Every finding on record at Chestelm Health and Rehabilitation Center

Based on review of the clinical records, facility documentation, facility policy, and interviews for 3 of 6 residents (Resident #6, Resident #44, and Resident #45 ) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the state agency was updated subsequent to the residents' new psychiatric diagnoses. The findings include: 1.Resident #6 had diagnoses that included stroke, anxiety, and post-traumatic stress disorder. The Notice of Negative PASRR Level I Screen dated 4/20/2020 identified Resident #6 had diagnoses of anxiety and Post Traumatic Stress Disorder (PTSD). The notice indicated that based on the information received, a Level II evaluation was not required at that time, and Level I was approved with a negative outcome. The notice further directed that if there was an exacerbation related to mental illness or a discrepancy in the reported information, a status change should be submitted to the state agency for further evaluation. a.The annual Minimum Data Set (MDS) dated [DATE] identified Resident #6 had severely impaired cognition and diagnoses that included stroke, anxiety, and PTSD. The MDS further identified Resident #6 did not have a diagnosis of dementia or depression. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 8/25/2022 identified he/she questioned whether Resident #6's underlying depression was related to the resident's stroke. The APRN recommended optimizing the use of Lexapro to help address depressive symptoms and directed to a diagnosis of depressive episodes. A physician's order dated 8/25/22 directed to administer Lexapro (antidepressant) 20 milligrams daily. b. The quarterly MDS dated [DATE] identified Resident # 6 had severely impaired cognition and diagnoses that included stroke, anxiety, PTSD, and depression. The Resident Care Plan (RCP) dated 10/1/22 identified Resident #6 had a diagnosis of depression with interventions that directed to refer to psych team as needed. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 11/3/22 identified Resident #6 had a new diagnosis of recurrent major depression. Review of the clinical record failed to identify the PASRR contracted agency was notified of the new psychiatric diagnoses of depressive episodes and recurrent major depression from 8/25/22 through 6/2/26 in order to conduct an additional Level I and Level II screen. Interview with Social Worker (SW) #1 on 6/2/2026 at 10:53 AM identified Admissions Coordinator #1 was responsible for receiving and updating PASRRs for all residents in the facility. SW #1 indicated that if a resident had a Level II PASRR, the MDS Coordinator or SW #1 would update the care plan. Interview and review of the clinical record with Admissions Coordinator #1 on 6/2/2026 at 12:07 PM identified she was responsible for updating the PASRR contracted agency when a resident received a new psychiatric diagnosis in order for an additional Level I or Level II screen to be conducted. Admissions Coordinator #1 identified Resident #6 only had the Level I screening on admission and the state agency was never updated as required when the resident received new mental health diagnoses. Admissions Coordinator #1 indicated that if she had been aware or had been notified that Resident #6 had a new diagnosis of depressive episodes or major depression, she would have updated the PASRR contracted agency right away. 2.Resident #44 had diagnoses that included depression and cognitive communication deficit. A Level I PASRR dated 1/14/2025, completed by the facility, identified Resident #44 had a diagnosis of depression and no history of dementia or mental health behaviors. The assessment directed that if changes occur or new information refutes the findings, a status change referral should be submitted for further evaluation. Review of Resident #44's medical record identified on 1/30/2025 a diagnosis of dementia was added to the medical record, on 4/23/2025 a diagnosis of delusional disorder was added to the medical record, and on 4/28/2025 a diagnosis of anxiety was added to the medical record. The quarterly MDS assessment dated [DATE] identified Resident #44 had a Brief Interview of Mental Status (BIMS) score of 10 indicative of moderately impaired cognition, experienced disorganized thinking and inattention, and had psychiatric diagnoses of depression, anxiety, and a psychotic disorder. The Resident Care Plan (RCP) dated 3/27/2026 identified Resident #44 had behaviors as evidenced by agitation, depression, anxiety, and a delusional disorder. Interventions included intervening as needed to ensure the safety of the resident and others, administering medications as ordered by the physician, and redirecting inappropriate behavior with food, fluids, music, a quiet environment, and one to one care. The RCP further identified Resident #44 had a potential alteration in mood, with reports that the resident wished he/she would pass. Interventions included administering medications as ordered, monitoring mood state for changes, and monitoring for safety. Review of the clinical record failed to identify the PASRR contracted agency was notified of the new psychiatric diagnoses of delusional disorder, anxiety, and dementia from 1/30/2025 through 6/2/2026 in order to conduct an additional Level I and Level II screen. Interview and review of the clinical record with Admissions Coordinator #1 on 6/2/2026 at 12:07 PM identified she was responsible for updating the PASRR contracted agency when a resident received a new psychiatric diagnosis. Admissions Coordinator #1 indicated she had not updated the PASRR contracted agency regarding Resident #44's new diagnoses of delusional disorder, anxiety, and dementia because she had not been made aware of the changes. Admissions Coordinator #1 identified the PASRR contracted agency should have been updated. Interview and review of the clinical record on 6/2/2026 at 2:02 PM with the Director of Nursing Services (DNS) identified he was responsible for ensuring the accuracy of Level I PASRRs for residents admitted to the facility. The DNS further identified Resident #44's PASRR had not been updated because during his training he had not been informed of the requirement to notify the PASRR agency when a resident experienced a change in mental status or received a new psychiatric diagnosis. Subsequent to surveyor inquiry, a PASRR screen submission request dated 6/2/2026 was made to the PASRR contracted agency for Resident #44. 3. Resident #45 was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's disease. Level I PASRR dated 4/10/2025, completed during hospitalization prior to admission to the facility, identified Resident #45 had no known or suspected mental health diagnosis. The outcome of the assessment indicated no referral for a Level II PASRR was required, as the Level I was negative due to insufficient evidence of a major mental illness. The PASRR Level I directed should changes occur or new information refutes the findings, a status change should be submitted for further evaluation. Review of Resident #45's medical record identified on 10/16/2025 a diagnosis of Post traumatic stress disorder (PTSD) was added to the medical record and on 4/9/2026 a diagnosis of anxiety disorder was added to the medical record. The annual MDS assessment dated [DATE] identified Resident #45 had a Brief Interview for Mental Status (BIMS) score of 3, indicative of severely impaired cognition, experienced disorganized thinking and inattention and had psychiatric diagnoses of an anxiety disorder and Post traumatic stress disorder (PTSD). The MDS additionally identified Resident #45 was not considered by the State Level 2 PASRR process to have a serious mental illness, intellectual disability, or related condition. The RCP dated 5/18/2026 identified Resident #45 had behaviors that included aggression, combativeness, and attempts to strike and bite staff. Interventions included intervening as needed to ensure the safety of the resident and others, administering medications as ordered by the physician, and obtaining psychiatry evaluations and follow-up. The RCP further identified that Resident #45 had a history of PTSD and relived periods of being in a war. Interventions included announcing self when approaching the resident for care to avoid startling the resident, assisting the resident with displacement techniques when angry or upset, and encouraging the resident to express emotions verbally rather than physically. Review of the clinical record failed to identify the PASRR contracted agency was notified of the new psychiatric diagnoses of PTSD and anxiety disorder from 10/16/2025 through 6/2/2026 in order to conduct an additional Level I and Level II screen. Interview and review of the clinical record with Admissions Coordinator #1 on 6/2/2026 at 12:07 PM identified she was responsible for updating the PASRR contracted agency when a resident received a new psychiatric diagnosis. Admissions Coordinator #1 indicated she had not updated the PASRR contracted agency regarding Resident #45's new diagnoses of PTSD and anxiety delusional disorder because she had not been made aware of the changes. Admissions Coordinator #1 identified the PASRR contracted agency should have been updated. Interview and review of the clinical record on 6/2/2026 at 2:02 PM with the DNS identified he was responsible for ensuring the accuracy of Level I PASRRs for residents admitted to the facility. The DNS further identified Resident #45's PASRR had not been updated because during his training he had not been informed of the requirement to notify the PASRR agency when a resident experienced a change in mental status or received a new psychiatric diagnosis. Subsequent to surveyor inquiry, a PASRR screen submission request dated 6/2/2026 was made to the PASRR contracted agency for Resident #45. Review of the facility Pre-admission Screening and Resident Review (PASRR) Program Policy not dated, directed, in part preadmission screening is for residents with a mental health disorder and/or intellectual disabilities is required for all new residents. A nursing facility must notify the state mental health authority promptly after a significant change in the mental or physical condition of a resident who has a mental illness or intellectual disability for resident review.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #74) reviewed for hospitalization, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when a resident was transferred to the hospital. The findings include:Resident #74 was admitted to the facility on [DATE] with diagnoses that included respiratory failure with hypoxia, pneumonia, and heart failure. The Resident Care Plan (RCP) dated 3/11/26 identified Resident #74 had the potential for alteration in respiratory status related to pneumonia and respiratory failure. Interventions included monitoring vital signs and oxygen levels as ordered and as needed.The admission MDS dated [DATE] identified Resident #74 had severely impaired cognition.Physician's order dated 3/29/26 directed to obtain a chest X-ray due to shortness of breath, wheezing and crackles in left mid to base section of lungs, apply oxygen via nasal cannula at 2 liters per minute continuously, and administer Levaquin (antibiotic) 500 milligram (mg) daily for 10 days for pneumonia.APRN note dated 3/30/26 at 10:00 AM identified Resident #74 was evaluated for hypoxemia and new bilateral pneumonia. The APRN note further identified Resident #76 required a higher level of care and he/she agreed to the hospital transfer.The nurse's note dated 3/30/26 at 12:26 PM identified Resident #74 was sent to the emergency room due to an inability to maintain an oxygen saturation level of 92% while receiving oxygen at 4 liters per minute via mask and had a decreased pulse rate. The APRN was present and ordered the resident's transfer to the emergency room.Review of the Census Report identified on 3/30/26, Resident #74 was placed on a stop-billing status, and the action code was documented as discharge. Review of the Facility Ombudsman's Emergency Hospital Report dated 4/8/26 identified Resident #74 was not included in the report for March 2026.Interview with Medical Records #1 on 6/3/26 at 9:12 AM identified she was responsible for notifying the Ombudsman of all resident transfers and discharges to the hospital. Medical Records #1 identified she was aware Resident #74 was transferred to the hospital for evaluation on 3/30/26. Medical Records #1 indicated on 4/2/26 she ran a census report of residents discharged to the hospital and used the report to submit hospitalization information to the Ombudsman via the portal for March 2026. Medical Records #1 indicated on 4/2/26 after submitting the report, she realized Resident #74 was not included so she contacted Accounts Receivable #1 to correct the discrepancy on the census report. Medical Records #1 identified Accounts Receivable #1 informed her that the report would not be corrected until it was determined whether Resident #74 would be placed on bed-hold status. Medical Records #1 indicated she informed the prior administrator that Accounts Receivable #1 would not correct the census report. Medical Records #1 identified because the census report was not corrected, she did not update the Ombudsman that Resident #74 was transferred to the hospital on 3/30/26.Interview with Accounts Receivable #1 on 6/3/26 at 9:28 AM identified she was responsible for maintaining the census report for all admissions, discharges, and hospitalizations. Accounts Receivable #1 identified when Resident #74 was transferred to the hospital on 3/30/26, she entered Resident #74 as discharged on the census report. Accounts Receivable #1 indicated that when a resident is transferred to the hospital, she typically enters a hospital transfer status until it is determined whether the resident will return to the facility. Accounts Receivable #1 identified on 3/30/26 in error she entered a discharge stop-billing status rather than a hospital transfer for Resident #74, which removed Resident #74 from the census report. Accounts Receivable #1 indicated she was still learning the facility's computer system. Accounts Receivable #1 identified on 3/30/26 she should have entered a hospital transfer rather than a discharge on the census report.Review of the facility Notice Requirements before Transfer and/or Discharge policy identified before the facility transfers or discharges a resident, the facility will notify the resident and/or resident representative of the transfer or discharge and the reason in writing and in a language and manner they understand. The facility will send a copy of the notice to a representative and to the Office of the State Long Term Care Ombudsman.

