Every finding on record at Copperfield Healthcare and Rehabilitation

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner in an environment that promotes maintenance or enhancement of his or her quality of life and recognizing each resident's individuality for 1 (Resident #1) of 4 residents reviewed resident rights. The facility failed to ensure CNA A treated Resident #1 with dignity and respect on [DATE] at 11:31 pm when discussing the need for incontinent care with the resident. This failure could place residents at risk for a diminished quality of life and a negative impact on the residents' psychosocial well-being. Findings included:Record review of Resident #1's face sheet revealed a 77- year- old man who was admitted to the facility on [DATE]. Admitting diagnoses were Parkinson's Disease (a progressive movement disorder of the nervous system), difficulty in walking, lack of coordination, muscle wasting and atrophy, and multiple myeloma without remission (type of blood cancer that originates in plasma cells, a type of white blood cell responsible for producing antibodies). Resident #1 received hospice services and was coded as a DNR (a medical directive instructing healthcare providers not to perform CPR if a patient's heart or breathing stops). Record review of Resident #1's MDS (resident assessment tool used to document a resident's clinical status, functional abilities, and care needs) completed [DATE] revealed a BIMS (cognitive assessment) score of 08 (moderate cognitive impairment). He required substantial and maximum assistance for toileting/hygiene and to shower and bathe himself. For toilet transfer, tub/shower transfer, sit to stand, and walk 10- 50 feet, Resident #1required supervision/maximal assistance. Record review of Resident #1's care plan initiated [DATE] revealed Resident #1 was dependent on staff for activities, cognitive stimulation, social interactions and he had the potential for problems with his psychosocial well-being related to hospice services and psychotic disorders. Care plan revealed a potential for ADL self-care performance and he was incontinent of bowel and bladder. Interventions highlighted checking for incontinence as required and allowed time to answer questions to verbalize feelings, perceptions, and fears. On [DATE] the care plan was updated to include that Resident #1 had the right to health, safety, and dignity as demonstrated by choice in implementation of the electronic device monitoring in his room. Record review of Resident #1's Request for Authorized Electronic Monitoring form 0066 dated [DATE] was signed by Resident #1's family member. In an interview on [DATE] at 11:28 a.m., Resident #1's FM stated on [DATE] around 11:30 p.m., she saw CNA A talking to Resident #1 after providing care to his roommate on video surveillance. FM stated that she would send the video footage to the surveyor for review. She stated that after this exchange, CNA A provided incontinent care to Resident #1. An observation on [DATE] at 2:31 p.m. of video footage inside of Resident #1's room on [DATE] at 11:31 p.m., CNA A asked Resident #1 if he needed to be changed. Resident #1 responded I will and CNA A stated You will? What that mean? You will or you do right now. When I'm leaving, I'm gone. Resident #1 responded, but it was low and inaudible through the footage. CNA A stated Well I'm asking, don't talk in riddles, I'm not well in riddles.either you need it now or you don't and the footage was cut off. In an interview on [DATE] at 12:06 p.m., Resident #1 said he could not remember the exchange between himself and CNA A when she provided incontinent care on [DATE] at 11:30 p.m. He said he remembered seeing her around 4:30 a.m., and she made him feel this big (small, used his left hand to his left thumb and pointer finger parallel to each other). He stated that CNA A made him feel like she wanted nothing to do with him and he tried not to be that way with people. In an interview on [DATE] at 1:51 p.m., CNA A stated that she worked at the facility for 6 years before she was terminated. She said she normally worked the 10 p.m.- 6 a.m. shift and her first time working with Resident #1 was on [DATE]. She stated that she did not remember the exchange between her and Resident #1. She said she was probably playing and she sometimes just said things although she was not familiar with him. She said if she normally interacted with residents in an offensive way then she would have been reported more times prior to the incident and she had to be distracted or something. CNA A stated she was aware there was a camera in the room and she was suspended on [DATE]. She said she was asked to come in on [DATE] for an in-service and a statement about what happened. CNA A stated that she felt confused and deceived because she did not view the video footage and thought she was terminated because she told Resident #1 that he had shit on his hands as she was about to provide incontinent care. In an interview on [DATE] at 3:09 p.m., the DON stated that Resident #1's FM reported that CNA A was disrespectful and unprofessional with him (Resident #1) and she was adamant she did not want CNA A to work with him. The DON said CNA A was suspended while administration began their investigation. The DON said when CNA A was asked to come in and provide her statement, she was defensive and overtalked. The DON stated CNA A had members of her family call the facility to curse out administration, which ultimately led to her termination. The DON stated if CNA A would have just answered the questions to clear up things, she would have been given a 1-1 in-service on customer service but she continued to dig herself into a deeper hole. In an interview on [DATE] at 3:33 p.m., the ADM stated CNA A's response about talking in riddles to Resident #1 was inappropriate. The ADM stated she usually received compliments regarding CNA A but if you did not know her, the way she talked to people would make you go woah. She stated CNA A had received a write up on her customer service in the past but could not recall the date. The ADM stated that CNA A was terminated because of her attitude, her customer service, and because her daughter had called her (the ADM) on the phone and cursed her out. Record review of CNA's A Counseling/ Disciplinary Notice dated [DATE] revealed that she received a verbal warning due to arguing with a resident's family member. CNA A documented on the notice that she felt disrespected by the family member but the customer was always right. She was given a 1-1 in-service on customer service and professionalism. Record review of CNA A's termination form dated [DATE] revealed that her last day worked was on [DATE] and she was involuntarily terminated due to professionalism and customer service concerns noted after review of video footage. CNA A was termed over the phone on [DATE]. Record review of a Staff Development/In-service titled Abuse, Neglect, Exploitation on [DATE] was given to all staff. Record review of a Staff Development/In-service titled Professionalism/ Customer Service on [DATE] was given to all staff. Record review of a Staff Development/In-service titled Resident Rights on [DATE] was given to all staff. Record review of the facility's policy titled Resident Rights and Responsibilities revised [DATE] revealed: It is the policy of this facility to inform the residents both orally and in writing of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. Prior to or upon admission, a representative of the admitting office will provide the residents with a written copy of residents' rights. To ensure that our residents, staff, and visitors are continually informed and aware of resident rights, grievance procedures, and responsibilities, large print copies may be posted in a prominent area in the facility.

Based on observation, interview, and record review the facility failed to ensure appropriate alternatives prior to installing a side or bed rail were used and if bed or side rails are used, the facility failed to ensure correct installation, use and maintenance of bed rails, including, but not limited to assessing the resident for risk of entrapment from bed rails prior to installation, reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation for 11 of 11 residents (Resident #8, #15, #22, #25, #44, # 60, #84, #90, #134, #145, and #149) reviewed for mobility bars/bedrails. 1. -The facility failed to assess Resident #84 for mobility bars, educate the resident RP on the risk and benefits of mobility bars, obtain a physician order and a consent for mobility bars. Resident #84 was observed in between the mobility and head of bed entrapped in her sheets and bedspread to her lower body torso (waist extending to lower legs). When Resident #84 attempted to get untangled, the mobility bar prevented her from moving. -2. The facility failed to assess residents, attempt alternatives, receive consent prior to placing bed rails on residents' beds for. Newly admitted residents, Residents #8, #90, #134, #145, #22, #66, #15, #25, #149 and #44 who had bedrails installed on their beds upon admission. An Immediate Jeopardy (IJ) situation was identified on 09/12/2025. While the IJ was removed on 09/16/2025, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. -These failures could place residents at risk for entrapment and injuries. Findings include: 1. Record review of Resident #84's face sheet, dated 09/12/25, revealed reflected that the resident was admitted to the facility on [DATE]. Resident #84 had diagnoses which included the following: hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty swallowing), chronic kidney disease, syncope and collapse (temporary loss of consciousness/fainting caused by sudden , brief decrease in blood flow to the brain), cognitive deficit, falls, cerebral infarction (blood flow to the brain is interrupted), hypertension (elevated blood pressure), muscle wasting and atrophy (muscle lose mass and strength). Record review of Resident #84's Physical Therapy evaluation, dated 08/08/25-09/04/25, and OT evaluation & Plan of Treatment, dated 08/08/25-09/04/25, did not reflect ed that residents' had been assessed for the safety of mobility bars on bed. Record review of Resident #84's Admissions MDS, dated [DATE], reflected the BIMS score was coded 0, which indicated indicating that resident cognition was severely impaired. Record review of Resident #84's Physician Order Summary Report, for the month September 2025, did not reflect an order for mobility bars. Record review of Resident #84's initial IDT meeting, dated 09/13/25, reflected mobility bars in place to aide in turning and repositioning while in bed. Further review did not reflect that the resident RP was educated on the risk and benefits of the mobility bars. Record review of Resident #84's Progress Notes for the month of August and September 2025 did not reflect that the nurses had assessed the resident for the safety of mobility bars on bed. Record review of Resident #84's Comprehensive Care Plan, dated 09/11/25, reflected that the resident was not being care planned for mobility bars on bed. Observation on 09/09/25 at 9:47 AM of revealed Resident #84 in room sitting on the left side of her bed. Resident #84 was sitting on the opposite side of the mobility bar in between the mobility bar and the head of bed. The resident was entrapped in her bed sheet and bedspread to her lower body torso. The resident could not figure out how to untangle herself. Resident #84 then lay on her back unable to get herself out of the situation. Resident #84 continued to try and untangled herself but was not successful. The State Surveyor called for help. Entering RN F, the Therapy Aide and Physical Therapy entered Resident #84's room was RN F and the Therapy Aide from Physical therapy. Both staff members began to assist Resident #84 by untangling Resident #84 and assisting assisted the resident out of bed in a wheelchair. RN- F then left Resident #84's room and went to his cart in the hallway. Interview on 09/12/25 at 9:45 AM with the Administrator, regarding mobility bars on Resident #84's bed, the Administrator said the Physical Therapy Department assesses assessed each resident who utilized mobility bars on their beds. The Administrator said the Physical Therapy Department provided their recommendations to the nurse. The Administrator said the nurse then contacted the Physician for an order to utilize the mobility bars. The Administrator said the State Surveyor would not be able to access the Physical Therapy Department documentation of assessments done for Resident #84, because the Physical Therapy Department was not on the same charting system as the facility. Interview on 09/12/25 at 9:45 AM, with the Rehab Director said both the Physical Therapist and Occupational Therapist could both do an assessment for a resident to see if the resident met the criteria for mobility bars/bedrails. Interview on 09/12/25 at 10:23 AM via phone with Occupational Therapist ZO said that she worked at the facility PRN. Occupational Therapist ZO said she assessed Resident #84 upon admission for functional status. Occupational Therapist ZO said she did not assess Resident #84 for mobility bars. Occupational Therapist ZO said if a resident was not being assessed for mobility bars/bedrails, it placed the resident at risk of getting entrapped, injury, and death. Occupational Therapist ZO said it was a learning moment and that she would be contacting the Director of Rehab on how to move forward. Attempted interview via phone on 09/12/25 at 10:52 AM with the RP of Resident #84 regarding if the facility had contacted her regarding the risk and benefits of the mobility bars was unsuccessful therefore, a voicemail was left. Interview on 09/12/25 at 11:53 AM, with the DON regarding mobility bars on Resident #84 bed. The DON said most of the residents had mobility bars on their beds. The DON said that the nurses done did the assessment for mobility bars as well as the Physical Therapy Department. The DON said she would have to clarify with the Physical Therapy Department regarding who done did the assessment for a resident to have mobility bars on their bed. The DON said it was important for a resident to be assessed for safety prior to mobility bars being placed on their bed. The DON said if the resident was not assessed for mobility bars it placed the resident at risk for injury, falls, and skin tears. Further interview with the DON said there was an assessment that the nurses done did for bed safety and would have to review the assessment form first to see what all the form entailed2. Record review of Resident #8's face sheet, dated 09/09/25, reflected, a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #8's BIMS Assessment, dated 08/13/25, reflected, moderately impaired cognition as indicated by a BIMS score of 12 out of 15. Record review of Resident #8's, undated, Care Plan reflected, no documented focus area for the use of bed rails for mobility purposes. Record review of Resident #8's EMR on 09/12/15 reflected, no record of a bed rail consent form or a bed rail assessment. An observation and interview on 09/12/25 at 10:40 AM revealed, Resident #8 in bed with grab assist bed rails on both sides of her bed. She said she used the rails occasionally and they were present on her bed on admission. Resident #8 said she was never assessed for bed rails; she did not give consent for the bed rail, but she had no safety concerns about the bedrails. 3. Record review of Resident #90's face sheet, dated 09/12/25, reflected, an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #90's BIMS Assessment, dated 08/28/25, reflected, intact cognition as indicated by a BIMS core of 15 out of 15. Record review of Resident #90's EMR on 09/12/15 reflected, no record of a bed rail consent form or a bed rail assessment. An observation and interview on 09/12/25 at 10:40 AM revealed, Resident #90 in bed with grab assist bed rails on both sides of her bed. She said she did not use the bars, and they were present upon admission. Resident #90 said she was not trained on the use of the bar, was not assessed for the use of the bar or gave consent for the use of the rail but it did not cause her any safety issues. 4. Record review of Resident #134's face sheet, dated 09/12/25, revealed, a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #134's BIMS Assessment, dated 09/04/25, revealed, intact cognition as indicated by a BIMS score of 14 out of 15. Record review of Resident #134's EMR, on 09/12/15, revealed, no record of a bed rail consent form or a bed rail assessment An observation and interview on 09/12/25 at 10:45 AM revealed, Resident #134 in bed with grab assist bedrails on both sides of her bed. She said she used the bars to reposition herself and they were on her bed upon admission. Resident #134 said she was not assessed for the use of the bar or gave consent for the use of the rail but it did not cause her any safety issues because she had used them on a previous admission 5. Record review of Resident #145's face sheet, dated 09/12/25, reflected, a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #145's BIMS Assessment, dated 09/08/25, reflected, moderately impaired cognition as indicated by a BIMS score of 12 out of 15. Record review of Resident 145's EMR on 09/12/15 reflected, no record of a bed rail consent form or bed rail assessment. Record review of Resident #145's, undated, Care Plan reflected, no documented focus area for the use of bed rails for mobility purposes. An observation and interview on 09/12/25 at 10:48 AM revealed, Resident #145 in bed with grab assist bed rails on both sides of her bed. She said she was not trained on the use of the bar; they were present upon admission, she was not assessed for the use of the bar or give consent for the use of the rail, but it did not cause her any safety issues, and she did not feel restrained by the bar. 6. Record review of Resident #146's face sheet, dated 09/12/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident 146's EMR on 09/12/15 reflected, no record of a bed rail consent form or bed rail assessment. Record review of Resident #146's, undated, Care Plan reflected, no documented focus area for the use of bed rails for mobility purposes. An observation and interview on 09/12/25 at 10:48 AM revealed, Resident #146 in bed with grab assist bed rails on both sides of her bed. She said she did not use the bed rails and then sat up, in the bed, without the assistance of the rail. Resident #146 said was not trained on the use of the bar, they were present on admission, she was not assessed for the use of the bar or was given consent for the use of the rail, but it did not cause her any safety issues, and she did not feel trapped by the bar. 7. Record review of Resident #23's face sheet, dated 09/12/25, reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #23's BIMS Assessment, dated 09/08/25, reflected, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #23's EMR on 09/12/15 reflected, no record of a bed rail consent form or bed rail assessment. Record review of Resident #23's, undated, Care Plan revealed, no documented focus area for the use of bed rails for mobility purposes. An observation and interview on 09/12/25 at 10:459 AM revealed, Resident #23 in bed with grab assist bed rails on both sides of his bed. He said he used the bar to get up in bed but was not trained on the use of the bar, they were present upon admission, he was not assessed for the use of the bar or gave consent for the use of the rail. Resident #23 said the rail did not cause him any safety issues and he did not feel restrained by the bar. 8. Record review of Resident #66's face sheet, dated 09/12/25, reflected, an [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #66's BIMS Assessment, dated 08/13/25, reflected, moderately impaired cognition as indicated by a BIMS score of 14 out of 15. Record review of Resident #66's EMR, on 09/12/15, reflected, no record of a bed rail consent form or bed rail assessment. Record review of Resident #66's, undated, Care Plan reflected, no documented focus area for the use of bed rails for mobility purposes. An observation and interview on 09/12/25 at 11:00 AM revealed, Resident #66 in bed with grab assist bed rails on both sides of his bed. He said he didn't use the bar; they were present upon admission, he was not trained on the use of the bar, was not assessed for the use of the bar or gave consent for the use of the rail. Resident #66 said the rail did not cause him any safety issues and he did not feel restrained by the bar. 9. Record review of Resident #15's face sheet, dated 09/12/25, reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #15's BIMS Assessment, dated 08/25/25, reflected, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #15's EMR on 09/12/15 revealed, no record of a bed rail consent form or bed rail assessment. An observation and interview on 09/12/25 at 11:00 AM revealed, Resident #15 in bed with grab assist bed rails on both sides of his bed. He said he didn't use the bar; and they were present upon admission. Resident t#15 said he was not trained on the use of the bar, was not assessed for the use of the bar or gave consent for the use of the rail. Resident #15 said the rail did not cause him any safety issues and he did not feel restrained by the bar. 10. Record review of Resident #25's face sheet, dated 09/12/25, reflected an [AGE] year-old female who admitted to the facility on [DATE]. Resident #25 had diagnoses which included: difficulty walking and hip fracture. Resident #25 was at the facility for orthopedic aftercare. Record review of Resident #25's BIMS assessment, dated 09/01/25, revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #25's, undated, Care Plan revealed, no documented focus area for the use of bed rails for mobility purposes. Record review of Resident #25's EMR on 09/12/15 revealed, no record of a bed rail consent form or bed rail assessment. An observation and interview on 09/12/25 at 10:55 AM revealed, Resident #25sat in her wheelchair at her bedside table located in front of the foot of her bed. She said she did not use the bars; they were present upon admission, and her bars were wobbly. She said she notified maintenance of the wobbly bars, and he changed the bolts. Resident #25 said maintenance told her even though they wobbled they were still secure, but she didn't feel safe using it. She said she was not assessed for the use of the bar or gave consent for the use of the rail. 11. Record review of Resident #149's face sheet, dated 09/12/25, reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #149's BIMS Assessment, dated 09/08/25, revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #149's EMR on 09/12/15 revealed, no record of a bed rail consent form or bed rail assessment. An observation and interview on 09/12/25 at 11:07 AM revealed, Resident #149 in bed with grab assist bed rails on both sides of his bed. He said the bars were present upon admission, he was not trained on the use of the bar, was not assessed for the use of the bar or gave consent for the use of the rail. Resident #149 said the rail did not cause him any safety issues and he did not feel restrained by the bar. 12. Record review of Resident #44's face sheet, dated 09/12/25, reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #44's BIMS Assessment, dated 09/02/25, revealed, intact cognition as indicated by a BIMS score of 13 out of 15. Record review of Resident #44's EMR on 09/12/15 revealed, no record of a bed rail consent form or bed rail assessment. An observation and interview on 09/12/25 at 11:05 AM revealed, Resident #44 in bed with grab assist bed rails on both sides of his bed. He said the bars were present upon admission, he was not trained on the use of the bar, was not assessed for the use of the bar or give gave consent for the use of the rail. He said he used the bars but they were shaky so he was concerned about using them. In an interview on 09/12/25 at 11:53 AM, the DON said all residents had mobility bars immediately upon admission because the facility did not consider them bed rails. She said upon admission nursing and therapy staff should assess residents for bed rail safety but at this time she did not know who was responsible for the task in the facility and she needed to clarify. The DON said only therapy had the competency to assess a resident's functional ability to determine their need for bed rails and to ensure residents were safe to use them. She said failure to assess a resident prior to the use of bed rails could place them at risk for skin tears, discoloration, fall and possible injury. In an interview on 09/12/25 at 01:32 PM, the Administrator said upon admission the admitting nurse was expected to assess resident's, but the facility did not call mobility bars, bed rails. She said it was an interdisciplinary effort between nursing, therapy and the IDT team to determine if a resident was appropriate for a bed rail. She said mobility bars were considered grab bars and assist bars and prior to use, the facility required consent from the resident or their RP. The Administrator said she did not know if the facility attempted to use alternatives prior to implementation of mobility bars and she would have to check with the nursing team but any attempted alternatives if applicable should be documented in the resident's chart. The Administrator could not answer if nurses, especially LVNs, had the competencies to assess a resident's appropriateness for mobility bars (bed rails) and she would have to clarify. She said failure to assess residents for their functional ability and safety to use a mobility bar (bed rail) could place them at risk of accidently hitting the bed rail, bruising and skin discoloration. The Administrator said confused residents or those with dementia were at a higher risk of injuries with mobility bars. Record review of the facility's policy on Bedrails, last revised April 2025, reflected in part: .It is the policy of this facility to attempt to use appropriate alternatives prior to installing a side rail or bed rail. If a bed or siderail is used, the facility must ensure correct installation, use, and maintenance of bedrails.Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail.Examples of bed rails include, but are not limited to: siderails, bedrails, safety rails: and grab bars and assist bars.After the facility has attempted alternatives to bedrails and determined that these alternatives failed to meet the resident's assessed needs the facility interdisciplinary team (IDT) will assess the resident for risk of entrapment.If the resident use of bedrails is recommended by the IDT, the facility must obtain informed consent from the resident, or if applicable, the resident representative for the use of bedrails prior to installation or use.Update the resident care plan as needed related to the identified and/or ongoing need or resident choice for the use of bedrails. This was determined to be an Immediate Jeopardy (IJ) on 09/12/2025 at 3:16 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 09/12/2025 at 3:16PM.The following Plan of Removal (POR) was submitted by the facility and was accepted on 09/14/25 at 2:02PM. PLAN OF REMOVAL F700 Name of facility: 09/13/2025 Immediate Action POR F-700 Facility failed to ensure residents were assessed and educated for the use of bed rails, bedrails are default, consent is not given, and alternatives are not attempted prior to initiation. Resident #84 was observed entrapped in a sheet between the mobility bar and the head of the bed.1. The Medical Director was notified of the IJ by the Executive Director on 9/12/2025 at 4:51 pm.2. Head to toe assessment on Resident #84 was completed on 09/12/2025 by the charge nurse for any signs or symptoms of injury. No injuries were noted. Resident #84 was screened by physical therapy and met the criteria for mobility bars. A bed rail safety assessment was completed on 09/13/2025 by the IDT that included a physical therapy screen where it was indicated that the resident requires mobility bars for increased independence and can utilize them appropriately. No issues were identified regarding safety during the use of mobility bars. Maintenance director designee performed a bed safety assessment, and no issues were identified. Resident has floor mats in place on both sides of the bed and bed in lowest position already. Resident will be monitored every hour by nursing staff and documented in POC/ PCC. The least restrictive device recommended for this resident to aid in mobility is mobility bars. After a lengthy discussion with physical therapy, there is not a suitable alternative when mobility bars are used for their intended purpose of enhancing a resident's independence and functional mobility as is the case with this resident. If the mobility bars were removed, it would have a negative impact not only on this resident's physical capabilities, but her emotional well-being as she heavily relies on the mobility bars to turn and reposition self in bed. The risks and benefits of the mobility bars were discussed with the family member by nursing management on 09/12/2024 and again by the Executive Director on 09/14/2025. The Family Member agreed on the continued use of the mobility bars. The Care plan was updated with interventions by the MDS coordinator on 09/12/2025 and updated again on 09/13/2025.3. Facility-Wide Bed Audit: A comprehensive audit of all facility beds, both occupied and unoccupied, was completed on 09/12/2025 by Administrator/ designee. All mobility bars (bed rails) on unoccupied beds were removed by the Maintenance Director/ designee. All residents identified with mobility bars on their bed were screened by physical therapy for need of mobility bars, and if the resident was found to need a mobility bar, the IDT met and discussed and completed a bed rail safety assessment. This was completed by 09/13/2025.4. On 09/12/2025, a facility-wide evaluation of all residents was conducted by the Director of Nursing (DON) or designee, Nurse Managers, and cluster partners. The LN Restraint/Enabling Device/Safety Device Evaluation - V2 [ tool was utilized to identify which residents will benefit from mobility bars. For residents who were identified as not benefiting from mobility bars, those devices were immediately removed by the maintenance director/ designee. On 09/13/2025, all residents were screened by physical therapy for need of mobility bars. A note was entered into PCC. No risks were identified regarding safety for the use of mobility bars. A bed rail safety evaluation was completed by the IDT for all residents identified as needing mobility bars. This was completed by 09/13/2025.5. For residents determined to benefit from mobility bars per therapy screen, appropriate physician orders were obtained, informed consents were secured for residents missing consents that included education on risks and benefits, and care plans were updated with interventions. Administrative nurse and clinical resource nurses obtained the orders. MDS nurses updated the care plans. Administrative nurses obtained consents. Target completion date: 09/13/20256. On 09/12/2025, the DON/ designee provided education to all licensed nurses. Training topics included but were not limited to: Proper completion of the LN Restraint/Enabling Device/Safety Device Evaluation - V2, review of the facility's bed rails policy, obtaining informed consent, including discussion of potential risks and benefits with the resident/ responsible party, obtaining physician orders when bed rails are indicated. All training will be completed before nurses begin their next shift. CNAs will be educated on the use of mobility bars that will also include risks/ benefits by 09/13/2025. Those residents that have mobility bars, will have that indicated in the resident care profile which pulls over to the CNA Kardex. A member of the management team will be present at each shift change to ensure completion. Nursing staff will not be allowed to work until training is completed. Training will be part of new hire orientation and mandatory for PRN staff before working on the floor. Target Completion Date: 09/13/2025.7. The Director of Rehabilitation Therapy re-educated physical therapy staff on completing a Therapy Consult screen and documenting with a note determining the need for mobility bars on all new admissions/ re-admissions by the next business day. This was completed 9/13/2025.8. The DON/designee administered post-training tests to nurses regarding the mobility bars protocol. Target completion date: 09/13/20259. The Interdisciplinary Team will review new admission/ re-admissions for the need for side rails/ mobility bars the next business day. The DON/ designee will be responsible for monitoring the process and ensure residents have completed assessments, care plans are updated with interventions, orders are obtained, and consents are secured.10. During the facility's weekly systems review, the Interdisciplinary Team (IDT) will review all residents currently utilizing mobility bars or other safety devices to ensure continued compliance, appropriateness of use, and documentation accuracy. In addition to the weekly reviews, these residents will be evaluated quarterly by the IDT.11. An ad hoc QAPI meeting regarding items in the IJ template was completed on 09/12/2025. Attendees included the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions.12. A summary of the IJ and corrective actions will be reviewed by the QA PI Committee:- Weekly for 4 weeks or until substantial compliance is achieved.- Then monthly for 90 days to ensure ongoing compliance. Monitoring of the Plan of Removal included the following: Interview on 09/15/25 at 10:57AM via phone, RN F said he worked the 6PM-6AM shift. RN F said he received an in-service on bedrails twice from the DON and Unit Managers. RN F said the in-service included assessing all new residents and readmits for mobility bars to see if they would benefit from using the bars. RN F said the resident or RP would have to be educated on the use of mobility bars about the benefits as well as the risk. RN F said a resident with severe mental cognition or required total care should not have mobility bars on their bed. RN F said once the nurse assessed the resident for mobility bars and thought they could benefit from the bars being on their bed, the Physical Therapy Department would then do an assessment. RN F said an IDT meeting would be held to discuss the use of the mobility bars, the Physician/NP was notified to get an order, and a consent was signed. RN F said when mobility bars were on a resident bed, the resident should be monitored for safety on every shift at least every 30 minutes to an hour or sooner pending the circumstance. RN F said the resident care plan had to be updated. Interview on 09/15/25 at 11:15AM with RN G via phone said she worked at the facility from 6PM-6AM. She said she was in-serviced on bedrails along with the risk and benefits. RN G said before the mobility bars were placed on a resident bed, the resident had to be assessed by the nurse as well as the Physical Therapy Department. RN G said the resident or RP had to be informed about the pros and cons of the mobility bars. RN G said an IDT meeting was done, physicians were notified and consent needed to be signed along with updating the resident care plan. Interview on 09/15/25 at 11:35AM, CNA AG via phone said she worked at the facility from 10PM-6AM full time. CNA AG said she was in-serviced to search in the POC to see if the resident had mobility bars on the bed. CNA AG said she was also in-serviced on the risk and benefits of mobility bars. Interview on 09/15/25 at 12:13 PM, LVN K said she worked the 6AM-6PM shift full time. LVN K said she was in-serviced on the risk and benefits of mobility bars. The risks were entanglement, entrapment, skin alterations, and it could decrease the resident mobility due to resident becoming dependent on the mobility bars. The benefits of the mobility bars were helping the residents position themselves in bed during care, transfers from bed to chair and chair to bed, and offering the residents some sense of security. LVN K said before mobility bars were attached to a resident bed, the resident had to be assessed by the nurse and rehab, an IDT meeting had to be held, physician or NP had to be contacted, and a consent had to be signed. LVN K said the resident care plan had to be updated. LVN K said the resident had to be continuously monitored for safety risk. LVN K said a resident who required total care should not have mobility bars on their bed. Interview on 09/15/25 at 12:32 PM, CNA AR said she worked at the facility full time from 6AM-2PM. CNA AR said she received in-services on residents who had mobility bars to make rounds on the residents every 30 minutes while in bed to ensure the residents' safety. CNA AR said the in-service included the risk and benefits of mobility bars, how to assist the residents with the mobility bars, and to look in the POC to see what residents were utilizing the mobility bars on their beds. Interview on 09/15/25 at 12:28 PM, the treatment nurse said she worked at the facility every other weekend. The treatment nurse said she received in-service on mobility bars to review LN in the computer regarding assessment of mobility bars, restraints, and enablers. The treatment nurse said on any new admission or readmit, the resident had to be assessed for usage of mobility bars. The treatment nurse said if the resident met the criteria, before the mobility bars could be placed on their bed, the Rehab Department had to do an assessment, and an IDT had to be done. The treatment nurse said once it was decided that residents could benefit in having the mobility bars on their bed, the resident or RP would be educated on the risk and benefits, a doctor order had to be obtained, and the resident care plan had to be updated regarding mobility bars. The treatment nurse said the residents needed to be reassessed quarterly or experienced a changed in condition. Interview on 09/15/25 at 12:40 PM, the therapy aide said she received in-service on mobility bars and an assessment needed to be done on the resident by the Rehab Department, the resident had to be educated on the risk and benefits of having the bars on their bed and get an order from the physician. The therapy aide said she would have to look in PCC to see if the resident was assessed for mobility bars on their bed. Interview on 09/15/25 at 12:47 PM, the MDS nurse said she worked at the facility Monday through Friday. The MDS nurse said she received in-service on the importance of educating the resident or RP about the risk and benefits of mobility bars, making sure the resident as assessed for mobility bars, getting a physician order and consent from the resident or RP. The MDS nurse said prior to mobility bars being attached to the resident bed, and IDT

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (CR #1) reviewed for quality of care. - The facility failed to act on 08/24/25 when CR #1's family member notified the nurse of slurred speech and altered mental status that indicated a stroke until 08/25/25. - On 08/25/25 CR #1 was transferred to the hospital where he was diagnosed with acute ischemic infarct (a type of stroke where blood flow to a part of the brain is interrupted, causing brain tissue to die). After the stroke CR #1 suffered from a significant ADL decline going from walking 150 feet with supervision to being unable to walk more than 3 steps with substantial/maximum assistance. An Immediate Jeopardy was identified on 09/10/25. The IJ template was provided to the Administrator and DON on 09/10/25 at 1:06 PM. While the immediacy was removed on 09/14/25 at 02:04 PM, the facility remained out of compliance at a severity level of no actual harm, with a potential for more than minimal harm that was not an immediate jeopardy, and at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Failure outside of the IJ - The facility failed to obtain a physician order to discontinue Resident #12's mid-line that had been inserted on 08/05/25. The resident completed her IV antibiotic therapy on 08/28/25. The facility did not obtain an order to discontinue resident mid-line until 09/10/25. These failures could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, suffering, and death. Findings included Record review of CR #1's Face Sheet, dated 09/09/25, revealed, a [AGE] year-old male, admitted on [DATE], diagnoses including metabolic encephalopathy (change in the brain that can cause confusion and memory loss), difficulty walking, high blood pressure, and elevated liver enzymes. CR #1 discharged to the hospital on [DATE]. Record review of CR #1's admission MDS, dated [DATE]. revealed moderately impaired cognition as indicated by a BIMS score of 11 out of 15, no acute onset mental status change, no behaviors, no upper or lower body impairment and the use of a crane/crutch. Record review of CR #1's undated Care Plan revealed, Focus- Had an alteration in neurological status r/t Metabolic encephalopathy; Goal: Monitor for Confusion, Memory Problems, Drowsiness and Lethargy, Muscle Weakness and Fatigue, Breathing Difficulties. Record review of CR #1's PT Progress Note dated, 08/22/25 at 08:56 AM, revealed CR #1 could walk 150 feet with only supervision or touching assistance and his Mobility Function Score was 10 out of 12 with 12 being the highest function). - Lying to sitting on side of the bed: Setup or clean-up assistance. - Chair/bed to chair transfer: supervision or touching assistance. - Ambulation - Walking 150 feet with supervision or touching assistance. - Mobility Function Score (ranges from 0-12; 12 being the highest function) = 10. Record review of the facility 300 Hall 24 Hour Report log revealed: - On 08/24/25 there was nothing documented regarding CR #1. - On 08/25/25 CR #1 experienced a change in condition: decreased cognition and STAT orders for CBS, BMP, UA with CS were entered. On 08/26/25 CR #1 was transferred to the hospital on [DATE] for AMS. Record review of CR #1's NP Progress Note, dated 08/25/25, revealed, History: visit type- family concern; LVN J notified this FNP patient family is concerned and reporting he is having AMS, decreased cognition and follow up visit completed. ROS: Musculoskeletal: Muscle Weakness. Neurological: AAOx3, sensation normal to touch. Negative tongue deviation. Face is symmetrical. Motor strength strong and equal in BUE and BLL. ASSESSMENT & PLAN: AMS/Cognitive Decline-acute illness that poses a threat to bodily function-Ordered STAT CBC, BMP, and UA with C&S if indicated. Called [Family Member #1] and notified her of my evaluation and orders given. She requested (Resident #1) be sent to ED for eval and this done per her request. Record review of CR #1's Change in Condition Evaluation dated 08/25/25 signed by LVN J revealed, the change was effective on 08/25/25 at 01:00 PM and CR #1 experienced decreased cognition. Nurse observed decreased cognition and slower speech from CR #1, increased confusion and needed more assistance with ADLS and dressing. The NP was notified on 08/25/25 at 12:57 PM and orders were given for STAT CBC with differential, BMP and UA with CS. CR #1 experienced a personality change, he was not cooperating as usual and no neurological changes were observed. Record review of CR #1's Progress Note, dated 08/25/25 at 06:06 PM, signed by LVN J revealed the Nurse received verbal order to send patient to hospital non emergent to evaluate slurred speech and decreased cognition Family Member #1. Nurse called EMS for transport. Nurse called. Report given to EMS staff. Patient was being picked up at this time. Family Member #1 was notified of patient departure. Record review of CR #1's Hospital Records, dated 08/25/25 to 09/02/25, revealed CR #1 arrived at the hospital on [DATE] at 06:58 PM and discharged on 09/02/25 at 08:24 PM. Record review of CR #1's Hospital Records MRI of the Brain, dated 08/25/25, revealed Acute non-hemorrhagic infarcts (acute ischemic stroke). Record review of CR #1's Hospital Inpatient neurology consult, dated 08/26/25 at 04:04 PM, revealed Chief Complaint- patient present with slurred speech. General: Patient is alert and oriented to name, hospital with choices, not time. Speech is halting with frequent pauses for word findings sometimes unable to continue his thought. Assessment & Plan: cerebrovascular accident (medical condition caused by a loss of blood flow to the brain) due to embolism (a condition where a blood clot or other foreign material travels through the blood stream and blocks a blood vessel). MRI brain (scan of the brain) revealed acute infarcts. Record review of CR #1's Hospital Discharge summary, dated [DATE], revealed Hospital Course: This is a [AGE] year-old male with past medical history of HTN, obesity, anemia of chronic disease presented from SNF due to worsening confusion and slurred speech was noted to have acute CVA to left midbrain and left frontal lobe. Neurology was recommended to continue DAPT (treatment with 2 blood thinners) aspirin and Plavix for 21 days and then monotherapy (single treatment) with aspirin. Patient has had behavioral and mood changes which neurology has attributed to his recent stroke. He is being discharged to an Inpatient Rehab facility in good condition for further therapies. Outpatient follow-up with neurologist. Record review of CR #1's Hospital Physical Therapy Flowsheets dated 09/02/25 revealed, Transfers- substantial to maximum assistance. Distance with walker- 3 steps with substantiate/maximum assistance with 2 people with a front wheeled walker. In an interview on 09/08/25 at 03:56 PM, Family Member #1 said when she spoke to CR #1 on Sunday, 08/24/25, the resident did not seem the same. She said CR #1 had slurred speech and a change in his condition so she contacted the facility. Family Member #1 said CR #1's nurse said there was no doctor on site since it was a Sunday, but she would notify administration and the change would be discussed in the facility's morning meeting on Monday. She said she knew the facility typically had their morning meeting around 10 AM so she waited until after the meeting on Monday 08/25/25 to follow up on CR #1's change in condition. Family Member #1 said when she called on Monday, she was notified that the resident's vitals were normal and was advised to schedule CR #1 to see a neurologist (doctor who specializes in disorders of the brain, spinal cord and nerves). Family Member #1 said she spoke to the NP who said she could wait for CR #1 to see the neurologist or she could send him out to the ER. She said she requested CR #1 be sent to the hospital for further evaluation, and when admitted , the hospital said CR #1 had 2 strokes. Family Member #1 said since the strokes the resident suffered a significant decline. Prior to the strokes the resident had good memory and received PT/OT and walked 125 feet independently while tethered (attached to an object or individual) but now the resident had to be followed by the turn team and needed significant speech therapy. The resident could not swallow now, had a modified diet and was unable to even open his phone. Family Member #1 said she noticed CR #1's slurred speech on 08/24/25 in the afternoon and the resident was not sent out till over 24 hours later, on 08/25/25, which resulted in his change of condition and hospitalization from 08/25/25 to 09/02/25. In an interview on 09/09/25 at 09:05 AM, LVN J said on 08/24/25 she was notified by Family Member #1 that CR #1 experienced a change in condition that he had slurred speech and he was a little different so she said she immediately notified NP A. She said NP A assessed the resident and gave orders to send him to the Hospital for further evaluation. LVN J said NP A said he did not need to go out 911 so she requested emergency transportation In an interview on 09/09/25 at 12:07 PM, RN H said she was no longer employed with the facility. She said on Sunday, 08/24/25, Family Member #1 reported that CR #1 was confused and unable to articulate his words. She said she assessed the resident and there was nothing wrong so she spoke to Family #1 about getting a consultation because his symptoms were most likely early dementia. RN H said CR #1 had paused thinking but he did not have slurred speech, he could not articulate his words and when he spoke you had to give him time. She said she told Family Member #1 she could request a psych consultation for Monday. RN H said she did not document Family Member #1's complaint or her assessment of CR #1, she did not send out any notifications and she did not communicate the events to the night shift nurse. In an interview on 09/09/25 at 12:37 PM, NP A said symptoms of stroke included slurred speech and altered mental status. She said the facility's stroke protocol was to notify the provider immediately of any symptoms of a stroke. She said If she was in the facility at the time of the notification she would see the resident immediately if she was not in the facility she would rely on the nurses assessment and description of symptoms. She said on 08/25/25 she was notified of CR #1's family members concerns that the resident had altered mental status and slower cognition. NP A said when she assessed CR #1 he was tired and fatigued but he did not have slurred speech, and he had normal neurological response. She said Family Member #1 was concerned CR #1 had a stroke so she told them the only way to absolutely rule out a stroke was with imaging, so Family Member #1 requested CR #1 be sent to the hospital for further evaluation. NP A said she was not aware CR #1's symptoms were reported on Sunday, 08/24/25. She said she was the on call provider on the weekends (Sunday, 08/24/25) and no notification was sent to her or her supervising physician prior to 08/25/25. NP A said she expected to be notified of any resident changes reported or identified and delayed notification of a resident's change in condition could result in delayed identification and treatment of conditions. She said delayed identification/treatment of a stroke could result in worsening symptoms like slurred speech, one sided weakness, decreased strength and decreased speech. NP A said, I will be honest, I don't think it was a stroke. In an interview on 09/09/25 at 01:00 PM the DON said when a resident had a change of condition or a family member expressed concerns of a change of condition the resident should be immediately assessed, notification should be sent out to the: provider, staff and then the resident's representative; and the information documented in the resident's chart as a change in condition. She said it didn't matter if the event occurred over the weekend or on the weekday, the resident should be assessed with the information documented and notifications sent out to the provider and the family. She said signs and symptoms of a stroke included drooling, general fatigue, slurred speech, changes in speech, and sometimes the resident could not speak. The DON said if a resident displayed symptoms of a stroke staff should immediately assess the resident, document it as a change of condition send notification to the NP and send the resident to the hospital via 911. She said a delay in identification and intervention on a stroke could result in worsening symptoms and the resident suffering multiple strokes. The DON said she only found out about the delayed notification of CR #1's family concerns about stroke after she returned from leave in September. She said RN H failed to report the concerns on 08/24/25 and LVN J caught it on Monday, 08/25/25 and too her knowledge no information was communicated to the provider or facility administration about CR#1's slurred speech or altered mental status from Sunday to Monday. She said the 5 hour wait until CR #1 was transferred to the hospital was unacceptable. Record review of the facility policy titled Charting and Documentation, dated 05/2007 revealed, 1. A charting entry should be made every shift when a resident status reflects unstable condition. The following are examples of conditions which will require documentation every shift: 2- unstable physical conditions which require every shift monitoring of . any other nursing observations that are indicated. 7. Responsible party of family contacts in person or per telephone. Record review of the facility policy titled 24 Hour Report Summary, dated 05/2007 revealed, policy: it is the policy of this facility to use a 24-hour report summary as a communication tool in the ongoing resident evaluation process. Purpose: The 24-hour report summary is used to track individual resident events ,conditions, or symptoms over a period of one month. The information is logged from the daily 24-hour report and is a significant tool in the ongoing resident evaluation process. It provides a comprehensive picture of the resident and is more likely to identify changes in status than a one time snapshot obtained through a formal assessment. 2- Instructions for completion: Name of the resident in room number. Date. Unit. The following information should be included on the 24-hour report but not limited to: Change in condition. Record review of the facility policy titled Change in Condition, dated 06/2019 revealed, 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): Change or a trending change in vital signs; Change in ability or decline in physical function; Change in mental status. 2. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. 3. The resident will then be placed on the 24-Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs, needed assist and resident behavior / acceptance of increased need of assistance will be monitored. 4. The nurse will communicate the change to the Resident and/or Responsible Party and to other departments as appropriate. Updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his / her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. The resident / resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care. 6. Each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly. The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident Electronic Medical Record (EMR). This was determined to be an Immediate Jeopardy (IJ) on 09/10/25. The Administrator and DON were notified. The Administrator was provide with the IJ template on 09/10/25 at 1:06 PM. The following Plan of Removal submitted by the facility was accepted on 09/11/25 at 10:50 AM. Plan of removal for F684: 09/10/2025 CR#1 experienced a delay of over 24 hours in identification and treatment after he displayed signs and symptoms of stroke including slurred speech, slow speech, altered mental status, and fatigue. Upon admission to the hospital, CR#1 was diagnosed with an acute ischemic infarct due to a suspected embolism. 