at 1:00 p.m. The NHA said if the facility ran out of distilled water, staff were able to purchase distilled water from a local store until more distilled water could be ordered. The NHA and the DON said a resident should have a physician's order for a CPAP machine that included cleaning instructions. The rehabilitation aide (RA) was interviewed on 4/25/24 at 2:30 p.m. The RA said she worked as a CNA at the facility and a resident's CPAP machine should be cleaned daily. The RA said CNAs cleaned the CPAP machines at the facility and the cleaning task should show in the CNA task list to complete. The RA said if the facility was out of distilled water for a resident's CPAP machine she would notify a nurse. Licensed practical nurse (LPN) #4 was interviewed on 4/25/24 at 2:45 p.m. LPN #4 said a CNA would clean or change the water in a CPAP machine, although it could depend on how the physician's order was written. LPN #4 said a resident should have a physician's order for a CPAP machine that included cleaning instructions.

Based on interviews and record review, the facility failed to ensure residents were free from significant medication errors for one (#89) of 11 residents reviewed for medication errors out of 22 sample residents. Specifically, the facility failed to ensure Resident #89 was administered blood pressure medications according to the physician's order. Findings include: I. Facility policy The Medication Administration policy, revised 8/22/22, was provided by the nursing home administrator (NHA) on 4/29/24. It read in pertinent part, It is the policy of this facility that medications are to be administered as prescribed by the attending physician. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record medications. Medications must be administered in accordance with the written orders of the attending physician. II. Resident status Resident #89, age less than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included heart disease and high blood pressure. The 4/3/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status score (BIMS) score of 11 out of 15. The resident was on medications for high blood pressure. III. Record review According to the medication administration record (MAR) for March 2024 and April 2024, Resident #89 was receiving the following medications: Lisinopril 40 milligrams (mg) for high blood pressure. Hold medication if systolic blood pressure less than 110 milligrams per deciliter (mg/dl). The medication was administered on 4/5/24 when the resident's recorded blood pressure was 104/40. -The medication should have been held per the physician's order because the resident's systolic blood pressure was less than 110 mg/dl. Carvedilol 25 mg for high blood pressure. Hold medication when systolic blood pressure was below 100 mg/dl or heart rate below 60 beats per minute (bpm). The medication was administered on the following dates: -3/31/24 with a recorded blood pressure of 107/37; -4/3/24 with a recorded heart rate of 57 bpm; -4/11/24 with recorded heart rate of 59 bpm and a blood pressure of 89/36 mg/dl; and, -4/12/24 with a recorded blood pressure of 98/49 mg/dl. -The medication should have been held per the physician's orders on the above dates because the resident's heart rate and/or systolic blood pressure were below the physician specified parameters for holding the medication. -Review of the progress notes between March 2024 and April 25, 2024 revealed no supporting progress notes on the above dates for why the nurse gave the medications despite the resident's heart rate and systolic blood pressures being below the physician specified parameters for holding the medication. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 4/25/24 at 10:05 a.m. LPN #2 said prior to administration of blood pressure medications, a resident's blood pressure should be checked to make sure it was above the recommended parameters. She said if the blood pressure was below the recommended parameters, the medication should be held. LPN #2 said for carvedilol it was important to monitor the resident's heart rate as the medication affected the frequency of heart rate, and if the heart rate was below 60 beats per minute, the medication should not be administered. The nurse practitioner (NP) was interviewed on 4/25/24 at 10:20 a.m. The NP said the parameters when to hold medications were put in place for safety. She said since medication would lower blood pressure and reduce the heart rate, it was important not to administer the medication when the resident already had low blood pressure and/or a reduced heart rate. She said administering the medications when the heart rate and/or blood pressure were below the parameters to hold the medication was a significant medication error as it could have lowered the blood pressure or heart rate further and resulted in an emergency situation. The NP said, in addition, Resident #89 was on two different medications that had the same effect of lowering blood pressure. She said in situations when medication was given by mistake, she should have been notified and she would have instructed the staff on how the resident should have been monitored due to the error. The NP said she did not recall that she was notified and she was not aware that medications were administered to Resident #89 incorrectly. The director of nursing (DON) was interviewed on 4/25/24 at 11:21a.m. The DON said the medications should have been held when Resident #89's blood pressure and/or heart rate were below the recommended parameters for holding the medication. She said the physician should have been notified when the medications were administered when they should not have been. She said she would provide education to the nurses immediately to ensure medications were administered correctly.

Based on record review and interviews, the facility failed to ensure residents who required dialysis received dialysis services consistent with professional standards of practice for one (#11) of two residents out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #11's comprehensive care plan included a care plan for dialysis; -Consistently and accurately monitor pre and post dialysis weights for Resident #11; and, -Ensure communication forms between the facility and the dialysis center were completed consistently and accurately for Resident #11. Findings include: I. Facility policy and procedures The Dialysis Protocol policy, last revised 8/5/22, was provided by the Regional clinical director (RCD) on 1/25/23 at 11:06 a.m. It read in pertinent part, Orders will be written on when resident is scheduled for dialysis. Dialysis batch orders will be initiated. Dialysis communication sheets will be given to the dialysis center with facility and resident information. -The facility was asked for a policy regarding pre and post dialysis monitoring of residents. The facility did not provide the requested policy. II. Resident status Resident #11, age younger than [AGE] years, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders, diagnoses included end stage renal disease and dependence on renal dialysis. The 12/30/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. He required one-person limited assistance for bed mobility and transfers. He required one-person supervision for dressing, toilet use, and personal hygiene. He received dialysis services. III. Resident interview Resident #11 was interviewed on 1/23/23 at 3:38 p.m. Resident #11 said he received dialysis at a dialysis center on Tuesdays, Thursdays, and Saturdays. He said the facility was supposed to send him to dialysis with a communication form and he would give it to the nurses at the facility when he returned if the dialysis center sent the form back with him. He said the facility staff weighed him before dialysis and sometimes when he came back from dialysis, however, he said the staff did not always get his weight when he returned. IV. Record review Review of Resident #11's comprehensive care plan, initiated on 12/24/22 did not reveal a care plan for dialysis services and monitoring of the resident. Review of Resident #11's January 2023 CPO revealed a physician's order to record pre and post dialysis weights one time a day every Tuesday, Thursday, and Saturday. The order had a start date of 12/24/22. Review of the weights documented in the vitals section of Resident #11's electronic medical record revealed the following inconsistencies: -12/24/22: One weight of 195.8 pounds entered in the vitals section. The weight did not clarify if it was a pre or post dialysis weight; -12/27/22: One weight of 197.3 pounds entered in the vitals section. The weight did not clarify if it was a pre or post dialysis weight; -12/29/22: No weights were documented in the vitals section; -12/31/22: Two weights of 168.3 pounds and 166.8 pounds were entered in the vitals section, however the weights had been crossed out; -1/3/23: Two weights of 195.8 pounds and 192.6 pounds were entered in the vitals section. The weights did not clarify if they were pre or post dialysis weights; -1/5/23: Two weights of 193.8 pounds and 193.2 pounds were entered in the vitals section. The weights did not clarify if they were pre or post dialysis weights; -1/7/23: No weights were documented in the vitals section; and, -1/14/23: Two weights of 188.2 pounds and 192.8 pounds were entered in the vitals section. The weights did not clarify if they were pre or post dialysis weights. Review of Resident #11's December 2022 and January 2023 medication administration records (MAR) revealed the following: -12/24/22: No post dialysis weight documented; -12/27/22: No post dialysis weight documented; -12/29/22: No pre or post dialysis weights documented; -12/31/22: No pre or post dialysis weights documented; -1/3/23: No post dialysis weight documented; -1/5/23: No post dialysis weight documented; -1/7/23: No pre or post dialysis weights documented; -1/10/23: No post dialysis weight documented; -1/12/23: No post dialysis weight documented; -1/14/23: No post dialysis weight documented; -1/17/23: No post dialysis weight documented; -1/19/23: No post dialysis weight documented; -1/21/23: No post dialysis weight documented; and, -1/24/23: No post dialysis weight documented. Review of Resident #11's dialysis communication forms revealed the following incomplete or missing communication forms: -12/24/22: There was no section to document the pre dialysis weight on the form; -12/27/22: There was no section to document the pre dialysis weight on the form; -12/29/22: There was no communication form in the electronic medical record (EMR); -12/31/22: There was no communication form in the EMR; -1/3/23: There was no communication form in the EMR; -1/5/23: There was no communication form in the EMR; -1/7/23: There was no communication form in the EMR; -1/10/23:There was no blood pressure documented on the form. The sections for medications sent with resident, meal provision, and condition alert were not filled out; -1/14/23: The sections for medications sent with resident and meal provision were not filled out; -1/19/23: There was no communication form in the EMR; -1/21/23: The section for meal provision was not filled out; and, -1/24/23: The sections for medications sent with resident and meal provision were not filled out. V. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 1/25/23 at 9:37 a.m. LPN #3 said she was not sure how often residents on dialysis were weighed. She said she thought they were weighed at least daily. She said a communication form was sent with residents to dialysis. She said the form had information the nurses filled out to communicate with the dialysis center. LPN #3 said the resident was supposed to bring the form back from dialysis and give it to the nurse. She said the forms would then be uploaded to the resident's EMR. LPN #2 was interviewed on 1/25/23 at 9:50 a.m. LPN #2 said residents on dialysis were weighed before and after each dialysis appointment. She said the pre and post dialysis weights were documented on the MAR and in the vitals section of the resident's EMR. She said every time a resident went to dialysis a nurse filled out a communication form that included the resident's vitals, weight, what medications were given, and any other pertinent information the dialysis center might need to know. LPN #2 said the communication form was sent with the resident to the dialysis center and the dialysis center sent the form back with the resident after dialysis with any pertinent information the facility needed to know about the dialysis appointment. She said nurses collected the form from the resident, documented what information was on it, and then the form was put in the file folder for medical records to pick up and upload to the resident's EMR. The medical records director (MRD) was interviewed on 1/25/23 at 11:48 a.m. The MRD said nurses were to put any documents which needed to be uploaded to the resident's EMR in the alphabetized file folder at the nurses station. She said she picked up documents from the folder at least daily, and then they were uploaded to residents ' EMRs as soon as she had time. The MRD said she was behind on uploading documents and some of Resident #11's dialysis communication forms may not have been uploaded to his EMR yet. She said she would go through the records that had not been uploaded and look for the communication forms. The MRD was interviewed a second time on 1/26/23 at 9:40 a.m. The MRD said she had provided all of the dialysis communication forms that she could find in the medical records office. She said she was unable to locate a communication form for 12/29/22, 12/31/22, 1/3/23, 1/5/23, 1/7/23 and 1/19/23. The director of nursing (DON) was interviewed on 1/26/23 at 11:22 a.m. The DON said residents who received dialysis were weighed before and after every dialysis appointment. She said a post dialysis weight was obtained at the dialysis center and if the resident was not reweighted at the facility, the nurse would enter the weight obtained from the dialysis center as the post dialysis weight. The DON said ideally, the nursing staff would obtain a post dialysis weight at the facility every time because the scales at the facility and the dialysis center likely weighed differently. She said when weights were entered into the vitals section of the EMR, staff should clarify if the weight was a pre or post dialysis weight. The DON confirmed post dialysis weights were not being documented on Resident #11's MAR. She said both the pre and post dialysis weights should be documented on the MAR. The DON said nurses completed a dialysis communication form that was sent to dialysis with the resident. She said the form included pertinent information the dialysis center might need to know. She said the form should be filled out completely, including vitals, pre dialysis weight, and all lines, even if no medications were given or the resident did not eat prior to dialysis. She said the communication form should come back with the resident to the facility and the nurse should document the information from the dialysis center and then put the form in the file folder for medical records to upload. The DON said the dialysis center did not always send the communication form back with the resident. She said if the form did not come back to the facility the nurse should contact the dialysis center to have a copy faxed to the facility. The DON said Resident #11's comprehensive care plan should have included a care plan for dialysis. She said there were significant things that needed to be monitored with a resident on dialysis that staff should be aware of in order to properly care for and monitor a resident receiving dialysis services. She said a dialysis care plan should include dates the resident received dialysis, daily monitoring of the fistula (access site for dialysis), how often to obtain vital signs and weights, and monitoring of the fistula dressing on dialysis days.

Based on observations, record review and interviews, the facility failed to ensure that self-administration of medications was clinically appropriate for two (#54 and #49) of 12 residents out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #54 and Resident #49 were assessed for the appropriateness and safety of self-administration of medications; -Ensure Resident #54 and Resident #49 had physician's orders to self-administer medications; and, -Ensure Resident #54 had a physician's order for the medication being self-administered. Findings include: I. Facility policy and procedures The Self-Administration of Medications policy, last revised 2/8/21, was provided by the regional clinical director (RCD) on 1/25/23 at 11:14 a.m. It read in pertinent part, Residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the nursing staff will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. In addition to general evaluation of decision-making capacity, the nursing staff will perform a more specific skill assessment, including (but not limited to) the resident's ability to read and understand medication labels, comprehension of the purpose and proper dosage and administration time for his or her medications, ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication, and ability to recognize risks and major adverse consequences of his or her medications. The nursing staff will ask residents who are identified as being able to self-administer medications whether they wish to do so. The nursing staff will document their findings and the choices of residents who are able to self-administer medications. Self-administered medications must be stored in a safe and secure place, which is not accessible by other patients. II. Resident #54 A. Resident status Resident #54, age 83, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), mild neurocognitive disorder due to known physiological condition without behavioral disturbance, and cognitive communication deficit. The 1/26/23 minimum data set (MDS) assessment revealed that the brief interview for mental status (BIMS) had not been completed with the resident yet. The 1/26/23 MDS assessment further revealed the resident's functional status had not been completed yet. According to the comprehensive nursing admission assessment dated [DATE], the resident was alert and oriented to person, place, time, and situation. She was independent with bed mobility. She required supervision or touching assistance with transfers. She required set-up or clean-up assistance with eating, oral hygiene, and toilet hygiene. B. Resident interview and observations On 1/23/23 at 3:24 p.m., Resident #54 was sitting up in bed. The resident's daughter was seated in the recliner next to the bed. The resident had a bottle of artificial tears eye drops that she was administering to herself. Resident #54 said her daughter brought the bottle of artificial tears eye drops to her and she kept the bottle in her bedside drawer. The resident said she used the eye drops whenever her eyes felt dry. The resident's daughter said the resident could administer the eye drops herself. On 1/24/23 at 12:16 p.m., Resident #54 was sitting up in her bed. Her son was visiting and was seated in the recliner next to her bed. There was a bottle