Based on observations, review of clinical record, review of facility policy, review of facility documentation, and interviews for one of three residents (Resident #19) reviewed for pressure ulcer/injury, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with open wounds to ensure the appropriate personal protective equipment (PPE) was utilized when providing wound care. The findings include:Resident #19's diagnoses included vulva cancer status-post surgical interventions with surgical wound, stage 3 pressure ulcer on coccyx, and lymphedema.Physician's orders dated 5/27/26 directed to cleanse the vaginal and suprapubic surgical sites with normal saline, pat dry, and apply witch hazel daily on the evening shift and as needed when soiled, and cleanse the coccyx pressure ulcer with normal saline, apply Santyl ointment, and cover with a dry occlusive dressing.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 had intact cognition and was independent with personal hygiene and transfers. The MDS further identified Resident #19 had a surgical wound and one stage 3 pressure ulcer.The Resident Care Plan (RCP) dated 5/28/26 identified Resident #19 had existing wounds that included a non healing vulvectomy site, incision and drainage site to the right groin, and a coccyx wound. Interventions included referral to the wound care provider as needed, treatments as ordered, and monitoring for healing progression.a. Observations on 6/1/26 at 9:53 AM and on 6/2/26 at 1:00 PM identified that no Personal Protective Equipment (PPE) and no Enhanced Barrier Precautions (EBP) signage were present outside Resident #19's room. PPE was not readily accessible either outside or in the immediate vicinity of the room. EBP signage was not posted to indicate staff were required to don gowns and gloves before performing high-contact activities with the resident.b. Observation on 6/2/26 at 1:08 PM of Licensed Practical Nurse (LPN) #1 performing wound care identified the gauze and absorbent foam dressing removed from Resident #19's right groin surgical wound was heavily saturated with drainage. Although LPN #1 changed her gloves and performed hand hygiene appropriately, she did not wear appropriate PPE ( gown) while performing Resident #19's wound care.Interview with LPN #1 on 6/2/26 at 1:08 PM identified she was familiar with Resident #19's wounds. LPN #1 identified Resident #19's right groin surgical wound frequently produced significant drainage and at times required additional dressing changes. LPN #1 identified she did not believe EBP applied to Resident #19 because she understood EBP to pertain only to infectious diseases. LPN #1 indicated she relied on the Infection Preventionist to notify staff if a resident required EBP. LPN #1 identified she did not wear PPE because Resident #19 was not on EBP.Interview with Resident #19 on 6/2/26 at 1:12 PM identified the dressing on his/her right groin surgical wound often becomes saturated with drainage to the point that it seeps through and is no longer contained by the dressing.Interview with Registered Nurse (RN) #1, Infection Preventionist, on 6/2/26 at 2:15 PM identified he was responsible for determining when residents require Enhanced Barrier Precautions (EBP). RN #1 identified residents with wound drainage that cannot be contained within the dressing are placed on EBP. RN #1 indicated he was not aware Resident #19 had drainage from the surgical wound to the right groin requiring frequent dressing changes because the dressing was often saturated and at times the drainage leaked through the dressing. RN #1 stated Resident #19 should have been placed on EBP.Subsequent to surveyor inquiry, RN #1 identified that Resident #19 was placed on contact precautions, pending a wound culture due to uncontained drainage and uncertainty regarding multidrug-resistant organism (MDRO) status. RN #1 stated that if the wound culture does not indicate an MDRO, then Resident #19 will be placed on Enhanced Barrier Precautions.Physician's order dated 6/2/26 directed contact precautions for a wound with uncontainable drainage, including donning and doffing a gown and gloves upon entering and exiting the resident's room.Review of the facility Precautions Policy dated 8/26/2025, directed, in part, residents who have a wound with secretions that cannot be covered or contained, and who are not known to be infected or colonized with an MDRO, should be placed on Enhanced Barrier Precautions if they do not meet the criteria for contact precautions. Residents who have a wound without secretions that are unable to be covered or contained, and who are not known to be infected or colonized with an MDRO, should be placed on Enhanced Barrier Precautions. Enhanced Barrier Precautions require staff to wear a gown and gloves while performing high contact activities with residents.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had a new medication ordered for a change in condition and there was a noted medication interaction identified by the pharmacy, the facility failed inquiry the pharmacy why the medication had not been available and to notify the provider for six (6) days. The findings include: Resident #1's diagnoses included constipation, failure to thrive, and aphasia following cerebral infarction (a stroke resulting in damage to areas of the brain responsible for language). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating slight memory recall deficits, was dependent on staff for toileting and was always incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 6/18/25 identified Resident #1 was at risk for constipation related to a history of constipation, impaired mobility, opiate use (narcotic pain medication) and a history of an ileus (a disruption of the normal propulsion of the intestine caused by lack of peristalsis or mechanical obstruction). Interventions directed to observe for signs of constipation, record the amount and characteristics of each bowel movement, follow the bowel protocol per policy and administer laxatives as ordered. The nurse's note dated 7/4/25 at 12:51 PM identified Resident #1 was noted with a moderate amount of bright red blood from the rectum, no external hemorrhoids were observed and the resident denied any pain to the area. The note identified the on-call provider was notified, and a new order was obtained for hydrocortisone suppositories twice daily for seven (7) days for a question of internal hemorrhoids. A physician's order dated 7/4/25 directed to insert one (1) hydrocortisone acetate rectal suppository 25 milligrams (mg) rectally every evening and night shift for seven (7) days for hemorrhoids. The nurse's note dated 7/4/25 identified an order note reported a drug protocol alert/warning was triggered. The note identified the interaction was with the Aspirin 81 milligrams. Review of the nurse's notes dated 7/4/25 through 7/10/25 failed to identify a provider was notified of the drug interaction until 7/10/25. Review of the July 2025 Treatment Administration Record (TAR) identified the hydrocortisone acetate suppository was not administered on the night shift from 7/4/25 through 7/10/25 because it was not available and was not administered on the evening shift on 7/5/25, 7/6/25 and 7/8/25. The TAR identified the hydrocortisone acetate suppository was administered on the evening shift on 7/7/25, 7/9/25 and 7/10/25. Review of the nurse's notes dated 7/4/25 through 7/10/25 failed to identify a provider was notified of the missed doses and the hydrocortisone acetate suppository was not available. An order administration note dated 7/10/25 at 6:07 AM identified the Advanced Practice Registered Nurse (APRN #1) was updated and directed the pharmacy to dispatch the hydrocortisone acetate suppository despite the allergy/drug interaction. The nurse's note dated 7/11/25 at 4:47 AM identified Resident #1 was noted with a moderate amount of rectal bleeding in the brief but denied any pain or discomfort, personal care was then provided, and no active bleeding occurred at that time. The note identified the on-call provider was notified of the incident, but no new orders were obtained. The nurse's note dated 7/11/25 at 8:49 AM identified Resident #1 was observed with worsening dark red rectal bleeding, expelling a large blood clot from the rectum, nausea, and upper right abdominal discomfort, the on-call provider was notified, and an order was obtained to transfer Resident #1 to the Emergency Department (ED) for evaluation. Review of the Bowel Movement Report identified Resident #1 had a medium bowel movement on 7/8/25, a medium bowel movement on 7/9/25, a large bowel movement on 7/10/25 and a large bowel movement on 7/11/25. The hospital Discharge summary dated [DATE] identified on 7/11/25 Resident #1 presented to the ED with a lower GI bleed and bright red blood from the rectum due to severe constipation requiring urgent disimpassion in the Operating Room (OR) on 7/11/25. The summary identified Resident #1 remained stable with no further signs of bleeding and was transferred back to the facility on 7/15/25. Interview with APRN #1 on 8/13/25 at 11:17 AM identified a provider should be notified for each scheduled medication that is not administered to a resident, reporting if the hydrocortisone acetate suppository was not available from the pharmacy and had he been notified, he would have held the hydrocortisone acetate suppository and ordered an alternative medication pending the arrival of the originally ordered hydrocortisone acetate suppository. APRN #1 reported he met with Resident #1 on 7/7/25 per request of the facility staff and no one mentioned to him at that time the hydrocortisone acetate suppositories had still not been received from the pharmacy or that there was an issue with the order. APRN #1 reported with the level of stool impaction that was noted on the hospital documentation, he did not believe the hydrocortisone acetate suppositories would have made a significant difference in relieving the impaction or preventing the resident's hospitalization but could have made him/her more comfortable. Interview with Person #2 (pharmacy supervisor) on 8/13/25 at 2:24 PM identified when the facility initially entered the order for the hydrocortisone acetate suppository on 7/4/25, there was a noted medication interaction so they (the pharmacy) called the facility and spoke with the 3-11 PM Nursing Supervisor, Registered Nurse (RN) #3, who reported she would clarify the interaction with the provider. Person #2 identified the pharmacy faxed a clarification form to the facility to complete and return, however he/she had no documentation the form was returned back to the pharmacy and reported there were no notes in their system indicating the facility called back to follow-up on the medication, so the hydrocortisone acetate suppositories were not sent. Interviews with the charge nurses, RN #1, Licensed Practical Nurse (LPN) #2, LPN #5, LPN #6 and LPN #7 on 8/13/25 identified they did not contact either the nursing supervisor nor the provider each time the hydrocortisone acetate suppository was scheduled and not available for administration, reporting they thought everyone knew and it had already been reported. LPN #7 reported although she did not report the missed administration on 7/9/25 and should have, she did write it in the provider book to be reviewed by APRN #1 on 7/10/25. Interviews with LPN #4, LPN #6 and RN #1 identified although they signed off the hydrocortisone acetate suppository was administered on 7/7/25 (evening shift), 7/9/25 (evening shift) and 7/10/25 (evening shift) they could not recall administering the suppository to Resident #1, stating they must have signed off in error. They reported that when the medication was not available, they should have called the pharmacy to check on the delivery status, notified the nursing supervisor and then notified the provider of the missed administration but reported that they had not. Interviews with the nursing supervisors, RN #3, RN #4 and RN #5 on 8/13/25 identified they were not notified by the charge nurses the hydrocortisone acetate suppositories had not yet been received from the pharmacy and were not available for administration 7/4/25 through 7/10/25. They reported they should have been notified and would have assisted if notified but ultimately the charge nurses were responsible for inquiring about the medication with the pharmacy and notifying the provider of the missed medication administration. Interview with the Director of Nursing (DON) on 8/13/25 at 1:43 PM identified the provider should have been notified of each occurrence when the hydrocortisone acetate suppository was not administered to Resident #1 so a hold order or an order for an alternative medication could have been obtained The DON indicated if the medication was not available from the pharmacy, the pharmacy should also have been contacted to inquire about the delivery. Although attempted, interviews with LPN #1 and LPN #3 were not obtained. Review of the Medication Administration Procedures policy (undated) directed, in part, that nursing staff it to notify the physician/prescriber for any held medications or suspected adverse drug reactions.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for constipation, the facility failed to ensure an abdominal assessment was conducted and continued monitoring following an incident of rectal bleeding. The findings include: Resident #1's diagnoses included constipation, failure to thrive, aphasia following cerebral infarction (a stroke resulting in damage to areas of the brain responsible for language) and atrial fibrillation (an irregular heart rate). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicating no memory recall deficits, was dependent on staff for toileting and was always incontinent of bowel and bladder. The Resident Care Plan dated 6/18/25 identified Resident #1 was at risk for constipation related to a history of constipation, impaired mobility, opiate use (narcotic pain medication) and a history of an ileus (a disruption of the normal propulsion of the intestine caused by lack of peristalsis or mechanical obstruction). Interventions directed to observe for signs of constipation, record the amount and characteristics of each bowel movement, follow the bowel protocol per policy and administer laxatives as ordered. The nurse's note dated 7/4/25 at 12:51 PM identified Resident #1 was noted with a moderate amount of bright red blood from the rectum, no external hemorrhoids were observed, and Resident #1 denied any pain to the area. The note identified the on-call provider was notified, and a new order was obtained for hydrocortisone suppositories twice daily for seven (7) days for a question of internal hemorrhoids. The note failed to identify a Gastrointestinal (GI) assessment was performed to include an abdominal assessment, the inspection, auscultation, and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness A physician's order dated 7/4/25 directed to insert one (1) hydrocortisone acetate rectal suppository 25 milligrams (mg) rectally every evening and night shift for seven (7) days for hemorrhoids. Review of the July 2025 Treatment Administration Record (TAR) identified that the hydrocortisone acetate suppository was not administered on the night shift from 7/4/25 through 7/10/25 because it was not available and was not administered on the evening shift on 7/5/25, 7/6/25 and 7/8/25. The TAR identified the hydrocortisone acetate suppository was administered on the evening shift on 7/7/25, 7/9/25 and 7/10/25. Review of nurse's notes from 7/4/25 through 7/11/25 failed to reflect documentation a Gastrointestinal (GI) assessment was performed to include an abdominal assessment, the inspection, auscultation, and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness The nurse's note dated 7/11/25 at 4:47 AM identified Resident #1 was noted with a moderate amount of rectal bleeding in the brief but denied any pain or discomfort, so personal care was then provided, and no active bleeding occurred at that time. The note identified the on-call provider was notified of the incident, but no new orders were obtained. The third eye health note dated 7/11/25 at 5:48 AM identified Resident #1 with know hemorrhoids had a formed stool last night after an enema. This morning the brief had more stool along with several blood smears, not currently bleeding, Resident #1 had pain last night related to difficulty evacuating stool and the brief was seen by the provider on the video. The note failed to identify a gastrointestinal assessment was performed. The nurse's note dated 7/11/25 at 8:49 AM identified Resident #1 was observed with worsening dark red rectal bleeding, nausea and upper right abdominal discomfort, and the on-call Advanced Practice Registered Nurse (APRN) was notified, and while speaking with the provider, Resident #1 was observed expelling a large blood clot from the rectum so an order was obtained to transfer Resident #1 to the Emergency Department (ED) for evaluation, Resident #1 was transported via Emergency Medical Services (EMS) at 7:44 AM. The hospital Discharge summary dated [DATE] identified on 7/11/25 Resident #1 presented to the ED with a lower GI bleed and bright red blood from the rectum due to severe constipation requiring an urgent disimpassion in the Operating Room (OR) on 7/11/25. The summary identified Resident #1 remained stable with no further signs of bleeding and was transferred back to the facility on 7/15/25. Interview with APRN #1 on 8/13/25 at 11:17 AM identified although Resident #1 should have received the hydrocortisone acetate suppository the level of stool impaction that was noted on the hospital documentation, he did not believe the hydrocortisone acetate suppository, would have made a significant difference in relieving the impaction or preventing Resident #1's hospitalization. APRN #1 identified on 7/4/25, Registered Nurse (RN) #2 should have been aware Resident #1 had a history of constipation, should have performed a full GI assessment to include bowel sounds and an abdominal assessment and should have communicated all of the information to the on-call when Resident #1 had the initial rectal bleeding, which could have changed the course of treatment. Interview with Registered Nurse (RN) #2 on 8/13/25 at 12:53 PM identified on 7/4/25 when Resident #1 was noted with rectal bleeding, she only did a visual assessment and did not conduct an abdominal assessment or check Resident #1's bowel sounds. RN #2 reported she did not review Resident #1's clinical record prior to assessing Resident #1 so she was unaware Resident #1 had a history of constipation or was already on three (3) scheduled medications daily to treat the constipation. RN #2 identified had she reviewed the clinical record prior and known Resident #1's history, she would have done a full GI assessment. Interview with the Director of Nursing (DON) on 8/13/25 at 1:43 PM identified on 7/4/25 RN #2 should have reviewed Resident #1's clinical record prior to assessing Resident #1 and contacting the provider with the change in condition so that a complete and accurate history was communicated, and if she had, she would have known Resident #1 had a history of constipation and should have performed a full GI assessment to include bowel sounds and an abdominal assessment. Review of the Change in Condition policy dated 12/17/24 directed, in part, that residents will be monitored by all nursing staff members to determine the need for additional health services monitoring unstable conditions or changes in the residents' baseline. The Unit Nurse will assess the resident for noted changes and notify the RN. The RN will assess the resident for significant changes in condition. The attending physician/APRN will be notified to determine a course of action. A progress note will be entered into the resident record in relation to the change in condition and 72-hour monitoring will be implemented.