1. The Medical Director was notified of the IJs by the Executive Director on 09/10/2025 at 1:38 pm. 2. The attending nurse practitioner was notified of the IJs by the Executive Director on 09/10/2025 at 1:52 pm. 3. CR#1 was discharged to the hospital on [DATE] and did not return to the facility after that. He was discharged to inpatient rehab from the hospital. The RN who worked 8/24/2025 received a disciplinary action and is no longer employed with the facility. The nurse that worked 8/25/2025 day shift will be provided with 1-on-1 education and training by 09/11/2025 regarding timely transportation of residents to the hospital after orders are received from the MD/ NP. 4. An audit was completed by the DON/designee on 09/10/2025 for all residents with a history of stroke. A head-to-toe assessment was conducted on these residents by the DON/designee, ADON, MOS, Clinical Resource Nurse, and Nurse Managers to ensure no active signs or symptoms of stroke are present. No residents with active signs/ symptoms of stroke were identified. 5. Education initiated on 09/10/2025 by DON/ designee on licensed nurses that included- A. Stroke/ TIA protocol including identification of signs and symptoms B. Change of condition which includes timely notification to MD/NP, DON, and RP. C. Communication- between nursing (24-hour report) and between nursing staff and provider D. Documentation and charting which includes notification to nurse management, MD/ NP, and RP. E. Head to toe assessment with competency checks all licensed nurses. F. Emergency and non-emergency transfers and notification to MD/NP if there is a delay in transport arrival. G. Resident/ family concerns regarding COC which includes notification to the MD/ NP of the concerns reported and assessment findings. Target completion date: 09/11/2025 6. Education initiated on 09/10/2025 by DON/ designee on all staff that included- A. Stroke/ TIA protocol including identification of signs and symptoms. B. Change of condition C. Resident/family concerns regarding COC Target completion date: 09/11/2025 7. Nurses are responsible for notifying the DON/ designee upon identification of a change of condition. DON/ designee will review the 24-hour report daily for change of condition with timely notification of MD/ NP. 8. Care plans will be updated for all residents with a history of stroke to include personalized/ individualized interventions/ prevention-this will be completed by MDS coordinator/ designee to be completed 9/10/2025. 9. The DON/designee will administer post-training tests to all staff regarding the stroke protocol. Testing began on 09/10/2025 and will be completed by 09/11/2025. 10. All training and competency checks will be completed in-person before staff begin their next shift. A member of the management team will be present at each shift change to ensure completion. Staff will not be allowed to work until training and competencies are completed. Training will be part of new hire orientation and mandatory for PRN staff before working on the floor. Target Completion Date: 09/11/2025. 11. An ad hoc QAPI meeting regarding items in the IJ template will be completed on 09/11/2025. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions. 12. A summary of the IJ and corrective actions will be reviewed by the QAPI Committee: Weekly for 4 weeks or until substantial compliance is achieved. Then monthly for 90 days to ensure ongoing compliance. Monitoring of the POR In an interview on 09/13/25 at 09:20 AM, LVN J said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/12/25. LVN J displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:23 AM, MA D said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition within the last 3 days. MA D displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:27 AM, PTA H said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/11/25. PTA H displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:20 AM, RN E said he received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/12/25. RN E displayed competency on the topics he received training on. In an interview on 09/13/25 at 09:27 AM, LVN K said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/11/25. LVN K displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:27 AM, MA C said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/11/25. MA C displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:20 AM, RN F said he received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition in the last view days. RN F displayed competency on the topics he received training on. In an interview on 09/13/25 at 01:18 AM, CNA AR said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition within the last 3 days. CNA AR displayed competency on the topics she received training on. Record review for POR monitoring revealed: - On 09/10/25 the facility had an ad hoc QAPI meeting regarding notification of changes, quality of care and changes of condition. The DON, ADONs, Administrator and Medical Director were in attendance. - On 09/10/25 the facility in-serviced all staff on Stroke Protocol/signs and symptoms of a stroke. Residents #5, #24, #27, #120 and #126 were identified as having history of stroke without the appropriate care plan and their care plans were updated appropriately. - On 09/10/25 the facility in-serviced all staff on changes of condition, stop and watch early warning tool, documentation and notification of change. - On 09/11/25 the DON completed a 1on1 in-services with LVN J on CIC, Nursing Communication, Physician Notification, Stroke Police, Hospital Transport - On 09/10/25 the facility in-serviced all staff on documentation, change of condition and required charting. - On 09/10/25 the facility in-serviced all staff on Hospital Transport. - On 09/10/25 the facility in-serviced nurses on Nursing communication and 24-hour report/rounding. - On 09/10/25 the facility in-serviced all staff on Resident/Family concerns regarding a change in condition. - On 09/10/25 the facility completed competency assessments on stroke for both licensed and non-licensed staff. - On 09/10/25 the facility completed competency assessments with all licensed staff on Changes of Condition - On 09/10/25 the facility completed competency assessments on licensed and non-licensed staff for Head-to-Toe Assessments - On 09/10/25 the facility completed an audit of all changes of conditions from 07/10/25 to 09/10/25. All reported CIC had appropriately timed provider notifications. - On 09/10/25 the facility completed an audit on all residents with a stroke diagnosis: - Their Care Plans were audited- Residents #5, #24, #27, #120 and #126 were identified as having history of stroke without the appropriate care plan and their care plans were updated appropriately. - On 09/11/25 the DON completed a 1on1 in-services with LVN J on CIC, Nursing Communication, Physician Notification, Stroke Police, Hospital Transport - On 09/12/25 the facility completed an audit on the 24-hr. report for 09/11/25. - On 09/13/25 the facility completed an audit on the 24-hr. report for 09/12/25. - On 09/14/25 the facility completed an audit on the 24-hr. report for 09/13/25. An IJ was identified on 09/10/25. The IJ template was provided to the Administrator on 09/10/25 at 01:06 PM. While the IJ was removed on 09/14/25 at 02:04 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 8 residents (CR #1) reviewed for notification of changes. The facility failed to notify CR #1's physician when the resident's family member reported slurred speech and altered mental status on 08/24/25. On 08/25/25 CR #1 was transferred to the hospital where he was diagnosed with acute ischemic infarct (a type of stroke where blood flow to a part of the brain is interrupted, causing brain tissue to die). After the stroke CR #1 suffered from a significant ADL decline that left him unable to walk An Immediate Jeopardy was identified on 09/10/25. The IJ template was provided to the facility on [DATE] at 1:06 PM. While the immediacy was removed on 09/14/25 at 02:04 PM, the facility remained out of compliance at a severity level of no actual harm, with a potential for more than minimal harm that was not an immediate jeopardy, and at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, suffering, and death. Findings included: Record review of CR #1's Face Sheet, dated 09/09/25, revealed, a [AGE] year-old male, admitted on [DATE], diagnoses including metabolic encephalopathy (change in the brain that can cause confusion and memory loss), difficulty walking, high blood pressure, and elevated liver enzymes. CR #1 discharged to the hospital on [DATE]. Record review of CR #1's admission MDS, dated [DATE]. revealed moderately impaired cognition as indicated by a BIMS score of 11 out of 15, no acute onset mental status change, no behaviors, no upper or lower body impairment and the use of a crane/crutch. Record review of CR #1's undated Care Plan revealed, Focus- Had an alteration in neurological status r/t Metabolic encephalopathy; Goal: Monitor for Confusion, Memory Problems, Drowsiness and Lethargy, Muscle Weakness and Fatigue, Breathing Difficulties. Record review of CR #1's PT Progress Note dated, 08/22/25 at 08:56 AM, revealed CR #1 could walk 150 feet with only supervision or touching assistance and his Mobility Function Score was 10 out of 12 with 12 being the highest function- Lying to sitting on side of the bed: Setup or clean-up assistance.- Chair/bed to chair transfer: supervision or touching assistance.- Ambulation - Walking 150 feet with supervision or touching assistance.- Mobility Function Score (ranges from 0-12; 12 being the highest function) = 10. Record review of the facility's 24 Hour Report log ,dated 08/24/25, revealed no documentation of any changes to CR #1. Record review of CR #1's NP Progress Note, dated 08/25/25, revealed, History: visit type- family concern; LVN J notified this FNP patient family is concerned and reporting he is having AMS, decreased cognition and follow up visit completed. ROS: Musculoskeletal: Muscle Weakness. Neurological: AAOx3, sensation normal to touch. Negative tongue deviation. Face is symmetrical. Motor strength strong and equal in BUE and BLL. ASSESSMENT & PLAN: AMS/Cognitive Decline-acute illness that poses a threat to bodily function-Ordered STAT CBC, BMP, and UA with C&S if indicated. Called [Family Member #1] and notified her of my evaluation and orders given. She requested (Resident #1) be sent to ED for eval and this done per her request. Record review of CR #1's Change in Condition Evaluation, dated 08/25/25, signed by LVN J, revealed the change was effective on 08/25/25 at 01:00 PM and CR #1 experienced decreased cognition. Nurse observed decreased cognition and slower speech from CR #1, increased confusion and needed more assistance with ADLS and dressing. The NP was notified on 08/25/25 at 12:57 PM and orders were given for STAT CBC with differential, BMP and UA with CS. CR #1 experienced a personality change, he was not cooperating as usual and no neurological changes were observed. Record review of CR #1's SNF/NF to Hospital Transfer Form dated 08/25/25 revealed CR #1 was sent to the hospital from the facility on 08/25/25 at 05:35 PM. Record review of CR #1's Progress Notes revealed there were no documented notes on 08/24/25. Record review of CR #1's Progress Note, dated 08/25/25 at 06:06 PM, signed by LVN J revealed the Nurse received verbal order to send patient to hospital non emergent to evaluate slurred speech and decreased cognition Family Member #1. Nurse called EMS for transport. Nurse called. Report given to EMS staff. Patient was being picked up at this time. Family Member #1 was notified of patient departure. Record review of CR #1's Hospital Records, dated 08/25/25 to 09/02/25, revealed CR #1 arrived at the hospital on [DATE] at 06:58 PM and discharged on 09/02/25 at 08:24 PM to an in-patient rehab facility. Record review of CR #1's Hospital Records MRI of the Brain, dated 08/25/25, revealed Acute non-hemorrhagic infarcts (acute ischemic stroke). Record review of CR #1's Hospital Inpatient neurology consult, dated 08/26/25 at 04:04 PM, revealed Chief Complaint- patient present with slurred speech. General: Patient is alert and oriented to name, hospital with choices, not time. Speech is halting with frequent pauses for word findings sometimes unable to continue his thought. Assessment & Plan: cerebrovascular accident (medical condition caused by a loss of blood flow to the brain) due to embolism (a condition where a blood clot or other foreign material travels through the blood stream and blocks a blood vessel). MRI brain (scan of the brain) revealed acute infarcts. Record review of CR #1's Hospital Discharge summary dated [DATE] revealed, Hospital Course: This is a [AGE] year-old male with past medical history of HTN, obesity, anemia of chronic disease presented from SNF due to worsening confusion and slurred speech was noted to have acute CVA to left midbrain and left frontal lobe. Neurology was recommended to continue DAPT (treatment with 2 blood thinners) aspirin and Plavix for 21 days and then monotherapy (single treatment) with aspirin. Patient has had behavioral and mood changes which neurology has attributed to his recent stroke. He is being discharged to an Inpatient Rehab facility in good condition for further therapies. Outpatient follow-up with neurologist. Record review of CR #1's Hospital Physical Therapy Flowsheets dated 09/02/25 revealed, Transfers- substantial to maximum assistance. Distance with walker- 3 steps with substantiate/maximum assistance with 2 people with a front wheeled walker. In an interview on 09/08/25 at 03:56 PM, Family Member #1 said when she spoke to CR #1 on Sunday, 08/24/25, the resident did not seem the same. She said CR #1 had slurred speech and a change in his condition so she contacted the facility. Family Member #1 said CR #1's nurse said there was no doctor on site since it was a Sunday, but she would notify administration and the change would be discussed in the facility's morning meeting on Monday. She said she knew the facility typically had their morning meeting around 10 AM so she waited until after the meeting on Monday 08/25/25 to follow up on CR #1's change in condition. Family Member #1 said when she called on Monday, she was notified that the resident's vitals were normal and was advised to schedule CR #1 to see a neurologist (doctor who specializes in disorders of the brain, spinal cord and nerves). Family Member #1 said she spoke to the NP who said she could wait for CR #1 to see the neurologist or she could send him out to the ER. She said she requested CR #1 be sent to the hospital for further evaluation, and when admitted , the hospital said CR #1 had 2 strokes. Family Member #1 said since the strokes the resident suffered a significant decline. Prior to the strokes the resident had good memory and received PT/OT and walked 125 feet independently while tethered (attached to an object or individual) but now the resident had to be followed by the turn team and needed significant speech therapy. The resident could not swallow now, had a modified diet and was unable to even open his phone. Family Member #1 said she noticed CR #1's slurred speech on 08/24/25 in the afternoon and the resident was not sent out till over 24 hours later, on 08/25/25, which resulted in his change of condition and hospitalization from 08/25/25 to 09/02/25. In an interview on 09/09/25 at 09:05 AM, LVN J said on 08/24/25 she was notified by Family Member #1 that CR #1 experienced a change in condition that he had slurred speech and he was a little different so she said she immediately notified NP A. She said NP A assessed the resident and gave orders to send him to the Hospital for further evaluation. LVN J said NP A said he did not need to go out 911 so she requested emergency transportation. In an interview on 09/09/25 at 12:07 PM, RN H said she was no longer employed with the facility. She said on Sunday, 08/24/25, Family Member #1 reported that CR #1 was confused and unable to articulate his words. She said she assessed the resident and there was nothing wrong so she spoke to Family #1 about getting a consultation because his symptoms were most likely early dementia. RN H said CR #1 had paused thinking but he did not have slurred speech, he could not articulate his words and when he spoke you had to give him time. She said she told Family Member #1 she could request a psych consultation for Monday. RN H said she did not document Family Member #1's complaint or her assessment of CR #1, she did not send out any notifications and she did not communicate the events to the night shift nurse. In an interview on 09/09/25 at 12:37 PM, NP A said symptoms of stroke included slurred speech and altered mental status. She said the facility's stroke protocol was to notify the provider immediately of any symptoms of a stroke. She said If she was in the facility at the time of the notification she would see the resident immediately if she was not in the facility she would rely on the nurses assessment and description of symptoms. She said on 08/25/25 she was notified of CR #1's family members concerns that the resident had altered mental status and slower cognition. NP A said when she assessed CR #1 he was tired and fatigued but he did not have slurred speech, and he had normal neurological response. She said Family Member #1 was concerned CR #1 had a stroke so she told them the only way to absolutely rule out a stroke was with imaging, so Family Member #1 requested CR #1 be sent to the hospital for further evaluation. NP A said she was not aware CR #1's symptoms were reported on Sunday, 08/24/25. She said she was the on call provider on the weekends (Sunday, 08/24/25) and no notification was sent to her or her supervising physician prior to 08/25/25. NP A said she expected to be notified of any resident changes reported or identified and delayed notification of a resident's change in condition could result in delayed identification and treatment of conditions. She said delayed identification/treatment of a stroke could result in worsening symptoms like slurred speech, one sided weakness, decreased strength and decreased speech. NP A said, I will be honest, I don't think it was a stroke. In an interview on 09/09/25 at 01:00 PM the DON said when a resident had a change of condition or a family member expressed concerns of a change of condition the resident should be immediately assessed, notification should be sent out to the: provider, staff and then the resident's representative; and the information documented in the resident's chart as a change in condition. She said it didn't matter if the event occurred over the weekend or on the weekday, the resident should be assessed with the information documented and notifications sent out to the provider and the family. She said signs and symptoms of a stroke included drooling, general fatigue, slurred speech, changes in speech, and sometimes the resident could not speak. The DON said if a resident displayed symptoms of a stroke staff should immediately assess the resident, document it as a change of condition send notification to the NP and send the resident to the hospital via 911. She said a delay in identification and intervention on a stroke could result in worsening symptoms and the resident suffering multiple strokes. The DON said she only found out about the delayed notification of CR #1's family concerns about stroke after she returned from leave in September. She said RN H failed to report the concerns on 08/24/25 and LVN J caught it on Monday, 08/25/25 and too her knowledge no information was communicated to the provider or facility administration about CR#1's slurred speech or altered mental status from Sunday to Monday. Record review of LVN J's Orientation and Annual Skills Checklist: Licensed Nurses dated 10/02/24, revealed, Role of Charge Nurse: 2. Understands how to document & report change of condition and unusual occurrences to MD, Family and DON. A- change of shift reporting; b. when change of condition occurs documentation implementation. 5- Understands the use of: 1. 24 hour/alert charting book. V- Charting/Medical Records: 1- change of condition/skilled charting. VII: Admission, Transfers, Discharge & Death of Residents- 3- Understands how to discharge a resident to: Hospital or another facility and to emergency room. LVN J was documented as competent for all skills assessed. Record review of RN H's Orientation and Annual Skills Checklist: Licensed Nurses, dated 06/15/25 revealed, Role of Charge Nurse: 2. Understands how to document & report change of condition and unusual occurrences to MD, Family and DON. A- change of shift reporting; b. when change of condition occurs documentation implementation. 5- Understands the use of: 1. 24 hour/alert charting book. V- Charting/Medical Records: 1- change of condition/skilled charting. VII: Admission, Transfers, Discharge & Death of Residents- 3- Understands how to discharge a resident to: Hospital or another facility and to emergency room. RN H was documented as competent for all skills assessed.Record review of RN H's Counseling/Disciplinary Notice dated 09/02/25 revealed, Type of Action Being Taken Final Written Warning. 2. Reason(s) why counseling/disciplinary action is necessary: Employee was informed of a concern brought forth by Family Member #1 about a possible change in condition on 08/24/2025 evening. Employee stated that she immediately assessed the resident and there was no change of condition noted in the resident upon assessment. Employee failed to document the family concerns and assessment in the resident's chart and the 24-hour report for monitoring. Nurse was educated on the phone by the DON in front of the Administrator present on 09/02/2025 since the nurse had left on maternity leave effective 09/01/2025. Record review of the facility policy titled Charting and Documentation, dated 05/2007 revealed, 1. A charting entry should be made every shift when a resident status reflects unstable condition. The following are examples of conditions which will require documentation every shift: 2- unstable physical conditions which require every shift monitoring of . any other nursing observations that are indicated. 7. Responsible party of family contacts in person or per telephone. Record review of the facility policy titled Change in Condition, dated 06/2019 revealed, 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): Change or a trending change in vital signs; Change in ability or decline in physical function; Change in mental status. 2. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. 3. The resident will then be placed on the 24-Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs, needed assist and resident behavior / acceptance of increased need of assistance will be monitored. 4. The nurse will communicate the change to the Resident and/or Responsible Party and to other departments as appropriate. Updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his / her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. The resident / resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care. 6. Each department notified will perform their own evaluation and assessment to determine if thechange requires further intervention and implement actions accordingly. The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident Electronic Medical Record (EMR). This failure was identified as Immediate Jeopardy (IJ) on 09/10/25. The Administrator and DON were informed and was provided the IJ template on 09/10/25 at 1:06 PM. Plan of Removal (POR) was requested. The following Plan of Removal was submitted by the facility and was accepted on 09/11/25 at 10:50 AM. Plan of removal: 09/10/2025Facility staff failed to timely notify CR#1's provider after reported signs/ symptoms of stroke including slurred speech, slow speech, and altered mental status which resulted in a delay of over 24 hours in identification and treatment of a stroke. Upon admission to the hospital, CR#1 was diagnosed with an acute ischemic infarct due to a suspected embolism. 1. The Medical Director was notified of the IJs by the Executive Director on 09/10/2025 at 1:38 pm. 2. The attending nurse practitioner was notified of the IJs by the Executive Director on 09/10/2025 at 1:52 pm. 3. CR#1 was discharged to the hospital on [DATE] and did not return to the facility after that. He was discharged to inpatient rehab from the hospital. The RN who worked 8/24/2025 received a disciplinary action and was no longer employed with the facility. 4. An audit was completed by the DON/designee on 09/10/2025 for all residents with a history of stroke. A head-to-toe assessment was conducted on these residents by the DON/designee, ADON, MOS, Clinical Resource Nurse, and Nurse Managers to ensure no active signs or symptoms of stroke were present. No residents with active signs/ symptoms of stroke were identified. 5. An audit of all residents with changes in condition in the last 2 months will be completed by the DON/ clinical resource/ designee by 09/11/2025 for MD notification. Results were pending. 6. Education initiated on 09/10/2025 by DON/ designee on licensed nurses that included-A. Stroke/ TIA protocol including identification of signs and symptomsB. Change of condition which includes timely notification to MD/NP, DON, and RP.C. Communication- between nursing (24-hour report) and between nursing staff and providerD. Documentation and charting which includes notification to nurse management, MD/ NP, and RP.E. Head to toe assessment with competency checks all licensed nurses.F. Emergency and non-emergency transfers and notification to MD/ NP if there is a delay in transport arrival.G. Resident/ family concerns regarding COG which included notification to the MD/ NP of the concerns reported and assessment findings.Target completion date: 09/11/2025 7. Nurses are responsible for notifying the DON/ designee upon identification of a change of condition. DON/ designee will review the 24-hour report daily for change of condition with timely notification of MD/NP. 8. Education initiated on 09/10/2025 by DON/ designee on all staff that included-A. Stroke/ TIA protocol including identification of signs and symptoms.B. Change of conditionC. Resident/ family concerns regarding COC Target completion date: 09/11/2025 9. Care plans will be updated for all residents with a history of stroke to include personalized/ individualized interventions/ prevention-this will be completed by MDS coordinator/ designee to be completed 9/10/2025. 10. The DON/designee will administer post-training tests to all staff regarding the stroke protocol. Testing began on 09/10/2025 and will be completed by 09/11/2025. 11. All training and competency checks will be completed in-person before staff begin their next shift. A member of the management team will be present at each shift change to ensure completion. Staff will not be allowed to work until training and competencies are completed. Training will be part of new hire orientation and mandatory for PRN staff before working on the floor. Target Completion Date: 09/11/2025.12. An ad hoc QAPI meeting regarding items in the IJ template will be completed on 09/11/2025. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions.13. A summary of the IJ and corrective actions will be reviewed by the QAPI Committee: Weekly for 4 weeks or until substantial compliance is achieved. Then monthly for 90 days to ensure ongoing compliance Monitoring of the POR In an interview on 09/13/25 at 09:20 AM, LVN J said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/12/25. LVN J displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:23 AM, MA D said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition within the last 3 days. MA D displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:27 AM, PTA H said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/11/25. PTA H displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:20 AM, RN E said he received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/12/25. RN E displayed competency on the topics he received training on. In an interview on 09/13/25 at 09:27 AM, LVN K said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/11/25. LVN K displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:27 AM, MA C said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition on 09/11/25. MA C displayed competency on the topics she received training on. In an interview on 09/13/25 at 09:20 AM, RN F said he received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition in the last view days. RN F displayed competency on the topics he received training on. In an interview on 09/13/25 at 01:18 AM, CNA AR said she received training on the facility stroke protocol, changes in condition, communication between nurses, documentation, head to toe assessments, emergency and non-emergency transfers and resident/family concerns regarding changes in condition within the last 3 days. CNA AR displayed competency on the topics she received training on. Record review for POR monitoring revealed:- On 09/10/25 the facility had an ad hoc QAPI meeting regarding notification of changes, quality of care and changes of condition. The DON, ADONs, Administrator and Medical Director were in attendance.- On 09/10/25 the facility in-serviced all staff on Stroke Protocol/signs and symptoms of a stroke. Residents #5, #24, #27, #120 and #126 were identified as having history of stroke without the appropriate care plan and their care plans were updated appropriately.- On 09/10/25 the facility in-serviced all staff on changes of condition, stop and watch early warning tool, documentation and notification of change.- On 09/11/25 the DON completed a 1on1 in-services with LVN J on CIC, Nursing Communication, Physician Notification, Stroke Police, Hospital Transport- On 09/10/25 the facility in-serviced all staff on documentation, change of condition and required charting.- On 09/10/25 the facility in-serviced all staff on Hospital Transport.- On 09/10/25 the facility in-serviced nurses on Nursing communication and 24-hour report/rounding.- On 09/10/25 the facility in-serviced all staff on Resident/Family concerns regarding a change in condition.- On 09/10/25 the facility completed competency assessments on stroke for both licensed and non-licensed staff.- On 09/10/25 the facility completed competency assessments with all licensed staff on Changes of Condition- On 09/10/25 the facility completed competency assessments on licensed and non-licensed staff for Head-to-Toe Assessments- On 09/10/25 the facility completed an audit of all changes of conditions from 07/10/25 to 09/10/25. All reported CIC had appropriately timed provider notifications.- On 09/10/25 the facility completed an audit on all residents with a stroke diagnosis:- Their Care Plans were audited - Residents #5, #24, #27, #120 and #126 were identified as having history of stroke without the appropriate care plan and their care plans were updated appropriately.- On 09/11/25 the DON completed a 1on1 in-services with LVN J on CIC, Nursing Communication, Physician Notification, Stroke Police, Hospital Transport- On 09/12/25 the facility completed an audit on the 24-hr. report for 09/11/25.- On 09/13/25 the facility completed an audit on the 24-hr. report for 09/12/25.- On 09/14/25 the facility completed an audit on the 24-hr. report for 09/13/25.The Administrator was informed the Immediate Jeopardy was removed on 09/10/25 at 01:06 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 8 residents (Resident #25, Resident #38 and Resident #104) reviewed for environmental concerns. - The facility failed to ensure Resident #38's room door did not have a lock that required a key which resulted in the resident, who was bed bound with her ankle fixed with screws, being locked in the room and inaccessible for 15-20 minutes.- The facility failed to ensure Resident #25's dresser drawers did not swing open on their own, leaving the resident concerned that her head would be hit by the drawer.- The facility failed to ensure Resident #25 and Resident #104's bathroom door did not swing shut on its own.These failures could place residents at risk of falls, injuries, and decreased quality of life. Findings include: Resident #38 Record review of Resident #38's face sheet, dated 09/14/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: a fall, lower leg fracture, ankle fracture and she admitted for orthopedic aftercare (care after a surgery on systems like the bones, joints, muscles and tendons). Record review of Resident #38's, undated, Care Plan revealed, Focus: multiple fractures: closed displaced fracture of lateral condyle of right femur and open displaced fracture of left ankle and underwent In situ fixation (R) lateral fracture and Ex-revision of left ankle with external fixation and flap (left lower leg fracture and ankle fracture, fixed with rods going through ankle and transplant of tissue from left thigh to right ankle); Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly. Record review of Resident #38's admission MDS, dated [DATE], revealed intact cognition, as indicated by a BIMS score of 15 out of 15. Resident #38 had impairment of both lower extremities (both legs), use of a wheelchair, total dependence for functional abilities of: roll left and right, sit to lying, lying to sitting on side of bed and chair/bed-to-chair transfer. She could not be assessed for her ability to: walk, car transfer, toilet/tub/shower transfer or go from sit to stand. Surgical procedures: Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot) and she received surgical wound care. Record review of Resident #38's BIMS assessment, dated 09/02/25, revealed intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #38's Progress notes, from 09/11/25 to 09/14/25, revealed the following, - 09/13/2025 at 2:27 PM: Patient was assessed head to toe neurological assessment done, patient is alert and oriented x 4, no distress or discomfort observed. No complaint of pain verbalized. An observation on 09/13/25 at 01:18 PM revealed, Family Member #2 waiting at the nursing station as facility staff gathered around Resident #38's door attempting to open the door. Staff pulled and pushed at the door lever in an attempt to open the door and tried multiple keys, but the door would not open. Family Member #2 attempted to open the door forcefully pushing up and down on the lever and pushed and pulled on the door with no success. At 01:25 PM, the DON arrived with keys and opened the door to Resident #38's room. An observation and interview on 09/13/25 at 01:26 PM revealed Resident #38's door opened and an interior push lock that required a key to unlock on the exterior was observed on the door handle. There was a window facing the street and Resident #38 was in bed in no immediate distress with her call light within reach, her right ankle was fixed in place a metal pin/rod going through her entire ankle. The stopper was mounted to the wall and the interior push button locking mechanism engaged when the door was pushed into the stopper. Family Member #2 said he did not lock the door when he left the room and when he returned Resident #38's room door was locked and he and staff were unable to access the resident for 15-20 minutes. Resident #38 said she had her call light within reach, did not need any care while the door was locked and she would not have been able to open the door even if she wanted due to her leg being fixed with pins. An observation on 09/13/25 at 10:30 AM revealed no other resident rooms had a lock that required a key to open to gain access to the room from the corridor. At 10:30 AM, Resident #38's door lever was replaced with one that could not lock. In an interview on 09/13/25 at 01:50 AM, the Administrator said Resident #38's room door was locked and that was the only room in the facility that required a key to unlock from the exterior and she was unsure about how long the door was locked. She said no resident rooms should have a lock that restricted access for resident safety. She said the presence of a lock placed residents at risk of staff not being able to access them to provide services or under emergency conditions. The Administrator said the DON was able to unlock Resident #38's room with a universal key she had in her office. In an interview on 09/15/25 at 09:08 AM, Resident #38 said she only realized her door was locked when she heard people trying to get into the room, banging and pushing the door. She said when her door was locked, she did not need services, and her call light was within reach. Resident #38 said while her door was locked Family Member #2 went to her room window a bunch of time to check on her so she wasn't really concerned. In an interview on 09/15/25 at 09:12 AM, the Administrator said facility staff learned from Resident #38's family member the residents door was locked. She said the resident didn't need anything at the time and she did not miss any care because of the locked door and facility staff monitored the resident from the window. The Administrator said if there was an emergency and staff could not access Resident #38; they would have broke the window to gain access. Resident #25 Record review of Resident #25's face sheet, dated 09/12/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included: difficulty walking, hip fracture; she was at the facility for orthopedic aftercare. Record review of Resident #25's BIMS assessment, dated 09/01/25, revealed intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #25's, undated, Care Plan revealed Focus: fracture of left hip with surgical repair: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Focus: ADL Self Care Performance Deficit due to left hip fracture; Interventions: Requires staff participation with transfers. Requires staff assistance with incontinent care. Requires staff participation with reposition and turn in bed. Requires staff assistance with bathing/showering as per schedule and as necessary. Record review of the facility work order reports submitted from 08/01/25 to 09/12/25 revealed, no work orders documented to address self-closing doors, doors with locks that required keys to open or loose and self-opening drawers. An observation and interview on 09/12/25 at 10:55 AM revealed Resident #25 sat in her wheelchair at her bedside table located in front of the foot of her bed. There was a built in cabinet less than a foot in front of the residents head with the top 2 drawers open. Resident #25 said the drawers in her cabinet did not stay closed, which was not safe because it could hit her in the head. Resident #25 said as a result of the sliding drawers she left them open out of fear of hitting her head against them. She said she put in a service request with the maintenance director when she initially admitted and he said he would place a clip at the top to stop the drawers from sliding forward but nothing had been done yet. Resident #25 pushed the drawers closed and they were observed to slide open on their own, holding the drawers closed was the only way to ensure they stayed closed. The State Surveyor observed the contents of the drawer to only occupy less than 1/2 of the space, all rails or tracks were clear from any debris or clutter. Resident #25 said her bathroom door closed by itself, it did not stay open and it hit the back of her wheelchair when she went to the restroom, but she was not injured. She said the door closed too fast for her to make it through before it hit her and she was scared she could be injured by the door so she waited for staff to assist her with the door when she wanted to use the restroom. Resident #25 said it was inconvenient to wait for someone to hold the door of the restroom open, since it could take a while, so she put in a request with the maintenance department but she was informed nothing could be done since it was required by the safety inspectors. The door was observed to be self-closing when opened, with the door closing faster the wider it was opened. The force at which the door closed was not hard but the speed at which it closed would not allow an unsteady, slow paced individual to make it into the bathroom without getting hit. Resident #104 Record review of Resident #104's face sheet, dated 09/12/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #104 had diagnoses which included: difficulty walking, fracture in the top of the left shin bone, (tissue located in the knee joint) injury and was at the facility for orthopedic aftercare. Record review of Resident #104's BIMS assessment, dated 09/01/25, revealed moderately impaired cognition as indicated by a BIMS score of 09 out of 15. Record review of Resident #104's, undated, Care Plan revealed Focus: left shin bone fracture; Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Focus: ADL Self Care Performance Deficit r/t after care following orthopedic surgery r/t fracture of left lateral portion of left tibial plate. Interventions: Requires staff participation with transfers, Requires staff participation with reposition and turn in bed. In an interview on 09/14/25 at 12:02 PM, Resident #104 said her bathroom door was self-closing and she was informed by the Maintenance Director that nothing could be done due to fire and safety regulations. She said she had not suffered any injuries from the self-closing doors. In an interview on 09/14/25 at 09:36 AM, the Maintenance Director said he handled maintenance requests immediately once he received them, which was usually within 24 hours. He said he completed rounds in the facility, daily, weekly and quarterly and he inspected cabinets, beds and rails. The Maintenance Director said all cabinet drawers must close because if they didn't, the drawers could hit the resident and cause injury. He said Resident #25 notified him her drawers didn't close and when he inspected it, the cabinet was not leveled, and the rail mechanism that kept the door locked was worn which resulted in the drawer sliding open. The Maintenance Director said since the cabinet was built in, he could not level it so he installed a magnet as a mechanism to keep the drawer from swinging open. He said some resident rooms had swinging self-closing doors in order to prevent the levered door handles from the bathroom and room entrance from getting stuck together so he could not stop the doors from being self-closing. He said no residents had suffered any injuries due to the door. The Maintenance Director said self-closing doors placed residents at risk of having doors that closed on them which could cause injury. The Maintenance Director said prior to 09/13/25, he was unaware Resident #38's room door still had a door that required a key to unlock. He said Resident #38's room door had a lock because it was previously used as an office for MDS staff but when it was converted back to a resident room, the lock must not have been changed. The Maintenance Director said there were master keys with the DON, Administrator, himself and in a lock box by his office that could open doors in the facility in case of an emergency, but doors that required keys to unlock could place residents at risk of delayed care if something happened to them while they were locked in the room. In an interview on 09/15/25 at 01:24 PM, the Administrator said it was the maintenance director's responsibility to ensure the facility was in good and safe condition and no resident rooms should have locks on the doors. She said Resident #38's room used to be used as an office, but about 1 1/2 years ago it was converted back to a resident room, no one had ever been locked in the room in the past, and that was the only resident room that had a keyed lock. The Administrator said for a reason unknown Resident #38's room door became locked, but while facility staff tried to get access to the resident in the room other staff observed the resident through the window that faced the street. She said the resident was in no immediate distress, and once staff got access to the room she was assessed, and no injuries or concerns were identified. The Administrator said facility staff immediately inspected all door handles to ensure there were no other keyed locks and once they got access to the resident, Resident #38's room door was immediately changed to one that did not lock. She said drawers in resident rooms should not swing open on their own and maintenance was notified. She said locked resident rooms and loose drawers could place residents at risk of delay in care during an emergency and injury if hit by the drawer. The Administrator said self-closing doors could potentially hit residents increasing their risk of falls and injuries. Record review of the Maintenance Supervisor Job Description revealed, Position Summary: The primary purpose of your job is to supervise the Maintenance Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Executive Director, to assure that our facility is maintained in a safe and comfortable manner. The position may be classified as salaried exempt and is justified by a program requiring at least 50% of time dedicated to the management of the department and personnel. Essential Duties And Responsibilities: Coordinate daily maintenance services with nursing services when performing maintenance assignments in resident living and/or recreational areas. Promptly report equipment or facility damage. Record review of the facility's policy titled Quality of Life- Homelike Environment, revised 10/2009, revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Record review of the facility's, undated, policy titled Accident Prevention revealed, 29. Any other unsafe condition or potential hazard should be reported to the Administrator or DNS.

Based on observation, interview and record review the facility failed to ensure residents were free of any significant medication errors for 2 of 7 residents (Residents #2 and Resident #109) reviewed for significant medication errors. - The facility failed to ensure nursing staff administered pre-prandial (before a meal) insulin to Resident #2 safely by administering it more than 15 -minutes before meals on 25 occasions from 08/01/25 to 09/11/2025. - The facility failed to ensure nursing staff administered medication to Resident #109 as ordered when LVN K applied a Lidocaine patch to the resident's right knee without an order. These failures could place residents at risk of uncontrolled blood sugars, hypoglycemia (low blood sugars), hyperglycemia (high blood sugars), worsening of diabetes, medication errors and adverse reactions to medications. Findings include: Resident #2 Record review of the facility dining room meal teams revealed, Breakfast 07:45 AM to 08:15 AM, Lunch 11:45 AM to 12:15 PM, and Supper: 05:00 PM to 05:30 PM. Record review of the HumaLOG Highlights of Prescribing Information revised 03/2013 revealed, Subcutaneous (under the skin) Injection: Administer within 15 minutes before a meal or immediately after a meal. HUMALOG is a rapid-acting insulin. You should take HUMALOG within fifteen minutes before eating or right after eating a meal.Record review of Resident #2's face sheet, dated 09/17/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: kidney failure, enlarged prostate, irregular heartbeat and type 2 diabetes. Record review of Resident #2's Annual MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 12 out of 15. Resident #2 used a wheelchair and required partial to moderate assistance with all ADLs. Record review of Resident #2's Order, dated 02/26/25, revealed, HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals for diabetes : if 201 - 250 = 4 units SQ; 251 - 300 = 6units SQ; 301 - 350 = 8 SQ; 351 - 400 = 10 units SQ; 401 - 450 = 12 SQ; 451 -999 = Call MD/NP Call the MD/NP immediately for blood glucose greater than 451. Resident #2's HumaLOG was scheduled for 07:00 AM, 12:00 PM and 05:00 PM Record review of Resident #2's August 2025 MAR revealed Resident #2 received HumaLOG more than 15 minutes of scheduledmeals on: 1. 08/01/25 at 4:25 PM2. 08/01/25 at 11:33 AM3. 08/03/05 at 11:25 AM4. 08/03/25 at 07:02 AM5. 08/03/25 at 11:25 AM6. 08/03/25 at 04:48 PM7. 08/06/25 at 11:08 AM8. 08/09/25 at 11:19 AM9. 08/13/25 at 11:04 AM10. 08/18/25 at 11:03 AM11. 08/20/25 at 04:35 PM12. 08/23/25 at 06:21 AM13. 08/23/25 at 11:05 AM14. 08/24/25 at 04:20 PM15. 08/25/25 at 04:22 PM16. 08/27/25 at 11:20 AM17. 08/27/25 at 04:34 PM18. 08/28/25 at 11:13 AM19. 08/28/25 at 04:25 PM20. 09/01/25 at 04:23 PM21. 09/03/25 at 04:50 PM22. 09/04/25 at 02:30 PM23. 09/06/25 at 02:25 PM24. 09/07/25 at 11:05 AM25. 09/15/25 at 10:35 AM Record review of Resident #2's Progress Notes from 08/01/25 to 09/11/25 revealed, no documented episodes or signs and symptoms of hypoglycemia. Record review of Resident #2's Weight & Vitals: Blood Sugar dated 09/11/25 revealed, 11:31 AM- 181 An observation and interview on 09/11/25 at 11:30 AM revealed, LVM M prepared for insulin administration to Resident #2. She used a glucose meter to test the residents blood sugar on his left index finger and his result was 181. LVN M said the resident did not require insulin per his order and the resident ate his meals in the dining room. At 11:35 AM a CNA collected Resident #2 from his room and pushed him in his wheelchair to the dining area. An observation on 09/11/25 at 12:30 PM revealed residents sitting at tables in the dining area. Lunch had not been served; there was no food on Resident #2's table. In an interview on 09/15/25 at 12:29 PM, the DON said pre-prandial insulins were fast acting and they should be administered within 30 minutes of meals. She said pre-prandial insulin was administered before meals to treat high blood sugars and to also prevent spikes in blood sugar due to upcoming meals. The DON said pre-prandial insulin should not be administered early to prevent hypoglycemia and to ensure there was insulin available to treat the meal related blood sugar increase. She said prior to 09/11/25 the facility provided snacks after lunch and breakfast and not before breakfast or lunch so there was nothing in place to prevent hypoglycemia when meals were delayed. She said the facility had now moved Resident #2's insulin administration closer to his scheduled meals, trained nurses to hold insulin administration to within 30 minutes of meals and snacks were now available to resdients if meals were delayed. In an interview on 09/17/25 at 10:45 AM, NP A said pre-prandial (before eating) insulin was administered to treat blood sugars in anticipation of a meal and they should be administered not too long before meals, in a 30 minute window. She said failure to do so could place residents at risk for low blood sugars. In an interview on 09/17/25 at 10:50 AM, Resident #2 said he had not experienced any symptoms of hypoglycemia such as shaking or feeling weak or fatigued. Record review of the facility's policy titled Insulin Administration revised 10/2010 revealed, Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose; Rapid- acting insulin had an onset of 10-15 minutes. Resident #109 Record review of Resident #109's face sheet, dated 09/10/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #109 had diagnoses which included: stroke due to a blood clot, type 2 diabetes and paralysis to the right dominant side and Gastrostomy status (a tube passed through the abdomen into the stomach used for feeding and medication administration). Record review of Resident #109's admission MDS, dated [DATE], revealed severely impaired cognitive skills for daily decision making, total dependence for all ADLs and functional abilities and presence of a feeding tube while a resident was at the facility. Record review of Resident #109's, undated, Care Plan revealed Focus: potential for alteration in comfort; Intervention: follow pain scale to medicate as ordered. Record review of Resident #109's Order Summary Report, dated 09/10/25, revealed Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain. There were no other orders for pain management. Record review of Resident #109's Progress Notes, from 09/11/25 to 09/17/25, revealed the following- 9/11/2025 09:24 signed by LVN K: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition. NP order to monitor for any changes. Family member is aware of lidocaine pain patches she states her [Resident #109] used them prior at home and was not concern or warrant about the error. Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: Monitor site for any reaction. An observation and interview on 09/11/25 at 08:47 AM, revealed LVN K prepared for medication administration to Resident #109. She retrieved a Lidocaine 4% patch, performed hand hygiene, put on a pair of gloves and applied the patch to the resident's right knee. LVN K said prior to medication administration nursing staff must check against the orders and then against the medication to ensure the 5 rights, right time, right person, right medication, right dose. She said she mixed up the medication for Resident #109 and her roommate. She said Resident #109 did not have an order for the Lidocaine patch and she made a mistake. LVN K said she would immediately remove the patch from the residents knee and report the error to the NP and facility administration. She said failure to verify orders could place residents at risk for adverse events and allergic reactions. In an interview on 09/15/25 at 12:29 PM, the DON said all medications must be administered pursuant to a physician order and prior to administering medications staff must verify the orders against the MAR and the blister pack. She said failure to verify medications against a resident order could result in a medication error which could place residents at risk for adverse reactions such as skin irritation in the case of the Lidocaine Patch. The DON said the nurse reported the incorrect patch applied to Resident #1 and after assessment Resident #109 suffered no side effects. Record review of the facility policy Specific Medication Administration Procedures, revised 11/13/18, revealed General Procedures to follow for all medications: b. Check expiration date on package/container. c. Read medication label three (3) times before pouring. d. Identify resident before administering medication. These guidelines refer to all medications, in addition to specific procedures for each type of medication. Administration: m. Residents are identified before medication is administered. Methods of identification include: 1) Checking identification band 2) Checking photograph attached to medical record 3) Calling resident by name 4) If necessary, verifying resident identification with other facility personnel.

