Every finding on record at Creekside Post Acute

Based on interview and record reviews, the facility failed to ensure the physician was notified of an abnormal laboratory results for one of five sampled residents (Resident 1) when a sputum culture (a laboratory test performed on mucus coughed up from the lungs or airways to identified the type of infection) results showed heavy growth (a large of bacteria grew from the sputum) of extended-spectrum beta-lactamase (ESBL - producing Klebsiella pneumoniae, a type of bacteria that can cause infection and is resistant to many commonly used antibiotics) received on June 23, 2026. This failure placed Resident 1 at risk for delayed medical evaluation and treatment of a potentially serious respiratory infection (a severe infection affecting the lungs or airways that, if worsens or spreads, may lead to a serious complications.)Findings: During a review of Resident 1's admission Record (contains demographic and medical information), it indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included gastrostomy status (feeding tube placed through the abdominal wall into the stomach for nutrition and medications), chronic respiratory failure with hypoxia ( a condition where the lungs cannot provide enough oxygen) and nontraumatic subdural hematoma (leading beneath the covering of the brain that can impair brain function). During a review of Resident 1's Sputum Culture report, dated June 23, 2026, the report indicated, the sputum specimen culture was collected on June 15, 2026, at 6:59 PM. The final, updated result was approved on June 23, 2026, at 10:29 AM. The report indicated, Critical SPUTUM CULTURE called to [name and title of the nurse who received the result] on June 23, 2026, at 10:53 AM. Final (Test).Extended spectrum beta-lactamase producing klebsiella pneumoniae.Growth.Heavy growth. During a telephone interview on July 27, 2026, at 4:30 PM, with the Operations Manager, (OM) the OM stated that when the facility staff receives a new critical infection-related laboratory result, the physician should be notified. The OM stated that the laboratory result and physician notification should be documented in the nursing progress notes. The infection preventionist should also be notified, and a change of condition (COC - a tool used by healthcare staff to quickly communicate a resident's change in condition to the provider) should be initiated when the results represent a new condition. The OM was unable to confirm what actions were taken regarding Resident 1's critical sputum culture result. During a review of the SBAR- Change of Condition Report (COC) dated June 25, 2026 5:30 AM, the COC indicated, 2. Situation concern (s) G-tube dislodged.,(a feeding tube move out of the stomach.) C. Assessment.,Patient was sent to hospital regarding G-tube dislodgement. Pt (patient) otherwise stable. The COC did not identify the June 23, 2026, critical sputum - culture result. During a review of Resident 1's Nursing Progress Notes, dated from June 8, 2026, through July 1, 2026, the Nursing Progress Notes, did not show documentation that the attending physician or pulmonologist was notified of the critical sputum culture result showing heavy growth of extended-spectrum beta-lactamase (ESBL) - producing klebsiella pneumoniae. There was no documented evidence in the Nursing Progress Notes that a follow - up instructions or treatment orders were obtained in response to the critical sputum result. During a concurrent telephone interview and record review on July 28, 2026, at 12:42 PM, with the Director of Nursing (DON), Resident 1's laboratory report for the Sputum Culture collected on June 15, 2026, and resulted on June 23, 2026, was reviewed. The laboratory test result indicated, ESBL - producing Klebsiella pneumoniae. The DON stated that, in this instance, the pulmonologist should have been notified, and a COC should have been completed. The DON further stated the facility's expectation was for critical laboratory findings to be reported to the physician immediately. During a concurrent telephone interview and record review on July 28, 2026, at 12:46, with the DON, Resident 1's SBAR - Change of Condition Report (COC) dated June 25, 2026, at 5:30 AM, was reviewed. The DON confirmed that the resident was transferred to the hospital on June 25, 2026 for G-tube dislodgment. The COC did not identify or address the June 23, 2026, sputum culture result indicating ESBL - producing Klebsiella pneumoniae. The DON stated that when the facility receives an abnormal or critical laboratory result, nursing staff are expected to assess the resident and to notify the physician and the pulmonologist. The DON stated that a COC addressing the sputum culture result should have been completed and reported to the physician immediately. During a concurrent record review and telephone interview on July 28, 2026, at 12:48 PM, the facility's policy and procedure titled Laboratory Testing Reviewed: January 16, 2026, was reviewed with the DON. The policy indicated, it is the policy of this facility to obtain laboratory.services when ordered by a physician, PA, NP or clinical nurse specialist and to promptly notify the ordering entity of test results., Procedures.,2. Results of laboratory.,and diagnostic test outside the clinical reference ranges shall be reported to the resident's attending physician, PA, (physician assistant), NP (nurse practitioner) or clinical nurse specialist promptly or as specified in the order. 3. Notification of test results will be documented in the resident's clinical record. 4. Results of all diagnostic services shall be made a part of the resident's medical record. The DON stated, It doesn't look like we followed that policy.

Based on interview and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1) when Resident 1 fell out of bed during wound care treatment. This failure resulted in Resident 1 falling off the bed, placing his safety at risk.During a review of Resident 1's admission Records (general demographics information), the admission Records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (partial or total loss of sensory or motor function), respiratory failure (lungs cannot supply oxygen), type 2 diabetes mellitus (body has trouble controlling blood sugar) and pressure ulcer on the left hip (wound to hip).During a review of Resident 1's Minimum Data Seta (MDS - clinical assessment tool used in nursing homes that serves as a comprehensive summary of a resident's functional capabilities, health conditions, and care needs.) Section GG Functional Abilities, dated March 25, 2026, the MDS Section GG Functional Abilities indicated, Code 2 (Impairment on both sides) . A. Upper Extremities (shoulder, elbow, wrist, hand) Code 2 given. B. Lower Extremities (hip, knee, ankle, foot) Code 2 given.During a review of Resident 1's Fall Risk Evaluation (clinical assessment tool used to evaluate an individual's likelihood of falling) from October 14, 2025, to June 6, 2026, the Fall Risk Evaluation indicated Resident 1 as High Risk for fall on June 06, 2026 , with 1-2 Falls in the past 3 months.During a review of Resident 1's Care plan (identifies the patients physical, psychosocial and emotional needs to target goals and interventions), the Care plan indicated The resident [Resident 1] has little or no activity involvement related to physical limitations. The resident [Resident 1] has Activities of Daily Living (ADLS) (physical task of daily life) self-care performance deficit related to activity intolerance.resident [Resident 1] totally dependent on staff. Resident [Resident 1] is at risk for falls and injury related to impaired mobility. need for assistance with care and treatments, sudden involuntary movements (coughing episodes) requirement for bedside procedures.During a review of Resident 1's Situation Background Assessment Recommendation (SBAR - assessment tool to communicate with physician about patients) notes, dated June 06, 2026, at 2:19 PM, the SBAR indicated Resident [Resident 1] experienced a witnessed fall-related incident during wound care treatment. Resident [Resident 1] was positioned on her left side, facing patio door in the center of the bed when a sudden coughing episode caused an abrupt movement toward the edge of the bed. During the incident, resident [Resident 1] struck her head on the nightstand, sustaining an open area above the right eyebrow. Wound care [Txt nurse 1] nurse immediately intervened and assisted resident [Resident 1] to the floor. Resident [Resident 1] complained of pain following the incident. Upon assessment, resident [Resident 1] sustained an open area/laceration to the right side of the head with bleeding noted. Bleeding was controlled with pressure. Resident [Resident 1]'s gastrostomy tube (G-tube - feeding tube provided directly to stomach) was also noted to be dislodged. Resident [Resident 1] exhibited signs and symptoms of pain including moaning, facial grimacing, and muscle tension following the incident. the resident [Resident 1] was transferred to the Emergency Department for a higher level of care (Resident 1 required services provided at a hospital).During a review of Resident 1' emergency room Visit Notes dated June 06, 2026, at 3:33 PM, stated, Visit for Fall, dislodged gastrostomy tube. No fractures. During an interview on June 24, 2026, at 12:32 PM, with Certified Nursing Assistant (can 1), CNA 1 stated, Resident 1 was total care (requires complete assistance with all activities) and was not able to assist with turning and repositioning. CNA 1 further stated, When wound treatment is done, the treatment nurse will call us to assist with the turning.During an interview on June 24, 2026, at 2:04 PM, with Certified Nursing Assistant (CNA 2), CNA 2 stated she helped Txt nurse 1 with Resident 1's treatment of the sacral wound. CNA 2 stated she asked Txt nurse 1 if she could perform wound care on Resident 1's foot by herself and she agreed. CNA 2 further stated she then stepped out of the room to attend to another resident, leaving Resident 1 lying on her side with Txt nurse 1 at bedside. CNA 2 stated when she went back into Resident 1's room, Resident 1 was on the floor, unable to hold the grab bar (a short rail attached to the bed for patients to grab and reposition or transfer).During an interview on June 24, 2026, at 12:43 PM, with License Vocational Nurse (LVN), LVN stated, Resident 1 required a two-person assist during care. LVN1 further stated, If the Treatment nurse did the wound treatments by themselves, it's not safe. This resident [Resident 1] is not able to assist while turning or providing care. LVN 1 stated, Regarding the fall, I think gravity took over due to her [Resident 1] knees, they are contracted. Her [Resident 1] knees will be over the bed on the other side, and it took her down.During an interview on June 24, 2026, at 12:56 PM, with Treatment Nurse (Txt nurse 2), the Txt nurse 2 stated, I do my wound treatments with the CNA. I was told this resident had a fall and the other wound treatment nurse [Txt nurse 1] was by himself doing the treatments when this happened. Txt nurse 2 stated Resident 1 was contracted to arms and lower extremities and it was safe to have 2 staff members present while providing wound care because Resident 1 also had an air mattress (inflates air to prevent and heal tissue damage and makes it easier for the residents to slide off), Resident 1 was not able to assist with the care.During an interview on June 24, 2026, at 1:26 PM, with the Director of Nursing (DON), the DON stated, Resident 1 was fully dependent and her knees are contracted. The nurse did state he had someone for the other wounds but not the ankle. She should not have fallen, and yes, she did have a fall.During a review of the facility's policy and procedure (P&P) titled, Fall Management, dated January 2026, the P&P indicated, This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible, Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents.