50250 Based on observation, review of the clinical record, facility policy and interviews for 15 of 70 residents (Resident #4, Resident #6, Resident #22, Resident #28, Resident #30, Resident #32, Resident #33, Resident #39, Resident #41, Resident #45, Resident #48, Resident #58, Resident #65, Resident #69, Resident #326) reviewed for preventative weekly body audits, the facility failed to perform preventative weekly body audits according facility policy and physician orders. The findings include: 1. Resident #4 was admitted to the facility in November of 2020 and had diagnoses that included cerebrovascular disease, abnormal posture, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), was at risk for developing pressure injuries and had moisture associated skin damage (MASD) with skin treatments. Resident #4 was dependent for bed mobility and transfers. The Resident Care Plan dated 10/11/24 identified Resident #4 was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included to complete a weekly body audit on shower day, turn and reposition on rounds, and to monitor skin integrity during morning and evening care. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 4/8/21) which directed to perform a weekly body audit on Fridays during the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/4/24) which directed to apply barrier cream every shift for MASD and a provider order (start date of 11/16/24) which directed to cleanse the open area to Resident #4 ' s sacrum with normal saline and apply Silvadene (topical antimicrobial) followed by a clean dressing every morning. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/11/24, 10/18/24, 11/1/24, and 11/22/24. There was no body audit performed for Resident #4 for 21 days from 10/4/24 through 10/25/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:15 PM and identified that Resident #4 had no skin issues or abnormalities. The Weekly Body Audit failed to identify MASD or an open area to the sacrum correlating to the active treatment orders in place. 2. Resident #6 was admitted to the facility in August of 2019 and had diagnoses that included congestive heart failure, rheumatoid arthritis, and anemia. The annual Minimum Data Set assessment dated [DATE] identified Resident #6 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), had abnormal posture, dementia, was at risk for developing pressure injuries and had skin treatments. Resident #6 was dependent for bed mobility and transfers. The Resident Care Plan dated 11/20/24 identified Resident #6 was at risk for pressure injuries related to severely impaired mobility and total functional incontinence. Interventions included to ensure Resident #6 had only 2 layers between his/her skin and the mattress, to turn and reposition during rounds, and to perform a weekly body audit on the scheduled shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 10/3/19) which directed to complete a weekly body audit on Fridays during the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 5/26/24) which directed to apply barrier cream to reddened buttocks 2 times a day and as needed after every incontinent episode. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/4/24, 10/18/24, 11/8/24, and 11/22/24. There was no body audit performed for Resident #6 for 14 days from 11/1/24 through 11/15/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:18 PM and identified that Resident #6 had no skin issues or abnormalities. The Weekly Body Audit failed to identify redness to the buttocks correlating to the active treatment orders in place. 3. Resident #22 was admitted to the facility in October of 2024 and had diagnoses that included a repair of a left femur fracture, muscle weakness, and anemia. The admission Minimum Data Set assessment dated [DATE] identified Resident #22 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), was at risk for developing pressure injuries, had a surgical wound, and had skin/wound treatments. Resident #22 required substantial/maximal assistance for bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 10/28/24 identified Resident #22 was at risk for pressure injuries related to impaired mobility, incontinence and bony prominences. Interventions included to monitor for pain on or near bony prominences and pressure points, reposition in chair on rounds, and to complete a weekly body audit on shower day. The RCP further identified Resident #22 was at risk for infection related to a surgical incision to the left hip. Interventions included to document drainage, appearance of site, and signs and symptoms of infection. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 10/15/24) which directed to complete a weekly body audit on Tuesday ' s during the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 10/18/24) which directed to monitor an area surrounding a surgical incision to the left lower extremity and report abnormal findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/22/24, 11/5/24, 11/12/24, 11/19/24, and 11/26/24. There was no body audit performed for Resident #22 for 17 days from 11/9/24 through 11/26/24. Subsequent to surveyor inquiry, a Weekly Body Audit was performed on 11/26/24 at 5:21 PM and identified Resident #22 had no documented skin issues or abnormalities. The Weekly Body Audit failed to identify documentation of a surgical incision/healed incision to the left hip correlating to the active treatment order in place. 4. Resident #28 was admitted to the facility in February of 2021 and had diagnoses that included peripheral vascular disease (PVD), diabetes, and lymphedema. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #28 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), was at risk for developing pressure injuries and had skin treatments. Resident #28 required substantial/maximal assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 9/16/24 identified Resident #28 was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included protective skin barrier with incontinent care and staff assistance to change positions in bed on rounds. The RCP further identified Resident #28 was at risk of bruises, skin tears, and skin alterations related to PVD, lymphedema and a history of cellulitis. Interventions included to moisturize legs and arms daily with morning care and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 7/28/24) which directed to apply house stock barrier cream to the buttocks every shift for skin integrity. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/5/24) which directed to complete a weekly body audit on Fridays during the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified Weekly Body Audits were not completed on 10/1/24, 10/8/24, 10/22/24, 11/8/24, and 11/22/24. There was no body audit performed for Resident #28 for 17 days from 10/29/24 through 11/15/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:10 PM and identified Resident #28 ' s skin was clean, dry and intact. 5. Resident #30 was admitted in July of 2018 with diagnoses that included vascular dementia, osteoarthritis left shoulder, contracture right hand, and abnormal posture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 was severely cognitively impaired and required an assist of 2 for eating, oral hygiene, toileting hygiene, showering, and upper and lower body dressing. The Resident Care Plan (RCP) dated 9/19/24 identified Resident #30 was at risk of bruises and skin tears related to dementia and fragile skin and was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included to inspect skin daily with morning and evening care, to monitor skin pressure points, and perform weekly body audits on the shower day. A review of the October 2024 and November 2024 Treatment Administration Record (TAR) identified a Physician's order that directed to perform a body audit on Thursday's during the 3 PM to 11 PM shift and complete a weekly body audit form. The order was documented as completed for 11/7/24, 11/14/24, and 11/21/24. A review of Resident #30's clinical record identified the last body audit performed was on 10/31/24. Interview with RN #3 on 11/25/24 at 11:06 AM identified the last weekly body audit completed for Resident #30 was on 10/31/24, and nursing in the evenings was responsible to complete. Interview with the Director of Nursing (DNS) on 11/25/24 at 11:16 AM identified there were no weekly body audits completed for the month of November for Resident #30 and that nursing was responsible to complete. 6. Resident #32 was admitted to the facility in February of 2021 and had diagnoses that included Parkinson ' s disease and impulse disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), had muscle weakness, was at risk for developing pressure injuries and had skin treatments. Resident #32 required partial/moderate assistance with bed mobility and substantial/maximal assistance with transfers. The Resident Care Plan dated 11/07/24 identified Resident #32 was at risk for pressure injuries related to impaired mobility. Interventions included to avoid positioning Resident #32 on reddened areas and non-blanchable areas, to reposition in his/her chair on rounds, and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/08/24) directed to complete a weekly body audit on Fridays with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/11/24, 10/18/24, 11/1/24, 11/8/24, and 11/22/24. There was no Weekly Body Audit performed for Resident #32 for 21 days from 10/25/24 through 11/15/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:23 PM and identified Resident #32 had no documented skin issues or abnormalities. 7. Resident #33 was admitted to the facility in April of 2022 and had diagnoses that included Chronic Obstructive Pulmonary Disease, Dementia, Muscle Weakness, and Unsteadiness on Feet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 as moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 10), required set up assistance for eating, and was dependent for toileting and transfers. The Resident Care Plan dated 9/23/24 identified Resident #33 was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included to keep skin clean, dry, and moisturized, utilization of a pressure reducing mattress, repositioning in chair during rounds, and weekly body audit on shower day. Review of the clinical record identified documentation for weekly body audits were not completed on 5/4/24, 5/18/24, 5/25/24, 6/8/24, 6/22/24, 9/14/24, 10/12/24, and 10/19/24. An Order Summary document dated 11/25/24 included a provider order (start date of 4/13/24) that directed to provide a body audit weekly on shower day. Instructions directed to complete a weekly body audit form every Saturday, inspect for altered skin integrity, changes in moles or abnormalities of skin, and report findings to MD/APRN. Interview and clinical record review with the Director of Nursing (DNS) on 11/25/24 at 11:15 AM identified that the unit nurse is responsible for completing weekly body audits and that they should have been completed for Resident #33 per physician order and facility policy. Additionally, the DNS was unable to locate documentation or explain why body audits for Resident #33 were not completed on the following dates: 5/4/24, 5/18/24, 5/25/24, 6/8/24, 6/22/24, 9/14/24, 10/12/24, and 10/19/24. 8. Resident #39 was admitted to the facility in May of 2021 and had diagnoses that included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, emphysema, essential hypertension, and restless leg syndrome. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 as moderately cognitively impaired (brief interview for mental status (BIMS) score of 11), required set up assistance for eating, substantial/maximal assistance for toileting, personal hygiene, bed mobility and transfers. The Resident Care Plan (RCP) dated 4/29/24 identified Resident #39 was at risk for potential/actual alteration in skin, bruising and skin tears related to the aging process. Interventions included inspect skin daily with morning and evening care, observe for signs and symptoms of infection, and weekly body audits on shower day. Review of the clinical record identified documentation for weekly body audits were not completed on 4/12/24, 4/19/24, 5/3/24, 5/17/24, 5/24/24, 5/31/24, 6/14/24, 6/28/24, 7/12/24, 7/19/24, 7/26/24, 8/23/24, 9/6/24, 9/13/24, 10/18/24, 10/25/24, 11/1/24, and 11/8/24. Additional clinical record review identified there was no documentation of refusals in progress notes or the RCP. Interview and clinical record review with RN #7 on 11/25/24 at 12:30 PM, identified that weekly body audits should be done weekly on shower days. RN #7 identified that the unit nurse is responsible for completing weekly body audits and that the process includes NA ' s notifying the nurse of when a shower is provided, and the nurse completing the body audit during that time. RN #7 was unable to explain why body audits were not being completed weekly as ordered. An Order Summary document dated 11/26/24 included a provider order (start date of 6/4/21) that directed to provide a body audit weekly. Instructions directed to complete a weekly body audit form every Saturday, inspect for altered skin integrity, changes in moles or abnormalities of skin, and report findings to MD/APRN. Interview with the Director of Nursing (DNS) on 11/26/24 at 10:30 AM, identified that the unit nurse is responsible for completing weekly body audits. The DNS was unable to explain why body audits were not being completed weekly as ordered and identified that weekly body audit orders and the facility policy for weekly body audits should have been followed. Review of the Weekly Body Audit completed on 11/26/24 at 4:23 PM identified that Resident #22 had no documented skin issues or abnormalities. 9. Resident #41 was admitted to the facility in September of 2021 and had diagnoses that included polyosteoarthritis, polyneuropathy, and chronic pain. The annual Minimum Data Set assessment dated [DATE] identified Resident #41 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and independent with bed mobility and transfers. The Resident Care Plan (RCP) dated 11/6/24 identified Resident #41 was at risk for pressure injuries related to impaired mobility. Interventions included to turn and reposition on rounds and complete a weekly body audit on shower day. The RCP further identified Resident #41 was at risk for bruises and skin tears related to the aging process and dry flaky skin. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/30/22) which directed to complete a weekly body audit on Tuesdays during the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/1/24, 10/15/24, 10/29/24, 11/12/24, and 11/19/24. There was no body audit performed for Resident #41 for 19 days from 11/7/24 through 11/26/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:15 PM and identified Resident #41 ' s skin was clean, dry and intact. 10. Resident #45 was admitted to the facility in February of 2021 and had diagnoses that included polyneuropathy, osteoarthritis, and lumbosacral radiculopathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 was severely cognitively impaired, had dementia, was at risk for developing pressure injuries and had skin treatments. Resident #45 required partial/moderate assistance with bed mobility and substantial/maximal assistance with transfers. The Resident Care Plan (RCP) dated 9/26/24 identified Resident #45 was at risk for pressure injuries related to dementia, potential for declines in mobility, and incontinence. Interventions included a pressure reducing mattress and completion of a weekly body audit on shower day. The RCP further identified Resident #45 was at risk for bruises, skin tears, and alterations in skin related to dementia, fragile skin and the aging process. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 4/12/24) which directed to complete a weekly body audit on Thursdays during the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/3/24, 10/24/24, 11/7/24, and 11/21/24. There was no body audit performed for Resident #45 for 14 days from 10/31/24 to 11/14/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:19 PM and identified Resident #45 had no documented skin issues or abnormalities. 11. Resident #48 was admitted to the facility in October of 2021 and had diagnoses that included osteoarthritis, muscle weakness, and mild protein-calorie malnutrition. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #48 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 2), had dementia, was at risk for developing pressure injuries and had skin treatments, required substantial/maximal assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 9/23/24 identified Resident #48 was at risk for pressure injuries related to dementia, incontinence, and decline in mobility. Interventions included to keep skin clean, dry and moisturized and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 3/5/24) which directed to complete a weekly body audit on Thursdays during the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/17/24, 11/14/24, and 11/21/24. There was no body audit performed for Resident #48 for 19 days from 11/7/24 to 11/26/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:17 PM and identified Resident #48 had no documented skin issues or abnormalities. 12. Resident #58 was admitted to the facility in January of 2023 and had diagnoses that included hemiplegia and hemiparesis of the left side following a stroke, muscle weakness, and abnormal posture. The annual Minimum Data Set assessment dated [DATE] identified Resident #58 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13), was at risk for developing pressure injuries, had nonsurgical dressings and skin treatments, required substantial/maximal assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 10/11/24 identified Resident #58 was at risk for pressure injuries related to diabetes, impaired mobility and incontinence. Interventions included to keep skin clean, dry and moisturized and to provide a pressure reducing cushion in reclining chair. The RCP further identified Resident #58 was at risk for bruises and skin tears related to behaviors, dementia, and fragile skin. Interventions included to observe Resident #58 ' s position in his/her wheelchair and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 1/17/24) which directed to complete a weekly body audit on Tuesdays on the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 1/17/24) which directed to apply an optifoam dressing (protective dressing) to the left elbow every 3 days for protection, a provider order (start date of 11/13/24) which directed to cleanse a skin tear to the left forearm with normal saline and apply a dry clean dressing daily, and a provider order (start date of 11/25/24) which directed to cleanse an abrasion to the left thigh with normal saline and apply a Kerralite Cool (hydrogel) dressing every 3 days for 14 days. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/1/24, 10/15/24, 10/29/24, 11/12/24, and 11/19/24. There was no body audit performed for Resident #58 for 21 days from 11/5/24 to 11/26/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:02 PM and identified Resident #58 had a skin tear to the left forearm which measured 2.5 centimeters (cm) by 2 cm and an area to the left thigh which appeared to be resolved. The Weekly Body Audit failed to identify documentation of the skin appearance of the left elbow correlating to the active treatment order in place. 13. Resident #65 was admitted to the facility in December of 2023 and had diagnoses that included muscle weakness, venous insufficiency, and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #58 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 8), had dementia, was at risk for developing pressure injuries and had skin treatments, and was independent with bed mobility and transfers. The Resident Care Plan (RCP) dated 9/16/24 identified Resident #65 was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included to remind Resident #65 to change position in his/her chair and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 10/18/24) which directed to complete a weekly body audit on Thursdays on the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/17/24, 10/31/24, 11/7/24, and 11/21/24. There was no body audit performed for Resident #65 for 21 days from 10/24/24 to 11/14/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 4:56 PM and identified Resident #65 had discoloration/scar tissue to an area on the buttocks previously identified with no additional skin issues or abnormalities. 14. Resident #69 was admitted to the facility in November of 2024 with diagnoses that included lung cancer with metastasis to the brain, muscle weakness, and a rotator cuff tear of the right shoulder. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 8), had dementia, had a neurological surgery, was at risk for developing pressure injuries, had surgical wound care and skin treatments, and required supervision or touching assistance with bed mobility and partial/moderate assistance with transfers. The Resident Care Plan (RCP) dated 11/20/24 identified Resident #69 was at risk for pressure injuries related to dementia, impaired mobility, and incontinence. Interventions included to monitor for pain on/near bony prominences and pressure points and complete a weekly body audit on shower day. The RCP further identified Resident #69 was at risk for infection related to a surgical incision following a craniotomy. Interventions included to document drainage, appearance of site, signs and symptoms of infection, and how the treatment was tolerated. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/1/24) which directed to monitor the incision to the left parietal scalp for signs and symptoms of infection every shift and report abnormal findings to the provider, and a provider order (start date of 11/20/24) which directed to wash the skin tear to the right lower extremity with normal saline then apply a dry clean dressing every 3 days. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/22/24) which directed to complete a weekly body audit on Wednesday on the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified a weekly body audit was not completed on 11/22/24. There was no body audit performed for Resident #69 for 11 days (11/15/24 to 11/26/24). Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:20 PM and identified Resident #69 had an abrasion to the right lateral calf and failed to identify documentation of a surgical incision/healed incision to the parietal scalp correlating to the active treatment order in place. 15. Resident #326 was admitted to the facility in November of 2024 with diagnoses that included epilepsy, diabetes, and congestive heart failure (CHF). The Nursing Admission assessment dated [DATE] identified Resident #326 was admitted to the facility from the hospital following hospitalization for seizures and CHF. Resident #326 was alert and oriented to person, place, time, situation and was cognitively intact and had moisture associated skin damage (MASD) to the coccyx which measured 3 centimeters (cm) by 3 cm and required treatment with a barrier cream and placement of an air mattress. Resident #326 required assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 11/19/24 identified Resident #326 was at risk for pressure injuries related to impaired circulation, impaired mobility, and incontinence. Interventions included protective skin barrier with incontinent care and completion of a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/19/24) which directed to complete a weekly body audit on Mondays on the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified a weekly body audit was not completed on 11/25/24. There was no body audit performed for 7 days (11/19/24 to 11/26/24). Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:24 PM and identified Resident #326 had no documented skin issues or abnormalities. The Weekly Body Audit failed to identify MASD or resolution of an area of MASD to the coccyx correlating to the documentation on the Nursing Admission assessment on 11/19/24. Review of the Body Audit policy directed, in part, nurses would perform a complete body audit weekly and/or more often as indicated per physician's orders, the nurse would document any abnormal findings and notify the physician. 51101