Based on observation, interview, and record review the facility failed to administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #12) residents reviewed for parenteral fluids.The facility failed to obtain a physician order to discontinue Resident #12's mid-line that had been inserted on 08/05/25. The resident completed her IV antibiotic therapy on 08/28/25. The facility did not obtain an order to discontinue resident mid-line until 09/10/25. This failure placed Resident #12 at risk for unwanted infections and further decrease in quality of life. Resident #12Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included chronic respiratory failure (difficulty breathing), type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy) cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy, colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag, and gastrostomy (surgical incision that creates an opening through the abdominal wall. A tube is inserted to provide nutrition, fluids, and medications directly into the stomach). Record review of Resident #12's quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating that resident cognition was severely impaired. Record review of Resident #12's Physician Order Summary Report for the month of August 2025 reflected the following order: -Dated 08/05/25 Insert midline (type of IV catheter that is inserted into a vein in the upper arm) STAT -Dated 08/18/25 Monitor midline for s/s of infection/infiltrate (accumulation of a substance within a cell, tissue, or organ) every shift.notify provider if present. -Dated 08/18/25 Mid-line flushing with 5cc of 0.9% NS IV solution before and after each medication administration. -Dated 08/18/25 Mid-line care: change mid-line dressing q 7 days visible for assessment, change dressing PRN if wet, soiled, saturated or loose. -Dated 08/05/25 Cefepime intravenous solution 2gm/100ml one time a day for PNA for 7 days -Dated 08/13/25 Meropenem intravenous solution 500mg every 6 hours for sacral ulcer for 2 weeks. Discontinued 08/28/25. Record review of Resident #12's MAR & TAR for the months of August 2025 and September 2025 reflected that the facility was following the above physician orders. Record review of Resident #12's Comprehensive Care Plan, dated 01/08/25, did not reflect a care plan for resident's mid-line insertion. Observation on 09/10/25 at 10:22AM of Resident #12 revealed a mid-line to her right upper arm. Interview on 09/10/25 at 11:23AM, LVN M said she was the nurse for Resident #12. After LVN M reviewed Resident #12's physician orders and MAR & TAR, LVN M said the resident's antibiotic Meropenem IV was last given on 08/28/25. LVN M said normally when a resident received all their IV antibiotic therapy, the Physician or NP was called to get an order to discontinue the IV. LVN M said the nurses should perform a head-to- toe assessment on the residents at least once a shift. LVN M said if Resident #12 was no longer receiving medications through her mid-line, the Physician or NP should be called to get an order to discontinue the mid-line. LVN M said if this was not done, it placed the resident at risk for infections. LVN M said she was aware that Resident #12 had a midline line. LVN M said she normally did her head-to-toe assessments at the beginning of her shift. LVN M said she had not contacted the Physician or NP about discontinuing Resident #12's mid-line. Interview on 09/10/25 at 11:35AM, the NP, after reviewing Resident #12's chart, said antibiotic therapy stopped on 08/28/25. The NP said the facility had not notified her and that she learned from the surveyor that Resident #12 still had her midline. The NP said she would write an order to discontinue resident mid-line. The NP said if the mid-line was not being used, it needed to be discontinued. The NP said this placed Resident #12 at risk for infections. Interview on 09/10/25 at 12:12PM, the DON said the Infection Control Preventionist monitored resident IV lines, checked orders for antibiotic therapy, how long resident was on the antibiotic, and how long resident IV had been in. The DON said the Infection Control Preventionist should be assessing the IV lines weekly. The DON said she was aware that Resident #12 had a mid-line but did not know when resident completed her IV antibiotic therapy. The DON said after a resident's IV antibiotic was completed, the facility may wait a few days to see if the Physician wanted to draw labs afterwards from the line before discontinuing the IV. The DON said she was not aware that it had been pos 3 days that resident antibiotic IV therapy was completed. The DON said by not calling the Physician/NP to get an order to discontinue Resident #12's mid-line placed resident at risk for infections. The DON said the nurses should assess the residents at least once a shift addressing any abnormalities or new changes in resident condition and notifying the physician in a timely manner of their findings. The DON said the facility did not have a policy on when a mid-line needed to be discontinued. Interview on 09/10/25 at 1:12PM, the Infection Control Preventionist said she was the facility's Infection Control Preventionist for 1 year. She said it was part of her job description to check all new admissions for antibiotic therapy via IV or by mouth and monitor their therapy. She said she monitored residents that had intravenous lines. She said she assessed the resident IV lines on a weekly basis to see if the IV dressing was changed as ordered by the physician, for signs and symptoms of infection such as redness, drainage, or swelling at the site. The Infection Control Preventionist said she also monitored the stop dates of resident receiving antibiotic therapy. She said whenever a resident received IV antibiotic therapy, the IV line should be discontinued within 3-5 days to prevent infections. The Infection Control Preventionist said the Physician/NP should be called to get an order to discontinue the IV line. The Infection Control Preventionist said she believed Resident #12's IV antibiotic discontinued on 08/28/25 or 08/29/25. The Infection Control Preventionist said she did not call the Physician/NP to get Resident #12's mid-line discontinued and that it must have been an oversight on her part. Observation on 09/10/25 at 2:52PM, the Infection Control Preventionist removed Resident #12's midline practicing sterile technique. The tip of the midline insertion was still intact. The mid-line site was without redness, drainage, swelling, or foul odor. The facility only provided a policy on quality of care related to ADL's

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #12, Residents #80 and Resident #84) reviewed for comprehensive care plans. - The facility failed to care plan Resident #80's incontinence care due to a neurogenic bladder disorder.-The facility failed to care plan Resident #12 for an intravenous mid-line.-The facility failed to care plan Resident #84 for mobility bars on her bed.This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health. Resident #80Record review of Resident #80's face sheet, dated 09/11/2025, reflected a [AGE] year-old female admitted on [DATE] with diagnoses including stroke due to a blood clot, paralysis following stroke affecting left non-dominant side, dementia (loss of cognitive functioning like thinking, reasoning and memory and potential loss of emotional control and personality)., neuromuscular dysfunction of bladder (neurogenic bladder being a condition where an injury or disease leads to residents having urinary incontinence, loss of sensation of a full bladder, among other symptoms) and need for assistance with personal care.Record review of Resident #80's Quarterly MDS, dated [DATE], reflected a BIMS score of 03, indicating severe cognitive impairment. Resident #80 was totally dependent on staff for ADLs including eating, oral and personal hygiene and toileting. Resident #80 was totally dependent on staff to transfer from a bed to a chair and to get on and off a toilet. Record review of Resident #80's care plan reflected she was care-planned for having bowel and bladder incontinence related to stroke, impaired mobility and having a neurogenic bladder with a created date of 09/11/2025, with interventions including being checked as required for incontinence and care by staff and nurses monitoring skin at least weekly and reporting any changes to the doctor and POA. A later care plan dated 09/12/2025 reflected a focus area of Resident #80 being at risk for urinary retention related to a diagnosis of neurogenic bladder with interventions including monitoring and documenting for signs or symptoms of UTI and for therapy to evaluate and treat for pelvic floor exercise.Record review of Resident #80's skin assessments for August and September 2025reflected she had no skin issues documented. Record review of Resident #80's progress notes, MDS B documented on 9/11/2025 at 5:00pm that she notified Resident #80's physician assistant of her diagnosis for neurogenic bladder and order received for OT to evaluate and treat for pelvic floor exercise. MDS B documented that she notified the rehab ilitation department and left a message to Resident #80's RP. Observation and attempted interview with Resident #80 on 09/11/2025 at 11:00am, Resident #80 was in her chair outside her room with non-skid socks on and pillows propped under both legs. Resident #80 appeared in a pleasant mood and in no apparent discomfort or distress. Resident #80's face and hands had no signs of symptoms of dehydration or concerns. Resident #80 did not respond to questions and did not make eye contact.Interview with OT F on 09/13/2025 at 9:45am, she said she did not work with Resident #80. For residents with neurogenic bladder, OT F would look at frequency of voiding like the resident's schedule. OT F would monitor residents when they saw them in the hallways. OT F said therapy staff would educate nursing to monitor residents in the dining room. OT F said therapy did not have the certification to do bladder training for residents. OT F said the importance of monitoring was to ensure residents kept skin integrity and for excessive moisture. Interview on 09/14/2025 at 10:45am with MDS A and MDS B, they said they were not employed at the time that Resident #80 was admitted . They said during record review in the last few days, they found she had a neurogenic bladder due to stroke. The facility began Resident #80 on pelvic floor exercises. MDS B said resident #80 also did not have incontinent in her care plan and that was an oversight. MDS A said care plans were to make sure interventions were in place for residents and that MDS nurses were responsible for ensuring resident's conditions were care-planned. Interview on 9/14/2025 at 10:59am, the DON said the interdisciplinary team (a team consisting of therapy, nursing, social work and other department representatives working together to provide care to residents) was responsible for diagnoses, like during admission and the team included MDS, ADONs, and DON among other departments . The purpose of the care plan was to put in place interventions for residents' condition. The DON said things the facility would also put tasks in POC for staff to see interventions, telling nurses on the 24-hour report and put in ancillary or acute orders . Care plans were individualized, so if residents were not care-planned for diagnoses or conditions, residents could have a decline due to not be treated, missed out on potential treatments or prevented conditions. Care plans were also to let staff know that residents were stable. The MDS nurses were responsible for care plans and the DON was responsible for MDS nurses. The DON and MDS Nurses meet for morning clinicals and weekly meetings. When asked if the resident could have benefitted from therapy interventions when she was first admitted , the DON said the facility wanted to go through the motion of what she could benefit from so they referred Resident #80 to therapy but she had been totally incontinent upon admission.Interview with the Administrator and Regional Nurse on 9/14/2025 at 11:48am, she said the DON was responsible for ensuring residents were getting treatments for their diagnoses. If resident did not get treatments for diagnoses, it could affect their quality of life. The purpose of a care plan was an individualized intervention, and if they were not care-planned their condition would not get addressed. The Administrator said she would have to review Resident #80's full chart to see if she could have benefitted from intervention upon admission. The MDS Coordinator was over care-planning and Nurse Manager was responsible for oversight.Resident #12Record review of Resident #12's face sheet dated 09/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included the following: chronic respiratory failure, type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy) cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy, colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag, and gastrostomy (surgical incision that creates an opening through the abdominal wall. A tube is inserted to provide nutrition, fluids, and medications directly into the stomach).Record review of Resident #12's quarterly MDS revealed a BIMS score of 3 indicating that resident cognition was severely impaired.Record review of Resident #12's Physician Order Summary Report for the month of August 2025 reflected the following order:-Dated 08/05/25 Insert midline STAT-Dated 08/18/25 Monitor midline for s/s of infection/infiltrate (accumulation of a substance within a cell, tissue, or organ) every shift.notify provider if present.-Dated 08/18/25 Mid-line flushing with 5cc of 0.9% NS IV solution before and after each medication administration.-Dated 08/18/25 Mid-line care: change mid-line dressing q 7 days fi visible for assessment, change dressing PRN if wet, soiled, saturated or loose.-Dated 08/05/25 Cefepime intravenous solution 2gm/100ml one time a day for PNA for 7 days-Dated 08/13/25 Meropenem intravenous solution 500mg every 6 hours for sacral ulcer for 2 weeks. Discontinued 08/28/25.Record review of Resident #12's MAR & TAR for the months of August 2025 and September 2025 reflected that the facility was following the above physician orders.Record review of Resident #12's Comprehensive Care Plan dated 01/08/25 did not reflect a care plan for resident's mid-line insertion.Observation on 09/10/25 at 10:22AM of Resident #12 revealed a mid-line to her right upper arm. Resident #84 Record review of Resident #84's face sheet dated 09/12/25 revealed that resident was admitted to the facility on [DATE]. Resident diagnoses included the following: hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty swallowing), chronic kidney disease, syncope and collapse (temporary loss of consciousness/fainting caused by sudden , brief decrease in blood flow to the brain), cognitive deficit, falls, cerebral infarction (blood flow to the brain is interrupted), hypertension (elevated blood pressure), muscle wasting and atrophy (muscle lose mass and strength).Record review of Resident #84's Admissions MDS dated [DATE] BIMS score was coded 0 indicating that resident cognition was severely impaired. Record review of Resident Physician Order Summary Report for the month September 2025 did not reflect an order for mobility bars.Record review of Resident #84's Comprehensive Care Plan dated 08/08/25 did not reflect a care plan for mobility bars. Observation on 09/09/25 at 9:47AM of Resident #84 in room sitting on the left side of her bed. Resident #84 had mobility bars on her bed. Interview on 9/14/2025 at 10:59AM, the DON said the purpose of the care plan was to put intervention in place for residents' condition. The DON said the facility communicated interventions for staff to see by placing them in resident's medical records, communicating between nursing shifts through 24-hour reports and putting in ancillary or acute orders for staff to ensure interventions were being done for residents. The DON said care plans were individualized, so if residents were not care-planned for diagnoses or conditions, residents could have a decline due to not being treated and missing potential treatments. The DON said care plans were also utilized to let staff know that residents were stable. The DON said both herself and the MDS nurses were responsible for ensuring the residents had comprehensive centered care plans. Interview with the Administrator on 9/14/2025 at 11:48am, said the DON was responsible for ensuring residents were receiving treatments for their diagnoses. The Administrator said if resident did not get treatments for diagnoses, it could affect their quality of life. The Administrator said the purpose of a care plan was an individualized intervention, and if they were not care-planned their condition would not get addressed. Interview on 09/16/25 at 10:20AM with the MDS nurse said she had been working at the NF for over a year and became the MDS nurse September 01, 2025. The MDS nurse said she was responsible for Resident 84's care plan. The MDS nurse said it was important for the residents to have person-centered care plans to address the residents' diagnoses and needs. The MDS nurse said interventions also needed to be put in place to set obtainable goals, and to reduce the risk of further complications. The MDS nurse said she was not aware that Resident #84 was not being care planned for mobility bars. The MDS nurse said she recognized now that mobility bars needed to be specifically care planned for, because it placed the residents at risk for falls, entrapment, skin alterations such as skin tears, or other injuries.Interview on 09/16/25 at 10:30AM with MDS Coordinator said she was Resident #84's MDS nurse prior to MDS nurse. The MDS Coordinator said she was aware that Resident #84 had mobility bars on her bed. Further interview with the MDS Coordinator said it was an oversite on her part that Resident #84 was not care planned for mobility bars.Record review of the facility policy on Comprehensive Person-Centered Care Planning last revised April 2025 reflected in part: .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, which includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 1 of 7 residents (Resident #12) reviewed for tracheostomy care. The facility failed to ensure -LVN M did not turn Resident #12's oxygen off for 2 minutes when providing resident tracheostomy (surgical opening that creates an opening in the trachea [(windpipe]) to allow air to enter and exit the lungs) care. This failure could place residents at risk for respiratory distress and hypoxia (deficiency of oxygen). Findings include: Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included : chronic respiratory failure (difficulty breathing), type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy) cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy (surgical opening in the windpipe to help with breathing), colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag), and gastrostomy (surgical incision that creates an opening through the abdominal wall. A tube is inserted to provide nutrition, fluids, and medications directly into the stomach). Record review of Resident #12's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated the resident's cognition was severely impaired. Record review of Resident #12's Physician Order Summary Report for the month of September 2025 reflected the following orders: -Dated 06/27/25 Tracheostomy aerosol (tiny solid particles or liquid droplets) trach collar @ 20psi 28% humidity, 5-8L O2 to keep SPO2 > 90%, Shiley flex 6 cuffed (an inflatable balloon at the end of tube that helps create a seal in the trachea to help maintain the correct pressure for safety and effectiveness) trach, every shift for trach related chronic respiratory failure. -Dated 08/18/25 Tracheostomy care every shift for trach care. -Dated 08/18/25 Check and record oxygen saturation every shift while suctioning and as needed for s/s of respiratory distress. Record review of Resident #12's TAR for the month of September 2025 reflected resident oxygen saturation ranged from 92%-98%. Record review of Resident #12' Comprehensive Care Plan, dated 01/08/25, reflected resident being care planned for dependent on tracheostomy r/t respiratory failure with an intervention that included administering oxygen as ordered. Observation on 09/09/25 at 10:06 AM revealed Resident #12 was resting in bed with a trach collar connected to the oxygen machine (on the left side of resident bed) at 5-liters with a humidifier bottle connected and dated 09/09/25. There was a suction cannister sitting on the night stand on the left side of bed. Inside of the suction canister was clear frothy secretions. The cannister was dated 09/08/25. Observation and interview on 09/10/25 at 10:05AM of tracheostomy care for Resident #12 by LVN M revealed. LVN M said she had already disinfected her workspace (bedside table) that was positioned on the left side of resident bed. On the bedside table was an unopen tracheostomy kit and a package of unopened sterile gloves. LVN M entered the room and washed her hands with soap and water and began to don (put on) her PPE that consisted of a disposable gown and gloves. LVN M then went to the right side of the resident's bedside to stop the resident's continuous gastrostomy feedings and placed a pulse oximeter on the resident's right- hand finger. Resident #12's oxygen saturation fluctuated between 91-93%. LVN M left the pulse oximeter on the resident's finger and proceeded to listen to the residents' lung sounds by using a stethoscope. LVN M went to the left side of the resident's bed stood by the resident oxygen machine and prepared to remove soiled gloves, placed the gloves inside of a red biohazard bag. LVN M proceeded to place on a set of sterile gloves after sanitizing her hands to remove the old dressing from around the resident's tracheostomy site and disposed the soiled materials inside of the red biohazard bag. LVN M sanitized her hands again and proceeded to open the sterile tracheostomy kit which consisted of pre-cut, non-woven tracheostomy dressing, gauzes, and normal saline. The time was 10:14 AM with LVN M continuing to monitor the resident's oxygen saturation which continued to fluctuate between 91-93%. Resident #12 did not appear to be in any distress. LVN M established her right hand would be her dominant hand to clean around the resident's tracheostomy. LVN M proceeded to clean around the tracheostomy site, being careful not to introduce bacteria to the site, cleaning one wipe at time away from the site. When LVN M was done cleaning around the resident tracheostomy site, she placed the new sterile dressing around the resident's tracheostomy site and placed all soiled materials inside of the red biohazard bag. The time was 10:16 AM when LVN M stated Now I will turn back on the oxygen. The resident continued to not appear to be in any distress with respirations even and unlabored at a rate of 18per minute. LVN M checked the resident's heart rate which was 68. Interview on 09/10/25 at 10:16 AM, LVN M said she made a mistake. LVN M said she was so nervous when being observed by the state surveyor. LVN M said she was not supposed to turn off the resident's oxygen because it could cause Resident #12 oxygen saturation to desaturate which could lead to hypoxia (decrease in oxygen level). LVN M said she turned off the resident's oxygen right before she began tracheostomy care. LVN M said the last time she received an in-service on tracheostomy care was last month by the Respiratory Therapist. Interview on 09/10/25 at 12:12 PM, the DON said when the nurse provided tracheostomy care, the oxygen should not be turned off at any time because it would place the resident at risk of their oxygen level dropping which could lead to respiratory distress. The DON said competency skills were done with the nurses at the time of hire, annually, and as needed, which included tracheostomy care. The DON said the Respiratory Therapist came to the NF every week normally on Monday's and as needed. The DON said the Respiratory Therapist assessed the facility trach resident (s), provided education to the nurses regarding tracheostomy care, addressed any other concerns the facility might have regarding respiratory. Interview on 09/10/25 at 2:04 PM, the Respiratory Therapist said he observed nurse, LVN M, providing trach care and knew better not to turn off Resident #12's oxygen. The Respiratory Therapist said after LVN M came and told him what she did during observation of tracheostomy care with the state surveyor, he went and assessed Resident #12, whose oxygen saturation was saturating between 93%-94%, at 5 liters. The Respiratory Therapist said the resident order said the resident could be given 5-8 liters to keep the resident's oxygen saturation above 90%. The Respiratory Therapist said at one time Resident #12's tracheostomy was downsized from size 6 to 4 and done well. The Respiratory Therapist said at one time he had done trials with the Passy-Muir Valve (one-way valve that attaches to the tracheostomy tube, allowing for communication and swallowing) as tolerated and resident did well. The Respiratory Therapist said because of Resident #12 comorbidities, recurrent pneumonia, infections associated with her wounds, and having to be transferred to the hospital, resident was no longer a candidate for decannulation (surgical removal of a tracheostomy tube, or trach, from the neck, allowing a person to breathe on their own again). The Respiratory Therapist said he came to the facility once a week and provided any necessary in-services with the staff or addressed any concerns the facility might have. The Respiratory Therapist said Resident #12 was the only resident at the facility with a tracheostomy. The Respiratory Therapist said he ensured the nurses were competent in providing tracheostomy care by having the staff demonstrate the skill for him while maintaining sterile technique. Interview on 09/14/25 at 1:18 PM, the Nurse Practitioner said it was not detrimental to Resident #12 when LVN M turned off the resident's oxygen during tracheostomy care. The NP said the resident's oxygen saturation base line was 92%. The NP said if a resident's oxygen saturation dropped below 88% she would become concerned but even then, one would just need to increase Resident #12 oxygen back to her baseline. The NP said when good trach care was provided to a trach resident, Resident #12 would not be receiving 100% of their oxygen due to having to manipulate the oxygen mask to provide trach care or suctioning. Record review of the NF policy regarding Tracheostomy, Care and Cleaning, revised May 2007, did not reflect the resident oxygen being turned off.

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #72) reviewed for enteral feeding.The facility failed to ensure Resident #72's enteral feeding was turned off during bowel rest between 9AM and 11AM on 9/10/2025 . This failure could place residents at risk of health complications such as aspiration pneumonia or gastrointestinal injury. Record review of Resident #72's face sheet, captured 09/11/2025, reflected an [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. Resident #72 had diagnoses which included paralysis following stroke affecting left non-dominant side, type 2 diabetes mellitus (high blood sugar), cognitive communication deficit, gastrostomy status (tube that provides nutrition, medication and fluids directly to the stomach) and dementia (loss of cognitive functioning like thinking, reasoning and memory and potential loss of emotional control and personality).Record review of Resident #72's Quarterly MDS, dated [DATE], reflected he was rarely or never understood, and his BIMS was not coded, which indicated severe cognitive impairment. He was totally dependent on staff for all ADLs including eating, oral and personal hygiene and dressing and transferring in and out of bed. Resident #72 was coded for feeding tube and received 51% or more calories through parenteral or tube feeding.Record review of Resident #72's September 2025 MAR reflected he had bowel rest from 9AM and resumed feeding at 11AM ordered on 08/20/2025 and discontinued 09/11/2025.Record review of Resident #72's progress notes, on 9/11/2025 at 11:00AM, ADON A wrote, This writer reached out to NP that resident feeding was not turned off at 09:00, communicated with Dietician as well, received order to change Bowel rest time from 10:30 to 12:30PM, Communicated with Floor nurse.Record review of Resident #72's weights reflected no significant weight change from June 2025 to September 2025.Observation and attempted interview with Resident #72 on 09/09/2025 at 8:51 AM, he was aware and lying in a low bed on a feeding pump. Resident #72 appeared comfortable and in no respiratory distress and it was difficult to understand the resident's speech.Observation and interview on 09/11/2025 at 10:00 AM, revealed Resident #72 appeared to be asleep, in bed with no discomfort or distress. Resident #72's feeding pump was on. The DON was asked to come in, and she said Resident #72's feeding pump was still on. The DON went to get LVN H, who told the DON and the State Surveyor, LVN H had turned it off, but it turned back on. LVN H came in and turned off Resident #72's pump at 10:10 AM. LVN H said she remembered shaving Resident #72 and then turned on the pump. LVN H assumed the pump was going on for one hour and called the physician who said she would adjust the bowel rest period to 10:00 AM to 12:00 PM going forward. LVN H said she had no idea who turned it back on. LVN H said if residents did not get bowel rest, they could vomit, aspirate (when anything but air gets into your airways) or have diarrhea. LVN H received in-services and training on tube feeding and bowel rest at the facility.Interview with ADON A on 09/11/2025 at 1:13 PM, she said there was no excuse for Resident #72's pump to be on even if the nurse turned it off already. ADON A notified the RD and the NP. The RD said Resident #72 was okay, so nursing changed the bowel rest time to 10:30 AM to 12:30 PM. The ADON said the NP was also notified that Resident #72's feeding was on when it should have been off, and the NP had no concerns. ADON A said they were treating the event like there was no pause in Resident #72's feeding since she was not sure if the machine had turned back on or not. For safety purposes, ADON A said LVN H should have checked that she had turned the pump off. ADON A said nurses had competency checks and returned demonstration for enteral feeding. ADON A said bowel rest was to give residents' GI breathing time because humans did not eat 24 hours a day and that time was so the bowels could recuperate and prevent overfeeding. If residents did not get bowel rest as ordered it could cause overfeeding or aspiration because they would have had more than enough. Interview with the RD on 09/11/2025 at 12:42 PM, she said Resident #72's weights were stable. The RD said the purpose of bowel rest was to give residents time for activities throughout the day where they could not be on the feeding like for showering and she would account for the calories within the 22-hour timeframe. When the RD made recommendations, she would put 22 hours of feeding and 2 hours of rest and then nursing would decide when the 2 hours of rest was. The RD said if residents did not get bowel rest, they would not get the calories they needed and could have weight gain. Interview with the DON on 09/14/2025 at 10:59 AM, she said the purpose of bowel rest was to give residents time off the enteral feeding for ADLs. The DON did not know what really happened, but informed LVN H it was her responsibility to ensure she disconnected it completely. If residents did not get the prescribed bowel rest, they could either not get enough nutrition if they did not eat by mouth or if they got too much it could cause aspiration or adverse bowel reaction depending on the resident's diagnoses. Resident #72 was assessed and found to have no adverse reaction, and his bowel sounds were okay. The NP was notified. The Nurse managers followed nurses to ensure they were following orders for parenteral feeding and the DON in-serviced staff on g-tube, but she would do more in-services and was going to do one on disconnecting the pump completely and provide it. Interview with the Administrator on 09/14/2025 at 11:48 AM, she said the purpose of the bowel rest was for the resident to rest. She said risks to residents, if they had a delay or no bowel rest, would be a clinical question and referred to the nursing department. The Administrator said nursing management was responsible for monitoring nurses to ensure nurses were following orders. Record review of the facility's in-service on gastrostomy tube on 03/21/2025 read in part, it is the policy of this facility to provide proper care and maintenance of a gastrostomy tube. Only a licensed nurse may adjust, start, stop or disconnect the g-tube . 6. Follow physician orders for bowel rest. Record review of the facility's policy on gastrostomy tube care and management, last revised 04/2025, reflected the policy did not cover intermittent feeding.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 7 residents (Resident #11) reviewed for accidents and supervision. The facility failed to ensure a disinfectant Sani-wipes container was not placed at the bedside of Resident #11. This failure could place residents at risk for unwanted injuries and a decreased quality of life. Findings include:Record review of Resident #11's face sheet, dated 09/17/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's had diagnoses which included the following: cerebral infarction (interruption of blood flow in the brain), aphasia (difficulty in communicating), type 2 diabetes mellitus (when the body is unable to utilize blood sugar for energy in the body), and malignant neoplasm (cancer). Record review of Resident #11 quarterly MDS, dated [DATE], reflected a BIMS score of 2, which indicated the resident cognition was severely impaired. Observation on 09/09/25 at 10:00 AM revealed Resident #11 was awake in bed resting quietly. On the right side of the resident's bed on the night stand was a purple top container labeled Super Sani-Cloth Germicidal Disposable Wipe. The container read the following: disinfect in 2 minutes, not a skin or baby wipe, keep out the reach of children, and not to dispose in commode. Observation on 09/11/25 at 10:32 AM revealed the Sani-Cloth Germicidal Disposable Wipes was still on the resident's right side of the bed sitting on Resident #11's nightstand. Interview on 09/11/25 at 10:35 AM, CNA E said the disinfectant sani-wipes were not supposed to be stored at the resident's bedside for safety reasons. CNA E said the resident could try and open the container or a staff member could mistake the sani-wipes as disposable wipes. CNA E said if the resident encountered the sani-wipes, it would place the resident at risk for skin irritation or infections. CNA E said the sani-wipes were supposed to be stored outside of the resident room on the nurse medication cart. CNA E removed the sani-wipes from Resident #11's room and disposed of the container inside of the soiled utility room. Interview on 09/11/25 at 10:58 AM, LVN M said sani-wipes should not be in a resident's room. LVN M said if the resident encountered the sani-wipes it could harm the resident due to certain chemicals in the sani-wipes. LVN M said the staff could mistakenly use the sani-wipes on the residents thinking they were using disposable wipes to provide incontinent care. Interview on 09/11/25 at 11:09AM, with the DON said the disinfectant sani-wipes were never to be left in a resident room at the bedside. The DON said some residents had dementia and could try and open the container. The DON said the sani-wipes would be toxic to the resident causing injury. The DON said each resident was assigned an ambassador. The DON said the ambassadors were supposed to make rounds on their assigned residents to make sure their rooms were okay and if the residents had any concerns or questions that needed to be addressed Interview on 09/11/25 at 2:38PM with the Dietary Supervisor said she was the ambassador for Resident #11. The Dietary Supervisor said she made rounds on her assigned residents in the morning. The Dietary Supervisor said she ensured the assigned residents' rooms were okay by assessing the following; if resident was receiving oxygen to make sure that they were wearing their oxygen, having hydration at the bedside, call light in reach, making sure the resident was groomed, and if they had any questions or concerns. The Dietary Supervisor said she normally made rounds around 8:30AM and did make rounds on Resident #11 room on 09/10/25 and 09/11/25. The Dietary Supervisor said she did not recall seeing any disinfectant sani-wipes in Resident #11's room on his nightstand. The Dietary Manager said disinfectant sani-wipes should not be stored in the resident room because it placed the resident at risk of chemicals getting on the resident hand or possible the resident ingesting them sani-wipes. Record review of the Ambassadors list for Resident #11 reflected the Dietary Supervisor was the ambassador for the resident room. Record review of the facility's, undated, policy on Accident Prevention reflected in part: .The purpose is to ensure that the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent or minimize accidents. [

Based on observation, interview, and record review, the facility failed to provide personal privacy when providing personal care for 2 (Resident #12, Resident #150) of 7 residents observed for personal care. -CNA AR failed to provide privacy for Resident #150 during incontinent care. -LVN M failed to provide privacy for Resident #12 during tracheostomy care. This failure placed residents at risk for their loss of dignity, respect, and psychological distress. Findings included: Resident #150 Record review of Resident #150's face sheet, dated 09/16/25, revealed an [AGE] year-old female admitted on [DATE]. Resident #150's diagnoses included hypothyroidism, type 2 diabetes mellitus, protein-calorie malnutrition, hypertension (elevated blood pressure), pressure ulcer of left heel, chronic kidney disease, and gastrostomy (surgical procedure that creates an opening in the stomach to allow for feeding and medication administration into the stomach). Record review of Resident #150's MDS dated [DATE] coded 99 reflected a BIMS score of 15 indicating that resident cognition was intact. Record review of Resident #150's Care Plan, dated 09/07/25, reflected an ADL self-care performance deficit r/t disease process with an intervention the resident required incontinent care assistance. Observation on 09/09/25 at 9:15AM, CNA AR performed incontinent care for Resident #150. The CNA washed her hands and placed on her PPE (disposable gloves and gown). CNA AR proceeded to provide care for resident without pulling the resident's privacy curtain. During the care, there was a hospice CNA present in the room providing care for Resident #150's roommate. The hospice CNA was passing by Resident #150's bed to enter the bathroom while CNA AR continued to provide care for Resident #150. Interview on 09/09/25 at 9:28AM, CNA AR said she worked at the facility full time 6AM-2PM. CNA AR said she had worked at the facility for a year. CNA AR said she forgot to close Resident #150's privacy curtain while providing incontinent care. CNA AR said it was important to close the door as well as pull the privacy curtain to provide the resident privacy and dignity. Resident #12 Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female admitted on [DATE]. Resident #12's diagnoses included chronic respiratory failure (when the lungs are not performing adequately making it difficult to breathe), type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy) cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy(surgical opening made in the windpipe to provide airway and to help with breathing), colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag), and gastrostomy (surgical incision that creates an opening through the abdominal wall. A tube is inserted to provide nutrition, fluids, and medications directly into the stomach). Record review of Resident #12's quarterly MDS date 07/10/25 revealed a BIMS score of 3 indicating that resident cognition was severely impaired. Record review of Resident #12's Comprehensive Care Plan, dated 01/08/25, revealed that resident was care planned for being dependent for tracheostomy care r/t chronic respiratory failure. Observation on 09/10/25 at 10:03AM of tracheostomy care for Resident #12 by LVN M. LVN M entered the room and washed her hands with soap and water and began to don (put on) her PPE that consisted of disposable gown and gloves. LVN M went to the resident's bedside to perform tracheostomy care without closing the door or the pulling resident's privacy curtain. Resident #12's roommate was resting quietly in bed with eyes closed. Interview on 09/10/25 at 10:53AM, LVN M said when providing care for Resident #12 she was supposed to close the door and pull the resident's privacy curtain. LVN M said this was done to promote resident dignity. LVN M said she was nervous and forgot to close Resident #12's door and pull the privacy curtain. Interview on 09/10/25 at 12:12PM, the DON said whenever the nursing staff were providing care to a resident, they should provide privacy for the residents to promote dignity. Record review of the facility policy on Resident Rights/Dignity and Respect, dated revised October 2015, reflected in part: .It is the policy of this facility that all residents be treated with kindness, dignity and respect.The staff shall display respect for resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.Privacy of resident's body shall be maintained during toileting, bathing and other activities of personal hygiene.