Based on observation, interview, and record review, the facility failed to implement their Medication Administration policy and procedure for one (1) of three (3) sampled residents (Resident 1) when Resident 1's scheduled dose for 8:00 PM to 10:00 PM medications were not recorded as administered on Resident 1's Medical Administration Record (MAR) on December 31, 2025. This failure has the potential for Resident 1 to be at risk of overdose or missed doses.Findings: A review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Idiopathic Pulmonary Fibrosis (IPF- a serious lung disease where the lungs scar and stiffen, making it hard to breathe), and chronic respiratory failure with hypoxia (lungs aren't doing their job well enough to keep your body supplied with oxygen and clear out waster (Carbon dioxide)). A review of Resident 1's MAR for the month of December 2025 indicated multiple scheduled medications between 8:00 PM and 10:00 PM had no nursing signature or documentation to indicate that it was administered. The medications that had missing signatures were as follows: 1. Losartan Potassium Oral Tablet 50 mg (milligram - unit of measurement) - Give 1 tablet by mouth every 12 hours for hypertension (high blood pressure). (Scheduled to be administered at 8:00 PM.)2. Atorvastatin Calcium Oral Tablet 80 mg - Give 1 tablet by mouth at bedtime for hyperlipidemia (high levels of fat in the blood). (Scheduled to be administered at 9:00 PM.)3. Ezetimibe Oral Tablet 10 mg - Give 1 tablet by mouth at bedtime for hyperlipidemia. (Scheduled to be administered at 9:00 PM.)4. Amlodipine Besylate Oral Tablet 5 mg - Give 1 tablet by mouth every 12 hours for hypertension. (Scheduled to be administered at 9:00 PM.) 5. Carvedilol Oral Tablet 25 mg - Give 1 tablet by mouth every 12 hours for hypertension. (Scheduled to be administered at 9:00 PM.) 6. Pro-Stat Oral Liquid - Give 30 mL (milliliter - unit of measurement) by mouth every 12 hours for supplementation. (Scheduled to be administered at 9:00 PM.) 7. Ticagrelor Oral Tablet 90 mg - Give 1 tablet by mouth every 12 hours for DVT (Deep Vein Thrombosis - formation of blood cloth) prophylaxis (prevention). (Scheduled to be administered at 9:00 PM.) 8. Gabapentin Capsule 100 mg - Give 1 capsule by mouth every 8 hours for neuropathic pain (chronic condition caused by damage or disease affecting the somatosensory nervous system, resulting in abnormal sensations). (Scheduled to be administered at 9:00 PM.) 9. Pirfenidone Oral Tablet 801 mg, to be administered one tablet by mouth every 8 hours for respiratory failure, at 6:00 AM, 2:00 PM, 10:00 PM. (Scheduled to be administered at 10:00 PM.) During a concurrent telephone interview and record review with the Director of Nursing (DON), on January 20, 2026, at 12:16 PM, the DON reviewed Resident 1's MAR for the month of December 2025 and confirmed there was no documentation that Resident 1 received his scheduled dose for 8:00 PM to 10:00 PM medications on December 31, 2025. During a telephone interview on January 20, 2026, at 1:29 PM, with the License Vocational Nurse (LVN 1), LVN 1 stated he administered all of Resident 1's scheduled 8:00 PM to 10:00 PM medications on December 31, 2025, but he forgot to document it on Resident 1's MAR. He acknowledged that he should have signed the MAR immediately after administering the medication rather than waiting until the end of his shift. A review of the facility's undated policy and procedure titled, VIII. Specific Medication Administration Procedure, indicated, After administration, return to cart and document administration in Medication Administration Record (MAR) or Treatment Administration Record (TAR). A review of the facility's policy and procedure titled, Medication Administration, revised on January 16, 2026, indicated, .7. The Licensed nurse administering the medication must record such administration of medication in the medication administration record. (EMAR).

Based on observation, interview, and record review, the facility failed to ensure medication was administered in accordance with the facility's policies and procedures (P&P) for one (1) of three (3) sampled residents (Resident 1) when Resident 1 did not receive his medication, Pirfenidone (a medication for Idiopathic Pulmonary Fibrosis (IPF- a serious lung disease where the lungs scar and stiffen, making it hard to breathe), on three occasions, December 26, 2025 at 2:00 PM, December 27, 2025, at 2:00 PM, and December 28, 2025, at 10:00 PM. This failure had the potential to place Resident 1 at risk for adverse effect such as a return or worsening of idiopathic pulmonary fibrosis (IPF) symptoms, which includes shortness of breath, extreme tiredness, and dry hacking cough.Findings: A review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included IPF, and chronic respiratory failure (long-term condition where the lungs gradually become unable to get enough oxygen into the blood or remove enough carbon dioxide) with hypoxia (low levels of oxygen in the body). A review of Resident 1's physician's order, dated December 21, 2025, indicated Resident 1 had an order to receive Pirfenidone Oral Tablet 801 mg (milligram-unit of measurement) one tablet by mouth every 8 hours, 6:00 AM, 2:00 PM, and 10:00 PM. A review of Resident 1's Medication Administration Record (MAR) for the month of December 2025, indicated Resident 1 did not receive his medication, Pirfenidone, on three occasions, December 26, at 2:00 PM, December 27, at 2:00 PM, and December 28, at 10:00 PM. During a concurrent interview and record review on January 15, 2026, at 2:24 PM, with License Vocational Nurse (LVN 1), LVN 1 reviewed Resident 1's MAR for the month of December 2025 and stated he did not administer Resident 1's Pirfenidone on two occasions, December 26, 2025, at 2 PM, and December 27, 2025, at 2 PM. He further stated he did not find the medication in the cart, and he did not check with the previous nurse to see if the medication was available. During an interview on January 15, 2026, at 2:52 PM, with the Director of Nursing (DON), the DON stated her expectation was for communication between nurses to take place during shift changes, which unfortunately did not occur, leading to Resident 1 not receiving his medication as prescribed, an outcome that is deemed unacceptable. She acknowledged that it was the facility's duty to guarantee that medications were administered according to the prescribed orders. During a telephone interview on January 16, 2026, at 5:36 PM, with LVN 2, LVN 2 stated she did not administer Resident 1's Pirfenidone on December 28, 2025, at 10:00 PM because she was unable to locate the medication in the cart. A review of facility Policy and Procedures (P&P) titled, Medication Administration, reviewed January 16, 2026, indicated, .Medications must be administered in accordance with the written orders of the attending physician.

Based on interview and record review, the facility failed to ensure staff who had appropriate competencies and skill set completed the resident's Quarterly Nutrition Assessment (a detailed evaluation of eating habits, weight and overall health related to food, done every 3 months). This failure had the potential to place 52 highly vulnerable residents' health at risk due to not receiving an adequate nutritional assessment.During a review of Residents 5, 8, 25 and 26's Quarterly Nutrition Assessments (comprehensive evaluation of an individual's nutritional status, aiming to identify any nutritional deficiencies or risks, and guide personalized interventions) between November 2024, through June 2025, it indicated the assessments were completed and signed by the Dietary Service Supervisor (DSS 1).During a review of Resident 8, 25 and 26's Quarterly Nutrition Assessments between November 2024, through June 2025, it indicated the assessments were completed and signed by DSS 2.During an interview on July 17, 2025, at 10:00 AM with DSS 1, DSS 1 verified that the completion of the quarterly nutrition assessment was being conducted and signed by DSS 1.During a telephone interview and concurrent record review, with the Registered Dietitian (RD), on July 17, 2025, at 12:17 PM, the RD reviewed Resident 26's Quarterly Nutrition Assessment, which indicated Resident 26 had an Ideal Body Weight Range (IBWR - a weight range associated with the lowest risk of mortality for a given height, age, sex, and sometimes frame size) was 208 pounds to 213 pounds. The RD stated she was not sure where DSS 1 got that weight range and further stated it was not a correct weight range for Resident 26. The RD stated the Dietary Supervisor was not qualified to do nutrition assessments.During an interview on July 18, 2025, at 2:24 PM, with the Interim Director of Nursing (IDON), the IDON stated the DSS does not have the scope of practice to conduct assessments. The IDON further stated the quarterly assessments were not verified by anyone else beyond the DSS.

Based on observation, interview, and record review, the facility failed to store resident food safely when:1.The resident refrigerator had multiple food items that were not labeled or dated. 2. The temperature of the refrigerator had not been monitored in June 2025 and July 2025. These failures had the potential for food borne illness (any illness resulting from eating contaminated/spoiled foods) in 25 medically compromised residents who were able to store food in this refrigerator.During a concurrent observation and interview on July 16, 2025, at 9:57 AM, with the Social Worker (SW), in the dining room, the resident refrigerator was found to have multiple food items that were not labeled or dated. Two thermometers were located outside of the fridge. The SW stated the food items stored in the refrigerator should be dated and labeled with the resident's name.During a concurrent interview and record review on July 16, 2025, at 11:00 AM, with the SW, the temperature logs for the resident refrigerator were reviewed. The SW stated there were no temperatures logged for the months of June 2025 and July 2025.During a concurrent interview and record review on July 18, 2025, at 10:43 AM, with the SW, the facility's policy and procedure (P&P) titled, Resident/Personal Food Storage, dated January 2025, was reviewed. The P&P indicated . 3. All refrigeration units will have internal thermometers to monitor for safe food storage temperatures. 5. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's names, the item and the use by date. The SW stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to maintain the acceptable parameters of nutritional status (factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values), recognize, evaluate, and address the nutritional needs of one of three residents reviewed for nutrition (Resident 26) when: 1. Resident 26's tube feeding (method of providing nutrition directly into the stomach or small intestine when a person is unable to eat enough or at all by mouth) formula was administered as ordered by the physician on July 15, 2025, and July 16, 2025. Resident 26's had an order to receive 95 ml (milliliters, a unit of volume) per hour. On July 15, 2025, at 3:52pm Resident 26 only received 500 ml of formula for 9 hours, but should have received 855 ml (a difference of 355 ml). On July 16, 2025, at 3:32 PM, Resident 26 received 380 ml for 8 hours, of feeding but should have received 570 ml (a difference of 190 ml). 2. Residents 26's care plan (individualized treatment plan) interventions for pulling on his tube feeding and other life supporting medical equipment were not reevaluated since 2024. 