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #45) reviewed for activities of daily living (ADL), the facility failed to notify the physician of a change in condition. The findings include: Resident #45 was admitted in February of 2021 and had diagnoses that included chronic obstructive pulmonary disease (COPD), anxiety, and pneumoconiosis (chronic lung disease) due to asbestos and other mineral fibers. A physician's order dated 9/18/24 directed Resident #45 receive a regular diet at dysphagia level 2 (mechanically altered) texture, thin liquids, pureed vegetables, no rice, a 2 handled mug with concave lid and meal items served in individual bowls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 was severely cognitively impaired and required setup or clean-up assistance with eating, was dependent for personal hygiene, and required substantial/maximal assistance with transfers. The Resident Care Plan (RCP) dated 9/26/24 identified Resident #45 was at risk for alteration in nutrition related to dementia and he/she was without teeth (missing dentures since 9/16/21 that the responsible party decided not to replace). Interventions included observation of Resident #45's tolerance to the diet texture, a regular diet with dysphagia level 2 (ground) texture, and for staff to refer to the speech therapist as needed. An Interdisciplinary Referral and Rehabilitation Screen Request form submitted by Licensed Practical Nurse (LPN) #3 dated 10/23/24 identified the reason for the referral was resident choking on meats observed over two days and further identified Resident #45 was screened by the speech therapist on 10/25/24. A Speech Therapy Evaluation and Plan of Treatment dated 10/25/24 at 8:45 AM identified Resident #45 had been referred by nursing after Resident #45 had severe coughing and spitting up during oral intake of ground meat. The evaluation further identified Resident #45 had no teeth and during trials of ground textures, experienced oropharyngeal dysphagia (swallowing problem occurring in the mouth and/or throat) characterized by little to no chewing, food residue on the tongue and inner cheeks and 2 instances of an observed cough. During trials with puree texture, Resident #45 did not chew, however, there were no signs or symptoms of airway compromise. Recommendations included skilled speech therapy services for management of Resident #45's dysphagia and to downgrade to a full puree texture diet due to reduced chewing and observed signs and symptoms of oropharyngeal dysphagia. A Dietary Communication Slip dated 10/25/24 identified Resident #45 had a diet change from dysphagia level 2 (mechanically altered/ground) with thin liquids to dysphagia level 1 (puree) with thin liquids. Review of Nurse progress notes from 10/2/24 through 10/29/24 failed to identify documentation Resident #45 had had trouble swallowing, coughed while eating, choked on meats, spit up food while eating, or coughed at any time during the shift. Interview with LPN #3 on 11/26/24 at 1:53 PM identified that on 10/23/24 a nurse aide (NA) requested her to the Dining Room because Resident #45 was coughing and spitting up while swallowing meat from his/her meal. LPN #3 identified she instructed the NA to stop Resident #45 from eating the meat and LPN #3 went to the kitchen and requested a new meal without meat. LPN #3 identified she watched Resident #45 eat a few bites of the new meal and after observing him/her eating without coughing or spitting up, left Resident #45 with the NA. LPN #3 indicated she then completed a Speech Therapy Referral form and a new diet slip requesting a diet without meat textured food until further notice. LPN #3 could not identify why she did not document the incident in a progress note and could not recall if she notified the supervisor or provider of Resident #45 coughing with his/her meal. LPN #3 further identified she observed Resident #45 take a few bites of the alternate meal she requested but did no further monitoring after that. Interview with the Director of Nursing Services (DNS) on 11/26/24 at 2:50 PM identified that LPN #3 failed to write a progress note about Resident #45 coughing while eating, failed to update the supervisor and provider, and failed to monitor Resident #45 for signs and symptoms of aspiration. The DNS further identified that when filling out the speech screen referral, LPN #3 should have documented coughing rather than choking unless it was verified that Resident #45 was choking which would have required immediate emergency intervention. Interview with APRN #1 on 11/26/24 at 3:03 PM indicated he was not notified of Resident #45 having difficulty swallowing on 10/23/24, and he did not see notations in his records relating to the incident. APRN #1 identified that if he were notified, he would have inquired about Resident #45's baseline swallowing status and diet order and determined if a change in diet was required at that time. APRN #1 further identified he would have ordered a speech screen, monitoring for signs and symptoms of aspiration and if signs or symptoms of aspiration were identified, ordered a chest x-ray. Review of the Change in Condition policy directed, in part, that changes in a resident's baseline condition were monitored by nursing staff members, assessed by the Registered Nurse (RN), reported to the attending physician/APRN to determine a course of action, reported to the family representative, and documented in a progress note in the resident's medical record.

Based on clinical record review, facility documentation and staff interviews, the facility failed to provide medication administration education to a temporary agency staff nurse before starting work to meet professional standards of practice to prevent a significant medication error. The findings include: A Reportable Event Form dated 10/11/24 identified that Resident #1 received Resident #14's medications in error which included the following medications: Amlodipine 5 milligrams (mg) (lowers blood pressure), Aspirin 81mg (NSAID), Depakote 250mg (anticonvulsant), Cymbalta 120 mg (antidepressant), Gabapentin 800mg (anticonvulsant), lacosamide 100mg (antoconvulsant), Keppra 500 mg (anticonvulsant), Metoprolol 25mg (lowers blood pressure), Movantik 25mg (treats opioid induced constipation), Docusate (stool softener), Simethicone (gas relief), Vitamin D (supplement) and Vitamin B12 (supplement). Interview with LPN #1 on 11/25/24 at 1:47 PM identified that she was assigned to administer morning medications to Resident #1 on 10/11/24. LPN #1 identified that she went into the wrong room and administered Resident #14's medications to Resident #1 in error. LPN #1 identified that Resident #1 was not wearing a name identification bracelet. LPN #1 further identified that she called Resident #1 by the wrong name, Resident #1 did not respond to the name, but she assumed that she had the correct resident and administered the medications. LPN #1 identified that after administering medications to Resident #1, she realized that she administered medications to the wrong resident secondary to Resident #1 not having an ordered medical device which she would have needed to monitor. LPN #1 reported the medication error when she realized she administered medications to the wrong resident. LPN #1 identified that APRN #1 assessed Resident #1 and verbally instructed her to monitor Resident #1 every 2 hours for respiratory distress, lethargy, change in vital signs and to notify him of any change in vital signs. LPN #1 identified that Resident #1's systolic blood pressure dropped by 15 to 20 mmHg within the first two hours, which she reported to the DNS and APRN #1. Additionally, LPN #1 reported that she did not receive any form of medication administration re-education prior to continuing with her medication pass. LPN #1 indicated that she asked the DNS if she should write a statement and a progress note in the clinical record, regarding the medication error, but the DNS declined and stated he would complete the medication error statement, and a progress note for the incident. LPN #1 identified that she failed to follow the 5 rights of medication administration while administering medications to Resident #1 because she did not use any resident identifier to confirm she was administering medications to the right resident. LPN #1 identified that she should have verified the picture on electronic medical record or confirmed resident identity with another staff member when she realized Resident #1 had no name identification bracelet. Interview with the Human Resources Director (HRD) on 11/25/24 at 2:58 PM identified that the facility utilizes agency staff to fill vacant shifts. The HRD identified that prior to the initial shift worked at the facility, the agency staff would acknowledge and sign that they have received, read, and understood the facility Orientation for Pool Staff document. The document included facility policy information for Mission and Values, Confidentiality, Infection Control, Abuse and Neglect, Corporate Compliance, On-Site Hazards, Hazardous Materials, General Safety, Health Requirements, Identification, Patient's Rights, Weapons and Code of Conduct. Interview with the DNS on 11/26/24 at 10:59 AM identified that the facility does not provide orientation for agency nurses to include medication administration competency. The DNS indicated that LPN #1 was educated on the 5 rights of medication administration prior to continuing with medication administration on the day of the medication error but was unable to provide documentation that medication administration re-education was provided. The DNS provided documentation that facility staff nurses were educated on medication administration after the medication error incident, but did not implement any form of education for agency staff nurses related to medication administration and did not add the medication administration policy to the facility Orientation for Pool Staff document which is reviewed with agency nurses before working a shift in the fcaility.