Based on observation, interview and record review the facility failed to establish and maintain and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1of 3 staff reviewed for infection control. 1) RN E failed to practice hand hygiene before and after assisting Resident #84' with care. 2) RN E failed to sanitize the blood pressure device after taking Resident #3's blood pressure. 3)The facility failed to label and bag all personal care items in room [ROOM NUMBER]. Resident #12 resided in room [ROOM NUMBER]. These failures placed the residents at risk for cross contamination and infections. Findings include: Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included the following: chronic respiratory failure, type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy), cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy (surgical opening in the windpipe to improve breathing), colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag), and gastrostomy (surgical incision that creates an opening through the stomach wall to provide nutrition, fluids, and medications directly into the stomach). Record review of Resident #3's face sheet, dated 09/17/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included dementia, dysphagia, hypertension, and bipolar disorder (mental illness that causes unusual shifts in mood, ranging from highs to low. with one experiencing a change in their thinking, behavior, and sleep. Record review of Resident #84's face sheet, dated 09/12/25, reflected the resident was admitted to the facility on [DATE]. Resident #84 had diagnoses which included the following: hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty swallowing), chronic kidney disease, syncope and collapse (temporary loss of consciousness/fainting caused by sudden , brief decrease in blood flow to the brain), cognitive deficit, falls, cerebral infarction (blood flow to the brain is interrupted), hypertension (elevated blood pressure), muscle wasting and atrophy (muscle lose mass and strength).Observation on 09/09/25 at 9:40 AM of RN E at the bedside of Resident #3 revealed the RN was wearing gloves and took the resident's vital signs. When RN E was done, he removed his gloves and did not wash or sanitize his hands and left the room with the gloves in his hands walking back to the cart on the hallway. RN E laid the blood pressure machine on top of cart and did not sanitize the equipment and proceeded to work at his cart. Observation on 09/09/25 at 9:47 AM revealed RN E entered Resident #84's room and donned gloves to assist with care by assisting the resident to the wheelchair. Resident #84's brief was soiled with feces, and the resident had placed her brief on the floor. After RN E assisted Resident #84 and placed the soiled brief in trash can, RN E removed his gloves and left the room without washing his hands or sanitizing. RN E proceeded to go back to cart on the hallway and work. Observation on 09/09/25 at 10:13 AM revealed in room [ROOM NUMBER] (Resident #12's bathroom) was 2 gray wash basins on top of the commode chair. One of the wash basins were not labeled and the other had Resident #12's name on it. The wash pans were not inside of plastic bags. Interview on 09/09/25 at 10:19 AM, CNA V said she was the CNA for Resident #12. After CNA V observed the wash pans on the commode chair, she said all resident personal care items should be labeled and bagged to prevent cross contamination and infections. CNA V said she would take care of the incident right away. Interview on 09/09/25 at 3:30 PM, RN E said he received in-service on fall preventions, infection control, and hand washing to prevent cross contamination and infections. RN E said it was important to wash hands before putting on gloves and washing hands after removing gloves, before touching a resident, after assisting residents with carer, and before leaving a resident room. RN E said he was in-serviced on sanitizing resident care equipment which included blood pressure devices and blood glucose machines after using and in between usage on each resident to prevent cross contamination and the spread of infections. RN E said the reason he was not practicing infection control regarding handwashing/sanitizing hands and sanitizing resident care equipment was because he must have gotten in a hurry and forgot. RN E said this placed the residents at risk for cross contamination and infections. Interview on 09/11/25 at 10:58 AM, LVN M said resident personal care items such as wash pans should be labeled and bagged separately to prevent cross contamination and infections. LVN M said it was the CNA's who were supposed to label resident wash pans and bag them separately. LVN M said it was the nurse's responsibility to ensure was being done. Interview on 09/11/25 at 11:09 AM, the DON said the resident personal care items were supposed to be labeled and bagged to prevent cross contamination. The DON said the facility had not designated this task to anyone yet. The DON said the facility had just hired a new staff member who would be taking the resident weights and this particular staff member would be assuming the role of making sure all resident personal care items were labeled and bagged. The DON said although this role had not been assigned to the new hire, the nurses and the CNA's were responsible in making sure residents personal care items were labeled and bagged. Record review of the facility's policy on Equipment cleaning, revised May 2007, reflected in part: .It is the policy of this facility to implement the following procedures to ensure equipment is cleaned and care for appropriately. Durable medical equipment must be cleaned before reuse by another resident.Reusable resident items are cleaned and disinfected between residents . Record review of the facility's policy on Hand Hygiene, revised April 2025, reflected in part: .It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene.Hand hygiene after removing gloves.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (200 Hall Nurse Cart) and 1 of 8 residents (Resident #52) reviewed for medication storage. LVN K failed to ensure Resident #52's Tresiba Insulin Pen was not left unattended on top of the nursing cart on the 200 Hall. This failure could place residents at risk of misappropriation of medication and adverse reactions. Findings include: Record review of Resident #52's face sheet, dated 09/17/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included: lack of coordination, high blood pressure, high cholesterol, dementia and type 2 diabetes. She discharged home from the facility on 09/11/25 at 05:55 PM. Record review of Resident #52's Order Summary Report, dated 09/17/25, revealed Tresiba FlexTouch (Insulin Degludec)- Inject 22 unit subcutaneously one time a day for type 2 diabetes. Record review of Resident #52's Location of Administration Report, dated 09/17/25, revealed on 09/11/25 at 08:04 AM LVN J administered Insulin Degludec to Resident #52 at 08:04 AM. An observation on 09/11/25 at 08:36 AM revealed an opened and in-use insulin pen on top of the locked 200 hall nursing cart located at the end of the hall. There were no residents or staff around the cart. In an interview on 09/11/25/25 at 08:40 AM, LVN K said medications were expected to be locked when not under direct supervision of nursing staff to prevent unauthorized access to medications. She said medications should not be left on the top of the nursing cart because it could place residents at risk of adverse health effects, change of condition, and allergic reaction if the medication was used by an unauthorized resident. LVN K said she forgot to lock the insulin pen when she went to provide care to another resident. Record review of LVN K's Orientation and Annual Skill Checklist: Licensed Nurse, dated 09/08/25, revealed VIII. Medication & Treatment Passes: 1. Understands Medication Pass Procedure Including Charting: Rights of Medication Administration. She was signed as competent for all skills assessed. Record review of the facility's policy titled Storage of Medication, revised 04/2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage ANDpreparation areas in a clean, safe, and sanitary manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Record review of the facility's policy Specific Medication Administration Procedures, revised 11/13/18, revealed During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on interview and record review, the facility failed to ensure MDS data was transmitted within 14 days of completion for 1 of 5 closed record reviews (CR #62), in that: -CR #62's MDS discharge assessment was not completed and submitted to CMS.This failure could place the resident at risk for receiving unnecessary services or inadequate care.Findings included:Record review of CR #62's face sheet, dated 09/17/2025, revealed a [AGE] year-old female admitted on [DATE] and discharged [DATE]. Her diagnoses included: pneumonia, ulcerative colitis (a chronic inflammatory bowel disease that affects the large intestine), moderate protein-calorie malnutrition, legal blindness, congestive heart failure, and muscle weakness.Record review of CR #62's most recent MDS, dated [DATE], was an admission MDS. Record review of CR #62's EMR on 09/17/2025 revealed the history and status of all of the residents' MDS assessments completed and submitted. A discharge MDS assessment was not completed or accepted for her 05/09/2025 discharge from the facility:4/14/2025 Medicare - 5 Day Completed4/14/2025 admission Accepted4/8/2025 Entry Accepted4/5/2025 Discharge Return Not Anticipated Accepted3/23/2025 Medicare - 5 Day Completed3/23/2025 admission Accepted3/17/2025 Modification of Entry Accepted3/17/2025 Entry ModifiedIn an interview on 09/17/25 at 12:46 PM, MDS A stated she did not know why the discharge MDS for the resident was not completed or submitted. She reported they would do an audit to determine if other discharge MDS assessments were not completed and if so, they would do a root cause analysis so that it would not happen again.Record review of Chapter 5 of the RAI Manual 3.0, revised October 2024, reflected that the submission time frame for a discharge assessment was no later than the date of the RN assessment coordinator's signature, indicating that the MDS assessment was complete, within 14 days.

Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for treatment of pressure ulcers. - The facility failed to notify the MD and receive orders for CR #1's sacral pressure ulcer from 1/24/25-1/27/25. There was no documentation of size until 1/27/25. The noncompliance was identified as PNC. The noncompliance began on 1/24/25 and ended on 2/24/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for worsening wounds, infection, and hospitalization . Findings included: Record review of CR #1's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of acute respiratory failure (not enough oxygen in the body), severe protein-calorie malnutrition, COPD (lung diseases that cause ongoing breathing problems), stage III (exposing the underlying fatty tissue, but not reaching muscle or bone) pressure ulcer of the sacral region (bony area at the base of the spine), failure to thrive, dementia (decline in mental function), muscle wasting and atrophy, and difficulty in walking. Record review of CR #1's medical record revealed an Admission MDS assessment was not completed due to the resident being in the facility for 8 days. Review of CR #1's Care Plan dated 1/26/25, revealed the resident had an ADL self-care performance deficit r/t disease process and required the assistance of staff with all ADL's. She also had the potential for further pressure ulcer development r/t decreased mobility, incontinence, and being admitted with a decubitus ulcer (area of skin damage that develops when pressure is applied to the same spot for an extended period). Interventions included daily body checks, notifying the MD of any new areas of skin breakdown, out of bed unless contraindicated, pressure relieving mattress, and head to toe skin assessment. CR #1 also had a focus that revealed she had a stage III (full-thickness skin loss where subcutaneous fat is visible, but bone, tendon, or muscle is not exposed) pressure injury r/t disease process, h/o ulcers, immobility, incontinence, and failure to thrive. Interventions included administering treatments as ordered, assess/record/monitor wound healing, encourage to turn and reposition, inform family/MD of new skin breakdown, low air loss mattress, Vit C to promote wound healing, monitor dressing to ensure it is intact and adhering, report any loose dressing to Wound Care Nurse, and weekly head to toe skin assessment. Record review of CR #1's undated, Admission Nursing Report received from the hospital revealed the resident had an open Stage III to the sacrum. Record review of CR #1's previous hospital's After Visit Summary from 1/24/25 at 5:00pm revealed, Location: sacral wound- Cleane with Vashe sol. [type of wound cleanser] Apply Replicare dressing [type of wound dressing] to wound and change every 3 days Turning Regimen- Turn every 1-2 hours; Use wedges; No diapers to be use Sacrum/coccyx [last bone at the bottom (base) of your spine]- Protection sacral foam. Lift and assess EVERY shift. Change every 5 days *Discontinue if changed 2 or more times within 24 hours due to moisture issues Heels- Offload using 2 pillows. No socks or heel foam to be use. Record review of CR #1's Transfer Report from the previous hospital dated 1/24/25, revealed the resident had a Stage III sacral wound. Record review of CR #1's Progress Note dated 1/24/25 at 6:25pm by LVN O, revealed the resident presented with an open sacral wound. Record review of CR #1's Initial Admission Record dated 1/24/25 at 6:30pm by LVN O, revealed she came from an acute care hospital, and the Physician was notified of the admission. The resident was alert, could follow simple commands, and could make her needs known. LVN O documented the resident was always incontinent of bowel and bladder. She also documented the resident had a sacral wound present. Record review of CR #1's Braden Scale for Predicting Pressure Sores dated 1/24/25 by LVN O, revealed the resident was high risk. Record review of CR #1's Daily Skilled Note dated 1/25/25 at 7:46pm by LVN P, revealed the resident had MASD to her coccyx. Record review of CR #1's Progress Note dated 1/26/25 from PA V revealed the resident had a sacral wound stage 2 (partial-thickness skin loss, appearing as a shallow, open sore) on arrival. Record review of CR #1's Progress Note dated 1/26/25 at 11:06am, revealed NP V saw the resident and requested the Wound Care MD to see the resident and it was noted. Record review of CR #1's January 2025 Physician Orders revealed no orders for Wound Care. Record review of CR #1's Progress Note dated 1/26/25 at 12:43pm by RN S, revealed the resident had 2 open areas on her sacrum. He cleaned the areas with NS, applied skin prep to the edges, and covered them with a dry protective dressing. Record review of CR #1's Skin Evaluation dated 1/27/25 at 8:40am by Wound Care Nurse G, revealed the resident had a sacrum pressure ulcer site 1 that was 0.5cm x 0.5cm x 0.1cm that was a stage II. She also had a sacrum pressure ulcer site 2 that was 2cm x 1.5cm x 0.1cm and was a stage III. Record review of CR #1's Physician Orders revealed the following orders from MD W: - Sacrum: Cleanse with Normal Saline, pat dry, apply collagen, cover with duoderm, change Q M-W-F. Ordered on 1/27/25 at 9:57am. - Sacrum: Cleanse with Normal Saline, pat dry, apply calcium alginate, cover with border dressing Q Day. Ordered on 1/27/25 at 11:56am. - Low air loss mattress to bed, monitor for proper function Q shift. Ordered on 1/27/25 at 2:23pm. Record review of CR #1's Wound Care Note dated 1/27/25 at 11:57am by MD W, revealed the resident had a stage III pressure ulcer to her sacrum that was 2cm x 1cm x 0.1cm. Record review of CR #1's Weekly Skin Pressure Ulcer dated 1/27/25 at 3:19pm by Wound Care Nurse G, revealed the resident had a sacrum stage III pressure ulcer that was present on admission, that was 2cm x 1cm x 0.1cm. The wound had moderate amount of serous exudate (clear drainage), no odor, and granulation tissue (healing tissue) present. Record review of CR #1's Daily Skilled Note dated 1/27/25 at 7:01pm by LVN M, revealed the resident had a skin injury/ulcer to her buttock and she was compliant with treatment and interventions were in place. Record review of CR #1's Change in Condition dated 2/3/25 at 11:27am, revealed she had shortness of breath and decreased level of consciousness and was being transferred to the hospital. Record review of CR #1's hospital records dated 2/3/25 at 11:36pm, revealed she had an acute on chronic sacral ulcer and wound care was consulted. Record review of CR #1's hospital discharge summary dated 2/24/25 at 2:20pm, revealed she had a stage 3 decubitus ulcer on admission, surgery was consulted, and a bedside debridement was performed. CR #1 was discharged home on hospice. In a telephone interview with CR #1's family member on 2/23/25 at 12:58pm, she said the resident was only at the facility for 8 days and when she first admitted to the facility on [DATE] she only had 2 small spots on her sacrum, but by the time she went to the hospital it had developed into a bigger stage III pressure ulcer with osteomyelitis (bone infection). CR #1's family member also said she would go to the facility and find CR #1's wound uncovered even though the resident was incontinent. In an interview with Wound Care Nurse G on 2/23/25 at 1:41pm, she said she assessed CR #1 on Monday (1/27/25) and the wound had some slough (dead skin). She said there were no orders in the system for the resident. She said she measured the wound and called the Wound MD to get orders and then followed them. She said her process for skin assessments was to find out who admitted to the facility from Friday evening, Saturday, and Sunday and then she would perform a skin assessment on them. She said if the new admissions had a wound, she would dress it and call the Wound MD. She said wounds should always be covered and nursing staff should be able to put the dressing back on. In an interview with RN S on 2/23/25 at 3:36pm, he said he came in on 1/26/25 and the family came to him and told him the wound care had not been done since the resident had been at the facility. He said Wound Care Nurse R was there, but she had gotten into an argument with CR #1's family so she did not go back in and do any treatment on the resident. He said he did a head-to-toe assessment and saw there were dressings still on her heals from the hospital, but they were just for protection, so he removed them. RN S said he cleaned the sacrum and covered it with a protective dressing. He said he called the on-call service but could never reach a doctor. He said the family member told him what wound care they were doing before the resident went to the hospital, and he told that to Wound Care Nurse R. He also informed Wound Nurse R to call MD W and inform her of the wounds. RN S said Wound Care Nurse R did not tell the MD W and never assessed the resident. He said Wound Care Nurse R did not assess the resident because she never went back into the room after the altercation with the family member. He also heard from other staff that no orders were ever put in until the Wound Care Nurse came in on Monday. In an interview with the DON on 2/23/25 at 3:48pm she said CR #1 admitted on [DATE] and LVN O said she had a wound but did not tell the MD. Wound Care Nurse R, also the Weekend Supervisor, came in Saturday morning (1/25/25) and applied barrier cream to the resident's bottom but left the wound undressed. The DON said Wound Care Nurse R did an assessment on Saturday (1/25/25), but the DON accidentally deleted it. The DON said on Sunday (1/26/25), the family member was upset because nothing had been done about CR #1's wound. She said Wound Care Nurse R got an attitude with the family member and said she was not going to do something and upset the family member. The DON said RN S performed a complete head to toe assessment, cleaned the wound and dressed it. Then on Monday (1/27/25) Wound Care Nurse G did the assessment, notified all parties, and received treatment orders. The DON said Wound Care Nurse R was not skilled at wounds but never said she needed help with anything. She terminated Wound Care Nurse R for customer service and documentation issues related to CR #1. She said she also did a 1-1 with LVN O and RN S. The DON said she also started a QIT and performed a bunch of check offs on Skin Assessments. In a telephone interview with LVN P on 2/29/25 at 4:17pm, she said the NP notified the Wound Care Nurse about the wound care consult and then the Wound Care Nurse would put the order in, that was why NP V did not put orders in. She said the protocol for open wounds on admission was for the admitting nurse to notify the MD about the wound when the nurse called to get admission orders. She said if the nurse could not reach the MD, then the nurse was supposed to clean the wound with NS, pay dry, and cover with a dry dressing. In a telephone interview with LVN O on 2/24/25 at 8:53am she said she had only been at the facility for a couple months. She said she was told by the DON that the protocol for admitting residents with wounds was that she would document them and then the Wounds Care Nurse would see the resident within 24hr to assess and enter orders. She said she was never told to inform the MD at admission about it because the Wound Care Nurse was supposed to handle it. LVN O said when she spoke to the MD about the admission, she went over the meds and labs, but not the wound. She said she did not cover the wound or take off the heel protectors. In a telephone interview with Wound Care Nurse R on 3/5/25 at 10:22am, she said she was never trained on wound care and only shadowed the previous Wound Care Nurse for 2 days before starting. She said she saw CR #1's sacrum and there were 2 little spots that she documented on 1/25/25, but the DON accidentally deleted her note. She said she only took care of the existing wounds with orders and assessed new wounds the nurses would tell her about. She said she did not know to look for new admissions or to call the Wound Care MD for orders. She said the family member was 'over the top' and was mad because the resident had not been turned and the wound was not addressed, on Saturday (1/25/25). Wound Care Nurse R said she tried to take the heel protectors off and turn the resident to put a dressing on her sacrum, but the resident screamed out in pain, so she left the heel protectors on and was unable to dress the sacrum. She said she would have covered the sacrum, but she could not turn the resident due to pain. She said since the family member was mad at her and did not want her to go back in the room, she did not see the resident on Sunday (1/26/25) and the nurse went in to take care of the resident instead. She said she was terminated because it looked bad and the DON did not really want to terminate her, but she had to. Record review of the facility's policy and procedure on Skin and Wound Monitoring and Management (Revised 12/2023) read in part: .A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The purpose of this policy is that the facility provides care and services to: .Promote the healing of pressure injuries that are present .Resident Assessment: The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: Complete Initial Admission Record and Braden Scale to identify risk and to identify any alterations in skin integrity noted at that time .Skin and wound assessment on admission and readmission: A licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, will be documented on the initial Admission Record. A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident .Measuring the skin injury, Staging the skin injury (when the cause is pressure), Describing the nature of the injury (e.g., pressure, stasis, surgical incision), Describing the location of the skin alteration, Describing the characteristics of the skin alteration. Ongoing Skin and Wound Assessments: A licensed nurse will assess/evaluate a resident's skin at least weekly. Areas of breakdown, excoriation, or discoloration, or other unusual findings (either initially identified at the time of admission or as new findings) must be documented in the nursing notes or on the appropriate weekly assessment form .A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident .Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order. Treatments per physician order, should be documented in the resident's clinical record at the time they are administered .Communication of Changes: Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be communicated to: .The resident's physician . Record review revealed a Quality Team Tracking Form was initiated on 2/3/25. The problem areas were skin assessments not being completed in a timely manner, and wound orders not being obtained in a timely manner. The compliance goal was the skin system would be monitored weekly and PRN, and interventions and implementation would be re-evaluated before March 2025. Team members who were part of the goals were the Medical Director, Wound Care Nurse G, ADON, DON, and the ADM. Record review of the Quality Team Tracking Form revealed the following problems: - Detailed skin assessments not completed within 24hrs of admission. - Wound orders not obtained and implemented in a timely manner. - Failure to thrive/poor intake related to malnutrition. - Lack of communication regarding the dressing removal/changes between the nurse and CNA. - Lack of nutrition. Record review of the Quality Team Tracking Formed revealed the following interventions: - On 2/3/25 re-education was provided about how the Charge Nurse would assess upon admission, and the Wound Nurse/designee would assess within 24hr of admission. - On 2/3/25 re-education was provided about how detailed skin assessments would be done within 24hrs of admission by the Wound Nurse/designee. - On 2/3/25 re-education was given about obtaining wound orders if a wound was present upon admission. Revised 2/24/25. - On 2/3/25 re-education was given about the Wound Nurse/designee completing the Care Plan within 24hr of admission and updating the skin Care Plans as needed when a change occurs. A verbal update was also given to the MDS and ADONs to assist with the Care Plans. - On 2/4/25 skin competency skill check offs were initiated with the nurses, Med Aides, and CNAs. - From 2/3/25-2/4/25 Braden Scales were performed on all residents and the residents who were high risk had their interventions reviewed to ensure they were in place and implemented. - From 2/3/25-2/4/25 the facility performed a facility wide skin sweep with no concerns. - On 2/4/25 orders for supplements were obtained and carried out. This would be re- evaluated weekly in the IDT skin/nutrition meeting. - On 2/3/25 re-education was provided to nurses and CNAs on communication about dressings to wounds being removed/missing and soiled. - On 2/3/25 re-education was provided to the nursing department about signs/symptoms of wound infection. - On 2/3/25 re-education was provided regarding the importance of supplements for wound healing. - On 2/3/25 re-education was provided to the nurses about completing skin assessments when the resident leaves/returns to the facility (like for appointments, out on pass, ER visit, etc.). - On 2/3/25 re-education was provided on turning and repositioning and incontinence care frequency. - On 2/3/25 skin/wound tests were initiated. - On 2/24/25 education was given about standing orders for skin tears, MASD, wounds, and redness. Record review of in-services revealed the following was done across all shifts and included all staff: - Incontinent Care performed on 2/3/25 with 53 staff member signatures. - Routine and PRN Wound Dressings preformed on 2/3/25 with 56 staff signatures. - Turning and Repositioning performed on 2/3/25 with 56 signatures. - No Facility Acquired Pressure Injuries performed on 2/3/25 with 44 staff signatures. - Initial Skin Assessments/Treatment Orders and Standing Orders for New Admissions for nurses performed on 2/24/25 with 12 staff signatures. - MASD for nurses performed on 2/24/25 with 28 staff signatures. - ADL's (Resident Showers) performed on 3/5/25 with 20 staff signatures. Record review revealed a staff development/in-service from the DON with LVN O on 2/3/25 regarding skin and wound assessment on admission and re-admission. Record review revealed a counseling/disciplinary notice from 2/4/25 for RN S about ensuring proper orders are received from the PCP/NP and immediately transcribing medications/treatments to ensure they were on the MAR/TAR. Record review revealed a counseling/disciplinary action notice from 2/4/25 for Wound Care Nurse R that revealed she was terminated on her last day of work, which was 1/26/25. Wound Care Nurse R was terminated due to failing to complete a head-to-toe assessment and failing to cover the wound. In an interview with LVN C on 2/23/25 at 2:10pm, she said if a wound was not covered, to look for orders and follow them and if there were not any orders to call the MD. She said skin assessments were done every day, but they had a schedule, so it depended on the room numbers, and some were done in the morning, and some were done at night. In an interview with CNA A on 2/23/25 at 2:20pm, she said they rounded every 2hrs and PRN. She said if a dressing was not on a wound, she would notify the nurse, or if she saw a new skin issue, she would tell the nurse. In an interview with CNA B on 2/23/25 at 2:28pm, he said he rounded every 2-3hrs and PRN. He said if he saw a wound on a resident, he would do a stop and watch (particular form to fill out) and if the dressing was missing, he would tell the nurse. In an interview with the DON on 2/23/25 at 5:00pm, she said the process now was that the resident got admitted and the nurse performed a head-to-toe assessment and documented the wounds on the admission record. She said if the resident was getting wound care at the hospital, the nurse would ask during report if the resident would continue those orders or get new orders. If the hospital said to get new orders, then the nurse needed to reach out to MD W and see if she wanted to continue the hospital orders or give new ones. The DON said if staff could not reach MD W, then they would call the regular MD, and if they could not reach them then they would call her. If the staff were unable to reach any MD, there were now standing orders to clean the wound with NS, pat dry, and cover with a dry dressing until someone sees the wound and orders treatment. In an interview with Wound Care Nurse P on 3/6/25 at 9:23am, she said the process for new admissions was that she checked all the new admissions that came in Friday night and through the weekend until Monday. She then would perform a full head-to-toe assessment on the new admissions and takes off any bandages, and treated any skin concerns as she went. She said if there were any orders from the hospital, she would use those until she spoke to MD W. She said she also performed the weekly skin assessment, the Braden Scale on admission and then every 4wks, and the pressure risk assessment. She said she did the assessments in less then 24hr from when the resident was admitted if they admitted M-F. She said if the resident had any skin concerns, she would talk about it to MD W and if there were any open wounds MD W was always consulted. She said there are standing orders now in place for wounds, MASD, pink skin, etc, so the nurse would know what to do until the Wound Care Nurse could see them. In an observation of Wound Care Nurse P on 3/6/25 at 9:30am, she was observed providing wound care to a resident's sacrum pressure ulcer. She followed all the infection control techniques by sanitizing the table, putting down a barrier, and washing her hands after each contact with an item. She appropriately turned and prepared the resident and sanitized her hands and re-gloved after removing the dirty dressing. She continued to sanitize and re-glove between each new wound care procedure performed. The resident's sacrum ulcer never touched the contaminated brief and remained clean the whole time. Wound Care Nurse P finished and sanitized her hands and changed gloves and assisted the resident into a comfortable position with a wedge under her right side for offloading. In an interview with NP T on 3/6/25 at 11:48am, he said the process for wounds was the admitting nurse would call him and tell him about any wounds while they were doing the admission. He then would consult MD W and he would order some kind of wound care until MD W could see the resident. He said if it was the weekend, the on-call would do the same. In an interview with MD W on 3/6/24 2:27pm, she said clinically, CR #1's wound appeared non-infected, and non-necrotic so it did not appear to have worsened, but she couldn't say for sure. However, it did not have any slough or infection noted and she did not have to debride it which is what she would need to do if it had worsened. She said in theory, if a wound isn't covered or treated for 3 days, yes it could get worse. In an interview with Med Aide E on 3/6/25 at 3:40pm, he said if there were any wounds on a resident, he would fill out the stop and watch form and notify the nurse. He said they also filled out shower sheets and documented on them if they saw any skin concerns and notified the nurse of any skin concerns. If he were to see any new wounds or a wound missing a dressing, he would notify the nurse. In an interview with RN F on 3/6/25 at 3:45pm, he said they had in-services on repositioning, skills check offs, checking the POC, skin assessments, shower sheets, and wound dressings. He said repositioning was for prevention of wounds and healing. The POC was where someone could see how the resident transferred. He also said skin assessments needed to always be done so wounds could be observed. In an interview with CNA D on 3/6/25 at 3:48pm, she said she had in-services on informing the nurse about any wounds, filling out shower sheets with any skin concerns. She said she notified the nurse if a wound was not dressed. She said they did skills check off also. In an interview with Med Aide G on 3/6/25 at 3:51pm, she said if she were to see any wounds or skin concerns, she would notify the nurse or Wound Nurse. She said she turned the residents every 2hrs. She said she filled out the shower sheets with any skin concerns and notified the nurse and she notified the nurse when the resident refused a shower also. In an interview with CNA H on 3/6/25 at 3:45pm, he said he gave daily showers and had to fill out the shower sheets with any skin concerns. He said he alerted the nurse about any wounds or missing dressings. He also said he turned and checked on the residents every 2hrs. In an interview with the DON on 3/6/25 at 5:50pm, she said the ADONs and herself checked behind all of the nurses to ensure the admissions and skin assessments were completed. The Administrator was informed of the past noncompliance on 3/6/25 at 4:10pm.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 3 of 14 residents (Residents #274, #77 and #14) reviewed for medication errors. -MA L did not administer the full dose of Trintellix (vortioxetine) HBr (a medication used to treat major depressive disorder) to Resident #274 as ordered by the Physician. -MA L administered Multi-Vitamin with Minerals to Resident #77 instead of Ocuvit eye + Multivitamin with Minerals (a medication used to help protect eye health) as ordered by the Physician. -RN T administered Lidocaine Patch 5 % (a medication used to help relieve pain) to Resident #14 instead of Aspercream 4% Lidocaine as ordered by the Physician. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings Included: Record review of Resident #274's face sheet dated 07/24/2024 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypothyroidism (a condition where the thyroid gland does not produce enough hormones), major depressive disorder, hypertension (high blood pressure readings) and malaise (a general feeling of being ill, unhappy or uneasiness). Record review of Resident #274's MDS (a Resident Assessment and Care Screening) dated 07/23/2024 revealed no pertinent data due to the MDS was still in progress. Record review of Resident #274's undated care plan included Focus - at risk for impaired cognitive function/dementia or impaired thought process. Goal - will remain oriented to (person, place, situation, time) through the review date. Interventions included - communication: Use simple, directive sentences. Provide with necessary cues-stop and return if agitated. Focus - ADL self-care performance deficit. Interventions included Resident #274 required assistance from staff with all ADLs. Further review revealed major depressive disorder was not addressed. Record review of Resident #274's Psychoactive Medication Therapy Informed Consent Form dated 07/17/2024 and signed by Resident Representative, revealed Psychoactive Medication Prescribed: Vortioxetine for Depression: feeling down, depressed, or hopeless. Record review of Resident #274's Physician Orders as of 07/24/2024 included an order for Vortioxetine oral tablet 10mg, give 1 tablet by mouth one time a day for Depression. Record review of Resident #274's MAR for July 2024 revealed MA L documented administering Vortioxetine 10mg on 07/24/24 at 7:30 AM. Further review revealed MA L documented that she gave Vortioxetine 10mg on the following dates: 7/19/24, 7/20/24, 7/21/24 and 7/22/24. MA E documented as administered on 7/23/2024. In an observation on 07/24/2024 at 8:20 AM, MA L prepared Resident #274's medication. Observation of the label on the blister packet for Trintellix tablet 5mg, indicated a dispense date of 7/18/24, read quantity of 7. The blister pack for Trintellex contained 2 tablets prior to MA L administering one 5mg tablet to Resident #274. Resident #274 was sitting up in bed, alert, watching TV. Resident #274 was cooperative and did not speak when greeted. In an interview on 07/24/2024 at 3:00 PM, MA E confirmed her initials on Resident #274's MAR for July 2024. MA E stated she gave Vortioxetine 5mg x 2 tablets to Resident #274 on 07/23/2024. MA E stated if Resident #274 received a lower dose than what was ordered then it would not be following orders and that it may not be as effective for depression. In an interview on 07/24/2024 at 5:25 PM, the DON said she expected whoever discovered the discrepancy with Resident #274's Vortioxetine (Trintellix) to notify the Charge Nurse right away. The Surveyor asked the DON about the effects of receiving a lower dose. The DON stated Resident #274's mood had not changed from admission and the plan was for Psychiatry to evaluate her. In an interview on 07/25/2024 at 12:28 PM, MA L stated the step she takes prior to administering medications include checking the name on the E-MAR, make sure the name matches on the screen and name on the door, match the ordered dose and the name of the drug matches the blister pack. The Surveyor asked MA L why she gave Vortioxetine 5mg to Resident #274 when the order was for 10mg. MA L stated she just missed and overlooked it and that it was a mistake by the pharmacy who sent the wrong dose. MA L did not have an answer as to why she did not notify the supervisor prior to administration when she saw the discrepancy. MA L stated she told the DON afterwards. The Surveyor asked if she gave 10mg on dates she documented as giving Vortioxetine 10mg on 7/19/24, 7/20/24, 7/21/24,7/22/24, that the blister pack originally contained seven 5 mg tablets on 7/18/24 and that had she given the ordered dose of 10mg, the blister pack had enough full doses for only 3 days and more would have had to been ordered starting 7/22/24. MA L had no comments. MA L stated she would look more carefully next time if it were to happen again, and the blister pack did not match the physician order, then she would notify the nurse right away. MA L stated she had orientation on 6/1/2024 and had 2 weeks on the floor for training on giving medications. In an interview on 07/25/2024 at 1:55 PM, with RN A and the DON, the DON stated the ball was dropped and the pharmacy had not been consistent with delivery of medications. The DON stated the pharmacy did not send the 10mg of Vortioxetine. The DON stated RN A had caught the error for Resident #274's Vortioxetine order during medication reviews on 07/18/2024 for newly admitted residents. RN A stated she placed an order for the correct dose in the computer which directly linked to the pharmacy. The DON stated she was putting more trust in the nurses and med aides that they would follow procedures. The DON stated, what should have happened was that a change of order sticker be placed on the package of Vortioxetine 5mg, to alert the nursing staff and to make sure the correct order/dose was administered. Record review of Resident #274's Order Audit Report dated 07/24/2024 revealed the order summary was for Vortioxetine oral tablet 10mg, give 1 tablet by mouth one time a day for Depression and was created by RN A on 07/18/2024. The Order Supply Summary revealed there was Trintellix (Vortioxetine) 5mg on hand and that the form was auto linked to the pharmacy. Record review of Resident #77's face sheet dated 07/2/42024, revealed a [AGE] year-old female admitted to the facility on [DATE] and originally admitted on [DATE]. Her diagnoses included Alzheimer's disease, Diabetes, need for assistance with personal care, muscle weakness, dementia, hyperlipidemia, polyosteoarthritis, age related osteoporosis and HTN. Record review of Resident #77's Physician's Progress Note, DOS 06/26/2024 by the APRN revealed the resident had a past medical history of macular degeneration (a vision impairment resulting from deterioration of the retina). Record review of Resident #77's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. MDS revealed she had adequate vision and that she did not use corrective lenses. She required partial to substantial assistance from staff with ADLs. Record review of Resident #77's undated care plan revealed Focus - at risk for impaired visual function r/t macular degeneration. Goal - will have no indications of acute eye problems through the review date. Interventions - Review medications for side effects which affect vision. Record review of Resident #77's Physician Orders as of 07/24/2024 included an order for artificial tears 2 drops to both eyes every 12 hours PRN for eye irritation. Eyelid Cleansers pad everyday shift for discharge from eyes. Occuvite Eye and Multi Vitamins-Minerals, give 1 tablet by mouth one time a day for supplement, order date 10/12/2022. Record review of Resident #77's MAR for July 2024 revealed Occuvite Eye + Multivitamin with Minerals, give 1 tablet by mouth one time a day for Supplement and scheduled for 7:30 AM. Record review of Resident #77's eye exam dated 04/09/2024 and written by the Eye Doctor revealed her chief complaint was blurred vision, itching, burning, and watering eyes. Medication included Occuvite eye 1 tablet every day. In an observation and interview on 07/24/2024 at 8:30AM, MA L checked Resident #77's BP. Results were 230/98, 76 pulse. MA L notified the RN P of the elevated BP result. MA L prepared Resident #77's medications including a Multi vitamin with minerals 1 tablet. Resident #77 was sitting in her wheelchair just inside her bedroom door. She was alert and pleasant. Resident was rubbing her eyes and said to MA L that she wanted eye drops. MA L stated she would let the nurse know. In an interview on 07/25/2024 at 12:06 PM, MA L stated the Occuvit Eye supplement was for Resident #77's eyes. MA L stated she gave the correct medication because in the physician orders it read Multivitamins with minerals. MA L stated she did not know what the difference was until the Surveyor explained that the Physician Order read Occuvit Eye and Multivitamins with Minerals. MA L stated she was not clear what the medication was for but that it could be why her eyes were itching. MA L stated she recently received inservice on medication administration around 7/19/24 or 7/22/2024 as well as on 07/24/2024. Record review of Resident #14's face sheet dated 07/25/2024 revealed a [AGE] year-old female admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included Alzheimer's disease, Diabetes, bipolar disorder, anxiety, osteoarthritis, difficulty walking, dementia, muscle weakness and depression. Record review of Resident #14's Physician's Progress Note, DOS 07/18/2024, written by the APRN/FNP read in part: .Assessment and Plan .Osteoarthritis/Lower Back Pain-chronic illness with progression . Record review of Resident #14's quarterly MDS dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition. She was independent with all ADLs. She required supervision with tub/shower transfers. Record review of Resident #14's undated care plan revealed, Focus - Resident #14 has acute/chronic pain r/t generalized pain. Goal - Will not have an interruption in normal activities due to pain. Interventions included - monitor/document for side effects of pain medication. Pain assessment every shift. Further review revealed low back pain was not specifically addressed. Record review of Resident #14's Physician Orders active as of 07/25/2024 revealed Aspercreme 4% Lidocaine Dx: pain, every 12 hours, apply to lower back, order date 04/22/2024. Further review revealed no order for Lidocaine 5 % patch. Record review of Resident #14's MAR for July 2024 revealed Aspercreme 4% Lidocaine was scheduled for 9:30 AM and 9:30 PM. RN T documented administration on 07/25/2024 at 9:30 AM. In an observation on 07/25/2024 at 3:30 PM, RN T applied Lidocaine 5% patch to Resident #14's lower back as Resident #14 stood up holding on to her walker. In an interview on 07/26/2024 at 11:12 AM, the DON said the Lidocaine 5% patch was not the same as Aspercreme 4% Lidocaine. The DON checked records for Resident #14 and said there was no one time order found for Lidocaine 5% patch. The DON said Resident #14 did have an order for Lidocaine 5% patch that was discontinued in April 2024. The DON stated RN T should have clarified the order prior to administration. The DON stated Resident #14 was receiving the Aspercreme 4% Lidocaine patch for the diagnosis of pain. The DON stated Resident #14 probably had a shower and needed the pain patch replaced afterwards and that would explain why a patch was administered in the afternoon. The Surveyor asked the DON what the risks were to the resident. The DON stated Resident #14 could develop an adverse reaction to the Lidocaine 5 % patch or it could not be effective at all in reducing the pain. The DON stated moving forward she will provide 1 one 1 education with RN T. In a telephone interview on 07/26/2023 at 1:30 PM, RN T stated she gave Resident #14 the ordered pain patch in the afternoon of 07/25/2024. RN T stated it was not true that she did not give something that was not ordered. RN T stated she did not remember what all happened the previous day and would need to come in to work and look at the computer to see what happened. RN T called Surveyor at 1:43 PM and said she was unable to come in to work to check Resident #14's records due to an emergency. In an interview on 07/26/2024 at 1:38 PM, Resident #14 said the patch to her lower back helps with her pain and they always apply a patch vs a cream. Resident #14 stated she got a shower around 2:30 PM on 07/25/2024 and recalls she did have a pain patch in the morning. She stated it would have had to come off and then a new one put back on after her shower. Record review of MA L's Skills Checklist for Oral Medication Pass dated 6/17/24 revealed MA L demonstrated competency including verifying medication and strength with order as prescribed. Record review of RN T's Orientation and Annual Skills Checklist dated 6/07/2024 revealed she met the requirements including Understanding Medication Pass Procedure Including Charting: Rights of Medication Administration, PRN pain medications. Record review of the facility Staff Development/Inservice Attendance Sheet dated 06/10/2024 for Medication Administration, presented by the DON/RN A included the 12 Rights of Medication Administration: Right Resident, Right Dose, Right Route, Right Time, Right Response, Right Reason, Right Documentation, Right Assessment and Evaluation, Right Resident Education, Right to Refuse Medication and Right Expiration Date. MA L signed the sheet. Record review of the facility's Medication Administration policy, revised on 05/2007, read in part: .It is the policy of this facility that medications shall be administered as prescribed by the attending physician 14. Prior to administering the resident's medication, the nurse or MA should compare the drug and dosage schedule on the Resident's E-MAR with the drug label. NOTE: If there is any reason to question the dosage or the schedule, the nurse should check the physician's orders .