3. Resident 26's intake and output (the measurement and recording of fluids consumed by a patient (intake) and fluids eliminated from the body (output)) was not accurately documented by the staff in accordance with the facility's policy. These failures had the potential to have contributed to Resident 26, a medically compromised patient, to lose 22 pounds in six months.Findings: 1. During a review of Resident 26's face sheet (contains demographic and medical information), it indicated Resident 26 was admitted to the facility on [DATE], with diagnosis of anoxic brain injury (brain damage from lack of oxygen), chronic respiratory failure (chronic lung disease that causes decreased oxygen) and hypertension (high blood pressure). During a review of Resident 26's physician orders, dated May 31, 2025, it indicated Resident 26 had an order to receive Enteral Feed Order, [Brand Name] 1.5 at 95 ml/hr (hour) x (for) 20 hours to provide 1900ml/ (or) 2850 kcal (a unit of energy measurement used in nutrition) due to weight loss. On at noon and off at 8:00 AM During a review of Resident 26's weight record, dated January 1, 2025, to June 25, 2025, it indicated Resident 26's weight on January 1, 2025, was 217 pounds, and 195 pounds on June 24, 2025 (22 pounds weigh lost). During a review of Resident 26's Progress Note, dated June 9, 2025, it indicated, .WT TREND (weight trends) -22# (a loss of 22 pounds) x(in) 6 months (10.1%) . During an observation on July 15, 2025, at 3:52 PM, with a Licensed Vocational Nurse (LVN 9), in Resident 26's room, Resident 26's was lying in bed, sleeping. Resident 26's tube feeding formula, which was hanging on a pole next to the resident, was inspected. Its label indicated the formula was initially hung on July 15, 2025, at 3:00 AM. It had approximately 1100 ml remaining, of a total volume of 1500 ml. (Resident 26 received 500 ml of formula for 9 hours, [Enteral Feed Order. on at noon and off at 8:00 AM] but should have received 855.) During another observation on July 16, 2025, at 3:32 PM, with LVN 9, in Resident 26's room, Resident 26 was lying in bed and appeared restless while pulling on the cord of his tube feeding. Resident 26's tube feeding formula, which was hanging on a pole next to the resident, was inspected. Its label indicated the formula was initially hung on July 16, 2025, hung at 4:00 AM. It had approximately 1400 ml remaining of a total volume of 1500 ml. (Resident 26 only received 380 ml of formula for 8 hours, [Enteral Feed Order. on at noon and off at 8:00 AM] but should have received 570 ml). During an interview on July 17, 2025, at 12:17 PM, with the Registered Dietitian (RD), the RD stated Resident 26 should have received 855 ml of the prescribed tube feeding for 9 hours but only received 500 ml. The RD further stated he did not receive 355 ml of the prescribed tube feeding for the day. The RD also stated that on July 16, 2025, Resident 26 should have received a total of 570 ml of the prescribed tube feeding for 6 hours, however only 190 ml were administered, leading for Resident 26 to miss 380 ml of the prescribed tube feeding. During a continued interview, RD stated Resident 26 should have received the correct amount ordered by the physician. The RD further stated she could not deny that missed feedings could contribute to weight loss. The RD stated Resident 26 was completely bed bound and was losing muscle mass, and the nursing staff should have documented the reason why the full tube feeding order was not provided. During a review of the facility's policy and procedure (P&P) titled, Nutrition Status Management, dated January 25, 2025, it indicated . ensure that all residents maintain acceptable parameters of nutritional status, such as body weight. During a review of the facility's P&P titled, Enteral Formula, Administration of Closed System, dated January 25, 2025, it indicated . This policy provides a means to safely administer a complete nutritional feeding to the resident. 2. During an observation and concurrent interview on July 16, 2025, at 3:32 PM, with Licensed Vocational Nurse (LVN 9), in Resident 26's room, Resident 26 was lying in bed, restless, and was pulling on the cord of his tube feeding. LVN 9 stated, the housekeeping staff just cleaned up because the resident had pulled on his tube feeding the water flush fell on the floor and spilled water on the floor. LVN 9 stated Resident 26 has a history of pulling at his feeding tube and other medical equipment. During a review of Resident 26's nurses note, dated November 26, 2024, at 1:00 PM, it indicated Resident continues to have episodes of pulling out life sustaining devices. During a review of Resident 26's nurses note, dated December 20, 2024, at 6:50 PM, it indicated . residents g-tube (gastrointestinal tube - medical device inserted into the stomach or small intestine to provide nutrition, fluids, or medications when a person is unable to eat or swallow adequately) is dislodged. During a review of Resident 26's nurses note, dated January 23, 2025, at 2:19 PM, it indicated Rounds made resident noted with continued behaviors of pulling of life sustaining medical devices, such as g-tube. During an interview and concurrent record review on July 22, 2025, at 4:00 PM, with the Interim Director of Nursing (IDON), the IDON reviewed Resident 26's care plan for .behavior problem of self-grounds, combative, continuous pulling on trach (tracheostomy tube is a curved tube inserted into a surgically created opening (stoma) in the trachea (windpipe) to facilitate breathing when a patient's upper airway is compromised), medical equipment which indicated it was first initiated on June 19, 2024, and was last revised on November 8, 2024. There was no documented evidence to indicate the care plan was reviewed and/or revised to address the incidents on November 16, 2024, December 20, 2024, and January 23, 2025. The IDON confirmed that interventions for this area of focus had not been updated and reevaluated to meet Resident 26's needs since 2024. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, dated January 25, 2025, it indicated, .The resident's comprehensive plan of care will be reviewed and/or revised by the IDT (Interdisciplinary Team- a group of healthcare professionals from various disciplines who collaborate to provide comprehensive care for a patient) after each assessment, including both the comprehensive and quarterly review assessments. 3. During an interview on July 16, 2025, at 3:47 PM, with LVN 9, LVN 9 stated she does not document how much of the tube feeding was given to Resident 26. LVN 9 further stated she was not sure how much was given at the prior shift. She stated that during her shift she had to turn off the feeding once because Resident 26 pulled on the feeding tube cord and knocked over the pole with the feeding and the water. LVN 9 stated that she did not document Resident 26's intake and output. During a record review of Resident 26's physician orders, it indicated Enteral Feed Order, [Brand Name] 1.5 at 95 ml/hr (hour) x (for) 20 hours to provide 1900ml/ (or) 2850 kcal (a unit of energy measurement used in nutrition) due to weight loss. On at noon and off at 8:00 AM During a concurrent interview and record review on July 18, 2025, at 3:41 PM, with the IDON, Resident 26's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for the month of July 2025, was reviewed. The IDON confirmed LVN 9 documented Resident 26 had completed prescribed feeding on July 15, 2025, and July 16, 2025. The IDON further stated that licensed nurses were not documenting the intake and output for Resident 26 in accordance with the facility's policy Enteral Formula, Administration of Closed System. During a review of the facility's P&P titled Enteral Formula, Administration of Closed System, dated January 25, 2025, it .17. Maintain and record intake and output.All resident requiring enteral tube feeding will be monitored and document daily according to the following guidelines. This policy provides a means to ensure that all residents who are fed via enteral tube feeding will receive appropriate treatment with the potential for complications minimized. 2. The licensed Nurse will record when the feeding is completed.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used were labeled in accordance with professional standards, and storage of medications were properly secured for two of 11 medication carts (Med Cart - used to transport medication to resident's rooms) when: 1. Two bubble packs (small package enclosing goods in transparent dome-shaped plastic on a flat cardboard backing) containing Resident 18's Eliquis (a medication used for blood thinner) were found without expiration dates. This failure had the potential to cause the medication to lose its potential effects and be used for Resident 18. 2. Eight tubes of Santyl (a medication used for wounds) ointment were found without resident's identification labels. This failure had the potential to be accessed and administered in error. 3. Licensed Vocational Nurse (LVN 2) left Med Cart 4-1 unlocked and unattended for ten minutes. This failure had the potential to increase the risk of unauthorized access, misuse, and/or harm to a highly vulnerable population of 52 residents. 4. LVN 8 left Med Cart 3-1 unlocked and unattended for 5 minutes. This failure had the potential to increase the risk of unauthorized access, misuse, and/or harm to a highly vulnerable population of 52 residents.Findings: 1. During an inspection of medication cart 4-1 with a Licensed Vocational Nurse 1 (LVN1), on July 17, 2025, at 6:29 AM, two bubble packs containing Resident 18’s Eliquis 5 mg (milligram-a unit of measurement), which had missing expiration dates, were found inside a drawer. LVN 1 verified the finding. During an interview on July 17, 2025, at 6:40 AM, with LVN 1, confirmed the two bubble packs of Eliquis did not have an expiration date. LVN 1 further explained that Registered Nurses typically verify the expiration dates upon receipt of medications from the pharmacy and she does not know why these two bubble packs have no expiration dates on the labels. During an interview with the Operational Manager (OP) on July 17, 2025, at 10:55 AM, The OP acknowledged both bubble packs were to be removed from the medication cart, re-ordered, and the pharmacy was contacted to send new packets. 2. During an inspection of the treatment cart with LVN 3, on July 17, 2025, at 7:25 AM. Eight tubes of unlabeled Santyl medications were found inside the treatment cart. LVN 3 verified the finding. During the interview with the OP on July 17, 2025, at 10:55 AM, the OP stated that each Santyl ointment tube must have a pharmacy-issued label for safe identification of the resident. During a concurrent interview and record review with the OP on July 18, 2025, at 10:44 AM, the Policy and Procedure (P&P) titled, “Labeling Requirements,” dated January 25, 2025, was reviewed. The P&P indicated, “All prescription drugs labels shall include the following information: (a) Brand or generic name of drug…(b) Strength of drug … (1) Quantity, (2) Expiration Date, (3) Resident’s name, (4) Direction of use, (5) Physician’s Name, (6) Date of dispensing, (7) Name, address and phone number of Pharmacy dispensing (8) Prescription number, (9) Any applicable Auxiliary Labels, (c) Improperly labeled containers will not be allowed for use and will be returned to the pharmacy as soon as possible, (d) Non-prescription/floor stock drugs must be kept in the original container … (e) Containers with soiled, damaged, incomplete, ineligible or makeshift labels are not to be used … (f) The nursing staff is not allowed to modify the Rx label in any way. Transferring content from one container to another is not allowed.” The OP acknowledged that the facility’s P&P were not followed. 3. During an observation on July 17, 2025, at 5:30 AM, LVN 2 was observed in hallway 4 preparing residents’ medications. LVN 2 entered room [ROOM NUMBER] to administer medications to residents in the room. LVN 2 was observed leaving the medication cart 4-1 unlocked, and unattended for 10 minutes. During an interview on July 17, 2025, at 5:40 AM, LVN 2 acknowledged the medication cart was unlocked and unattended. LVN 2 further stated the cart should have been locked when not in use. 4. During an observation on July 17, 2025, at 5:56 AM, a medication cart 3-1 was parked in hallway 3, outside of room [ROOM NUMBER], unlocked. LVN 8 was inside room [ROOM NUMBER], leaving the medication cart unlocked, and unattended for 5 minutes. During an interview on July 17, 2025, at 6:01AM, LVN 8 acknowledged the medication cart was unlocked and unattended. LVN 8 further stated the cart should have been locked when not in use. During a concurrent interview and record review, on July 17, 2025, at 7:15 AM, with the Interim Director of Nursing (IDON), the facility's policy and procedure (P&P) titled Security of Medication Cart, dated January 25, 2025, was reviewed. The P&P indicated, “…1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry…4. Medication carts must be securely locked at all times when out of the nurse’s view .” The IDON stated the P&P was not followed and further stated the medication carts should always be locked when unattended.