Based on clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #58) reviewed for accidents, the facility failed to ensure that side rails were used for positioning and bed mobility resulting in a fall. The findings include: Resident #58's diagnoses included hemiplegia (paralysis) affecting the left side, dementia, anxiety and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3) and was dependent for toileting hygiene, personal hygiene, bed mobility and transfers. The Resident Care Plan (RCP) dated 10/11/24 identified Resident #58 required assistance with ADL's due to left hemiplegia, mobility deficit and self-care deficit. Interventions included using 2 quarter siderails to assist with positioning and bed mobility, assistance with personal hygiene and maintaining proper body alignment and positioning. A facility fall investigation document dated 10/28/24 by RN #7 identified a witnessed fall incident on 10/28/24 at 1:23 PM. The form identified that NA #1 and NA #2 were providing care to Resident #58 while in bed and that when Resident #58 was being turned to the side, he/she slid off the bed. NA #1 and NA #2 both identified that the side rail was down when Resident #58 was being turned. Resident #58 was only oriented to person at the time of the fall. Post Fall assessment note dated 10/28/24 at 1:27 PM by RN #7 identified that she found Resident #58 laying on the side of the bed on his/her back and no injuries were noted. A Nurse's note dated 10/28/24 at 1:45 PM by LPN #2, identified that he was called to the room by NA #1 and observed Resident #58 with his/her back on the floor and his/her legs on the bed. The note identified that Resident #58 was only wearing a T-shirt at the time of the fall, the bed side rails were in the lowered position and noted NA #1 stated Resident #58 rolled out of bed while receiving incontinence care. The note identified that LPN #2 notified RN #7 who responded to the incident and assessed Resident #58. Interview with NA #1 on 11/22/24 at 10:30 AM, identified that she and NA #2 were providing incontinence care to Resident #58 when he/she fell out of bed. NA #1 further identified that NA #2 alerted her that she was going to roll Resident #58 over to the left side. NA #1 indicated that when Resident #58 was rolled over to the left side, she was unable to support Resident #58's weight and Resident #58 slid to the floor landing on his/her shoulders first followed by his/her entire upper body. NA #1 indicated that the bed was about 3 feet high, and the side rail was down at the time of the fall. NA #1 identified that she forgot to raise the side rail which could have helped prevent Resident #58 from falling out of bed. NA #1 indicated that Resident #58 appeared shocked when he/she realized he/she was on the floor and asked why he/she was on the floor and why he/she was naked. Furthermore, NA #2 identified that Resident #58 complained of pain, which she reported to RN #7. Interview with NA #2, on 11/22/24 at 11:35 AM, identified that she and NA #1 were providing incontinence care to Resident #58 when Resident #58 fell out of bed. NA #2 identified that she informed NA #1 that she was going to roll Resident #58 over, but when she rolled Resident #58 over, NA #1 was unable to support Resident #58 ' s weight and Resident #58 landed on the floor. NA #2 indicated that the side rail, which could have helped to prevent Resident #58 from falling out of bed, was down at the time of the fall. NA #2 further indicated that NA #1 stated that she forgot to raise the side rail before Resident #58 was rolled over. NA #2 identified that when she saw Resident #58 rolling over, she tried to catch him/her from across the bed, but it happened so fast that Resident #58 ended up on the floor. NA #2 indicated that Resident #58 appeared shocked when he/she realized he/she was on the floor and asked why he/she was on the floor. NA #2 identified that Resident #58 complained of pain, which she reported to RN #7. Interview and clinical record review with RN #7 on 11/25/24 at 12:30 PM, identified that she responded to the fall and completed a fall assessment when Resident #58 fell out of bed. RN #7 identified that she found Resident #58's torso on the floor and his/her legs were still in bed. RN #7 identified that she observed and palpated Resident #58's body, checked range of motion and noted slight blanchable redness on Resident #58's buttocks. Interview with the DNS on 11/26/24 at 10:30 AM, identified that NA #1 and NA #2 should have followed Resident #58's plan of care to use 2 quarter siderails for positioning and bed mobility while providing incontinence care. The DNS was unable to explain why NA #1 and NA #2 did not use side rails while positioning Resident #58 in bed leading to a fall out of bed. The DNS identified that education related to following the plan of care was provided to NA #1 and NA #2 after the fall incident on 10/28/24. Review of facility policy titled, Fall Management Program: Policy and Procedure, identified, in part, that the fall management program is designed to provide individualized person-centered care and manage resident falls and potential for falls with resident focused interventions.

1. Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 residents (Resident #22 and Resident #34) reviewed for nutrition, the facility failed to obtain a reweight as directed by provider order and failed to notify a provider of a weight change and failed to obtain daily weights as directed by a provder order. The findings include: Resident #22 was admitted to the facility in October of 2024 and had diagnoses that included periprosthetic fracture around other internal prosthetic joint, constipation, heart failure and acute prosthetic anemia. A Nutrition evaluation dated 10/16/24 at 11:57 AM identified a regular puree consistency diet with thin liquids and identified no swallowing difficulties. The evaluation identified Resident #22 had dentures but did not wear them, had 2 remaining teeth on the bottom, and had a left hip surgical site. A provider order dated 10/16/24 directed to obtain weekly weights for 4 weeks then obtain monthly weights. Instructions directed to compare current weight to previous weight and if there was a discrepancy of 5 pounds (lbs) a re-weight must be obtained for verification. The Weights and Vital Signs summary identified a weight entry on 10/16/24 at 11:57 AM of 122.4 lbs which was obtained using a mechanical lift (lifting device to obtain weight measurement). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was moderately cognitively impaired (brief interview for mental status (BIMS) score of 12) and required set up assistance for eating, supervision or touching assistance for personal hygiene, substantial maximum assistance to dependent for bed mobility, transfer, ambulation and toileting. The MDS further identified a weight of 122 lbs, no swallowing difficulties, no weight loss and a mechanically altered diet. The Resident Care Plan dated 10/29/24 identified potential for alteration in nutrition related to a mechanically altered diet, history of low body weight and limited oral intake. Interventions included to assess likes and dislikes and offer choices, pureed diet texture with thin liquids, offer health shakes in the evening, encourage 50% of meal intake, Registered Dietician assessment as indicated and refer to speech therapy as needed. Additionally, report significant weight changes and weights as ordered. A physician's order dated 11/19/24 at 3:00 PM directed to obtain a weekly weight. The Weights and Vital Signs summary identified a weight entry on 11/19/24 at 10:58 PM of 97 lbs which represented a 20.8% weight loss. A physician's order dated 11/20/24 at 6:20 AM directed to obtain a reweight. A Dietitian note on 11/20/24 indicated a weight review was done, a reweight was pending, and weight loss was discussed with the weight committee and the charge nurse. The note further indicated Resident #22 accepted health shakes (per the medication administration record (MAR) and nursing report), that there had been no significant change in oral intake and recommended offering chocolate ice cream. Review of the Medication Administration Record for November of 2024 identified there was no weight entry on 11/20/24. Interview and record review with the Director of Nursing (DNS) on 11/26/24 at 10:20 AM, verified the order for a reweight. The DNS confirmed that the reweight was not obtained as ordered and he did not know why the reweight was not obtained. The DNS identified that the Nursing Assistants (NA) are responsible for obtaining weights on the 11:00 PM to 7:00 AM shift and then the 7:00 AM to 3:00 PM shift NA's or nurses document the weights in the electronic medical record (EMR). Additionally, the DNS reviewed the clinical record and identified the provider was not notified of the documented weight loss. Observations on 11/26/24 at 12:01 PM, identified Resident #22's lunch tray was set up on the overbed table in front of him/her with pureed meat, potatoes and vegetables, soup and ice cream. Resident #22 indicated he/she only wanted the drinks on the tray and did not want to eat. Subsequent to surveyor inquiry, the facility added a weight entry of 113 lbs (7.68% weight loss) on 11/26/24 at 12:16 PM. Interview with the DNS on 11/26/24 at 2:30 PM indicated the 11/19/24 weight entry of 97 lbs was an error. Review of the Weight Trending policy and procedure directed, in part, residents with 5% or more weight change in 30 days, 7.5% in 90 days or 10% change in 180 days will be identified. If a 5 pound weight loss/gain is noted from prior weight the NA will reweigh to verify, and inform the charge nurse of the weight change. The charge nurse will document the weight change and inform the physician, family and the weight committee. The weight committee will review the weight history, and medical information. Additionally, will implement a high calorie nourishment snack of choice. The Dietician and DNS will record in the progress notes recommendations and interventions as indicated through the meeting and policy. 2. Resident #34's diagnoses included congestive heart failure (CHF), hypertension, acute posthemorrhagic anemia and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and required set-up assistance with eating, maximum assistance with personal hygiene and was dependent for toileting hygiene and transfers. A physician's order dated 10/31/24 directed to administer Torsemide (diuretic) tablet 20 milligrams (mg) by mouth one time a day. A physician's order dated 10/31/24 (discontinuation date of 11/9/24) directed to obtain daily weights and report a weight gain of 2 pounds in 24 hours or 5 pounds in one week, to the provider. A physician's order dated 11/9/24 at 11:00 PM directed to obtain daily weights and report a weight gain of 2 pounds in 24 hours or 5 pounds in one week to the provider. The Resident Care Plan (RCP) dated 11/9/24 identified Resident #34 was at risk for alteration in cardiac status related to congestive heart failure (CHF), Atrial fibrillation (an irregular and rapid heartrate resulting in poor blood flow), hypertension, coronary artery disease, hyperlipidemia (high fat particles/lipids in blood), valve disease, and severe aortic stenosis. Interventions included obtaining and reporting weights as ordered, therapeutic diet as ordered, monitoring intake and output per facility policy, lab work as ordered, elevating legs above heart while in bed or recliner, monitoring vital signs as ordered and elevating head of bed for ease in breathing. Review of the Weights and Vitals Summary identified no daily weights were recorded from 10/31/24 to 11/2/24 (3 days), and from 11/9/24 through 11/20/24 (11 days). Review of Resident #34's clinical record from 10/31/24 through 11/25/24 identified no documentation for weight refusals within the progress notes or RCP. Interview and record review with RN #7 on 11/25/24 at 12:30 PM identified Resident #34's daily weight order as current and in effect. RN #7 further identified that Resident #34 was not weighed daily as directed by the provider and indicated that both nurses and NA's could obtain weights but it is the nurses' responsibility to ensure that weights are obtained and communicate weight changes to the physician. RN #7 could not explain why Resident #34 was not weighed as directed by the physician but identified that Resident #34 should have been weighed daily due to CHF. Interview and clinical record review with the DNS on 11/26/24 at 10:30 AM identified Resident #34's daily weight order as current and in effect. The DNS identified that both NA's and licensed nurses are responsible for weighing residents, but licensed nurses are responsible for ensuring that weights are obtained and updating the provider of weight changes. The DNS was unable to explain why Resident #34 was not weighed as directed by the physician but identified that he/she needed to have been weighed daily per the physician's orders due to CHF. Review of facility policy, Weight Trending Policy and Procedures, identified in part, the intent of weight monitoring as maintaining the highest practical well-being of the residents/patients by monitoring weight loss/gain.

Based on clinical record review, facility documentation and staff interviews the facility failed to provide medication administration education to a temporary agency staff nurse before starting work in the facility and failed to provide documentation of medication administration education to a temporary agency staff nurse after a significant medication error. The findings include: A Reportable Event Form dated 10/11/24 identified that Resident #1 received Resident #14's medications in error which included the following medications: Amlodipine 5 milligrams (mg) (lowers blood pressure), Aspirin 81mg (NSAID), Depakote 250mg (anticonvulsant), Cymbalta 120 mg (antidepressant), Gabapentin 800mg (anticonvulsant), lacosamide 100mg (antoconvulsant), Keppra 500 mg (anticonvulsant), Metoprolol 25mg (lowers blood pressure), Movantik 25mg (treats opioid induced constipation), Docusate (stool softener), Simethicone (gas relief), Vitamin D (supplement) and Vitamin B12 (supplement). Interview with LPN #1 on 11/25/24 at 1:47 PM identified that she was assigned to administer morning medications to Resident #1 on 10/11/24. LPN #1 identified that she went into the wrong room and administered Resident #14's medications to Resident #1 in error. LPN #1 identified that Resident #1 was not wearing a name identification bracelet. LPN #1 further identified that she called Resident #1 by the wrong name, Resident #1 did not respond to the name, but she assumed that she had the correct resident and administered the medications. LPN #1 identified that after administering medications to Resident #1, she realized that she administered medications to the wrong resident secondary to Resident #1 not having an ordered medical device which she would have needed to monitor. LPN #1 reported the medication error when she realized she administered medications to the wrong resident. LPN #1 identified that APRN #1 assessed Resident #1 and verbally instructed her to monitor Resident #1 every 2 hours for respiratory distress, lethargy, change in vital signs and to notify him of any change in vital signs. LPN #1 identified that Resident #1's systolic blood pressure dropped by 15 to 20 mmHg within the first two hours, which she reported to the DNS and APRN #1. Additionally, LPN #1 reported that she did not receive any form of medication administration re-education prior to continuing with her medication pass. LPN #1 indicated that she asked the DNS if she should write a statement and a progress note in the clinical record, regarding the medication error, but the DNS declined and stated he would complete the medication error statement, and a progress note for the incident. LPN #1 identified that she failed to follow the 5 rights of medication administration while administering medications to Resident #1 because she did not use any resident identifier to confirm she was administering medications to the right resident. LPN #1 identified that she should have verified the picture on electronic medical record or confirmed resident identity with another staff member when she realized Resident #1 had no name identification bracelet. Interview with the Human Resources Director (HRD) on 11/25/24 at 2:58 PM identified that the facility utilizes agency staff to fill vacant shifts. The HRD identified that prior to the initial shift worked at the facility, the agency staff would acknowledge and sign that they have received, read, and understood the facility Orientation for Pool Staff document. The document included facility policy information for Mission and Values, Confidentiality, Infection Control, Abuse and Neglect, Corporate Compliance, On-Site Hazards, Hazardous Materials, General Safety, Health Requirements, Identification, Patient's Rights, Weapons and Code of Conduct. Interview with the DNS on 11/26/24 at 10:59 AM identified that the facility does not provide orientation for agency nurses to include medication administration competency. The DNS indicated that LPN #1 was educated on the 5 rights of medication administration prior to continuing with medication administration on the day of the medication error but was unable to provide documentation that medication administration re-education was provided. The DNS provided documentation that facility staff nurses were educated on medication administration after the medication error incident, but did not implement any form of education for agency staff nurses related to medication administration and did not add the medication administration policy to the facility Orientation for Pool Staff document which is reviewed with agency nurses before working a shift in the fcaility.