of artificial tear eye drops on the resident's bedside table which was in front of her. Resident #54 said she had just administered the eye drops to herself. C. Record review Review of Resident #54's January 2023 CPO revealed the resident did not have a physician's order for artificial tears eye drops. Further review of the January 2023 CPO revealed the resident did not have a physician's order to self-administer the artificial tears eye drops. Review of Resident #54's assessment history revealed the resident did not have a self-administration of medications assessment conducted. Review of Resident #54's comprehensive care plan, initiated 1/20/23, revealed the resident did not have a care plan focus for the self-administration of medications. D. Staff interview Licensed practical nurse (LPN) #2 was interviewed on 1/25/23 at 9:50 a.m. LPN #2 said she did not have any residents on her assignment who self-administered medications. She said if a resident wanted to self-administer medications, the nurse contacted the physician to obtain a physician's order for self-administration of medications. She said the physician's order should clarify which specific medications the resident was able to self-administer. LPN #2 said once the physician's order was obtained, the nurse conducted a Self-Administration of Medications assessment with the resident to determine if the resident was able to understand what the medication was for, how often it was to be given, and if the resident was able to administer the medication safely. She said a resident was to have the physician's order for self-administration and the assessment in place prior to the resident being allowed to self-administer any medications. LPN #2 said Resident #54 was cognitively intact but could be forgetful at times. She said the resident did not have a physician's order for artificial tears eye drops or a physician's order to self-administer the medication. She said the resident did not have a self-administration assessment completed for the artificial tears eye drops. E. Nurse follow-up On 1/25/23 at 9:55 a.m., LPN #2 entered Resident #54's room and asked the resident about the artificial tears eye drops. The medication was not visible in the room. The resident was not sure where the bottle of artificial tears eye drops was, however she allowed LPN #2 to search through her belongings. LPN #2 located the medication underneath Resident #54's bed covers. LPN #2 explained the facility's policy on self-administration of medications to Resident #54. The resident said she understood and said she wanted to continue keeping the medication at her bedside and administer it herself when she needed it. LPN #2 informed the resident she would need to remove the medication from the room until she had completed the necessary steps for the self-administration of medications process. Resident #54 said she understood and allowed LPN #2 to remove the medication from her room. On 1/25/23 at 10:07 a.m., LPN #2 conducted the self-administration of medications assessment with Resident #54. The assessment documented the resident was able to safely administer the artificial tears eye drops. On 1/25/23 at 10:25 a.m., LPN #2 obtained and entered a physician's order for the artificial tears eye drops. The order clarified that the resident was able to self-administer the medication. -Resident #54's care plan had not been updated to include the self-administration of the artificial tears eye drops. III. Resident #49 A. Resident status Resident #49, age 84, was admitted on [DATE]. According to the January 2023 CPO, diagnoses included epistaxis (nosebleeds) and congenital perforated nasal septum (a condition which causes changes to the structure and function of the nose). The 1/15/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. She required one-person limited assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. B. Resident interview and observations On 1/23/23 at 2:50 p.m., Resident #49 was seated in her recliner in her room. There was a bottle of Aller Flo nasal spray (an allergy relief nasal spray) sitting on the resident's bedside table next to the recliner, along with a plastic cup that had white powder in the bottom of it. Resident #49 said that the cup contained Miralax (a laxative medication). She said the nurses sometimes brought her the Miralax already mixed with water, however she said she asked that morning's nurse to bring the medication unmixed in a cup because she preferred to mix the medication herself in juice or her coffee. Resident #49 said she had not taken the medication yet because she had had a doctor's appointment that morning. She said the nurse left the medication for her to mix with her coffee when she returned from the appointment, however she had not gotten around to taking it yet. Resident #49 said she kept the nasal spray in her room and administered it to herself one time in the morning and one time in the evening. She said the nurses knew she had it because she always kept it on her bedside table or windowsill near her recliner. On 1/24/23 at 12:11 p.m., the bottle of Aller Flo nasal spray was sitting on the resident's windowsill. The resident was not in her room. There was no Miralax or any other medications observed in the room. On 1/25/23 at 9:14 a.m., the bottle of Aller Flo nasal spray was again sitting on Resident #49's windowsill. The resident was not in her room. There were no other medications observed in the room. On 1/25/23 at 2:36 p.m., Resident #49 was in her room. The bottle of Aller Flo nasal spray was no longer on the resident's windowsill. Resident #49 said the nurse had told her the medication could not be kept in her room and had removed it from her room. C. Record review Review of Resident #49's January 2023 CPO revealed the resident had a physician's order for Fluticasone Propionate nasal suspension 50 micrograms (mcg)/actuation (ACT) two sprays in both nostrils in the morning for allergic rhinitis. -Further review of the January 2023 CPO revealed the resident did not have a physician's order to self-administer the nasal spray. Review of Resident #49's assessment history revealed the resident did not have a self-administration of medications assessment conducted. Review of Resident #49's comprehensive care plan, initiated 1/9/23, revealed the resident did not have a care plan focus for the self-administration of medications. D. Staff interview LPN #3 was interviewed on 1/25/23 at 9:37 a.m. LPN #3 said she did not have any residents on her assignment who self-administered their medications. She said if a resident wanted to self-administer medications, the nurse would need to obtain an order from the physician that it was okay for the resident to administer their own medications. She said the nurse would also need to conduct a self-administration assessment with the resident to determine if the resident could safely administer their own medications prior to the resident being allowed to self-administer medications. LPN #3 said Resident #49 did not have a physician's order to self-administer the nasal spray or have a self-administration of medications assessment in her electronic medical record (EMR). LPN #3 entered Resident #49's room and confirmed the nasal spray was sitting on the resident's windowsill. She said she would need to remove the medication from the resident's room. LPN #3 said she would wait until the resident came back to her room before talking to her and removing the medication from her room. IV. Director of nursing (DON) interview The DON was interviewed on 1/26/23 at 11:22 a.m. The DON said she did not know if the facility had any residents who were approved to self-administer medications. She said if a resident wanted to self-administer medications, the nursing staff would obtain a physician's order that stated which medications the resident was allowed to self-administer. She said the nursing staff would also conduct a self-administration of medications assessment with the resident to determine if the resident was capable of safely administering their own medications. The DON said if a resident was observed to have any form of medication in their room, the nurse should check to see if the resident had an order to self-administer the medication and a self-administration assessment completed. She said if the resident did not have both a physician's order and a self-administration assessment the nurse should remove the medication from the resident's room. The DON said the self-administration of medications should be care planned in a resident's care plan and include the specific medications the resident was able to self-administer.