Based on interview and record review, the facility failed to provide evidence staff discussed with two of seven residents (Resident 7 and 54) whether the residents had an existing advance directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) and were educated on their rights to establish a new advance directive if desired.This failure had the potential for Residents 7 and 54 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the residents (or their representatives) wanted.1. A review of Resident 7’s “admission Record” (contains medical and demographic information) indicated Resident 7 was admitted on [DATE], with diagnoses which included acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body), cirrhosis of liver (a condition where scar tissue replaces healthy liver tissue due to long-term liver damage), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and a loss of interest) and tracheostomy status (medical condition of a person who has undergone a tracheostomy, a surgical procedure creating an opening in the trachea (windpipe) to facilitate breathing). During a review of Resident 7’s Electronic Health Record (EHR – electronic version of medical records), there was no documented evidence of whether or not Resident 7 had an existing advance directive and no documented evidence that Resident 7 had been informed about his right to formulate an advance directive. During a review of Resident 7’s undated “Physician’s Order for Life Sustaining Treatment” (POLST - written medical orders that addresses a limited number of critical medical decisions), it indicated under Section “D” (section regarding whether or not the resident had an existing advance directive or not) was left blank. During a concurrent interview and record review on July 18, 2025, at 11:51 AM, with the Corporate Medical Records Resource (CMRR), the CMRR stated she reviewed Resident 7’s medical records and was unable to find documented evidence to indicate whether or not Resident 7 or his representative had an advance directive or was provided information regarding the right to formulate an advance directive. The CMRR then reviewed Resident 7’s undated “POLST,” and acknowledged it was blank under section “D” regarding advance directives. During a review of the facility’s policy and procedure titled, “Advance Directives,” dated January 25, 2025, the policy indicated, “The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy…1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives…b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance…2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff…” 2. During a review of Resident 54’s medical record, the “admission Record, it indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included traumatic hemorrhage of cerebrum (bleeding within the brain tissue itself, resulting from an injury to the head), and chronic respiratory failure with hypoxia (the lungs' inability to adequately oxygenate the blood over an extended period). During a concurrent interview and record review on July 17, 2025, at 1:14 PM, with the Interim Director of Nursing (IDON), the IDON reviewed Resident 54’s clinical record and stated there was no documentation of Resident 54 and/or the representative being offered assistance to accept or decline the establishing of an advanced directive. During a concurrent interview and record review on July 17, 2025, at 1:14 PM, with the IDON, the facility’s policy and procedure (P&P) titled, “Advance Directives,” dated January 25, 2025, was reviewed. The P&P indicated, “ .1. if the resident or representative indicates that he or she has not established advanced directives, the facility staff will offer assistance in the establishing advanced directives…1a. the resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision…1b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance .”. The IDON stated the policy was not followed.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS- a computerized assessment instrument) Assessment was accurately completed to reflect the resident's status, care, and services for one of five sampled residents (Resident 2) reviewed for MDS, when Resident 2's schizophrenia diagnosis (a chronic and severe mental health disorder that affects how a person thinks, feels, and behaves) was not accurately coded on Resident 2's quarterly Minimum Data Set (a standardized, federally mandated evaluation of nursing home residents' health status, conducted every three months or more frequently if there's a significant change in condition) assessment. This failure had the potential to cause inaccuracy in identifying Resident 2's care and support needs.During a review of Resident 2's admission Record (contains demographic and medical information), it indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of acute and chronic respiratory failure with hypoxia (when the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body), leukopenia (decrease white blood cell count), hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream), and schizophrenia. During a review of Resident 2's Quarterly MDS, dated [DATE], under the Section I (Active Diagnosis), it indicated Resident 2 did not have a schizophrenia diagnosis. During a review of Resident 2's Psychiatrist Assessment (a process of gathering information to diagnose and develop a treatment plan for a person experiencing mental health challenges), dated February 17, 2024, November 12, 2024, December 5, 2024, and June 20, 2025, it indicated Resident 2 had a diagnosis of schizophrenia, and was being evaluated and monitored for it. During a concurrent interview and record review on July 17, 2025, at 1:24 PM, with the Minimum Data Set Nurse (RN 2), RN 2 reviewed Resident 2's Quarterly MDS Assessment dated May 16, 2024, and stated Resident 2's active diagnosis for schizophrenia should have been coded.During a concurrent interview and record review on July 17, 2025, at 2:05 PM, with the Interim Director of Nursing (IDON), the facility's policy and procedure (P&P) titled, Accuracy of Assessment (MDS 3.0), dated January 25, 2025, was reviewed. The P&P indicated, It is the policy of this facility to ensure that the assessment accurately reflects the resident's status . The IDON stated the policy was not followed. The IDON further stated it was important for the MDS to be accurately coded to make sure the care and support for the resident was accurate.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR - federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was re-submitted for one of five sampled residents reviewed for PASARR Assessment (Resident 2).This failure had the potential to result in Resident 2 not being accurately assessed regarding supplemental treatment and services to better meet the needs of the resident.During a review of Resident 2's admission Record (contains medical and demographic information), it indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included schizophrenia, respiratory failure (when the lungs cannot adequately oxygenate the blood or remove carbon dioxide, leading to hypoxia (low oxygen) and/or hypercapnia (high carbon dioxide), and hypothyroidism (when the thyroid gland doesn't make and release enough hormone into your bloodstream). During a review of Resident 2's Psychiatrist Assessment, dated February 17, 2024, eight days after Resident 2's admission, the assessment indicated Resident 2 was diagnosed with schizophrenia. During a review of Resident 2's clinical record, there was no documented evidence to indicate Resident 2's PASARR was updated and re-submitted to reflect his diagnosis of schizophrenia. During a concurrent interview and record review on July 17, 2025, at 1:24 PM, with the Minimum Data Set Nurse (RN 2), RN 2 reviewed Resident 2 clinical records and stated it was her responsibility to update and re-submit the PASARR when there were any new diagnoses. RN 2 further stated she did not update and re-submit a new PASARR Assessment Level 1 for Resident 2 when she should have. During a review of the facility's policy and procedure (P&P) titled, PASRR Completion Policy, dated January 25, 2025, it indicated, The center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed.3. Administrator is accountable for monitoring the process of completing the necessary paperwork for the admission.

Based on interview and record review, the facility failed to ensure one of one resident (Resident 4) reviewed for pressure ulcers (a localized injury to the skin and/or underlying tissue resulting from pressure on the skin) received care for skin breakdown as specified in the resident's care plan (an individualized plan for the medical care of a resident) and physician's orders when there was no documented evidence to indicate Resident 4 received physician ordered wound care treatment for multiple days in May, June, and July 2025.This failure had the potential for Resident 4 to experience worsening pressure ulcer wounds and delayed wound healing.A review of Resident 4's admission Record (contains medical and demographic information), indicated Resident 4 was initially admitted on [DATE], with diagnoses which included cerebral palsy (a neurological disorder that affects movement, posture, and muscle tone), multiple sclerosis (a condition that affects your brain and spinal cord [central nervous system]), and epilepsy (seizure disorder).During a review of Resident 4's care plan, titled Sacrum [triangular bone at the base of the spine] stage 4 pressure injury [a pressure ulcer that has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints], dated May 20, 2025, it indicated, .goal - The resident's pressure ulcer will show signs of healing.interventions.administer treatments as ordered and monitor for effectiveness.During a review of Resident 4's care plan titled, Left malleolus [bony prominence on outside of the left ankle] stage 3 pressure injury [a pressure ulcer that extends through the skin tissues and into the fat layers], dated May 20, 2025, it indicated, .goal - The resident's pressure ulcer will show signs of healing.interventions.Administer treatments as ordered and monitor for effectiveness.During a review of Resident 4's care plan titled, Right lateral foot [outer aspect of right ankle] unstageable pressure injury/neuropathy [a pressure sore which has dead or non-viable tissue inside it which does not allow for pressure sore staging], dated July 8, 2025, the care plan indicated, .goal - The resident's pressure ulcer will show signs of healing.interventions.administer treatments as ordered and monitor for effectiveness.During a review of Resident 4's Treatment Administration Record (TAR - a document used by staff to record treatments administered to the resident) for the month of May 2025, it indicated the following:-For the resident's left malleolus pressure ulcer, there was a physician's order to .cleanse with NS [normal saline], pat dry, Therahoney [a honey based wound dressing], 4x4 foam dressing [a type of wound dressing] every day shift for 21 days. Upon further review of the TAR, there was no documented evidence indicating treatment had been provided to the resident on the days of May 4,11, and 20th, of 2025.-For the resident's sacrum pressure ulcer, there was a physician's order to .cleanse with NS, pat dry, Therahoney, 4x4 foam dressing every day shift for 21 days. Upon further review of the TAR, there was no documented evidence indicating treatment had been provided to the resident on the days of May 4,11, and 20, of 2025-A physician's order dated March 18, 2025, indicated, low air loss mattress [a specialized mattress which utilizes air to help prevent and treat pressure wounds] for tissue load management. Check placement, motor and setting every shift for preventive measures. Upon further review of the TAR, there was no documented evidence indicating the low air loss mattress was checked by staff on the day shift of May 4, and 11, 2025, and the evening shift of May 16, 19, 21, 22, 26, 27, and 28, of 2025.During a review of Resident 4's TAR for the month of June 2025, it indicated the following:-For the resident's sacrum pressure ulcer, there was a physician's order to .cleanse with NS, pat dry, Santyl [an ointment used to remove dead tissue from a wound], pack with packing strip [a type of gauze], 4x4 foam dressing every day shift for 21 days. Upon further review of the TAR, there was no documented evidence indicating treatment had been provided to the resident on the days of June 8, and 11, of 2025.- A physician's order dated March 18, 2025, indicated, low air loss mattress for tissue load management. Check placement, motor and setting every shift for preventive measures. Upon further review of the TAR, there was no documented evidence indicating the low air loss mattress was checked by staff on the evening shift of June 7, 10, 16, and 17, of 2025.During a review of Resident 4's TAR, dated July 2025, it indicated the following:- A physician's order dated March 18, 2025, indicated, low air loss mattress for tissue load management. Check placement, motor and setting every shift for preventive measures. Upon further review of the TAR, there was no documented evidence indicating the low air loss mattress was checked by staff on the evening shift of July 5, 6, 7, 10, 11, 15, and 16, of 2025.During a concurrent interview and record review on July 18, 2025, at 2:05 PM, with the Interim Director of Nursing (IDON), Resident 4's TARs for the months May, June, and July 2025, were reviewed. The IDON acknowledged there were multiple days in which there was no documentation Resident 4 received physician ordered wound treatments. The IDON further stated it was important to ensure treatments were performed and documented as ordered by the physician.During a review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated January 25, 2025, the policy indicated, .4. The facility IDT [interdisciplinary team - a team of healthcare professionals] will develop and implement a comprehensive person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 43) reviewed for environment/accidents was free from accident hazards when Resident 43 fell from bed while receiving care from a Certified Nursing Assistant (CNA) on April 22, 2025.This failure may have contributed to Resident 43 to experience uncontrolled pain in the resident's coccyx area (often referred to as the tailbone, a small bone at the base of the spine) which resulted in the resident needing treatment and evaluation at a hospital.A review of Resident 43's admission Record (contains medical and demographic information), indicated Resident 43 was initially admitted on [DATE], with diagnoses which included osteomyelitis of vertebra (infection of the spine), dependence on respirator [ventilator] (ventilator- a machine which helps a person to breathe) status (refers to a patience reliance on a mechanical ventilator to breathe due to impaired lung function).During a review of Resident 43's Minimum Data Set Assessment (MDS assessment - a comprehensive assessment of a residents functioning status), dated April 4, 2025, the assessment indicated Resident 43 had impairment in both her upper and lower extremities (arm and leg) on one side of her body and was dependent upon staff when rolling left to right and right to left while in bed.During a review of Resident 43's Fall Risk Assessment (a scored assessment used to determine fall risk of a resident), dated March 28, 2025, the assessment indicated Resident 43 was, disoriented x 3 [disoriented to three of the following categories: person, place, time, situation] at all times and the resident was High Risk for falls.During a review of Resident 43's nursing progress note, dated April 22, 2025, the progress note indicated, CNA was in the process of changing Pt [patient] Pt was turned to her right, laying on her left. Pt turned further, and fell off the left side of the bed. Landed on her knees, then on to her coccyx.During a review of Resident 43's nursing progress note, dated April 22, 2025, the progress note indicated, N.O. [new order] received by NP [nurse practitioner] .transfer out to ER [emergency room] r/t [related to] uncontrolled back pain s/p [status post] fall.During a review of Resident 43's respiratory therapy progress note, dated April 22, 2025, the progress note indicated, Pt left with [name of ambulance company] .due to severe back pain after falling out of bed.During a review of Resident 43's Interdisciplinary Team note (IDT - a team of healthcare professionals from different disciplines working together to provide patient care), dated April 22, 2025, the IDT note indicated, Witnessed fall.root cause analysis, what was the root cause identified by IDT? CNA miscalculated pt's roll during her brief change.During a review of Resident 43's IDT note tilted, Post