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 2 residents (Residents #71 and #1) reviewed for medical records accuracy, in that: Resident #71's June 2024 MAR documentation was incomplete. RN M failed to document or sign off on the administration of physician ordered Oxycodone with Acetaminophen (a controlled substance) for pain. Resident #1's April 2024 MAR documentation was incomplete. RN M failed to document or sign off on the administration of physician ordered Hydrocodone with Acetaminophen (a controlled substance) for pain. Facility staff failed to sign the correct narcotic count sheet for Resident #71's Oxycodone with Acetaminophen. RX301757108. Facility staff failed to sign the correct narcotic count sheet for Resident #1's Acetaminophen/Codeine (a controlled substance) .RX301621561. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. Findings included: 1. Record review of Resident #71's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and originally admitted on [DATE]. Her diagnoses included metabolic encephalopathy (a change in how the brain works and can cause confusion), Diabetes (a chronic condition characterized by elevated levels of blood glucose), Crohn's disease (a condition that affects the digestive tract), knee pain, leg pain, Parkinsonism (an umbrella term for conditions that affect movement), dementia, lumbosacral plexus disorders (a disorder of the peripheral nervous system affecting the lower back), chronic pain syndrome, depression, and bipolar disorder. Record review of Resident #71's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15, which indicated intact cognition. She required substantial assist with personal hygiene and toileting hygiene, partial assistance with lower body dressing. She required supervision with transfers. She used a manual wheelchair for mobility. She had occasional pain over the last 5 days and the pain rarely interfered with sleep. She was receiving speech therapy, occupational therapy and physical therapy starting 01/12/2024. Record review of Resident #71's undated care plan revealed Focus - has acute/chronic pain r/t lower back pain, old wedge compression fracture of lumbar area and neuropathy (nerve damage). Interventions included: Administer analgesic medication as per orders. Anticipate need for pain relief and respond immediately to any complaint of pain. Record review of Resident #71's Physician Orders active as of 07/25/2024 revealed an order for Percocet oral tablet 10-325mg (Oxycodone with Acetaminophen) give 1 tablet by mouth every 24 hours as needed for pain, order date 12/16/2023. Record review of the associated Narcotic Count Sheet for Resident #71's Oxycodone with Acetaminophen 10-325mg revealed on 06/06/2024 at 9:00 PM, RN M signed out one tablet. Record review of Resident #71's MAR for June 2024 revealed no documentation Oxycodone with Acetaminophen 10-325mg was administered on 06/06/2024. Record review of Resident #71's Progress Notes dated 05/25/2024 to 06/25/2024 revealed no documentation that Oxycodone with Acetaminophen 10-325mg was administered on 06/06/2024. Record review of the associated Narcotic Count Sheet for Resident #71's Oxycodone with Acetaminophen 10-325mg revealed on 06/09/2024 at 3:00 AM, RN M signed out one tablet. Record review of Resident #71's MAR for June 2024 revealed no documentation that Oxycodone with Acetaminophen 10-325mg was administered on 06/09/2024. Record review of Resident #71's Progress Notes dated 05/25/2024 to 06/25/2024 revealed no documentation that Oxycodone with Acetaminophen 10-325mg was administered on 06/09/2024. Record review of the associated Narcotic Count Sheet for Resident #71's Oxycodone with Acetaminophen 10-325mg revealed on 06/19/2024 at 9:00 PM, RN M signed out one tablet. Record review of Resident #71's MAR for June 2024 revealed no documentation that Oxycodone with Acetaminophen 10-325mg was administered on 06/19/2024. Record review of Resident #71's Progress Notes dated 05/25/2024 to 06/25/2024 revealed that no documentation Oxycodone with Acetaminophen 10-325mg was administered on 06/19/2024. Record review of the associated Narcotic Count Sheet for Resident #71's Oxycodone with Acetaminophen 10-325mg revealed on 06/20/2024 at 9:00 PM, RN M signed out one tablet. Record review of Resident #71's MAR for June 2024 revealed no documentation that Oxycodone with Acetaminophen 10-325mg was administered on 06/20/2024. Record review of Resident #71's Progress Notes dated 05/25/2024 to 06/25/2024 revealed that no documentation Oxycodone with Acetaminophen 10-325mg was administered on 06/20/2024. Record review of the associated Narcotic Count Sheet for Resident #71's Oxycodone with Acetaminophen 10-325mg revealed on 06/28/2024 at 9:00 PM, RN M signed out one tablet. Record review of Resident #71's MAR for June 2024 revealed that no documentation Oxycodone with Acetaminophen 10-325mg was administered on 06/28/2024. Record review of Resident #71's Progress Notes dated 06/25/2024 to 07/26/2024 revealed that no documentation Oxycodone with Acetaminophen 10-325mg was administered on 06/28/2024. 2. Record review of Resident #1's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture to the left hip, urinary tract infection, muscle weakness, difficulty walking, dementia, Alzheimer's disease, deaf non-speaking, heart disease and chronic kidney disease. Record review of Resident #1's quarterly MDS dated [DATE], revealed she had short term and long-term memory problems. She had severely impaired cognitive skills for daily decision making. Her hearing was highly impaired, and she had no speech. She was dependent on staff for all ADL needs. She received scheduled pain medication in the last 5 days. Record review of Resident #1's undated care plan revealed she had a history of left hip fracture. Interventions included monitor/document/report to MD PRN s/sx of hip fracture complications such as unrelieved pain. Resident #1 had an arterial ulcer to the right foot. Interventions included analgesics as ordered. Record review of Resident #1's active Physician Orders as of 07/26/2024 revealed an order for Acetaminophen-codeine tablet 300-30mg, give 1 tablet by mouth every 8 hours as needed for pain, order date 04/11/2024. Record review of the associated Narcotic Count Sheet for Resident #1's Acetaminophen-codeine tablet 300-30mg revealed on 03/23/2024 at 9:00 PM, RN M signed out one tablet. Record review of Resident #1's MAR for March 2024 revealed no documentation that Acetaminophen-codeine tablet 300-30mg was administered on 03/23/2024. Record review of Resident #1's Progress Notes dated 02/23/2024 to 03/25/2024 revealed no documentation Oxycodone with Acetaminophen 10-325mg was administered on 03/23/2024. During a review on 07/24/2024 at 11:50 AM, of the 300 Hall Nurse Medication Cart revealed: -Resident #1's blister packs for APAP/Codeine tablet 300-30mg with RX301621561, dated 4/11/2024 had 81 tablets. The Count sheet read 81 tablets. The pharmacy label on the Count Sheet read: Resident #1 Hydrocodone/APAP tablet 5-325mg, RX301616097, dated 04/09/2024, and signed as received by RN M on 4/9/24. -Resident #71's blister pack for Oxycodone/APAP tablet 10-325mg, RX301757108, dated 05/29/2024 had 7 tablets. The Count sheet read 7 tablets. The pharmacy label on the accompanying Count Sheet read Resident #71, Oxycodone/APAP tablet 10-325mg, RX301598707, dated 4/03/24 and signed as received by RN M on 4/3/24. In an interview on 07/24/2024 at 12:00 PM, LVN C stated she did not know why the pharmacy labels on the blister packs for Resident #1's APAP/Codeine and Resident #71's Oxycodone/APAP did not match with the pharmacy labels on their respective count sheets. LVN C stated that when she signed out Narcotics, she made sure the resident name, the drug and dose match the physician orders and she did not look at the expiration dates and did not look to see if the RX numbers match up. LVN C stated regarding the pharmacy labels on the count sheets she did not know where the blister pack for Resident #1's Hydrocodone/APAP RX301616097 and blister pack for Resident #71's Oxycodone/APAP RX301598707 were located. In an interview on 07/24/2024 at 1:20 PM, the DON and RN A stated the Nurses were signing Resident #1's APAP/Codeine on the count sheet for Hydrocodone/APAP, which was incorrect. The DON stated Resident #1's Hydrocodone/APAP was discontinued and that she still had the blister pack and count sheet because she was still deciding on what to do with it. The count sheet for Resident #1's APAP/Codeine tablet 300-30mg with RX301621561 was switched with the count sheet for the Hydrocodone/APAP RX301616097. The DON stated Resident #71's Oxycodone/APAP, RX301757108 was signed out on a Count Sheet for the same drug but different pharmacy label: RX number (RX301598707). The DON stated Resident #71's Oxycodone/APAP RX301598707 was completed and no longer had the blister pack because it was empty and thrown out. The DON stated the nurses should be matching all information when signing out narcotics, including the RX number and not just counting pills. The DON stated also the nurse accepting the narcotics was responsible for accurate documentation. RN A stated they will be calling in all the nurses who signed out the narcotics and will conduct in-services. The DON and RN A stated they will also audit all the medication carts. Record review of Resident #1's Audit Report dated 07/25/24 revealed Hydrocodone/APAP 5-325mg was discontinued on 04/11/24. Record review of Resident #1's discontinued blister pack for Hydrocodone/APAP RX301616097, contained 3 tablets. The accompanying undated white invoice sheet noted RX301616097 was discontinued, with 2 nurse signatures. The accompanying pink count sheet noted there were 3 tablets, and the pharmacy label was for Resident #1's APAP/Codeine 300-30mg, RX301621561. In an interview on 07/25/2024 at 1:52 PM, the DON stated that the importance of the count sheet was to keep track of the narcotics to ensure the rights of medication administration was implemented, to follow all the 7 rights so they can keep track and hold the nurses accountable when giving the medications. The DON stated the responsibility for maintaining records for controlled substances goes through the chain of command. The DON stated the charge nurses were responsible if any discrepancies were found, they would then call the pharmacy, the DON, RN A and notify the MD and resident/RP. The DON stated it is part of accountability, responsibility and is simply basic Nursing 101. The DON stated she and RN A oversee the narcotics. The State Surveyor asked the DON what the risks would be if records were inaccurate. The DON stated the risks were drug diversion, the resident could have an adverse reaction and misuse of narcotics. The DON stated the Nurse Managers (RN A, ADON, DON, MDS nurse, Resource Nurse, Social Worker) ensures the records are reconciled and the medications are transcribed correctly. The DON stated, moving forward she and RN A and the other ADONs will be checking resident charts and count sheets as well as conducting staff inservices, including reminding staff when signing out narcotics to document right after administering the medications and not waiting until a later time. In an interview on 07/26/2024 at 10:00 AM, the DON stated RN M was no longer employed at the facility as of last week. She did not know the exact date. The DON stated RN M usually worked on 300 Hall. The DON stated she wanted RN M to work alongside of one of the LVNs in 200 Hall and RN M refused when told to do so. The DON stated RN M then quit and did not return. The DON stated, regarding Resident #71's Oxycodone/APAP signed out by RN M and no documentation they were administered, she stated she cannot say they were given and cannot say they were not. The State Surveyor asked the DON about how she would ensure other resident's medications were not inaccurately documented. The DON stated her plan was to implement monitoring, doing the check on narcotics when they are delivered from pharmacy on Mondays, Wednesdays, and Fridays. The DON stated she will start more in-depth inservices for the nurses. The DON stated it was very important that the check mark boxes were accurate, so the facility knows when the medications were administered. In an interview and observation on 07/26/2024 at 12:29 PM, Resident #1 was sitting up in bed, alert and eating lunch. She did not respond verbally to a greeting. She was in no apparent distress. Resident #1 resided in 300 Hall. In a telephone interview on 07/26/2024 at 1:20 PM, State Surveyor asked RN M if she signed out and administered Oxycodone for Resident #71 on the following dates: 6/6/24 at 9:00 PM, 6/09/24 at 3:00 AM, 6/19/24 at 9:00 PM, 6/20/24 at 9:00 PM, 6/28/24 at 9:00 PM and Hydrocodone for Resident #1 on 3/3/24 at 9:00 PM. RN M stated she could not recall the specific dates but that some days got busy, and she may have forgotten to document. RN M stated Resident #71 would get her pain medication on time and if not, the resident would remind her, so this is how she knew she gave her pain medication. RN M stated she was very sorry and should have documented and that she cannot lie as she is an RN. RN M stated she recalls giving Resident #1 her pain medication because the resident had a sacral wound and would cry from the pain. RN M stated there were so many distractions when working but she knows she gave those medications. Interview on 07/26/2024 at 1:38 PM, Resident #71, who resides in 300 Hall, stated she takes Oxycodone for pain in her knees and legs. She stated it does help with the pain but knows she can only have it once a day. She stated she does not use it daily and cannot remember how often she had taken it in the past. She stated when she needs the Oxycodone she asks, and the nurse always gives it to her. In a telephone interview on 07/26/2024 at 2:25 PM, the Consultant Pharmacist stated the DON notified him that there had been inaccuracies with narcotic count sheets. He stated when he does audits quarterly, he randomly chooses PRN and routine medications. He stated everyone is responsible for the accuracy of count sheets and the facility should always have a trail of records and make sure medication labels match up. He stated ensuring the count and all information was accurate is important for proper documentation. Consultant Pharmacist stated if he found any discrepancies, he would dig deeper to find out what happened to any medication not accounted for. In an interview on 07/26/2024 at 5:15 PM, the Administrator stated overall the DON and RN A were responsible for maintaining accuracy of documentation and narcotics. The Administrator stated her expectations of the staff were to ensure they follow correct protocols/follow policies and procedures when administering medications. The Administrator stated the nursing staff should sign medications out properly and timely for correct documentation and accurate medical record purposes. The State Surveyor asked the Administrator how she would ensure other resident's medication records were not disorganized or inaccurate. The Administrator stated she would follow up with evaluating, conduct a root cause analysis to determine what happened, and why the system was broken and needed fixing. The Administrator stated it was importance to make sure the residents get the correct medications as it is a liability for the facility if not done so. Record review of RN M's Orientation and Annual Skills Checklist dated 3/31/2024 revealed she met the requirements including Understanding Medication Pass Procedure Including Charting: Rights of Medication Administration, PRN pain medications. Record review of the facility's policy and procedure for Medication Administration, Administration of Drugs, revised on 05/2007, read in part: .It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedures: .3. All current drugs and dosage schedules must be recorded on the resident's medication administration record (EMAR) .9. The nurse or MA administering the medications must document in the E-MAR, upon completion of the resident's medication administration. 10. When PRN medications are administered, the nurse must record: A. The date and time administered; B. The dosage; C. the route of administration .E. Any complaints or symptoms for which the drug was administered; F. Any results achieved from administering the drug and the time such results were observed, and G. The signature and title of the person administering the drug . Record review of the facility's policy and procedure for Medication Administration, Controlled Drugs, revised on 05/2007, read in part: .It is the policy of this facility to: 1. Provide physical facilities and method of operation for the administration and control of narcotics, depressants, and stimulants which will meet the requirements of State and Federal narcotic enforcement agencies. 2. Insure maximum safety for residents and nursing personnel . Record review of the facility's policy and procedure for Drug Diversion Reporting and Response, revision/review date of 12/2023, read in part: .Definitions: Reconciliation refers to a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered, and/or, including the process of disposition .

Based on interview and record review, the facility failed to develop a comprehensive person-centered admission baseline care plan within 48 hours of admission for 1 of 6 residents (Resident #22) reviewed for baseline care plans in that: - Resident #22 did not have a baseline care plan that addressed his diagnosis of pneumonia completed within 48 hours of admission. This failure placed newly admitted residents at risk of not receiving services to meet their needs. Findings Include: Record review of Resident #22's Face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, Pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), chronic diastolic heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), obstructive hydrocephalus (occurs when the flow of CSF is blocked along one or more of the narrow passages connecting the ventricles), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). Record review on Resident #22's Admission MDS assessment dated [DATE], revealed he had a BIMS score of 0 out of 15, indicating she had severe cognitive impairments. Further record review revealed he was dependent for toileting, shower/bath, upper body and lower body dressing and personal hygiene. He required supervision or touching assistance for eating. He did not walk and used a wheelchair for mobility. He was dependent on chair to bed transfer and needed substantial assistance to roll left and right. Record review on of Resident #22's Baseline Plan of Care dated Admission: 6/15/2024, Focus, Goal and interventions were blank. There was no initiated date or revision date for pneumonia. Record review of Resident #22's Progress Notes dated 06/19/2024 written by APRN/FNP revealed; Room: 313-B History, Code Status: Full Scope of Treatment, Visit Type: SNF, F/U Problem, CC/HPI: Patient hospitalized on [DATE] and treated for Pulmonary Edema, Pneumonia, Sepsis, UTI, AKI d/t Metabolic Acidosis, and acute on chronic CHF. He was readmitted to this SNF on 6/16/24 with new order for Cefadroxil every 12 hours until 6/30/24. ER of abdomen and pelvis during hospitalization showed bilateral staghorn renal calculi. He was referred to Urologist Dr. Sathyamurthy that recommended observation at that time and to return to clinic in 2 to 3 weeks after DC from hospital to review imaging and discuss surgical planning. Patient has stage 4 PU to sacrum and had recent Osteomyelitis and has MRI scheduled for 6/19/24. Patient requiring evaluation and management of disease processes and visit completed. Interview on 7/25/2024 at 3:36 p.m., with RN A, said Resident #22's diagnosis of pneumonia was not care planned and it should have been care planned. She said when she put the antibiotic on the care plan, she did it for sepsis and not for pneumonia. She said if he is on antibiotics for pneumonia, it should be documented in his care plan. She said she was not aware that it was missed on his care plan. She said next time she will do it. She said it was important to have the diagnosis on the care plan because you must be able to assess the resident. She said you cannot trace back or follow interventions if it's not care planned. Interview on 7/25/2024 at 4:02 p.m., with the MDS Nurse, she said Resident #22's diagnosis of pneumonia was not care planned. She said it should have been care planned. She said all of it should have been care planned. She said it was important to have his diagnosis of pneumonia on the care plan to monitor for respiratory interventions because it could affect swallowing. She said she would get with DON, and IDT and they will come up with a plan to improve care plans. Interview on 7/25/2024 at 4:13 p.m., with the ADON, she said if Resident #22's diagnosis was on the care plan, it could help track where the infection was going. She said she would form a team with IDT and find a better way to go about care plans. she said it was a diagnosis it should have been on the care plan. She said she just started her position, and she was still learning what things go on the care plans. She said she would find out from the DON. Record review of the facility's policy titled Comprehensive Resident Centered Care Plan revised on (12/2023) read in part . The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. Cultural Competency - is a process of achieving achieve increasing levels of awareness, knowledge, and skills along a cultural competence continuum. Resident's Goal - refers to the resident's desired outcomes and preferences for admission, which guide decision-making during care planning. Interventions - are actions, treatments, procedures, or activities designed to meet an objective. Measurable - is the ability to be evaluated or quantified. Objective - is a statement describing the results to be achieved to meet the resident's goals. 1. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. 2. The baseline-care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders, b) Physician orders, c) Dietary orders, d) Therapy services, e) Social services; and f) PASARR recommendations, if applicable .

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, which included tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 2 of 3 residents (Resident #88 and Resident # 6) reviewed for oxygen therapy. The facility failed to ensure Resident #88's oxygen was set according to physician orders. The facility failed to ensure Resident #6's oxygen concentrator was functional, oxygen tank had oxygen and oxygen was set according to physician's order. These failures could place residents at risk of respiratory distress. The findings were: Resident #88 Record review of Resident #88's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed air flow from the lung), Encephalopathy (any disease of the brain that attacks brain function or structure), pleural effusion (abnormal collection of fluid between the thin layers of tissue lining the lungs and the walls of the chest cavity), and acute respiratory failure (occur when your lungs cannot release enough oxygen into the bloodstream, and it also occurs when your lungs cannot remove carbon dioxide from your blood). Record review of Resident #88's Admission MDS assessment, dated 04/05/23, revealed the BIMS score was 11, which indicated moderately impaired cognition. Further review of the MDS revealed It was not indicated Resident #88 used oxygen. Record review of Resident #88's care plan, initiated 04/07/23, revealed the following: Resident#88 has altered respiratory status/difficulty breathing related to COPD, respiratory failure, and pleural effusion. Intervention: oxygen at 2/min continues per nasal cannular . Record review of Resident #88's medication review report revealed oxygen at 2 liters per minute continuous per every shift for monitoring was dated 05/03/23. During an observation and interview on 05/16/23 at 12:37 p.m. revealed, Resident #88's oxygen concentrator was set to 3 liters, and the resident had a nasal cannula in her nostrils. Resident #88 said she did not know whatere her oxygen should be set at and did not change the setting. During an interview on 05/16/23 at 12:18 p.m., LVN A said she checked Resident #88 O2 sat at 8:30 a.m., and it was 95%. She said she did not check the oxygen setting on the concentrator . She said the nurse could increase the oxygen if the resident was in a crisis and then notify the doctor. She also said she did not get any report that Resident #88 was in distress during shift change. LVN A stated besides a crisis, the resident oxygen should not be changed without a doctor's order. She said it could cause more harm to Resident #88 because she had COPD. She said oxygen was considered medication, and a doctor's order was needed before it could be changed. She said the resident's oxygen should be set at 2 liters per minute. Record review on 05/16/23 at 12:47 p.m., the surveyor and LVN A reviewed Resident #88 progress notes and SBAR from 05/09/23 to 05/16/23 which did not reveal the resident was in any crisis. During an interview on 05/17/23 at 1:11 p.m., the DON said the nurse could change the oxygen from 2L/MIN to 3L/MIN in an emergency situation. She said she had not heard Resident #88 had any issues which would cause the oxygen to be increased. She said oxygen was considered medication and could only be changed with a doctor's order. She said if the resident had COPD, it would cause more harm than good. She said Resident #88 had COPD, and it caused the resident to go into respiratory distress because it could be hard for the resident to get rid of carbon dioxide. She said oxygen was medication, and a physician was needed before the oxygen setting could be changed. Resident #6 Record review of Resident #6's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed air flow from the lung), emphysema (a disorder affecting the tiny air sacs of the lungs), dementia(The symptoms of number of illnesses that affect the brain and emphasis ability to perform everyday task) and acute respiratory failure (occur when your lungs cannot release enough oxygen into the bloodstream, and it also occurs when your lungs cannot remove carbon dioxide from your blood). Record review of Resident #6's Quarterly MDS assessment, dated 02/23/23, revealed the BIMS score was 02, which indicated severely impaired cognition. Further review of the MDS revealed Resident #6 was on oxygen therapy Record review of Resident #6's care plan, initiated on 01/11/23, revealed the following: Resident#6 has emphysema and COPD. Intervention: give oxygen therapy as ordered by the physician. Record review of Resident #6's medication administration record dated for May 2023 reflected oxygen at 2 liters per minute via nasal cannula PRN, keep oxygen saturation above 90%. During an observation and interview on 05/17/23 at 7:10 a.m. revealed Resident #6 was in bed and had a nasal oxygen cannula in her nostrils. She was not in distress. The oxygen concentrator was on, but the black flow ball indicator of where the oxygen was set was on 0. There was an oxygen tank hung on her wheelchair, and it was set at 3 liters, and the red indicator which showed how much oxygen was in the tank was on zero . Resident #6 was asked if she felt the air in her nostrils. The resident did not respond to this surveyor. O2 sats were not taken at this time. During an observation and interview on 05/17/23 at 7:25 a.m., LVN B said the O2 concentrator was on, the black ball indicator of where the oxygen was set was on zero, and she tried to adjust the oxygen, and the ball would not move up. She said the concentrator was not working because the flow dial would not move. She also said Resident #6 was not getting any oxygen. She said she was Resident # 6's nurse and had yet to check the resident's concentrator or oxygen saturation. LVN B said if the resident did not get oxygen, the resident could have hypoxia (lack of sufficient oxygen in the blood, tissue, and/or cells to maintain normal physiological function) and difficulty breathing. LVN B said she should have checked the setting on the concentrator when she made her rounds when she first came to work. She said she had an in-service and skills check-off for oxygen administration. She said because Resident #6 was not getting any oxygen from the concentrator or the oxygen tank and the setting on the tank was on 3 liters, then the physician's order was not followed. LVN B said she could not tell how long the oxygen was empty because this was the first time, she had seen it since she came to work at 6:00 a.m. During an observation and interview on 05/17/23 at 7:35 a.m., ADON A said Resident #6 was not hooked up to the concentrator but to the oxygen tank. She stated the concentrator in the resident room should be in good working condition, and the nurses should check the equipment during rounds. The ADON looked at the setting on the tank and said it was set at 3 liters. Then she looked at the oxygen quantity indicator and she said it was on red, and when she was asked what it meant, the ADON said the tank was empty. She said LVN B should ensure the tank had oxygen before the resident was hooked up to the tank. She said she could not tell how long the tank had been on red. She said Resident # 6 could have respiratory distress. She stated the ADON monitored the nurses by making rounds and asking the nurses about the resident's condition. She said if the tank was empty, the doctor's order was not followed, and the same applied to the concentrator that was not functional. During an interview on 05/17/23 at 1:17 p.m., the DON said LVN B should check the O2 sat, concentrator setting, oxygen tank setting, and amount of oxygen left in the tank at the same time. The DON said LVN B should check the concentrators throughout the shift when she rounded and at shift change. The DON said since the O2 tank was empty, Resident #6 was not getting any oxygen, which meant the physician's order was not followed. She said when the ball was on zero, it meant the concentrator was not functional. She said the setting on the oxygen tank was 3 liters per minute, and if it was not set at the prescribed liters, then the resident received more oxygen than ordered, and like another medication. She said i f the resident was in distress and needed more oxygen; the nurse could change it but had to notify the doctor and document it. The DON stated when the crisis was over, the oxygen would be reduced to the original order unless the doctor changed it. Record review of the facility's policy for licensed nurse procedures for oxygen administration, reviewed/revised 4/5/2023, reflected in part . oxygen therapy is administered, as ordered by the physician