Based on record review, observations and interviews the facility failed to develop and implement a comprehensive centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two (#8 and #16) of 12 out of 31 sample residents. Specifically, the facility did not ensure care plans and interventions were developed for: -Resident #8's antidiabetic medications that included hypo/hyper glycemic protocols; and, -Resident #16's post-traumatic stress syndrome (PTSD) with triggers (something that causes flashbacks to occur). Findings include: I. Facility policies The Baseline Care, last revised on 6/30/22, was provided by the regional clinical director (RCD) on 1/25/23 at 1:00 p.m. The policy revealed the facility must develop a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The baseline care plan must reflect the resident's goals, objectives and include interventions that address his or her current needs. The baseline care plan must be developed within 48 hours of a resident's admission. The facility may develop a comprehensive care plan in place of the baseline care plan. The comprehensive care plan must be completed and implemented within 48 hours of admission. The facility must provide the resident and their representative, if applicable, with a summary of the baseline care plan. The Trauma Informed Care policy and procedures, revised 2/8/21, was provided by the RCD on 1/26/23 at 11:05 a.m. The policy revealed this facility ensures that residents who were trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice. Trauma was defined as an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life threatening, that had lasting adverse effects on the individual's functioning, mental, physical, social, emotional or spiritual well-being. Common sources of trauma might include, but are not limited too; natural disasters, accidents, war, physical emotional, sexual abuse at any age, rape, and unexpected life events (death of a child, personal illness) Trauma informed care was defined as an organization structure and treatment framework that involves understanding, recognizing, and responding to the effects of trauma. The facility would account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that might cause re-traumatization of the resident. Potential causes of re-traumatization by staff might include, but are not limited to: Being unaware of the resident's traumatic history; Failing to screen a resident for trauma history prior to treatment planning; Challenging or discounting reports of traumatic events; Endorsing a confrontational approach in counseling; Labeling behaviors/feelings as pathological; Failing to provide adequate safety; Minimizing, discrediting or ignoring resident responses; and Obtaining urine specimens in a non-private setting. II. Resident #8 A. Resident status Resident #8, age 75, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included type II diabetes mellitus with diabetic neuropathy, protein calorie malnutrition, chronic diastolic (congestive) heart failure, and [NAME] Syndrome (systemic autoimmune rheumatic disease that affects the entire body). The 12/24/22 minimum data set (MDS) assessment the resident was cognitively intake with a brief interview of mental status (BIMS) score of 14 out of 15 with no behaviors. The resident required extensive staff assistance for toileting. The resident required limited staff assistance for bed mobility, transfers, and personal hygiene. The resident required staff supervision for dressing, and eating. During the seven-day assessment period, the resident received injections and insulin for seven consecutive days. B. Record review A physician's order dated 12/18/22 at 6:10 a.m., revealed to obtain finger blood sugar checks before each meal. If the blood sugar level was less than 60, follow the hypoglycemia protocol and notify the provider. Also notify the provider of blood sugar levels above 300 before meals and at bedtime for a diagnosis of diabetes mellitus. Physician's orders dated 12/19/22 at 6:10 a.m., revealed to Humalog Kwikpen subcutaneous solution pen injection 100 unit/milliliter (U/ML) of Lispro insulin. Inject according to a sliding scale. If 0-99 inject 00 units, 100-179 inject 3 units, 180-199 inject 4 units, 200-249 inject 5 units, 250-299 inject 6 units and 300-349 inject 7 units. If blood sugar was 300-349 inject 7 units of insulin and contact the provider. Inject insulin subcutaneously before meals and at bedtime for diabetes. Physician's orders dated 12/31/22 at 8:59 a.m., revealed Humulin 70/30 subcutaneous solution 100 U/ML Neutral Protamine [NAME] Isophane (immediate acting) insulin and regular human insulin. Inject 44 units subcutaneously once a day for diabetes mellitus. Discontinue on 1/4/23 at 7:19 a.m. Physician's orders dated 1/1/23 at 2:35 p.m., revealed Humulin 70/30 subcutaneous solution 100 U/ML Neutral Protamine [NAME] Isophane insulin and regular human insulin. Inject 40 units subcutaneously at bedtime for diabetes mellitus. Physician's orders dated 1/4/23 at 7:18 a.m., revealed Humulin 70/30 subcutaneous solution 100 U/ML Neutral Protamine [NAME] Isophane insulin and regular human insulin. Inject 48 units subcutaneously once a day for diabetes mellitus. Discontinue on 1/10/23 at 11:59 a.m. Physician's orders dated 1/10/23 at 7:56 a.m., revealed Humulin 70/30 subcutaneous solution 100 U/ML Neutral Protamine [NAME] Isophane insulin and regular human insulin. Inject 52 units subcutaneously once a day for diabetes mellitus. Discontinue on 1/21/23 at 7:30 a.m. Physician's orders dated 1/20/23 at 12:58 p.m., revealed Humulin 70/30 subcutaneous solution 100 U/ML Neutral Protamine [NAME] Isophane insulin and regular human insulin). Inject 56 units subcutaneously one a day for diabetes mellitus. According to the medication administration record (MAR) for January 2023, the resident received insulin as physician ordered 112 times. -Review of the resident's comprehensive care plans revealed, the facility failed to develop a care plan related to antidiabetic medications. C. Staff interviews The director of nursing (DON) was interviewed on 1/26/23 at 10:30 a.m. She said a care plan was developed/initiated for the use of antidiabetic medications that included hypo/hyper glycemic protocols on 1/24/23. She agreed that this was after the survey started. She said a care plan helped the facility staff provide better care for a resident. A care plan also provided a personal, fluid and ever-changing set of goals and interventions that hopefully would reduce the need for a resident to return to the facility for additional rehabilitation. The detriment for not having a care plan would be that a whole picture of the resident was not presented to the staff. The RCD was interviewed on 1/25/23 at 1:31 p.m. She said an antidiabetic care plan was developed yesterday, after the survey started and was also updated today. She said there was no antidiabetic care plan until identified on survey. A care plan illustrates the individual needs, goals and interventions for a resident to maximize their rehabilitation to their fullest potential. A care plan also effectively communicated the resident's plans and goals to the facility staff. 40960 IV. Resident #16 (cross-reference F699 for trauma informed care) A. Resident status Resident #16, age above [AGE] years, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included post traumatic stress disorder (PTSD) and anxiety disorder. The 12/30/22 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He had no behaviors and did not reject care. He had a diagnosis of PTSD and received an antidepressant and antianxiety medication daily. B. Resident interview Resident #16 was interviewed on 1/26/23 at 9:15 a.m. He said he was easily frustrated and once he was frustrated it was hard to concentrate on the task at hand. He said when he went outside, he would have to scan the area to make sure he was safe. He said he was a Vietnam veteran and helicopters would set him off as well. He said one of his triggers was staff rushing him and not explaining things to him. He said no staff at the facility had spoken to him about his diagnosis of PTSD or what his triggers may have been. He said he felt it was important for staff to know what triggered his PTSD. C. Record review The psychotropic medication care plan, initiated 12/24/22, did not reveal the resident had PTSD. The facility failed to care plan for the residents diagnosis of PTSD and put interventions in place to identify triggers so as to not retraumatize the resident. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/26/23 at 9:31 a.m. She said Resident #16 should have a care plan in place for his diagnosis of PTSD and what his triggers were. She said the nurse admitting a resident was responsible for initiating the baseline care plan but was not sure who was responsible for initiating the comprehensive care plan. She said it would be important to identify and care plan the residents' PTSD and his triggers to retraumatize the resident. The case manager director (CMD) was interviewed on 1/26/23 at 9:46 a.m. She said Resident #16 had a diagnosis of PTSD and should have a care plan in place to identify triggers and put interventions. She said the admitting nurse was responsible for initiating the baseline care plan. She said after each discipline assessment, they were responsible for initiating a care plan for any new areas identified. She said she was not aware that Resident #16 did not have a care plan in place for his PTSD. She said it was important to have a care plan in place so staff was aware of his triggers to not to retraumatize him.