Fall Review, dated April 23, 2025, the review indicated, After investigation, it was concluded that while CNA was in the process of providing care to resident. CNA repositioned resident to have her laying on her left side of the bed and did not notice resident being too close to the edge of the bed at time of repositioning that resident rolled off the bed and landed on her knees and her coccyx.Interventions: .transfer out to hospital for unsubsided pain.staff in-service.During an interview on July 15, 2025, at 3:44 PM, Resident 43 stated she was sent to the hospital in April 2025 because she fell from her bed while a CNA was changing her brief. Resident 43 further stated there was one CNA present when she fell and she was sent to the hospital the next day because she had pain on her tailbone.During an interview on July 17, 2025, at 1:57 PM, with the Operation Manager (OP), the OP stated the facility investigation concluded that Resident 43's fall was the witness CNA's fault. The OP further stated when rolling residents in bed during cares, the resident was supposed to always be rolled towards the staff member, but the CNA stated she rolled the resident away from her instead, and that's when Resident 43 fell from the bed.During an interview on July 18, 2025, at 1:34 PM, with the Corporate Medical Records Resource (CMRR), the CMRR stated the facility did not have a policy and procedure regarding bed mobility or turning residents while in bed.During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated January 25, 2025, the policy indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility failed to ensure their manual resuscitation (process of assisting or taking over a patient's breathing using a handheld device) policy was implemented for one of three residents (Resident 4) reviewed for respiratory care, when Resident 4 did not have an Artificial Manual Breathing Unit bag (AMBU bag - a hand-held medical device used to provide respiratory support to patients who are not breathing or are having difficulty breathing. Also known as a bag-valve-mask (BVM) or a manual resuscitator) at the bedside.This failure had the potential for Resident 4 to receive delayed emergency resuscitative measures during an emergency as a result of not having the required medical equipment immediately available.A review of Resident 4's admission Record (contains medical and demographic information) indicated Resident 4 was initially admitted on [DATE], with diagnoses which included acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body), tracheostomy status (presence of a tracheostomy -surgically created opening in the neck that provides a direct pathway into the trachea for breathing), and dependence on respirator (ventilator- a machine which helps a person to breathe) status (refers to a patience reliance on a mechanical ventilator to breathe due to impaired lung function).During an observation on July 15, 2025, at 12:02 PM, Resident 4 was lying in her bed. Resident 4 had a tracheostomy which was connected to a ventilator. Resident 4 did not have an AMBU bag at her bedside or anywhere in the resident's immediate vicinity.During an interview on July 15, 2025, at 12:03 PM, with Respiratory Therapist 1 (RT 1), RT 1 stated every resident was supposed to have an AMBU bag at the head of their bed in case of an emergency.During a concurrent observation and interview on July 15, 2025, at 12:08 PM, with RT 1, in Resident 4's room,. RT 1 acknowledged Resident 4 did not have an AMBU bag available at the head of the bed or anywhere else in the resident's immediate vicinity. RT 1 looked for an AMBU bag in the resident's room but was unable to find an AMBU bag anywhere. RT 1 stated Resident 4 was supposed to have an AMBU bag available for her but did not. RT 1 further stated it is unacceptable.During an interview on July 18, 2025, at 1:36 PM, with the Respiratory Therapy Resource (RTR), the RTR stated the required equipment to be kept in the room for each resident included an AMBU bag and it was supposed to be at the resident's bedside. The RTR further stated it was important to keep an AMBU bag at the bedside in case they needed to perform manual ventilation of the resident (the process of assisting or taking over a patient's breathing using a handheld device, typically a bag-valve-mask (BVM) or AMBU bag, instead of a mechanical ventilator).During an interview on July 18, 2025, at 2:03 PM, with the Interim Director of Nursing (IDON), the IDON stated an AMBU bag was supposed to be at the bedside of all residents that had a tracheostomy and required the use of a ventilator.During a review of the facility's policy and procedure titled, Manual Resuscitation Device, dated April 17, 2025, it indicated, Policy: A manual resuscitator device will be placed at the bedside of each resident.Definition: A manual resuscitator device is a self-inflating bag-valve-mask device designed for the manual ventilation of a resident.

Based on interview and record review, the facility failed to ensure the documentation in the Electronic Health Record (EHR) was accurate for one of four residents (Resident 4) reviewed for advance directives (a legal document that outlines a person's healthcare wishes in the event that they become unable to make medical decisions for themselves due to illness, injury, or incapacity) when Resident 4's code status (refers to a patient's preferences regarding cardiopulmonary resuscitation [CPR] and other life-sustaining measures in the event of cardiac or respiratory arrest) contradictorily indicated Resident 4 was both Do Not Resuscitate (DNR - a medical order that instructs healthcare providers not to perform CPR if a patient's heart stops or breathing ceases) and Full-Code (indicates a patient's wish to receive all possible medical interventions, including CPR in the event the heart stops or breathing ceases).This failure had the potential for Resident 4 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the resident wanted.A review of Resident 4's admission Record (contains medical and demographic information), indicated Resident 4 was initially admitted on [DATE], with diagnoses which included acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body), tracheostomy status (presence of a tracheostomy), and dependence on respirator (ventilator) status (refers to a patience reliance on a mechanical ventilator to breathe due to impaired lung function).During a review of Resident 4's EHR, the residents code status indicated .Do not resuscitate.full code.During an interview on [DATE], at 8:50 AM, with the Interim Director of Nursing (IDON), the IDON stated staff could find out the code status of a resident based off a document titled Physicians Orders for Life Sustaining Treatment, (POLST) or in the resident's electronic health record. The DON further stated the Code Status in the EHR was supposed to reflect the correct code status for each resident and that it was important to ensure the EHR accurately reflected the residents code status because it indicated what wishes the resident or the representative have for the resident.During a concurrent interview and record review on [DATE], at 8:52 AM, with the Interim Director of Nursing (IDON), Resident 4's EHR was reviewed. The IDON acknowledged Resident 4's code status indicated both DNR and Full Code. The IDON stated the EHR was incorrect and should only indicate the resident was DNR. The IDON further stated it was the licensed nurses' responsibility to ensure the code status for each resident was correct in the EHR.During a review of the facility's policy and procedure titled, Documentation Content of the Record Set, (undated), the policy indicated, .Federal regulation (F842) requires that the facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized.

Based on observation, interview, and record review, the facility failed to ensure facility staff follow the Infection Control Policies and Procedure 's standards for Transmission-Based Precautions (actions implemented in addition to standard precautions that are based upon the means of transmission in order to prevent or control infections) when a staff member was observed entering a Contact Precaution (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) room without wearing the required Personal Protective Equipment (PPE- protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission.). This failure had the potential to place all residents, visitors, and staff at risk of being exposed to a contagious disease (illness caused by the spread of germs) that could compromise their health.Findings: During a review of the Resident 26's face sheet, it indicated Resident 26 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure (a long-term condition where the respiratory system cannot adequately exchange oxygen and carbon dioxide), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) status, and gastrostomy (a surgically created opening in the stomach, typically accessed through the abdominal wall, that allows for the insertion of a feeding tube) status. During a review of Resident 26's physician's orders, dated July 2025, it indicated Resident 26 was placed on Contact Precautions due to being diagnosed with Candida Auris (a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities) as of July 20, 2024. During an observation and interview, on July 15, 2025, at 12:37 PM, a Certified Nurse Assistant 1 (CNA1) was outside Resident 26's room. CNA 1 performed hand hygiene using Hand Alcohol Rub ([NAME]), removed a lunch tray from the food cart, and entered Resident 26's room. Resident 26's room had a sign at the door which read Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). CNA 1 entered the room without wearing PPE.During further observation, CNA 1 placed the tray on the over-the-bed table in front of Resident 26, returned to the door and removed a pair of gloves from the box located on the wall inside the room and don gloves. CNA1 returned to Resident 26's bedside, repositioned the resident in bed, placed a clothing protector, and opened the beverages from the lunch tray while wearing the same pair of gloves and no isolation gown. Upon exiting Resident 26's room, CNA 1 stated she usually wears a gown and gloves before entering a Contact Precaution room. CNA 1 could not explain why she had not done so on this occasion. During an interview with Licensed Vocational Nurse 7 (LVN 7), on July 15, 2025, at 12:37 PM, LVN 7 stated staff are required to perform hand hygiene and must wear a gown and gloves (PPE) before entering any Contact Precaution room. During an interview with the Infection Practitioner (IP) on July 16, 2025, at 11:12 AM, the IP stated all staff members are required to don (to put on) Personal Protective Equipment (PPE), including gowns and gloves, when entering such rooms. The IP further stated CNA1 should have performed hand hygiene, donned the appropriate PPE, requested another staff member to hand her the resident's lunch tray from the lunch cart, and then entered the room. The IP stated that CNA1 did not follow the facility's protocol when she entered the Contact Precaution room without wearing PPE. During a concurrent interview and record review with the Operational Manager (OP) on July 18, 2025, at 1:18 PM, the facility's Policies and Procedures (P&P) titled Isolation- Categories of Transmission-Based Precautions revised February 19, 2025, was reviewed. The P&P indicated, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy interpretation and implementation: (1) standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status, (2) Transmission-Based Precautions are additional measures that protect staff, visitors and other residents from becoming infected . The three types of Transmission-Based Precautions are contact, droplet and airborne . Contact precautions: (7) staff and visitors wear gloves when entering the room . (8) staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The OP acknowledged that the facility's P&P were not followed and stated CNA1 should have don PPE before entering the Contact Precaution room.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube- tube inserted through the abdomen into the stomach that delivers nutrition, hydration, and medications) was implemented in accordance with the facility's policy and procedure for three of six residents (Residents 18, 19, and 6) reviewed for g-tube when a Licensed Vocational Nurse (LVN 2) did not check Residents 18, 19, and 6's G-tube placement (listening to gurgling sound when flushing air through the g-tube to confirm for correct position) before administering medications. These failures had the potential to place Residents 18, 19, and 6 at increased risk of aspiration (when food or liquids enter the lungs). Findings: 1. During a review of Resident 18's Admission Record (contains demographic and medical information), it indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (condition where there is not enough oxygen in the body), seizures (sudden, uncontrolled burst of electrical activity in brain), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that obstructs airflow). During a review of Resident 18's Physician Order, dated February 4, 2024, it indicated Resident 18 had an order for licensed nurses to Check tube placement/patency, Every shift; 07:00 AM - 7:00 PM - 7:00 PM - 7:00 AM. A medication administration observation was conducted on June 4, 2024, at 8:01 AM, in Resident 18's room, with LVN 2. Resident 18 was lying in bed, listening to the radio, with the head of the bed elevated. LVN 2 attached a syringe onto the G-tube, checked for residual (fluid/contents that remain in the stomach), then proceeded to flush the G-tube with 30 mL (milliliters - unit of measurement) of water and administered cranberry (supplement) 425 mg (milligram - unit of measurement). LVN 2 did not check for G-tube placement. 2. During a review of Resident 19's Admission Record, it indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included sepsis (a body's extreme reaction to infection), cerebral infarction (reduced blood flow to brain by narrowed vessels), and encephalopathy (group of conditions that cause brain dysfunction). During a review of Resident 19's Physician Order, dated April 17, 2024, it indicated Resident 19 had an order for licensed nurses to Check tube placement/patency, Every shift; 07:00 AM - 7:00 PM - 7:00 PM - 7:00 AM. A medication administration observation was conducted on June 4, 2024, at 8:23 AM, in Resident 19's room, with LVN 2. Resident 19 was lying in bed, listening to the radio, with the head of the bed elevated. LVN 2 attached a syringe onto the G-tube, checked for residual, then proceeded to flush the G-tube with 30 mL of water and administered sodium bicarbonate (supplement) 650 mg. LVN 2 did not check for placement of the G-tube site. 3. During a review of Resident 6's undated Admission Record, it indicated Resident 6 was admitted to the facility on [DATE], with diagnoses of anoxic brain damage (complete lack of oxygen to the brain causing death of brain cells), cerebral infarction (disrupted blood flow to the brain-stroke) , contracture of muscle, right upper arm (stiffness or constriction in the connective tissues causing deformity), and contracture of muscle, left upper arm. During a review of Resident 6's Physician Order, dated October 5, 2023, it indicated Resident 6 had an order for licensed nurses to Check tube placement/patency, Every shift; 07:00 AM - 7:00 PM - 7:00 PM - 7:00 AM. A medication administration observation was conducted on June 4, 2024, at 9:01 AM, in Resident 6's room, with LVN 2. Resident 6 was lying in bed, watching television, with the head of the bed elevated. LVN 2 attached a syringe onto the G-tube, checked for residual, proceeded to flush the G-tube with 30 mL of water and administered pantoprazole (medication use to prevent stomach ulcers) 40 mg. LVN 2 did not check for placement of the G-tube site. During an interview with LVN 2, on June 4, 2024, at 10:11 AM, LVN 2 stated he should have checked Residents 18, 19, and 6's G-tube placement prior to medication administration. During a concurrent interview and record review, with the Director of Nursing (DON), on June 4, 2024, at 12:23 PM, the DON reviewed the facility's policy and procedure (P&P) titled, Maintaining Patency of a Feeding Tube (Flushing), revised December 2011, and stated the P&P was not followed by LVN 2. During a review of the facility's policy and procedure (P&P) titled, Maintaining Patency of a Feeding Tube (Flushing), revised December 2011, it indicated, .The following equipment and supplies will be necessary when performing this procedure . 5. Stethoscope . 7. Verify placement of tube by injecting air into tube while listening to abdomen with stethoscope for a bubbling sound.