Based on observations, interviews, and facility policy, the facility failed to inform residents of how to complete a grievance, failed to ensure forms were available and accessible to residents and visitors and failed to maintain the results of grievances for three years. The findings include: Observations on 11/20/24 at 11:50 AM identified the grievance folder and a suggestion box were hung on a wall at the end of a hallway on the subacute unit, not easily accessible to any residents, especially to those residents who utilize wheelchairs, secondary to the level hung on the wall. The grievance folder was empty with no available forms inside. Review of the facility's grievance binder on 11/21/24 at 10:00 AM noted to have no completed grievance forms for the year 2023 and 2024. Interview with the Administrator on 11/21/24 at 10:30 AM indicated the facility did not have any grievances, instead, the facility received complaints which were then resolved, therefore, the facility had no grievances for the years on 2023 and 2024. She further indicated that her definition of a grievance was a complaint which was unresolved. During a Resident Council meeting on 11/22/24 at 10:30 AM, 12 cognitively intact residents (Resident #44, Resident #41, Resident #3, Resident #57, Resident #21, Resident #62, Resident #37, Resident #27, Resident #9, Resident #13, Resident #43, Resident #47), were unaware of how to complete a grievance form and were unaware of where the forms were located. Review of the policy titled Grievance Policy and Procedure directed, in part, the Grievance Officer will acknowledge the grievances as promptly as possible, and written decisions will be issued to the residents and others as necessary. The Grievance Committee will maintain a tracking file on each grievance. All Grievances will be maintained for a period of three years.

Based on review of the clinical record, facility policy, and interview for 3 of 3 sampled residents, (Resident #45, Resident #58, and Resident #61), reviewed for change of condition, the facility failed to submit significant change in status (SCSA) Minimum Data Set (MDS) assessments for a decline in more than two functional ability areas. The findings include: 1. Resident #45 was admitted to the facility in February of 2021 and had diagnoses that included dementia, chronic obstructive pulmonary disease (COPD), and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 was severely cognitively impaired, used a manual wheelchair (w/c), was independent with wheeling 50 feet (ft) with 2 turns in the w/c, and was independent with wheeling 150 ft in the w/c. Resident #45 required supervision or touching assistance with eating, bed mobility, walking 10 ft, and walking 50 ft with 2 turns. Resident #45 required partial/moderate assistance with oral hygiene, upper body dressing, personal hygiene, going from sitting to standing, and transfers. Resident #45 required substantial/maximal assistance with putting on/taking off footwear. The MDS assessment further identified Resident #45 received physical therapy (PT) and occupational therapy (OT) which began on 6/17/24. The quarterly MDS assessment dated [DATE] identified Resident #45 was severely cognitively impaired, used a manual w/c, required supervision or touching assistance with wheeling 50 ft with 2 turns in the w/c, and required supervision or touching assistance with wheeling 150 ft in the w/c. Resident #45 required setup or clean-up assistance with eating. Resident #45 required partial/moderate assistance with bed mobility and walking 10 ft. Resident #45 required substantial/maximal assistance with oral hygiene, upper body dressing, going from sitting to standing, transfers, and walking 50 ft with 2 turns. Resident #45 was dependent for putting on/taking off footwear and personal hygiene, and no longer walked 150 ft. The MDS assessment further identified Resident #45 received PT which began 9/17/24, speech therapy (ST) which began 8/18/24, and Resident #45 had not received OT since 7/11/24. A decline in 14 functional mobility areas were identified when compared with the previous quarterly MDS assessment. The Resident Care Plan (RCP) dated 9/26/24 identified Resident #45 was a fall risk related to dementia, use of psychotropic medications, and independent ambulation (Resident #45 fell on [DATE] self-ambulating in the hallway). Interventions included to encourage and assist Resident #45 to the exercise activity program, obtain a medical work-up as needed for changes in condition, monitor for changes in gait, and Resident #45 was to be upright in the manual w/c with a full lap tray and pommel cushion for positioning with referral to the rehabilitation department with any change in status. The RCP further identified Resident #45 had impaired activities of daily living (ADL) function related to dementia. Interventions included assistance with dressing, grooming, hygiene, showers/bathing, and for a PT/OT evaluation with treatment as needed per provider order(s). Interview and clinical record review of Resident #45's MDS assessments with Registered Nurse (RN) #2 on 11/26/24 at 12:53 PM and 2:30 PM identified the clinical record failed to reflect documentation of an SCSA being submitted. RN #2 identified that she had not submitted a SCSA because it had been determined that Resident #45's decline was due to progression of dementia. After the MDS assessment information for 6/20/24 and 9/20/24 was reviewed and identified a decline in 14 areas of functional mobility, RN #2 stated that she hadn't realized Resident #45 had declined in areas other than ambulation and therefore a SCSA should have been completed and submitted. 2. Resident #58 was admitted in January of 2023 and had diagnoses that included traumatic hemorrhage of the cerebrum, diabetes, and hemiplegia affecting the left nondominant side. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13), used a manual wheelchair, and required setup or clean-up assistance with eating. Resident #58 required substantial/maximal assistance with oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and bed mobility. Resident #58 did not receive physical therapy (PT) and/or occupational therapy (OT) this quarter. The quarterly MDS assessment dated [DATE] identified Resident #58 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), used a manual wheelchair, and required supervision or touching assistance with eating. Resident #58 was dependent for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and bed mobility. Resident #58 did not receive PT this quarter, but received OT from 8/6/24 to 9/16/24 A significant decline in cognition and a decline in 9 functional mobility areas was identified when compared with the previous annual MDS assessment. The Resident Care Plan (RCP) dated 10/11/24 identified Resident #58 had impaired cognition related to a stroke and impaired decision making. Interventions included observation of cognitive status for changes in orientation, memory, recall, comprehension, and decision-making ability and for administration of medications as ordered. The RCP further identified Resident #58 had impaired activities of daily living (ADL) function related to brain hemorrhage, left side hemiplegia, mobility deficit, and self-care deficit. Interventions included a PT/OT evaluation with treatment as needed per provider order(s) and for placement of Resident #58 into an adaptive w/c with headrest, pommel cushion, left sided half lap tray and left footrest in place at all times with right footrest in place for transport and when w/c was reclined. 3. Resident #61 was admitted to the facility in April of 2023 and had diagnoses that included dementia, macular degeneration, and osteoarthritis. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 2) and used a walker and manual wheelchair. Resident #61 was independent with bed mobility, lying to sitting on side of bed, going from sitting to standing, chair and toilet transfers, walking 10 feet (ft), walking 50 ft with 2 turns, and walking 150 ft. Resident #61 required setup or clean-up assistance with oral hygiene and personal hygiene and supervision or touching assistance with toileting hygiene, going from sitting to lying down, and tub/shower transfers. Resident #61 required partial/moderate assistance with showering and upper body dressing, and substantial/maximal assistance with lower body dressing and putting on/taking off footwear. The MDS assessment further identified Resident #61 received occupational therapy (OT) starting on 3/22/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 1) and used a walker and manual wheelchair. Resident #61 required partial/moderate assistance with oral hygiene, toileting hygiene, going from sitting to lying, going from lying to sitting on the side of bed, and shower transfers. Resident #61 required substantial/maximal assistance with showering, upper and lower body dressing, putting on/taking off footwear, personal hygiene, going from sitting to standing, and chair and toilet transfers. Resident #61 was dependent with walking 10 ft, walking 50 ft with 2 turns, and walking 150 ft. The MDS assessment further identified Resident #61 received OT starting on 6/19/24 and physical therapy (PT) starting on 6/26/24. A decline in 15 functional mobility areas was identified when compared with the previous annual MDS assessment. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 2) and used a walker. Resident #61 no longer used the wheelchair, and was independent with bed mobility, going from sitting to lying, going from lying to sitting on the side of bed, going from sitting to standing, chair transfers, walking 10 Ft, and walking 50 ft with 2 turns. Resident #61 required supervision or touching assistance with toilet transfers, showering, and walking 150 ft. The MDS assessment further identified Resident #61 received OT 6/19/24 through 7/16/24 and PT 6/26/24-7/23/24. An improvement in 12 functional mobility areas was identified when compared with the previous quarterly MDS assessment. The Resident Care Plan (RCP) dated 9/26/24 identified Resident #61 had impaired activities of daily living (ADL) function related to dementia and a mobility deficit. Interventions included to monitor for declines in ADL function and mobility and refer for rehabilitation as needed and Resident #61's activity level was independent with a 2 wheeled walker and required assistance of 1 staff member for toileting. The RCP further identified Resident #61 was at risk for falls related to dementia and environmental changes. Interventions included to monitor for changes in gait and Resident #61 required assistance of 1 staff member for toileting. Interview and clinical record review of Resident #61's MDS assessments with Registered Nurse (RN) #2 on 11/26/24 at 12:53 PM and 2:30 PM identified the clinical record failed to reflect documentation of an SCSA being submitted for Resident #61's decline or improvement in 2 or more functional mobility areas. Subsequent to surveyor inquiry the Resident Assessment Instrument (RAI) manual definition of SCSA was reviewed and RN #2 acknowledged understanding of the 14-day requirement for submission of an SCSA but stated she had not realized that a SCSA should have been submitted for improvement in 2 or more areas of Resident #61's functional mobility.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #44 and 422) reviewed for indwelling urinary catheters, the facility failed to ensure the residents dignity when the urinary drainage bags were left uncovered and visible. The findings include: 1. Resident #44 was admitted to the facility with diagnoses that included benign prostate hyperplasia and obstructive and reflux uropathy. The quarterly MDS dated [DATE] identified Resident #44 had intact cognition, required extensive assistance with transfers, bed mobility, dressing, toileting, and personal hygiene and had an indwelling catheter. The care plan dated 12/22/22 identified Resident #44 had an indwelling urinary catheter with interventions that included to use a drainage bag cover at all times. Observation on 2/7/23 at 10:45 AM identified Resident #44 was sitting in a wheelchair on the left side of the bed next to the door. The indwelling urinary catheter drainage bag was hung on the wheelchair, contained dark amber urine, and was visible from the hallway. Interview with LPN #1 on 2/7/23 at 10:52 AM indicated Resident #44 has urinary retention and has an indwelling catheter. Observation with LPN #1 indicated the indwelling urinary catheter bag was visible from the hallway while Resident #44 was sitting in the wheelchair. LPN #1 indicated she knew at 7:00 AM that morning, that Resident #44 did not have a privacy bag covering the drainage bag but was waiting to ask the infection control nurse to get her one. During interview with LPN #1 she indicated that was 2 family members had just come in to visit with Resident #44 while the resident's drainage bag was visible. 2. Resident #422 was admitted to the facility with diagnoses that included dementia, neuromuscular dysfunction of bladder, and obstructive and reflux uropathy. A physician's order dated 1/28/23 directed to give Bactrim 800/160 mg 1 tablet two times a day for urinary tract infection and sepsis for 7 days. The care plan dated 1/30/23 identified the resident had an indwelling urinary catheter with interventions to use privacy bag covers at all times. The Medicare 5-day MDS dated [DATE] identified Resident #422 had moderately impaired cognition and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Additionally, Resident #422 had an indwelling urinary catheter. The nurse's note dated 2/4/23 at 10:49 PM identified Resident #422 continues on antibiotic for a urinary tract infection and the indwelling urinary catheter is draining clear yellow urine. The nurses note dated 2/7/23 at 6:36 AM indwelling urinary catheter patent draining clear straw-colored urine. Observation on 2/7/23 at 10:19 AM identified Resident #422 was lying in bed with the bed in the low position. The urinary catheter bag was visible from the hallway, hung at bottom of the bed frame, lying flat on the floor. Visible from the hallway and without a privacy bag, yellow urine could be seen in the tubing. Interview with RN #2 on 2/7/23 at 10:25 AM identified the charge nurse and nurse aides were responsible to make sure the indwelling urinary catheter bag was not on the floor and was covered with a privacy bag. The APRN progress note dated 2/8/23 at 9:52 AM indicated Resident #422 had an indwelling urinary catheter intact, patent and draining cloudy yellow urine with sediment. Interview with the DNS on 2/14/23 at 3:05 PM indicated the nurses and nurse aides were responsible to make sure the urinary drainage bags were off the floor at all times for infection control reasons, were hung below the level of the bladder, and when transporting the resident to a common area, to ensure a privacy bag is used. The DNS indicated she was unsure if the urinary drainage bag should be covered with a privacy bag while the resident is in his/her room. Review of the Resident bill of Rights identified residents have the right to be treated with consideration, respect, and full recognition of your dignity and individuality. Review of the infection control indwelling urinary catheter use policy identified for indwelling catheters to have a privacy bag at all times ensure residents dignity and privacy.