Based on record review and interviews, the facility failed to ensure the resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one (#6) of three residents out of nine sample residents. The facility failed to adequately assess and monitor the nutritional needs for Resident #6 timely. Resident #6 was admitted to the facility on [DATE] with known nutritional risks due to his diagnoses of history of cerebral infarction (stroke), advanced dementia, glaucoma, and dysphagia (swallowing difficulty). The resident's 10/5/22 admission nutritional assessment documented he was malnourished, and the registered dietitian (RD) ordered a nutritional supplement two times per day. The resident was placed on a restorative dining program for assistance due to his dysphagia. On 10/9/22, Resident #6's weight was 212.2 pounds (lbs). On 10/16/22, Resident #6 was noted to have sustained a 10.4 lb (4.9%) weight loss in one week. Despite the severe weight loss, Resident #6's nutritional supplement was not increased, nor were any other nutritional interventions put into place. The resident's weight continued to trend down, and on 11/6/22 Resident #6 was noted to weigh 196.7 lbs, which was a 15.5 lb (7.3%) weight loss in one month since 10/9/22. Resident #6's nutritional supplement was still not increased until 11/16/22, and no other interventions were put into place despite the severe weight loss. Following the increase of the resident's nutritional supplement to three times per day on 11/16/22, the resident's weight began to stabilize. However, the facility's failures to implement further nutritional interventions following the resident's initial noted weight loss of 4.9% contributed to Resident #6 sustaining an unplanned severe weight loss of 7.3% in one month. Findings include: I. Facility policy and procedure The Weight Loss Assessment and Intervention policy, last revised 8/22/22, was provided via email by the nursing home administrator (NHA) on 12/7/22 at 11:45 a.m. It read in pertinent part, The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: one month - 5% weight loss is significant, greater than 5% is severe; three months - 7.5% weight loss is significant, greater than 7.5% is severe; and six months - 10% weight loss is significant, greater than 10% is severe. If weight change is undesirable the physician and multi-disciplinary team will discuss with patient and/or family preventable measures to put in place. These measures will be documented and care planned. Interventions may be as follows: resident's choices, nutrition and hydration needs of resident, functions that may prohibit independent eating, chewing or swallowing concerns, medication use, use of supplementation or tube feedings, and end of life. II. Resident #6 A. Resident status Resident #6, age 83, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included history of cerebral infarction (stroke), advanced dementia, glaucoma, and dysphagia. The 11/8/22 minimum data set (MDS) assessment revealed that the resident was unable to complete the brief interview for mental status (BIMS). Based on the staff assessment for mental status, the resident had a problem with short-term and long-term memory, and his cognitive skills for daily decision making were moderately impaired. He required two-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. He required one-person supervision with eating. He coughed or choked during meals or when swallowing medications, and had complaints of difficulty or pain when swallowing. According to the MDS assessment, he did not have, or it was unknown if he had, a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months. B. Record review Review of Resident #6's recorded weights from 10/1/22 to 11/27/22 revealed the following: -10/1/22: 211.2 lbs; -10/2/22: 210.1 lbs; -10/9/22: 212.2 lbs; -10/16/22: 201.8 lbs; -10/30/22: 197.6 lbs; -11/6/22: 196.7 lbs; -11/13/22: 200.8 lbs; -11/22/22: 198.8 lbs; and, -11/27/22: 201.0 lbs. -There was no weight recorded for the week of 10/23/22 through 10/29/22. -Despite the 15.5 lb (7.3%) weight loss demonstrated in one month between 10/9/22 and 11/6/22, the facility did not increase the resident's nutritional supplement until 10 days later. Review of Resident #6's nutrition care plan, initiated 10/5/22 and revised 11/30/22, revealed the resident had a potential and/or was at risk for inability to maintain his nutrition due to history of stroke, dysphagia, dementia, and glaucoma. The resident had decreased appetite and recorded weight loss. Pertinent interventions included providing and serving supplements as ordered, monitoring meal intake and recording intake every meal, and registered dietitian (RD) monitoring and making nutritional recommendations as needed. -The RD updated the resident's care planned interventions on 11/30/22, after the weight loss concern was brought to the facility's attention, to include offering ice cream to promote increased oral intake and weight gain, and offering foods the resident liked, such as peanut butter and jelly sandwiches, soup and pot roast. Resident #6's preferences care plan, initiated 10/1/22 and revised 11/22/22, did not include any food preferences. -The director of nursing (DON) revised the resident's care planned preferences to include chocolate shakes and turkey sandwiches on 11/22/22, after the weight loss concern was brought to the attention of the facility. -The care plan did not include pertinent interventions to offer the resident's food preferences to him. Review of Resident #6's November 2022 CPO revealed the following physician orders for nutritional supplements: Ensure Plus two times a day for weight maintenance (Chocolate). The order had a start date of 10/5/22. The order was discontinued on 11/16/22 when the supplement was increased to three times a day. Ensure Plus three times a day for weight maintenance (Chocolate). The order had a start date of 11/16/22. Review of Resident #6's medication administration records (MARs) for October and November 2022 revealed the resident was offered the Ensure Plus as ordered. -The October and November 2022 MARs did not record how much of the nutritional supplement was consumed by the resident at each administration of the supplement. The nutrition assessment conducted by the registered dietitian (RD) on 10/5/22 identified Resident #6 as malnourished with a score of five out of 14 points. The RD documentation in the 10/5/22 nutrition assessment read in pertinent part, Resident is at high nutritional risk due to signs/symptoms of dysphagia and advanced dementia. Provide Ensure Plus two times per day. Resident may be appropriate for a restorative dining program, coordinate care. All current nutrition concerns addressed. Resident may not be able to make needs known, continue to monitor. Resident family aware of nutrition plan of care. Family encouraged to contact RD with questions. RD to follow. Review of Resident #6's electronic medical record (EMR) revealed the following progress notes documented in pertinent part by the RD: 10/20/22: Current body weight: 201.8 lbs on 10/16/22. Current body mass index (BMI): 27.4. Recent body weight: 212.2 lbs on 10/9/22. Resident with 10.4 lbs/4.9% weight loss in 11 days, clinically severe weight change. Weight change likely due to advanced dementia and varied intake. Medications: no diuretics (medication for fluid retention). Oral intake: varied, averaging two to three meals per day, most meals 25-50% consumed; adequate compliance with nutritional supplement daily (Chocolate Ensure Plus two times per day) Edema (fluid retention): none noted Nutrition Intervention: Continue on restorative dining. In restorative dining, encourage resident to eat foods first and use Ensure second, as a supplement to ensure adequate intake of nutrients from food. -Despite the RD documenting the resident had sustained a clinically severe weight loss of 4.9% in 11 days, the resident's nutritional supplement was not increased and there were no other nutritional interventions put in place. -Despite the RD documenting the resident had adequate compliance with the nutritional supplement, the October 2022 MAR did not document how much of the supplement was consumed by the resident at each administration, therefore there was no way to determine if the resident was consuming an adequate amount of the supplement. -There was no documentation to indicate that the RD had reached out to the resident's representative in an effort to determine what foods the resident had previously enjoyed eating. 11/3/22: Current body weight: 197.6 lbs on 10/30/22. Current body BMI: 26.8. Recent body weight: 211.2 lbs on 10/1/22. Resident with 13.6 lbs/6.4% weight loss in one month, clinically severe weight change. Weight change likely due to history of varied intakes, dementia, and weakness. Medications: no diuretics. Oral intake: varied, averaging two to three meals per day, most meals approximately 50% consumed; adequate (approximately 95%) compliance with chocolate Ensure Plus two times per day. Edema: 3+ bilateral extremity edema Nutrition intervention: Resident to continue with restorative dining. Resident has had significant improvement in oral intake since 10/30/22. Meals after 10/30/22 were 75-100% consumed. Currently, resident has significant edema. If weight loss continues, consider liberalizing diet from heart healthy to regular after checking with physician. -Despite the RD documenting the resident had sustained a clinically severe weight loss of 6.4% in one month, the resident's nutritional supplement was not increased and there were no other nutritional interventions put in place. In addition, the RD documented an increase in edema and meal intake, therefore the resident would not be expected to lose weight. -The resident had actually sustained a 14.6 lbs/6.9% weight loss in three weeks between 10/9/22 and 10/30/22. -Despite the RD documenting the resident had approximately 95% compliance with the nutritional supplement, the November 2022 MAR did not document how much of the supplement was consumed by the resident at each administration, therefore there was no way to determine if the resident was consuming an approximately 95% of the supplement. -Despite the RD documenting the resident had significant bilateral extremity edema, there were no other progress notes in the resident's EMR which documented the resident had edema, and the resident was not on any diuretics. -There was no documentation to indicate that the RD had reached out to the resident's representative in an effort to determine what foods the resident had previously enjoyed eating. 