Based on observation, interview, and record review, the facility failed to ensure medications being received by the residents were explained prior to administration to three of eight residents (Residents 18, 19, and 6) reviewed for medication administration. These failures had the potential to result in Residents 18, 19, and 6 being denied their right to know what medication is being given and breaking one of the seven rights of medication administration. Findings: 1. During a review of Resident 18's Admission Record (contains demographic and medical information), it indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (condition where there is not enough oxygen in the body), other seizures (sudden, uncontrolled burst of electrical activity in brain), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that obstructs airflow). An observation of medication administration for Resident 18 by LVN 2 was June 4, 2024, at 8:01 AM, in Resident 18's room. Resident 18 was lying in bed, listening to the radio, with the head of the bed elevated. LVN 2 administered medications to Resident 18 without providing explanation as to which medications were being received . 2. During a review of Resident 19's Admission Record, it indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included sepsis (a body's extreme reaction to infection), cerebral infarction (reduced blood flow to brain by narrowed vessels), and encephalopathy (group of conditions that cause brain dysfunction). An observation of medication administration for Resident 19 by LVN 2 was conducted on June 4, 2024, at 8:23 AM, in Resident 19's room. Resident 19 was lying in bed, listening to the radio, with the head of the bed elevated. LVN 2 administered medications to Resident 19 without providing explanation as to which medications were being received . 3. During a review of Resident 6's Admission Record, it indicated Resident 6 was admitted to the facility on [DATE], with diagnoses of anoxic brain damage (complete lack of oxygen to the brain causing death of brain cells), cerebral infarction (disrupted blood flow to the brain-stroke) , contracture of muscle, right upper arm (stiffness or constriction in the connective tissues causing deformity), and contracture of muscle, left upper arm. During a medication administration observation was conducted on June 4, 2024, at 9:01 AM, in Resident 6's room, with LVN 2. Resident 6 was lying in bed, watching television, with the head of the bed elevated. LVN 2 administered medications to Resident 18 without providing explanation as to which medications were being received . During an interview on June 4, 2024, at 10:13 AM with LVN 2, LVN 2 stated he should have explained the medications to Residents 18, 19, and 6 prior to administration. LVN 2 further stated it is part of the rights of medication administration for the residents to know what they are being given. During a concurrent interview and record review on June 4, 2024, at 12:26 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, revised November 2018 was reviewed. The P&P indicated, . Steps in the Procedure . 4. Prepare the resident: a. confirm the identity of the resident. b. explain the procedure to the resident . The DON stated the P&P was not followed. The DON further stated that his expectation was for all nurses to explain medications to their residents. During a concurrent interview and record review on June 4, 2024, at 12:25 PM with the DON, the facility's undated P&P titled, Resident Rights was reviewed. The P&P indicated, Employees shall treat all residents with kindness, respect, and dignity . o. be notified of his or her medical condition and of any changes in his or her condition . p. be informed of, and participate in, his or her . treatment. The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure storage of medications was secure for one of one medication room, when the medication refrigerator inside the medication room was found unlocked. This failure had the potential to increase the risk of unauthorized access, misuse, and/or harm to highly vulnerable population of 49 residents. Findings: During a concurrent observation and interview, on June 3, 2024, at 10:24 AM, with the Infection Preventionist (IP), the medication room was inspected. The medication refrigerator was unlocked. The IP acknowledged the finding and stated the refrigerator needs to be locked when not in use. During a concurrent interview and record review, on June 4, 2024, at 9:24 AM, with the Director of Nursing (DON), the DON reviewed and acknowledged the facility's undated policy and procedure (P&P), titled Policy and Procedure for Med Pass, and stated that based on the P&P for medication storage the medication refrigerator should also always be locked. During a review of the facility's undated policy and procedure (P&P), titled Policy and Procedure for Med Pass, it indicated . Schedule II, III, and IV controlled medications (including refrigerated items) are stored separately from other medications in a locked drawer or compartment designated for that purpose, under double lock.

Based on observation, interview, and record review, the facility failed to document the Restorative Nursing [nursing interventions that promote the residents' ability to adapt and adjust] Weekly Summary for one of six residents (Resident 6) reviewed for limited range of motion (ROM- full movement potential of a joint.). This failure had the potential to result in inaccurate progress or regression in range of motion exercises which could negatively impact the range of motion for Resident 6. Findings: During an observation on June 3, 2024, at 11:16 AM, in Resident 6's room, Resident 6 was laying down in bed with a stuffed plush carrot toy in his right hand and splint (strip of rigid material used for supporting a bone) on the left hand. During a review of Resident 6's Admission Record (contains demographic and medical information, it indicated Resident 6 was admitted to the facility on [DATE], with diagnoses of anoxic brain damage (complete lack of oxygen to the brain causing death of brain cells), cerebral infarction (disrupted blood flow to the brain-stroke) , contracture (s permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of muscle, right upper arm (stiffness or constriction in the connective tissues causing deformity), and contracture of muscle, left upper arm. During a review of Resident 6's History and Physical Examination dated June 10, 2023, it indicated .poor rehabilitation potential . During a review of Resident 6's Functional Abilities and Goals dated April 14, 2024, it indicated .Impairment on both sides . Upper extremity [shoulder, elbow, wrist, hand] . Lower extremity [hip, knee, ankle, foot]. During a review of Resident 6's Medication Review Report dated June 6, 2024, it indicated the following RNA orders from the physician: a. RNA Program for PROM (Passive Range of Motion- ROM that is achieved when outside force causes the movement of a joint) to BLE (Bilateral lower extremities) QD (every day) 3X (times) /WK (week) OR AS SAFELY TOLERATED. b. RNA PROGRAM: Apply Carrot to R (right) hand 3x/week to decrease risk of contraction and maintain ROM. c. RNA PROGRAM: Apply Elbow Extension orthotics (splint to extend the elbow joint) to both elbows, 3x/week, to decrease risk of flexion contracture. d. RNA PROGRAM: Apply Resting Hand Splint to L (left) hand QD 3x/week x 3hrs per day. During a concurrent interview and record review, on June 6, 2024, at 10:24 AM, with Restorative Nursing Assistant (RNA 1), RNA 1 reviewed Resident 6's Restorative Nursing Weekly Summary and could not find documentation for RNA Weekly Summaries from April 26, 2024, to June 6, 2024. RNA 1 stated there should have been documentation for that elapsed time. RNA 1 could not provide a rationale as to why the documentation was missing. During a concurrent interview and record review, on June 6, 2024, at 10:28 AM, with Restorative Nursing Assistant Lead (RNA Lead), RNA Lead reviewed Resident 6's Restorative Nursing Weekly Summary and could not find documentation for RNA Weekly Summaries from April 26, 2024, to June 6, 2024. RNA Lead stated there should have been documentation for the elapsed time of six weeks. During a concurrent interview and record review, on June 7, 2024, at 9:07 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Range of Motion Exercises, revised October 2010, was reviewed. The P&P indicated, .Documentation . 5. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 6. Any problems or complaints . 8. The signature and title of the person recording the data. The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure 10 of 16 sampled residents (Resident's 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) were provided with care and services to maintain their health as follows: 1 a. For Resident 1- the facility failed to give seventeen (14) doses of intravenous (medications given into the vein) antibiotics as ordered by the physician to treat [MEDICAL CONDITION] resistant staphylococcus aureas (MRSA- a resistant bacterial infection) in his wounds, between (MONTH) 28, 2918 through (MONTH) 20, 2019. The facility also failed to perform site care for his peripherally inserted catheter (PICC- a thin tube inserted into a large vein that carries blood to the heart). 1 b. For Resident 2- the facility failed to give seventeen (17) doses of IV antibiotics between (MONTH) 28, (YEAR) through (MONTH) 20, 2019, to [MEDICAL CONDITION] in his wounds as ordered by the physician. The facility also failed to perform site care to the PICC line. 1 c. For Resident 3- the facility failed to perform site care to his mid-line catheter (a long intravenous peripheral line placed in a large vein). This failure to have registered nurses available to provide the IV site care and administer antibiotics as ordered for Residents 1, 2, and 3, had the potential to cause worsening infections or for the residents to get an inaccurate dosing of IV antibiotics due to the antibiotics requiring titration (dosage adjustment) based on blood levels to prevent toxicity. Licensed Vocational Nurses (LVNs) cannot administer intravenous antibiotics 2 a. For Resident 1 -The facility failed to provide wound care to his amputated left first toe and to the blister on his penis as ordered. 2 b. For Resident 2- the facility failed to provide wound care to his left, lateral (side) lower leg [MEDICAL CONDITION] (a bacterial infection in the skin); a stage III pressure ulcer (full thickness injury of the skin from pressure) to the back of his left thigh, and a stage III pressure ulcer (full thickness wound that does not involve the muscle and bone) to right posterior (back of) thigh. 2 c. For Resident 3- the facility failed to provide wound care to the stage IV pressure ulcer (pressure injury down to bone and muscle) on the left ischium (hip). 2 d. For Resident 4 the facility failed to provide wound care to the unstageable wound (a wound covered in eschar-dead tissue that when opened will be a stage III or IV) on the coccyx (tailbone). 2 e. For Resident 5- the facility failed to provide wound care for a stage IV pressure ulcer wound to his coccyx. 2 f. For Resident 6- The facility failed to provide wound care to a stage IV pressure ulcer wound to the buttocks or to the right posterior (back) lateral leg, or sacrococcygeal (upper buttocks/tailbone) wound, which was unstageable. 2 g. For Resident 7- The facility failed to provide wound care for maintenance to the right scapula (shoulder blade) area, or to the re-opened stage III pressure ulcer to the top of the right foot. 2 h. For Resident 8 -The facility failed to provide wound care to a vascular wound (caused by lack of blood flow) on the left, lateral ankle. 