Based on observation, review of the clinical record, facility policy and interview for 1 of 2 residents (Resident #36) reviewed for positioning, the facility failed to ensure a physician's order was in place and nurse monitoring was regularly performed and documented, for a resident utilizing a positioning device, and for 1 resident (Resident #52) reviewed for accidents, the facility failed to ensure a RN assessment was completed when the resident had a change in condition. The findings include: 1. Resident #36's diagnoses included Alzheimer's disease, hypertension, and osteoarthritis. Review of the physician's order history identified a lap buddy (a positioning device) for positioning was ordered on 10/16/21 with instructions to document the resident's ability to remove the device every shift. Further review identified the lap buddy was discontinued 5 months later, on 3/24/22. The quarterly MDS dated [DATE] identified the resident had severely impaired cognition with behaviors of continuous disorganized thinking and fluctuating inattention. Further the MDS identified the resident required total 2-person assistance with transfers, extensive 1 person assistance with locomotion on and off unit, did not walk, utilized a wheelchair for mobility and had no restraints. The care plan dated 1/24/23 identified the resident had impaired ADL function related to late-stage Alzheimer's. Interventions included to transfer the resident out of bed to the adaptive wheelchair with cushion, Velcro calf positioning and leg rests in place at all times, reposition on rounds and as needed. The February 2023 monthly physician's orders directed the resident to be assisted out of bed to the adaptive wheelchair with cushion, Velcro calf positioning and leg rests in place at all times, and to reposition on rounds and as needed. Observation on 2/7/23 at 1:27 PM identified Resident #36 was up, dressed, and sitting in an adaptive wheelchair with a lap buddy in place. Observations on 2/8/23 at 10:30AM and 2/9/23 at 11:30AM identified the resident had a lap buddy positioning device in place while sitting up in the adaptive wheelchair. Review of the nurse's notes from 3/24/22 through 2/9/23 failed to reflect the use of a lap buddy positioning device or resident's ability to remove it. Review of the TAR's dated 3/24/22 through 2/9/23 (11 months) failed to reflect documentation for the use of, or monitoring of, a lap buddy positioning device. Review of the nurse aide care card failed to include the use of a lap buddy positioning device or direction on removal or reapplication. Interview with NA #1 on 2/9/23 at 9:30AM identified Resident #36 always has the lap buddy placed after being transferred out of bed to the adaptive wheelchair, indicating it remains in place until resident is assisted back to bed. Although NA #1 identified she could not recall when the resident began using the lap buddy, she indicated it has been in use for a long time. NA #1 identified the resident was able to remove the lap buddy and did so frequently during the day. Interview and review of the clinical record with the Director of Rehabilitation, (OT #1) on 2/9/23 at 12:45 PM identified although he was aware Resident #36 utilized a lap buddy positioning device, he could not recall when it was initiated or find any therapy documentation related to its use. OT #1 identified, because the resident has been under hospice services since July 2022, he thought maybe hospice had initiated the lap buddy. When review of the order history identified 10/16/21 as the original order date for the lap buddy, OT #1 indicated there should have been therapy documentation to support the initiation and use of the positioning device. OT #1 could not explain why there was none found. OT #1 indicated residents are assessed for the use of positioning devices for safety and fall prevention, either to keep them from slipping down, leaning forward or to the side. Interview and review of the clinical record with the Administrator and DNS on 2/15/23 at 9:45 AM identified they did not know why the lap buddy was discontinued on 3/24/22, because the resident continued to utilize the device since initially ordered on 10/16/21. The Administrator identified the resident had a change in condition during that time (March 2022) and perhaps the lap buddy was discontinued because the resident wasn't getting out of bed at that time, however the resident did recover and resumed utilizing the lap buddy when sitting up in wheelchair. Review of the nurse's notes failed to reflect documentation related to why the lap buddy was discontinued on 3/24/22. The Administrator and DNS identified when the lap buddy was discontinued on 3/24/22, it was removed from the TAR, care plan and nurse aide care card as well. The Administrator and DNS identified the order for the lap buddy should not have been discontinued, it should have remained in the care plan, on the nurse aide care card and on the TAR for nurse monitoring. The DNS indicated, subsequent to surveyor inquiry, the order for lab buddy for positioning, was obtained/written, and the TAR was updated to include assessing resident's ability to remove the lab buddy independently every shift. Review of the facility's Positioning Devices policy and procedures identified the interdisciplinary team will evaluate the residents need for the use of position devices to maintain body alignment and safety. The Resident Care Coordinator will be responsible for oversight of this policy. Rehab screens will be initiated to determine if devices are needed for proper positioning and body alignment. Consideration will be given to determine the effect it has on the resident to ensure it does not meet the definition of a physical restraint. (i.e. able to self-release). Additionally, nursing staff are to assess and document resident's ability to remove device daily. 2. Resident # 52 was admitted to the facility with diagnoses that included diabetes, and hemiplegia and hemiparesis following a stroke affecting the right dominant side. The admission MDS dated [DATE] identified Resident #52 had severely impaired cognition, was always incontinent of bowel and bladder and required total assistance with transfers, dressing, toileting, and personal hygiene. The care plan dated 6/10/21 identified impaired activities of daily living related to the stroke. Interventions included to transfer with a mechanical lift with 2 staff, non-ambulatory, and resident likes to get up early at 6:00 AM. Additionally, monitor skin integrity during morning and evening personal care, and check bony prominences and pressure points. a. The reportable event form dated 6/18/21 at 11:00 AM identified Resident #52 had increased pain as evidence by negative verbalization and grimacing during range of motion. APRN notified on 6/18/21 time not identified. The APRN progress note dated 6/18/21 identified the resident had increased pain, was very guarded and rigid, a significant change. Recommendations include x-ray to both hips, lumbar, spine and sacral areas. The nurse's note dated 6/18/21 at 3:57 PM, written by LPN #2, indicated resident was resting in bed, grimaces with movement and repositioning. The DNS and APRN are aware and assessed the resident. Resident is a poor historian and unable to state cause. The Radiology Report dated 6/18/21 at 10:11 PM identified an x-ray an acute left sub capital fracture with superior lateral displacement. A written statement by NA #2 dated 6/18/21 indicated that Resident #52's pain was just as bad on 6/17/21 as it was on 6/16/21. The nurse's note dated 6/19/21 at 2:58 AM identified subsequent to APRN notification, Resident #52 to the emergency room . EMS arrived at 3:15 AM for transportation. A statement written by the DNS dated 6/19/21 at 9:45 AM noted she had spoken with NA #4 who reported she provided evening care for Resident #52 on 6/14/21 during the 3:00 PM -11:00 PM shift and Resident #52 was in pain. NA #4 reported she had to go very slowly and take breaks to get Resident #52's pants off. NA #4 had reported the increased pain to charge nurse, LPN #2. A statement written by the DNS dated 6/19/21 at 10:20 AM noted she had spoken with NA #5, and he had Resident #52 on 6/17/21 during the 3:00 PM -11:00 PM shift. NA #5 reported he did not transfer the resident via a mechanical lift that shift but did provide care. NA #5 reported Resident #52 did not provide as much assistance as usual and refused the knee brace because he/she was in pain. A statement written by the DNS dated 6/19/21 at 11:05 AM noted she spoke with NA #6 who worked on 6/17/21 during the 11:00 PM - 7:00AM shift with Resident #52. NA #6 stated she was to get the resident out of bed in the morning before 7:00 AM but the resident refused because he/she was in pain. NA #6 noted she had informed the first shift nurse aide that the resident had refused to get out of bed because he/she was in pain. Interview with the DNS on 2/9/23 at 9:47 AM indicated Resident #52 required total care and could not roll him/herself over and required a mechanical lift for transfers to a wheelchair. The DNS indicated when the nurse aides reported on 6/14, 6/16, and 6/17/21 that the resident had a change in behaviors and increased pain to the charge nurses, a RN should have done an assessment to find out why, report the assessment to the APRN/MD, and document the situation in the clinical record. The DNS indicated she only had statements from the nurse aides and not the nurses so she could not explain why there were no RN assessments completed or documented on 6/14, 6/16, and 6/17/21. Review of the clinical record by the DNS identified there was no documentation from 6/14/21 - 6/17/21 by a charge nurse or RN about the residents increased pain, refusal to get out of bed, or refusal to wear the knee brace. The DNS indicated it was her expectation that when the resident experienced these changes, a head-to-toe assessment by a RN would have been done. The DNS noted on 6/18/21 when they did the head-to-toe assessment by the RN Resident #52 had increased pain noted through grimacing and had a scab on the bridge of the nose, going up to the forehead that was not reported. Interview with NA #5 on 2/14/23 at 11:59 AM indicated he was not assigned to Resident #52 on the evening shift of 6/17/21 but had Resident #52's roommate. NA #5 indicated when he had finished with the roommate, he went over to Resident #52 and offered to put the knee brace on but Resident #52 said no at approximately 9:00 PM. NA #5 indicated his/her knee hurt and the resident was in pain. NA #5 indicated he did report the residents knee pain and refusal of the knee brace to the charge nurse. b. The reportable event form dated 6/18/21 identified an abrasion noted to forehead bridge of nose with scabbed area. Additionally, the description of the event was a scabbed forehead and bridge of nose. The investigation noted a body audit was done on 6/11/21 and there were no new areas. Intervention was to ensure the resident was not wearing glasses in bed. The report noted the care plan was updated, a treatment was put into place, and the staff was educated. A written statement dated 6/18/21 by NA #3 indicated she noticed the scabs on 6/16/21 but assumed someone else had reported them. A written statement dated 6/18/21 by NA #7 identified she had noticed the scab today but did not report it because she assumed it had already been reported and did not know when or how it got there. The nurse's note dated 6/18/21 at 3:57 PM, written by LPN #2, indicated the resident was resting in bed and was identified with a 1.0 cm scab noted to forehead and a 2.0 cm x 1.0 cm scab noted to bridge of nose. The DNS and APRN aware and assessed the resident. Resident a poor historian and unable to state cause. Glasses noted slightly misshapen. Monitoring started for 72 hours and the scabbed areas to be left open to air. Interview with the DNS on 2/9/23 at 11:00 AM indicated the scab to the bridge of the nose and the forehead was not noted until the resident exhibited increased pain and was identified with a fracture on 6/18/21. The DNS could not identify when the area was first found, but noted it had to occur between 6/11/21 and 6/18/21. The DNS indicated the scab on the resident's nose may have been from wearing the glasses while in bed and being rolled side to side for care. The DNS indicated through her investigation the nurse aides thought because it was a scab, they assumed someone else had reported it, so they did not report it. The DNS indicated the intervention for the scabbed areas was for staff to take off glasses when providing care. The DNS indicated the intervention was placed in the care plan, but she did not do an education sheet with the staff. Interview and clinical record review with the DNS on 2/14/23 at 3:25 PM failed to provide documentation that when the resident was identified with a scab on the bridge of the nose, that a RN assessment was completed and documented. Although attempted, an interview with NA #2, NA #3, NA #4, NA #6, and LPN #1 was not obtained. Review of the Reportable Events Policy and Procedure identified regardless of how minor an incident may be, it must be reported to the department supervisor, and the reportable event form is to be completed on the shift that the incident occurred. An employee witnessing an incident involving a resident, must report immediately such occurrence to the supervisor. The charge nurse will evaluate the resident immediately and the RN will complete as assessment for any injury. In communication with the attending physician a course of action will be determined. 42117

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #44) reviewed for respiratory care, the facility failed to ensure respiratory equipment was dated per facility policy. The findings include: Resident #44 was admitted to the facility with diagnoses that included acute and chronic respiratory failure with hypoxia and chronic congestive heart failure. A physician's order dated 10/27/22 directed to apply oxygen at 2 liters per minute via nasal cannula and to change the oxygen tubing weekly on Tuesday during the night shift. The quarterly MDS dated [DATE] identified Resident #44 had intact cognition, had shortness of breath with exertion, while sitting at rest, and while lying flat and did not require oxygen prior to being at the facility. The care plan dated 12/22/22 identified the resident had alteration in respiratory status with interventions that included to provide oxygen as ordered and as needed per nursing measure and physician's order. A physician's order dated 12/31/22 directed to give Xopenex Nebulizer solution 1.25 mg/3ml inhale orally via nebulizer 3 times a day. The nurse's note dated 2/4/23 at 2:00 PM noted Resident #44 was on oxygen via a nasal cannula. Observation on 2/7/23 at 10:45 AM identified Resident #44 was sitting in a standard wheelchair next to his/her bed with oxygen tubing on from a concentrator and a nebulizer mask over it. Neither the nebulizer tubing nor the oxygen tubing had been dated as to when they were last changed. Interview with LPN #1 on 2/7/23 at 10:46 AM indicated the oxygen tubing and nebulizer mask tubing are changed weekly and as needed (prn) on the 3rd shift on Sunday night shift. LPN #1 indicated the nebulizer mask had been on the floor earlier and although she had changed it, she had not dated it. LPN #1 identified both the oxygen and the nebulizer tubing should have had a piece of nursing tape attached to them indicating the date and nurse's initials when they were last changed. LPN #1 indicated she did not change the oxygen tubing and noted it was not dated when last changed. Interview with the DNS on 2/14/23 at 3:23 PM indicated the oxygen and the nebulizer tubing must be dated when changed on a weekly basis and as needed per the facility policy. The DNS indicated as soon as a nurse changes the tubing, he/she must use a piece of nursing tape and at the least date it to identify when it was last changed. The DNS indicated if LPN #1 had changed the nebulizer mask and tubing, she should have dated it before the resident had used it. Review of the Oxygen Therapy Policy identified oxygen administration requires a physician order. Oxygen tubing needs to be dated. All oxygen tubing, bubblers, and bags must be changed weekly and as needed if damaged or soiled. All new equipment must be dated for that day.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 residents (Resident #7) reviewed for [MEDICAL TREATMENT], the facility failed to monitor a [MEDICAL TREATMENT] Arterio-Venous (AV) fistula. The findings include: Resident #7 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A Resident Care Plan dated 5/18/18 through 1/29/20 identified a problem with needing [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION]. Interventions included to notify physician for change in fistula, [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays, and do not draw blood or take blood pressures in the arm with the graft. The quarterly Minimum Data Set (MDS) assessment dated [DATE] and the 5 day (re-admission) MDS assessment dated [DATE] identified Resident #7 was cognitively intact and required extensive assistance of one for bed mobility, transfers, walking in the room, dressing, toilet use and personal hygiene. Additionally, the MDS identified Resident #7 received [MEDICAL TREATMENT]. Treatment Administration Record (TAR) identified from 8/1/19 through 8/14/19 (when Resident #7 was discharged ) Resident #7's AV fistula to the left arm was assessed for thrill/bruit every shift. TAR from re-admission on 8/15/19 through 1/17/20 failed to identify Resident #7's fistula to the left arm was assessed for thrill/bruit. physician's orders [REDACTED].#7's AV fistula for thrill/bruit. physician's orders [REDACTED]. The nurse's notes dated 1/28/20 at 1:42 PM and 10:20 PM identified that AV fistula was monitored for thrill and bruit; no other documentation of fistula monitoring was identified in the nurses' notes for the months of December 2019 and January 2020. Interview and clinical record review with DNS on 1/30/20 at 9:09 AM failed to provide documentation that the AV fistula was performed on a daily basis. Additionally, the DNS identified prior to 8/15/19, AV fistula monitoring was completed and documented for each shift on the TAR, but not after 8/15/19. The DNS identified she did not know the reason the AV monitoring was not renewed upon Resident #7's re-admission on 8/15/19. Additionally, the DNS identified it was facility expectation and standard of practice to monitor venous access devices. Review of facility Policy and Procedure for Monitoring and Surveillance of [MEDICAL TREATMENT] Vascular Access identified a procedure was to be followed to identify abnormalities early and for early intervention when abnormalities are identified. Frequency of monitoring and documentation was not identified in the facility policy and procedure. Subsequent to surveyor inquiry, the facility policy and procedure was updated to include the monitoring of the [MEDICAL TREATMENT] will be performed on the day and evening shift.