11/16/22: Current body weight: 200.8 lbs on 11/13/22. Current BMI: 27.2. Recent body weight: 212.2 lbs on 10/9/22. Resident with 11.4 lbs/5.4% weight loss in five weeks. Weight change is clinically severe. Weight change likely due to history of varied intakes, dementia, and weakness. Resident has gained 4.1 lbs in the last week. Medications: no diuretics Oral intake: adequate, averaging three meals per day, most meals 50-100% consumed. Nutritional supplement compliance: 100% (Ensure Plus two times per day chocolate) Edema: none Nutrition Intervention: RD increased nutritional supplement to three times per day, as resident likes supplement and has been drinking them. Resident to continue on a heart healthy diet. Resident continues on restorative dining program to encourage oral intake. RD to continue to monitor weight and nutritional status and will adjust interventions as needed. -Despite the RD documenting the resident had adequate compliance with the nutritional supplement, the November 2022 MAR did not document how much of the supplement was consumed by the resident at each administration, therefore there was no way to determine if the resident was consuming 100% of the supplement. -Despite the RD increasing the nutritional supplement, there was no documentation to indicate that the RD had reached out to the resident's representative in an effort to determine what foods the resident had previously enjoyed eating. 11/23/22: Current body weight: 198.8 lbs on 11/22/22. Current BMI: 27.0. Recent body weight: 211.2 lbs on 10/1/22. Resident with 12.4 lbs/5.87% weight loss in one month and 22 days. Weight change is clinically severe. Weight change likely due to dementia, weakness, and a history of varied intakes. Medications: no diuretics. Resident preferences/dislikes: Resident dislikes spicy foods and spaghetti. Resident likes peanut butter and jelly sandwiches, ice cream, soup and pot roast. RD added these preferences and dislikes to the resident's menu. Oral intake: adequate in the last two weeks (since 11/10/22), averaging two to three meals per day, most meals 75-100% consumed, one meal 25-50% consumed. Nutrition supplement compliance: Resident took his Ensures 91.6% of the time. RNs will now start documenting percent intake for each Ensure for a more accurate depiction of intakes. Edema: none noted Nutrition Intervention: RD spoke with the resident's sister and notified her of weight loss. Sister states resident has 'always been picky' and she has been encouraging oral intake. Sister states resident dislikes spicy foods and spaghetti. Resident likes peanut butter and jelly sandwiches, ice cream, soup and pot roast. RD added these preferences and dislikes to his menu. If resident does not like meal selections for the day, kitchen staff will give him a peanut butter and jelly sandwich in addition to whatever else he would like, as sister states it is one of his favorite foods. He prefers it over a turkey sandwich, which was previously listed. Resident will now get chocolate or vanilla ice cream with every dinner. RD updated the menu to reflect this and notified culinary staff. Resident remains on the restorative dining program Monday through Friday during breakfast and lunch to encourage oral intake. RD will continue to monitor weight and nutritional status and adjust interventions as needed. -The RD reached out to the resident's sister and added the resident's food preferences to the resident's menu during the survey after the weight loss concern had been brought to the facility's attention. -The November 2022 MAR was updated to reflect the amount of the nutritional supplement consumed by the resident at each administration. The MAR was updated during the survey after the weight loss concern had been brought to the facility's attention. Review of Resident #6's EMR for October 2022 revealed the following documented meal intakes: -The resident refused nine meals out of 82 documented meals; -The resident consumed 0-25% of six out of 82 documented meals; -The resident consumed 26-50% of 22 out of 82 documented meals; -The resident consumed 51-75% of 23 out of 82 documented meals; and, -The resident consumed 76-100% of 22 out of 82 documented meals. -Resident #6's meal intake was not recorded for breakfast on 10/16/22; lunch on 10/4/22 and 10/16/22; and dinner on 10/3, 10/6, 10/10, 10/11, 10/17, 10/22, and 10/29/22. Review of Resident #6's EMR for November 2022 revealed the following documented meal intakes: -The resident refused zero meals out of 82 documented meals; -The resident consumed 0-25% of five out of 82 documented meals; -The resident consumed 26-50% of five out of 82 documented meals; -The resident consumed 51-75% of nine out of 82 documented meals; and, -The resident consumed 76-100% of 63 meals out of 82 documented meals. -Resident #6's meal intake was not recorded for breakfast on 11/13/22; lunch on 11/4/22 and 11/13/22; and dinner on 11/1, 11/17, 11/19, 11/24, and 11/27/22. III. Staff interviews Registered nurse (RN) #1 was interviewed on 11/22/22 at 12:10 p.m. RN #1 said she had worked at the facility since August 2022. She said the nurses did not document how much of a nutritional supplement the residents consumed at each administration. She said the nurses only documented whether or not the resident accepted the supplement. Licensed practical nurse (LPN) #1 was interviewed on 11/22/22 at 12:21 p.m. LPN #1 said staff documented whether or not the resident received the supplement. She said there was no place on the MAR to document how much of the nutritional supplement the resident consumed. She said Resident #6 liked his supplement. The RD was interviewed on 11/22/22 at 2:10 p.m. The RD said she had worked at the facility since October 2022. She said the electronic medical record system would trigger and alert her if a resident sustained a significant or severe weight loss. She said she would review any resident who was triggered by the system as having a weight loss concern. The RD said she would talk with residents with weight loss or their families to determine what their food preferences were. She said she also might fortify the resident's food and include extra protein as an intervention for weight loss. The RD said Resident #6 was on a restorative dining program Monday through Friday for breakfast and lunch, which meant that a restorative certified nurse aide (CNA) would sit with him and encourage him with his eating. She said the restorative CNA would physically assist him with eating if he needed it. She said a floor CNA or nurse was supposed to assist the resident at dinner and on the weekends. The RD said Resident #6 had sustained a weight loss that was considered clinically severe. She said she was a firm believer in utilizing food over supplements to maintain weight. However, she said Resident #6's nutritional supplement should have been increased sooner than it was. She said she had not contacted Resident #6's family to determine what types of food the resident had enjoyed eating prior to his admission to the facility. The RD said that food preferences should be care planned so staff knew what types of foods to offer to residents if they did not eat the food that was served. The RD confirmed that no other nutritional interventions were put into place between 10/16/22 and 11/16/22 to prevent further weight loss for Resident #6. The director of nursing (DON) and the NHA were interviewed together on 11/22/22 at 2:50 p.m. The DON said the facility was aware that Resident #6 had sustained a severe weight loss. She said she did not know if the resident allowed staff to physically assist Resident #6 when he did not eat. The DON said if a resident triggered for weight loss, the facility would continue to monitor the resident and implement appropriate interventions in an attempt to prevent further weight loss. She said families should be asked what foods a resident liked and those foods should be on the resident's care plan so staff could offer those types of foods to the resident when needed. The DON said she did not see a progress note that indicated Resident #6's family was asked about his food preferences. She said the facility should have contacted the family to obtain that information. The DON said documentation for nutritional supplements should include how much of the supplement was consumed by the resident for each administration of the supplement. She said the amount of supplement should be documented so the RD could determine if the resident was even consuming the supplement in order to see if another intervention should be put into place. She said she did not see documentation on Resident #6's October and November 2022 MARs to indicate how much of the supplement he was consuming. The DON said Resident #6's nutritional supplement should have been increased sooner than it was, or another nutritional intervention put into place to try to prevent further weight loss for the resident. The NHA said food preferences should be documented on the care plan so that staff knew what else to offer if the resident did not like the meal choices. She said care plans should be individualized for each resident. She said Resident #6's food preferences could be added to his care plan. The RD was interviewed again on 12/1/22 at 9:35 a.m. The RD said she had talked to Resident #6's family regarding his food preferences. She said his care plan had been updated to include his food preferences. The RD said that going forward, the facility would ensure that residents' care plans were individualized and included food preferences for each resident.