2 i. For Resident 9- the facility failed to provide wound care to a vascular ulcer on the top of the left foot. 2 j. For Resident 10- the facility failed to provide wound care to a stage IV pressure ulcer on the left ischium. The failure to provide care as ordered by the physician had the potential for all wounds to decline in 10 of 10 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) and did result in two of the ten residents (Residents 2 and 4) having wounds which declined as a result of missed treatments. The overall failure to provide care and services as ordered by the physician resulted in a substandard level of care being provided by the facility. Findings: An unannounced visit was made to the facility on (MONTH) 14, 2019 to investigate a complaint regarding issues which included lack of care, and lack of sufficient staff to provide treatments and intravenous (IV- goes into the vein) antibiotics medication. During an interview with a Certified Nurse's Assistant (CNA 1) on (MONTH) 14, 2019, at 3:45, CNA 1 stated the facility was, very short staffed today, they had one Licensed Vocational Nurse (LVN) for the building today. The facility's lack of licensed staff affects the ability to have medications, treatments and assessments done timely. During an interview with a Licensed Vocational Nurse (LVN 1), on (MONTH) 14, 2019, at 4:00 PM, LVN 1 indicated, she was the only LVN on the morning shift. LVN 1 stated she was passing medications for all 50 residents in the facility. She further stated, If it were only medications that would be one thing, but I am expected to look at labs, answer questions from the doctor and the residents. It is scary trying to take care of and pass medications for 50 residents. LVN 1 stated that she was starting to pass the evening shift medications, since there was one staff who had called off and the other LVN had not shown up yet. The facility's lack of licensed nursing staff delays medication pass times and prevents the licensed nurse to be able to focus on other duties such as treatments and assessments. 1. a. During an observation of Resident 1, on (MONTH) 14, 2019 from 4:15 PM to 4:20 PM, a Registered Nurse (RN 1) was at the side of his bed dressed in personal protective equipment (PPE- gown, gloves, and mask are used when a resident is placed in isolation for an infection), moving IV (intravenous) bags and tubing around two IV pumps at the bedside. The resident was overheard telling the RN that she does not know what she is doing. Resident 1 stated to the RN, Why are you asking me questions about the meds. If you knew what you were doing you would not be asking me. During an observation, and interview, with Resident 1 in his room, on (MONTH) 14, 2019, at 4:20 PM, Resident 1 is in a hospital gown with a sheet covering him, a dressing is on his left upper arm revealing a PICC line (Peripherally Inserted Central Catheter - a thin tube inserted into a large vein that carries blood to the heart for antibiotic medication, only Registered Nurses (RN) may administer medication through the PICC), and a dressing is present on his left foot. Resident 1 stated his medications are never given on time if he gets them at all, especially his IV antibiotics. Resident 1 further stated that he never knows if there will be a RN in the building to give them to him. He stated that he, has to rely on the staff for almost everything, and there was never enough staff to take care of us, and on the weekends it is worse. A review of Resident 1's face sheet (demographic and medical information) indicated Resident 1 was originally admitted to the facility on (MONTH) 3, (YEAR), and readmitted on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. Upon re-admission, the additional [DIAGNOSES REDACTED]. During a review of Resident 1's Order Summary Report dated (MONTH) 28, (YEAR), were two physician's orders for IV antibiotics as follows: a. [MEDICATION NAME] HCL Solution (a broad spectrum antibiotic), use two (2) grams (GM -unit of measure) intravenously every 8 (eight) hours [MEDICAL CONDITION] of the wound for 6 (six weeks). b. [MEDICATION NAME] HCL Solution (antibiotic used to treat serious bacterial infections) use 1.25 mg (mg-milligram a unit of measure) every 12 hours [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus - a bacterium with antibiotic resistance) of wounds for 6 (six) weeks. A review of Resident 1's Intravenous Therapy Administration Record dated (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR), reflected the following dates the IV antibiotics were not given as ordered: a. On (MONTH) 28, (YEAR), the [MEDICATION NAME] HCL Solution, 2 GM dose was not given at midnight. b. On (MONTH) 31, (YEAR), the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at 2100 (9:00 PM). c. On (MONTH) 31, (YEAR), the [MEDICATION NAME] HCL Solution, 2 GM dose was not given at 1600 (4:00 PM). A review of Resident 1's Intravenous Therapy Administration Record dated (MONTH) 1, 2019 through (MONTH) 31, 2019, reflected the following: a. On (MONTH) 1, 2019, the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at 2100 (9:00 PM). b. On (MONTH) 1, 2019, the [MEDICATION NAME] HCL Solution, 2 GM dose was not given at midnight. c. On (MONTH) 2, 2019, the [MEDICATION NAME] HCL Solution, 2 GM dose was not given at midnight. d. On (MONTH) 3, 2019, the [MEDICATION NAME] HCL Solution, 2 GM dose was not given at midnight. e. (MONTH) 3, 2019, the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at 2200 (10:00 PM). f. On (MONTH) 8, 2019, the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at 2200 (10:00 PM). g. On (MONTH) 9, 2019, the [MEDICATION NAME] HCL Solution, 2 GM dose was not given at midnight. h. On (MONTH) 10, 2019, the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at 2200 (10:00 PM). i. On (MONTH) 11, 2019, the [MEDICATION NAME] HCL Solution, 2 GM dose was not given at midnight. j. On (MONTH) 11, 2019, the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at 2200 (10:00 PM). k. On (MONTH) 12, 2019, the [MEDICATION NAME] HCL Solution, 2 GM dose was not given at midnight. During an interview and concurrent record review with the Director of Nurses (DON) on (MONTH) 15, 2019 at 11:30 AM, she confirmed the IV antibiotic doses for Residents 1 and 2 had not been given as ordered. A review of Resident 1's Order Summary Report, dated (MONTH) 1 through (MONTH) 31, 2019, reflected after the missed doses of [MEDICATION NAME] the physician increased the dosage from 1250 mg to 1750 mg every 12 hours. During a review of Resident 1's Progress Notes, there was no documentation to address the missed medications nor documented evidence the physician was made aware the doses had been missed. During an interview and concurrent record review with the DON, on (MONTH) 21, 2019 at 14:00 PM, the DON stated she was aware that Resident 1's medication doses were increased from 1250 mg to 1750 mg. She further stated that she was aware higher doses of the medication could cause kidney damage and hearing loss. The DON stated the missed doses could result in a more resistant organism. The DON confirmed the Resident 1's physician had not been notified of the missed doses of medications between (MONTH) 28, (YEAR) and (MONTH) 12, 2019. She stated, We did not have any nurse to give them (IV antibiotics) on those days. The DON further stated that the facility had not called registry to see if a registered nurse was available. During an interview with Resident 1's Physician and Medical Director (MD) of the facility, on (MONTH) 22, 2019 at 11:30 AM, he stated that no one from the facility had notified him of the missed doses of IV antibiotics. The MD stated, Please tell me that they did not miss the [MEDICATION NAME], when confirmed Resident 1 had missed a total of 14 doses of the [MEDICATION NAME] and [MEDICATION NAME], the MD stated, How can I trust this place with my patients if they can't give them their medications. A review of Resident 1's physicians order, dated (MONTH) 28, (YEAR), indicated, PICC Line Care every shift for PICC line maintenance (process to ensure the tubing and dressing in intact, clean, and have no visible signs or symptoms of infection present). Review of Resident 1's Intravenous Therapy Administrative Record, dated (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR), indicated on (MONTH) 31, (YEAR), there was no PICC line maintenance documented as being completed on the evening and night shifts. Review of Resident 1's Intravenous Therapy Administrative Record, dated (MONTH) 1, 2019 through (MONTH) 31, 2019, indicated the following: a. On (MONTH) 1, 2019, no PICC line maintenance was documented on the evening and night shifts. b. On (MONTH) 2, 2019, no PICC line maintenance was documented on the night shift. c. On (MONTH) 8, 2019, no PICC line maintenance was documented on the night shift. d. On (MONTH) 10, 2019, no PICC line maintenance was documented on the night shift. e. On (MONTH) 13, 2019, no PICC line maintenance was documented on the day shift. During a review of Resident 1's Progress Notes, there was no documentation to address the missed PICC line care nor evidence that the physician had been notified. 1. b. During an observation and interview with Resident 2 on (MONTH) 15, 2019, at 10:45 AM, Resident 2 stated he did not get his medications every day and there was not enough staff to give medications, change wound dressings or assist with daily care. Resident 2 was laying under the covers in his bed, his room was dark and his curtains were drawn shut. A clinical record review of Resident 2's face sheet (demographic and medical information) indicated Resident 2 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. During a review of Resident 2's Order Summary Report, dated (MONTH) 8, 2019, indicated there was a physician order for [REDACTED]. During a review of Resident 2's Intravenous Therapy Administration Record, dated (MONTH) 1, 2019 through (MONTH) 31, 2019, showed the following times the IV antibiotics were not given as ordered: a. On (MONTH) 9, 2019, the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at midnight. b. On (MONTH) 10, 2019, the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at midnight. c. On (MONTH) 11, 2019, the [MEDICATION NAME] HCL Solution, 1250 mg dose was not given at 0000 (00:00 AM). During an interview with the DON on (MONTH) 15, 2019 at 11:30 AM, she confirmed the IV antibiotics for Residents 1 and 2 had not been given as ordered. A review of the Order Summary Report dated (MONTH) 1 through (MONTH) 31, 2019, showed that after the missed doses Resident 2's [MEDICATION NAME] was increased to from 1250 mg to 1500 mg, 750 mg every 12 hours. During a review of Resident 2's Progress Notes, there was no documentation to address the missed medications, nor documented evidence to reflect the physician was informed the doses had not been given so he could address the missed medications and determine if he wanted to adjust the current dosage. During a review of Resident 2's Medication Review Report dated (MONTH) 12, 2019, indicated, Flush PICC (Peripherally Inserted Central Catheter - a thin tube inserted into a large vein that carries blood to the heart) BID (twice a day) with 5 ml (unit of measure) normal saline every 12 hours for IV maintenance. A review of Resident 2's Intravenous Therapy Administrative Record, dated (MONTH) 1, (YEAR) through (MONTH) 31, 2019, indicated that on (MONTH) 20, 2019 there was no flush of the PICC line. During an interview, and concurrent record review with the Director of Nurses (DON) on (MONTH) 15, 2019 at 11:30 AM, of Residents 1 and 2's Intravenous Therapy Administration Records, the DON confirmed the IV antibiotic doses were not given. The DON stated she did not have available Registered Nurses (RN's) on those days to provide the Residents with their medication. She confirmed the facility had not attempted to request an RN from their contracted registry to cover on the days they would need additional help. 1c. During an observation and interview, with Resident 3, on (MONTH) 14, 2019 at 4:00 PM, Resident 3 was lying in bed with a sheet covering; he had a dressing over a midline IV site. Resident 3 stated, The care in here is lousy, you don't know when or if