Based on clinical record reviews, facility documentation and interviews for one of three sampled residents (Resident #39) who was at risk for falls, the facility failed to ensure the resident was transferred out of bed and ambulated with the appropriate number of staff and/or supervised when toileted in accordance with the care plan to prevent a fall with injury. The findings include: Resident #39's [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set assessment dated [DATE] identified Resident #39 had severe cognitive impairment, difficulty focusing attention, required extensive two (2) person assistance for toilet use, was frequently incontinent of bowel and bladder and a history of falls with injury. The fall risk assessment dated [DATE] identified Resident #39 was a high risk for falls related to impaired judgement, balance deficits and a history of falls. The Resident Care Pan dated 8/21/17 identified a potential for injury related to being at risk for falls, non-compliant with use of the call bell and/or waiting for assistance. Interventions directed a sign was made and placed in view to remind the resident to call and wait for assistance before attempting to ambulate, assist of two (2) to transfer, and staff to remain near the resident while in the bathroom for safety, as the resident forgets to call for assistance. The nurse's note dated 9/15/17 at 9:51 PM identified at 4:00 PM Resident #39 had called out after a thud was heard coming from the room. Resident #39 was observed sitting on the bathroom floor in front of the toilet with his/her back leaning against the toilet bars. The note identified the resident was assessed and noted too be able to move the upper and lower body well, but complained of severe back pain. A body audit was completed and redness was noted to the lower right back. The note identified the resident stated I was on the toilet and tried to get up alone and fell on my bottom. The note indicated the Advanced Practice Registered Nurse (APRN) was notified and directed to obtain x-rays of the bilateral hips, pelvis, both femurs and sacrum/coccyx area. The note identified that the x-ray results were negative for fractures. The Reportable Event Form dated 9/15/17 at 4:00 PM identified Resident #39 was calling for help after a thud was heard, and upon entry to the bathroom the resident was observed sitting on floor in front of the toilet. The report identified the resident complained of right upper back pain and right hip pain. The investigation identified the nurse aide assisted Resident #39 to the toilet and told the resident to ring when he/she were done. The investigation identified, in a written statement, the 7-3PM charge nurse had instructed a nurse aide to assist Resident #39 to the toilet. The statement identified the nurse aide came to the desk, informed the charge nurse she had to answer call bells on her unit, so the nurse aide told another nurse aide Resident #39 was on the toilet. The nurse aide responded okay and then walked away. Review of the nurse's notes from 9/15/17 through 9/18/17 identified Resident #39 complained of abdominal pain, right upper quadrant pain, the abdomen was noted to be firm and distended, and pain to the right lateral trunk was present with movement. The notes identified the APRN was made aware and directed to provide pain management and ordered additional x-rays and an abdominal ultrasound. The x-ray results of the chest, hips, and pelvis were negative for fractures and the ultrasound noted [MEDICATION NAME] distention. The nurse's note dated 9/18/17 at 3:41 PM identified Resident #39 complained of severe abdominal pain in the left upper quadrant, flank side. The note identified the resident was assessed by the APRN, who spoke with the family and because Resident #39 had abnormal amounts of pain, the resident was transferred to the hospital for an evaluation. The hospital admission documents dated 9/18/17 identified Resident #39 had sustained a fall three (3) days prior to. The x-rays identified mildly displaced rib fractures on the right lateral side the fifth through ninth ribs and the posterior side the eighth through eleventh rib, and a right side hemothorax with associated compressive atelectasis of a portion of the right lung. Resident #39 was discharged back to the long term care facility on 9/23/17. Interview with the 7-3 PM charge nurse, Licensed Practical Nurse (LPN) #1, on 12/18/17 at 2:20 PM identified Resident #39 was calling out to use the bathroom, a nurse aide, Nurse Aide (NA) #1 was walking by and she asked NA #1 to toilet the resident. LPN #1 stated that NA #1 assisted the resident into the bathroom and then came out of the bathroom and said she had call bells going off on her unit and she needed to get back. LPN #1 stated she told NA #1 the resident can't be left alone in the bathroom and NA #1 told another nurse aide the resident was on the toilet and NA #1 left the unit. LPN #1 identified Resident #39 was not to be left on the toilet alone because the resident was not safe and would attempt to stand on him/her own. LPN #1 stated that she did not direct the NA #1 to stay with the resident because she knew the resident could not be left alone on toilet per facility policy. Interview with NA #1 on 12/19/17 at 1:00 PM identified she was walking by the nursing station when LPN #1 asked her to toilet Resident #39. NA #1 stated she went to the resident's room, placed a gait belt on the resident, ambulated the resident to the bathroom and sat Resident #39 on the toilet. NA #1 stated she left Resident #39's room, told another nurse aide the resident was on the toilet and went back to her unit to answer call bells. NA #1 identified that although she was aware the resident was a two (2) person assist with transfers, and was not to be left alone on the toilet because of the resident's history of getting up on his/her own, she left Resident #39 alone. Interview with the Director of Nursing (DON) on 12/19/17 at 2:15 PM identified that the facility policy for transferring a resident to the bathroom was to remain with the resident, unless care planned for and/or determined otherwise. The DON stated NA #1 should not have transferred the resident alone and/or left the resident alone in the bathroom. Review of facility policy and procedure for transfers in the bathroom identified the nurse and/or nurse aide was to remain with the resident and keep direct visual eye contact on the resident after transferring for toileting. Direct visual contact means the caregiver is either in the bathroom with the resident or right outside the door maintaining constant visual contact.

Based on record review and staff interview for one of five sampled resident reviewed for unnecessary medications (Resident #44), the facility failed to ensure pharmacy recommendations were conveyed to the facility and/or responded to regarding the completion of a Baseline Abnormal Involuntary Movement scale (AIMS) upon the initiation of an antipsychotic medication. The finding include: Resident #44's [DIAGNOSES REDACTED]. A Re- Admission/5 day MDS assessment dated [DATE] identified the resident as moderately cognitively impaired and requiring extensive assistance of one for Activities of Daily Living (ADL). The MDS admission assessment further identified the resident had not exhibited any behavioral disturbances. A care plan dated 5/18/17 identified a behavioral problem of refusing treatment, severe irritability with attempts to bite/spit and scratch staff. Interventions include: to attempt non-pharmacological interventions, provide psychiatry evaluation and follow up and to provide psychotherapy as recommended. The nurse's note dated 6/21/17 at 3:16 P.M. identified the resident spat at a NA while attempting to prevent the resident from leaving by holding the door and offering to bring the resident outside. The psychiatry notes from MD#1 dated 6/21/17 identified the resident exhibiting behavioral disturbances and was becoming more aggressive over the last two months. MD#1 directed [MEDICATION NAME] (Anti-psychotic) 0.25 Milligrams (MG) by mouth every 9:00 A.M. and 5:00 P.M. for one week and psychiatry to follow up. Psychiatry notes dated 7/26/17 directed to administer [MEDICATION NAME] 0.25MG by mouth twice daily for continued behaviors of refusing dressing changes and refusing care. Review of the physician orders [REDACTED].M. with the Nursing Administrative Assistant (NAA) identified the resident received [MEDICATION NAME] 0.25 MG by mouth twice daily from 6/21/17 through 7/3/17 and from 7/26/17 to present. Review of the electronic health record with the Nursing Administrative Assistant on 12/21/17 at 10:08 A.M. identified the AIMS was not completed until 8/31/17. Further interview with the NAA identified it was the responsibility of the prescribing Psychiatrist to complete the AIMS test at the time the antipsychotic was prescribed (6/21/17). A Consultation Summary Report that was sent to the facility and electronic pharmacy recommendations dated 6/29/17 directed to monitor a [MEDICAL CONDITION] Stimulating Hormone (TSH) annually and failed to identify to the need to complete a baseline AIMS. Interview with Pharmacy Consultant #1 on 12/21/17 at 11:30 A.M. identified that although the recommendation to complete an AIMS on 6/29/17 was identified in her/his medication review of Resident # 44 in her/his computer, it was not scanned into the electronic health record at the facility by the facility. Subsequent to surveyor inquiry, Pharmacy Consultant#1 electronically mailed a report dated from 6/29/17 which recommended the completion of an AIMS test. Interview with the Medical Records Secretary on 12/21/17 at 1:00 P.M. identified she/he is responsible for scanning the Pharmacy recommendations into the electronic health record and there was no recommendation on 6/29/17 sent by Pharmacy Consultant#1 for completion of an AIMS to be scanned into the computer.

Based on clinical record review, review of facility policy and procedures and interview for one of five residents (Resident #51) reviewed for unnecessary medications, the facility failed to conduct orthostatic blood pressures for a resident who utilized an antipsychotic medication in accordance to the facility policy and procedures. The findings include: Resident #51's [DIAGNOSES REDACTED]. The RCP for dated 9/12/16 for [MEDICAL CONDITION] drug use related to [MEDICAL CONDITION] noted an intervention to complete orthostatic blood pressures as ordered. Resident #51's quarterly Minimum Data Set ((MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12 indicative of moderate cognitive impairment and indicated the resident required extensive assistance with one person for transfers. The physician's orders [REDACTED]. A review of Resident #51's clinical record, physician's orders [REDACTED]. Interview with the DNS on 11/22/16 at 2:00 PM indicated orthostatic blood pressures are a physician's orders [REDACTED]. The DNS on 11/22/16 at 2:00 PM identified Resident #51 should have had orthostatic blood pressures completed. Review of the Facility's Orthostatic Blood Pressures Policy and Procedures directed in part that any resident who has an order for [REDACTED].>

Based on clinical record reviews and interviews for two of five residents who required an assistance of one for transfers (Resident #1 & Resident #2) the facility failed to provide assistance with transferring and/or utilize an alarm to prevent a fall. The findings include: 1 Resident #1's [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] identified Resident#1 as a 20 (10 or above indicates a risk of falling). The Minimum Data Set (MDS) dated 3/21/11 identified a Brief Interview for Mental Status as 10 (8-12 moderately impaired), balance with transitions and walking as not steady, only able to stabilize with human assistance and necessitating extensive assist with transfers. The physician's orders [REDACTED]. The resident care plan dated 4/4/11 identified an assist of one with rolling walker and directed the utilization of a Miami Collar. Review of the nurses' notes dated 4/4/11 at 4:00 PM identified Resident#1 was found on the floor in the bathroom and complaining of rib pain. Review of radiology report dated 4/4/11 identified Resident #1 sustained a fracture involving the lateral portion of the right 6th, 7th, and 8th ribs. Review of facility accident and investigation report dated identified that Nurse Aide (NA) #1 had assisted Resident #1 in the bathroom and left Resident #1 standing behind him/her while he/she reached out of the room to get the wheelchair. Interview with the Physical Therapist and the Director of Rehabilitation on 8/18/11 at 12:15 PM identified that if a resident is determined to be an assist of one there needs to be hands on assistance at all times. Interview with NA#1 on 8/18/11 at 2:40 PM identified that he/she was standing in front of Resident #1 reaching for the wheelchair without physically assisting Resident #1 at that time. 2. Resident #2's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified a Brief Interview for Mental Status Score of 10 (8-12 moderately intact) and an assist of one for transfers. Review of physician's orders [REDACTED]. Review of the resident care plan dated 6/30/11 identified that Resident #2 had fallen and a new intervention was identified to apply a Resident Free Alarm ( RFA-tabs alarm) at all times. Review of the nurse's notes dated 7/5/11 at 2:50 PM identified the roommate calling out that Resident #2 was on the floor in the bathroom. Review of facility accident and investigation report dated 7/5/11 identified an alarm was not in use at the time of the fall. Interview with Registered Nurse (RN) #1 on 8/18/11 at 2:00 PM identified that an alarm did not sound at the time of the incident. Interview and review of the clinical record with the Director of Nursing on 8/18/11 at 1:30 PM failed to identify that the 6/30/11 intervention for the utilization of the RFA was ever implemented.