Based on observations, record review, and staff interviews, the facility failed to ensure three (#26, #20 and #2) of four out of 27 sample residents received the care and services necessary to prevent the development of pressure injuries and to promote healing of pressure injuries. Specifically, the facility failed to implement timely treatment interventions for Residents #26, #2 and #20 which resulted in the residents acquiring pressure injuries. The facility's failures above contributed to the development of one trauma related pressure injury to Resident #26's back. Resident #26 was admitted to the facility on [DATE] with a reddened area of skin on her back due to the [MEDICATION(S)] lumbar sacral orthosis (TLSO) back brace that was ordered for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . After debridement, the pressure injury was classified as a stage 3 full thickness wound. The facility's failure to implement person specific interventions and accurately document daily skin assessments contributed to the development of a pressure injury for Resident #26. Furthermore, for Resident #20, the facility failed to prevent the development of pressure injuries. Resident #20 was admitted [DATE] to the facility with intact skin. On 9/12/21, the resident developed an open area to her right buttock that progressed to unstageable full thickness by 9/29/21. Upon admission to the facility, the resident was not assessed for risks of developing pressure injuries, a person centered care plan was not developed, and there were no person specific interventions put in place to prevent the development of pressure injuries for this resident. In addition, daily skilled nurses' notes about daily skin condition were inconsistent and incomplete, and treatments were not consistently documented and/or performed. The facility's failure to implement person specific interventions and accurately document daily skin assessments contributed to the development of pressure injuries for Resident #20. In addition, the facility failed to accurately document and provide timely care for the Resident #2 who had an immobilizer. Resident #2 developed two pressure injuries related to the immobilizer. The facility failed to identify and implement interventions to prevent pressure ulcers from developing. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from http://www.npuap.org (10/6/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. 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. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy The Pressure Ulcer policy, revised 7/21/21, was provided by the nursing home administrator (NHA) on 10/5/21. It read in pertinent part, The (facility) will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards of practice. Procedures included, Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin. In addition the assessment should describe and document the following: full evaluation of pressure sore including description of the wound, pain evaluation, patient mobility status, current treatments if applicable, and physician and family notification. The physician will assist in identifying factors contributing or predisposing patients to skin breakdown. For example: medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or [CONDITION(S)] causing a catabolic state, macerated or friable skin. When a new skin concern is found, staff will: complete an incident report inside of risk management to include notifications to the physician, complete a change of condition progress note, place the patient on the 24 hour nursing report and notify the director of nursing (DON) and wound specialist as needed. III. Resident #26 A. Resident status Resident #26, age 85, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/30/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. She required extensive assistance from staff to perform bed mobility, transfers, locomotion on the unit, toileting and dressing. The resident did not have any pressure injuries at the time of assessment but was at risk of developing pressure injuries. B. Resident interview and observations Resident #26 was interviewed on 9/30/21 at 12:27 p.m. She was seated in a reclining chair next to her bed. She was wearing a back brace that was raised up on her body and could be observed above her shoulders. She had a pillow placed between her back brace and the chair. Green foam that was squared off and torn was observed above the resident's shoulders and coming out from the brace. She said that she had broken her ribs and back but that the brace was uncomfortable and caused pain in the middle of her back and shoulder blades. She said rubbing from the back brace had caused her to develop bed sores. A pressure relieving mattress was observed on her bed. IV. Record review The initial skin assessment, dated 8/23/21 documented, spine redness from brace, dressing in place. The baseline care plan, initiated on 8/24/21, revealed that the resident had spinal and rib fractures, however, did not identify that the resident wore a back brace. She required physical assistance from one staff person to perform transfers, walking, bed mobility, bathing, grooming and toileting. The resident had the potential for skin breakdown. The resident's goal for admission and discharge was strengthening and healing my back. A Braden Scale for Predicting Pressure Ulcer Risk assessment was completed on 8/25/21. The resident's score was 17, mild risk for developing pressure injuries. The assessment identified a potential problem: during a move skin probably slides to some extent against sheets, chair, restraints or other devices. A weekly skin evaluation, dated 8/25/21, identified that the resident had an abrasion and redness to the back, under her back brace. -There was no evidence the physician was notified, treatment orders requested/implemented, or the care plan updated. A daily skilled nursing note dated 8/26/21 documented the resident's skin as spine abrasion, back brace. A daily skilled nursing note dated 8/27/21 documented the resident's skin as abrasion (on) spine, back brace. The comprehensive care plan, initiated on 8/27/21, included that the resident had the potential for skin breakdown. Interventions included to apply moisturizer to the skin; staff not to apply over bony prominences and use mild cleansers for peri-care/washing, encourage proper nutrition and hydration, skin evaluations as ordered, pressure relieving mattress per facility protocol. -The resident's back brace was not identified as a risk factor contributing to the development of a device related pressure injury despite redness and abrasion to the back caused by the brace, which was documented on the admission skin assessment. No interventions were implemented to prevent further injury. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A daily skilled nursing note dated 8/28/21 documented the resident's skin as back redness and abrasion. A daily skilled nursing note dated 8/29/21 documented the resident's skin as back redness and abrasion. A daily skilled nursing note dated 8/30/21 documented the resident's skin as abrasion and redness on back. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -This was the first physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden Scale for Predicting Pressure Ulcer Risk assessment was completed on 9/1/21. The resident's score was 17, mild risk for developing pressure injuries. A weekly skin evaluation, dated 9/1/21, identified that the resident had blanching redness and an abrasion to her back under the brace. A daily skilled nursing note dated 9/5/21 documented the resident's skin as abrasion, back brace. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -This order was not scheduled and had no other specifications such as type, size, shape or placement of the foam padding. A weekly skin evaluation, dated 9/8/21, identified that the resident had blanching redness and an abrasion to her back caused by the back brace. The wound care physician (WCP) notes revealed that the resident was initially referred to be seen by the wound doctor on 9/7/21. The WCP first observed the resident's wound on 9/8/21. The WCP documented that the wound was unstageable with an approximate timeline that had been present for greater than 10 days. The wound was an unstageable, device-related pressure injury which measured 5.5 centimeters (cm) by 1.8 cm with a surface area of 9.9 cm. The procedure note read, The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique, curette was used to surgically excise 1.48 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied. The dressing treatment plan prescribed [MEDICATION(S)] Calcium Alginate applied three times per week and as needed, saturation for 30 days and recommendation to offload the wound. -By the time the facility requested WCP treatment, the resident's wound had progressed from redness to abrasion to unstageable needing debridement. Braden Scale for Predicting Pressure Ulcer Risk assessments were completed on 9/8/21, 9/15/21, 9/22/21 and 9/29/21. On each of these assessments the resident's score was 19, not at risk for developing pressure injuries. -The assessments did identify the device-related risk to the resident and the resident had actual skin injury at the time each of the assessments were completed. A wound care evaluation was completed on 9/8/21, and documented that the resident had a pressure injury to her right lower back that was 5.5 centimeters (cm) in length, 1.8 cm wide and an undetermined depth. A daily skilled nursing note dated 9/8/21 documented the resident's skin as back abrasion and redness. -However, the resident had developed a stage 3 device-related pressure injury by this date. A daily skilled nursing note dated 9/10/21 documented the resident's skin as abrasion, back brace. Braden Scale for Predicting Pressure Ulcer Risk assessments were completed on 9/8/21, 9/15/21, 9/22/21 and 9/29/21. On each of these assessments the resident's score was 19, not at risk for developing pressure injuries. On 9/15/21 the resident was seen for follow-up by the WCP. A stage 3 device-related pressure injury was documented as 4 cm length by 3 cm width by 0.15 cm depth. The procedure note read, The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique, curette was used to surgically excise 1.20 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied. -The wound, which the facility continued to inaccurately document as an abrasion, was debrided for the second time and was now a stage 3. A wound care evaluation was completed on 9/15/21, and documented that the resident had a pressure injury to her right lower back that was 4 cm in length, 3 cm wide and 0.15 cm in depth. -The wound stage (3) was still not documented. On 9/22/21, the resident was seen by WCP for follow-up. The pressure injury was documented as 4 cm in length by 2.5 cm wide by 0.1 cm depth. The note read, The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique, curette was used to surgically excise 0.50 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.15 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied. A wound care evaluation was completed on 9/22/21, and documented that the resident had a stage 3 pressure injury to her right lower back that was 4 cm in length, 2.5 cm wide and 0.1 cm in depth. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan was updated on 9/23/21 (14 days after the resident was identified as having a stage 3 pressure ulcer) to include that the resident had a pressure injury. Interventions included to administer treatments as ordered and monitor effectiveness. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. A wound care evaluation was completed on 9/29/21, and documented that the resident had a pressure injury to her right lower back that was 1.5 cm in length, 0.8 cm wide and 0.15 cm depth. On 9/29/21 the resident was seen by the WCP for follow-up. The pressure injury was documented as being 1.5 cm in length, 0.8 cm wide and 0.15 cm in depth. The procedure note read, The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique, curette was used to surgically excise 0.24 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied. E. Staff interviews The charge nurse (CN) was interviewed on 10/4/21 at 3:51 p.m. She said that full skin assessments should be completed on all residents upon admission and skin should be monitored on an ongoing basis during care and weekly full skin assessments; identified concerns should be documented, monitored and the physician notified. The physician should be notified of any concerns and monitored. She said that she did not participate in wound rounds and was not familiar with the resident's wound. She had helped with entering orders but did not participate in wound care or assessments. The wound nurse (WN) was interviewed on 10/4/21 at 3:59 p.m. She said that she was the facility's MDS coordinator, however, she was filling in as the wound nurse. She said the previous wound nurse had left the position on or around 8/26/21. She said that she began filling in as the wound nurse on 9/1/21. She said that Resident #26 was admitted to the facility with a TLSO back brace. At the time of admission, the resident had an area of redness from where the brace rubbed on her back. She said the resident had kyphosis (a significant curvature of the back). She said that the resident acquired the device-related pressure injury while at the facility. She said that interventions should be in place for residents and skin closely monitored due to the risk of developing skin breakdown or injuries. She said, after reviewing Resident #26's electronic health record, that interventions were delayed and addressing the Resident's pressure injury had fallen through the cracks. Licenced practical nurse (LPN) #4 was interviewed on 10/5/21 at 12:53 p.m. She said that when a resident was admitted with a reddened area or skin concerns, she would document it on the comprehensive nursing admission assessment, notify the physician and obtain a treatment order. She said skin concerns should be monitored every shift to determine if they were worsening. She said that Resident #26 had developed a device-related pressure injury from her back brace rubbing on her back. She said the resident had admitted to the facility with a reddened area caused by the brace. LPN #3 was interviewed on 10/5/21 at 12:58 p.m. She said that the facility had issues with consistent oversight of the wound management program. She said the facility did not have an acting assistant director of nursing (ADON) or wound care nurse. She said that nursing staff and the facility's minimum data set (MDS) coordinator were filling in with wound care which impacted communication and some residents were falling through the cracks. She said that the MDS coordinator appeared to struggle with maintaining communication and oversight of the wound management program while she was filling in as the wound nurse. The physical therapy assistant (PTA) was interviewed on 10/5/21 at 1:26 p.m. She said that Resident #26 was admitted to the facility with the TLSO brace. She said that the resident had complained of pain associated with wearing the brace. She said that the nursing staff had placed a green foam padding between the resident's clothing and the brace. She said that she had noticed that the foam padding would shift and would become displaced at times. She said the therapy department had not been involved in evaluating the placement of the foam. The director of rehab (DR) was interviewed on 10/5/21 at 2:03 p.m. He said that TLSOs were a type of brace that are more generalized to fit many different body shapes. He said that the resident had a prominent protrusion in the shape of her back. He said no matter how a brace is donned and doffed, it will shift throughout the day and require readjusting. He said that adding foam between the resident and the brace would impact how the brace fits. He said the brace could rub against the skin. He said mole skin or padding could be used to prevent rubbing and/or injury to the resident. He said that therapy staff were not involved with the assessment and placement of the foam padding for Resident #26. He said Resident #26's TLSO brace tended to drift up on her body. The WCP was interviewed on 10/5/21 at 2:29 p.m. He said that when he first assessed Resident #26, she had an unstageable device-related pressure injury. He said he could not tell how deep the wound was during his initial assessment. He said based on the progression of the wound and nursing notes, he had approximated that the wound had developed 10 days prior. He said when he saw the resident a week later and could accurately measure the wound, it was classified as stage 3. He said the resident required weekly debridement procedures to remove necrotic tissue and establish the parameter of healthy skin. He said that the nursing staff had added foam padding between the resident and the brace. He said that the therapy department should be involved with the placement and shape when adding the foam padding to ensure that it matched up with the brace. He said that the fit of the foam was important to ensure its effectiveness as an intervention. He said the resident had a protrusion to her back and therefore he did not feel an air mattress would have been an effective intervention. He said that he had recommended some type of offloading for the wound. He said that the facility has struggled with some short staffing and the MDS coordinator was substituting in as the wound nurse and doing the best she could. The regional nurse consultant (RNC) was interviewed on 10/5/21 at 11:03 a.m. She said that she was filling for the director of nursing (DON). She said when a resident was admitted to the facility, a full head-to-toe assessment should be completed and any areas of concern should be thoroughly documented and the physician notified. She said areas at risk of developing pressure injuries should be monitored every shift, interventions should be implemented, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . IV. Failure to prevent pressure injuries for Resident #20 A. Resident #20's status Resident #20, age 86, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/20/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance from two staff members with all activities of daily living. She was identified at risk for developing pressure ulcers, and did not have any skin issues on admission. She was utilizing a pressure reducing device in bed, and was not on a turning and repositioning program. B. Record review The Braden Scale for Predicting Pressure Ulcer Risk assessment was not conducted on admission 8/13/21. It was conducted on 8/18/21 (five days after admission). The resident's score was 16, low risk for developing pressure ulcers, despite the fact that she had a paralyzed limb, and required extensive assistance with movement and repositioning. The baseline care plan, initiated on admission on 8/13/21, revealed the resident was dependent on one staff member for bed mobility, transfers, and toileting. She did not have any surgical wounds or other skin issues, but had a potential for skin breakdown. Interventions included to apply moisturizer to skin; evaluate skin condition and Braden assessments weekly; to monitor, remind and encourage the resident to reposition frequently; and work with physical therapy to increase independence. The initial skin assessment was not conducted on the admission day 8/13/21. The skin section had a note that the skin assessment was not conducted on admission. There was no explanation why it was not conducted. Daily skilled nurses notes between 8/13/21 and 9/11/21 continued to document no open areas and intact skin. The order to monitor bilateral heels every shift for signs and symptoms of skin breakdown every shift was initiated on admission, 8/13/21. -It was consistently documented with zeros through August, September and October 2021, indicating the resident had no problems with her heels. However, according to the wound care physician notes below, the resident had a DTI on her heel as early as 9/15/21. The order for barrier cream to the coccyx, buttock and peri area for prevention every shift and as needed was initiated on admission, 8/13/21, and discontinued on 9/17/21. -There were no orders to turn and reposition the resident, or to make sure her heels were offloaded, as recommended on the baseline care plan. The skin assessment on 9/12/21 documented the resident has what appears to be pre-pressure area on upper right buttock, bilateral heels red boggy and starting to break down. Skin prep applied this evening. (Resident) has [MEDICATION(S)] dressing in place for more protection. Coccyx intact. The skin assessment on 9/13/21 did not mention the pressure area on the right buttock and condition of heels. The weekly skin assessment on 9/15/21 documented the resident had a pressure injury to her coccyx with no measurements, no staging, and a pressure injury to her bilateral heels with no staging and no measurements. The note read: Coccyx red, small open area to right buttock. Bilat(eral) feet dry skin, heels red and soft. -The nurses notes and skin assessments above revealed that skin conditions were not documented consistently and accurately. After 9/15/21 the resident was followed weekly by the wound care physician, and no further nursing notes were documented. The wound care physician notes revealed that the resident was seen by the wound care physician starting on 9/15/21, when she was assessed for an unstageable DTI to the left posterior heel that was present for at least six days. Treatments included to apply skin prep three times a day for 30 days, float heels in bed and off load wound. In addition, the resident had an unstageable full thickness DTI of the right medial buttock, measuring 4.0 cm by 6.7 cm. Interventions and treatments included to off-load wound, reposition per facility protocol, and make sure the resident had a gel cushion to the chair. The resident refused the debridement during the appointment. The order for skin prep to both heels and float heels when in bed every shift for stage 1 pressure injury, was initiated on 9/10/21 and discontinued on 9/17/21. -However, the daily skilled nurses notes on 9/10/21, 9/11/21, 9/12/21, 9/13/21, and 9/14/21 documented the resident had no open areas. -The weekly skin assessment on 9/13/21 did not mention open areas on the resident's heels. The wound care order for right and left medial buttocks, to apply house barrier cream to buttocks three times a day, initiated on 9/17/21, was not signed on two occasions in September: 9/19/21 morning and day shift. -There were no orders for the air mattress or the setting for it. On 9/22/21 the resident was seen by a wound care physician for unstageable DTI to the left posterior heel that was healing, and for the unstageable full thickness DTI of the right medial buttock that was decreasing in size and healing as well. In addition, the resident developed two new pressure injuries: A new pressure injury on her sacrum was a partial thickness stage 2, measuring 0.9 cm by 0.7 cm. The second new pressure injury was a partial thickness stage 1 pressure injury of the left medial buttock measuring 5.0 by 1.7 cm. Recommendations included to apply barrier cream every shift, limit sitting to 60 minutes, off-load wound, and reposition per facility protocol. -The comprehensive care plan did not include a section for ADLs and for skin integrity until 9/23/21. The section for skin integrity, initiated on 9/23/21 with no revision date, revealed the resident had an unstageable pressure injury to the left heel, unstageable pressure ulcer to the right buttock, stage 1 pressure injury to left buttock, and stage 2 pressure injury to sacrum. The care p[TRUNCATED]