you will be taken care off, if you get your medications or wounds treated, they don't treat you right. A review of Resident 3's face sheet indicated, Resident 3 was admitted to the facility on (MONTH) 5, (YEAR), and readmitted on (MONTH) 13, 2019, with [DIAGNOSES REDACTED]. During a review of Resident 3's Medication Review Report dated (MONTH) 9, 2019, indicated Flush Mid Line (soft tubing placed in a large vein in the arm and ends in a large vein near the heart) BID (twice a day) every day and evening shift for IV management. Review of Resident 3's Intravenous Therapy Administrative Record, dated (MONTH) 1, (YEAR) through (MONTH) 31, 2019, it indicated on (MONTH) 5, 2019, Resident 3's midline IV was not flushed on the evening shift. During a review of Resident 3's Progress Notes there was no documentation to address the missed mid line care nor to show evidence the physician had been notified. During an interview, and concurrent record review, with the DON on (MONTH) 16, 2019 at 11:00 AM, the DON confirmed Resident's 1, 2, and 3 PICC and midline sites care was not provided as per physician's orders. She was unable to provide a policy and procedure when requested. During an interview, and concurrent record review with the Administrator (ADM) on (MONTH) 15, 2019 at 12:00 PM, the ADM confirmed the missed medications, and confirmed no registry staff was called to cover the RN shifts to give the medications for Residents 1 and 2. Licensed Vocational Nurses cannot administer IV antibiotics Review of the facility policy and procedure entitled, Medication Administration, dated 2013, indicates Policy: Medications are administered as prescribed in accordance with the manufacturers' specifications, standards of nursing practice, and only by persons legally authorized to do so. Procedure . 6. Medications are to be given within one hour of the prescribed time. The facility will specify routine medication times for medications that are scheduled to be given at intervals, such as three times a day. Review of the facility policy and procedure entitled, General Documentation dated 2013, indicates in Intravenous Therapy and Antibiotic Charting, that The facility may choose to only document issues related to the care, monitoring, medication administration and maintenance of any IV therapy on the IV flow sheet only. The nurse may use a narrative note if he or she wished to document information that he or she believes is not amenable to documentation on the IV therapy flow sheet. There was not documentation in Residents 1, 2 or 3's clinical record to indicate the IV antibiotics and/or site care as given as ordered. 2a. During an observation and interview with Resident 1 in his room, on (MONTH) 14, 2019, at 4:20 PM, Resident 1 stated he, has to rely on the staff for almost everything and there is never enough staff to take care of us and on the weekends it's worse. Resident 1 has a bandage to his toes. A review of Resident 1's face sheet (demographic and medical information) indicated Resident 1 was and readmitted on (MONTH) 27, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of the physician's orders for Resident 1, dated (MONTH) 29, (YEAR), indicated two treatment orders: a. Left 1st (first) toe amputation surgical: cleanse with N/S (normal saline) pat dry, apply xeroform (wound dressing consisting of a gauze soaked in a mixture of [MEDICATION NAME] tribromophenate and petroleum jelly and wrap with roll gauze QD (every day) x 14 days and PRN (when necessary) for 14 days. b. Monitor Blister to penis every shift for 14 days. A review of the Treatment Administration Record dated (MONTH) 1, 2019 through (MONTH) 31, 2019, indicated the following: a. On (MONTH) 1, 2019, Resident 1 did not receive wound care to surgical site. b. On (MONTH) 1, 2019, Resident 1 did not have his blister checked on his penis on the day , evening or night shifts During a review of Resident 1's Progress Notes, there was no documentation to address the missed wound care treatments or evidence the facility notified the physician so he could determine if he needed to change the treatment plan 2b. During an interview with Resident 2, on (MONTH) 15, 2019 at 10:45 AM, Resident 2 stated he does not get his medications every day and there is not enough staff to give medications, change wounds or assist with daily care. A review of Resident 2's face sheet indicated Resident 2 was readmitted to the facility on (MONTH) 13, 2019, with [DIAGNOSES REDACTED]. During a review of the physicians' order for Resident 2, dated (MONTH) 27, (YEAR), indicated three wound treatments: a. Left lateral(side) distal (end) lower leg post [MEDICAL CONDITION] (a spreading bacterial infection underneath the skin surface): cleanse with n/s (normal saline) pat dry apply [MEDICATION NAME] (a Vaseline type gauze) and wrap with roll gauze QD (every day) x 21 days and PRN (as needed) every shift for 21 days. b. Left posterior thigh Stage III (wound that extends through the second layer of the skin into the fatty subcutaneous tissue): cleanse with n/s pat dry, apply Collagen (a protein powder used in the repair of body tissues) to wound bed and barrier cream to peri-wound (skin around the wound) and cover with dry dressing QD x 21 days and PRN every shift for 21 days. c. Right posterior thigh Stage III (wound that extends through the second layer of the skin into the fatty subcutaneous tissue): cleanse with n/s pat dry, apply [MEDICATION NAME] and cover with dry dressing QD x 21 days and PRN every shift for 21 days. During a review of the Treatment Administration Record, dated (MONTH) 1, 2019 through (MONTH) 31, 2019, indicated the following: On (MONTH) 1, 5th and 6th, 2019, Resident 2 did not receive wound care to his left lower leg [MEDICAL CONDITION]. On (MONTH) 5th and 6th, 2019, Resident 2 did not receive wound care to the left posterior thigh Stage III pressure wound. On (MONTH) 1, 5th and 6th, 2019, Resident 2 did not receive wound care to the right posterior thigh Stage III pressure wound. A review of Resident 2's physicians' order dated (MONTH) 3, 2019, indicted, Coccyx Stage IV (four): cleanse with N/S, pat dry, apply collagen to wound bed and barrier cream to peri-wound and cover with dry dressing QD x 21 days and PRN every shift for 21 days. During a review of the Treatment Administration Record dated, (MONTH) 1, 2019 through (MONTH) 31, 2019, indicated the following: On (MONTH) 5, and 6th, 2019, Resident 2 did not receive wound care to the Coccyx Stage IV wound. Review of Resident 2's Skin Assessment - Pressure Ulcer V2 dated (MONTH) 4, 2019, indicated Resident 2's Stage IV - coccyx wound measured 1 x 1 x 0.3 cm (Centimeter-a unit of measurement), with a scant amount of drainage of serosangunious fluid (serum and blood.) The wound bed was described as 75% granulation tissue (new vascular tissue) and 25% slough (necrotic or dead tissue). Review of Resident 2's Skin Assessment - Pressure Ulcer V2 dated (MONTH) 11, 2019, indicated Resident 2's coccyx wound measured 1 x 1 x 0.5 cm, with a scant amount of drainage of serosangunious fluid (serum and blood). The wound bed was described as 70% granulation tissue (new vascular tissue) and 30% slough (necrotic or dead tissue). During a review of Resident 2's Weekly Wound Report indicated, Resident 2 had a decline in his wound from (MONTH) 4, 2019 through (MONTH) 11, 2019. During a review of Resident 2's Progress Notes, reflected there was no documentation to address the missed wound care or indication to show the facility notified the physician so he could determine if he wanted to prescribe a different treatment plan During an interview with Resident 2, on (MONTH) 16, 2019, at 10:30 AM, he declined an observation of his wound change. 2. c. A review of the Physician order for [REDACTED]. A review of the Treatment Administration Record for Resident 3, dated (MONTH) 1, 2019 through (MONTH) 31, 2019, indicated the following: On (MONTH) 1, 5th and 6th, 2019, Resident 3 did not receive wound care to the left hip Stage IV pressure wound. During a review of Resident 3's physicians' order dated (MONTH) 9, 2019, indicated two treatment orders: a. Left ischium (back of the hip) stage IV: cleanse with n/s pat dry apply Calcium alginate (a dressing that draws moisture) to wound bed, barrier cream to peri- wound and cover with gauze and dry dressing. One time only for one day. b. Right ischium stage IV (the most severe of pressure ulcers, the wound had deteriorated tissue all the way down to the bone): cleanse with n/s pat dry apply Calcium alginate to wound bed, barrier cream to peri-wound and cover with gauze and dry dressing. One time only for one day. During a review of the Treatment Administration Record, dated (MONTH) 1, 2019 through (MONTH) 31, 2019, indicated the following: On (MONTH) 9, 2019, Resident 3 did not receive wound care to his left ischium Stage IV wound or to the right ischium stage IV wound. During a review of Resident 3's Progress Notes, there was no documentation to address the missed wound care or that the facility notified the physician so he could determine if he wanted to prescribe a different treatment plan 2. d. During an and interview with Resident 4 on (MONTH) 16, 2019 at 1:30 PM, Resident 4 stated the staffing in the facility is low, and on those days it seems as if there is no one to do wound care or any other care. A review of Resident 4's face sheet indicated, Resident 4 was admitted to the facility on (MONTH) 29, (YEAR). Resident 4's [DIAGNOSES REDACTED]. During a review of the Treatment Administration Record dated, (MONTH) 1, 2019, through (MONTH) 31, 2019, indicated the following: a. Cleanse coccyx wound with N/S, pat dry, apply collagen to wound bed and barrier cream to peri- wound and cover with dry gauze and dry dressing every day shift for unstageable (pressure wound that is covered with eschar-dead tissue, that until removed cannot determine if stage III or stage IV) wound for 21 days. b. Coccyx unstageable: cleanse with N/S, pat dry, apply Santyl ointment to wound bed and barrier cream to peri- wound and cover with dry gauze and dry dressing every day for unstageable wound for 21 days. On (MONTH) 1, 2019, Resident 4 did not receive wound care to coccyx wound. On (MONTH) 5th and 6th, 2019, Resident 4 did not receive wound care to an unstageable coccyx wound. Review of Resident 4's Skin Assessment - Pressure Ulcer V2 dated (MONTH) 4, 2019, indicated Resident 4's unstageable coccyx wound measured 8 cm x 6 cm x 0.3 cm (centimeters a unit of measurement), with a small amount of drainage of serosangunious fluid (serum and blood). The wound bed was described as 50% granulation tissue and 30% slough. Review of Resident 4's Skin Assessment - Pressure Ulcer V2 dated (MONTH) 11, 2019, indicated Resident 4's unstageable coccyx wound measured 10 x 8 x 0.3 cm, with a small amount of drainage of serosangunious fluid (serum and blood). The wound bed was described as 75% granulation tissue and 25% slough. During a review of Resident 4's Weekly Wound Report indicated, the resident had a decline in his wound from (MONTH) 4, 2019 through (MONTH) 11, (YEAR), when the wound went form 8 cm. x 6 cm. x 0.3 cm to 10 cm. x 8 cm. x 0.3 cm in size During a review of Resident 4's Progress Notes, there was no documentation to address the missed wound care or evidence that the facility notified the physician so he could determine if wanted to prescribe a diferent treatment plan. 2. e. A review of Resident 5's face sheet indicated Resident 5 was admitted to the facility on (MONTH) 15, (YEAR), with a readmission on (MONTH) 5, 2019, with [DIAGNOSES REDACTED]. During a review of the Treatment Administration Record dated, (MONTH) 1, 2019 through (MONTH) 31, 2019, indicated the following: a. Coccyx Stage 4: cleanse with n/s pat dry, apply Saintly to wound bed apply barrier cream to peri-wound and cover with dry dressing QD x 21 days and PRN. On (MONTH) 1, 2019, Resident 5 did not receive wound care to the Stage IV Coccyx wound. b. Check central line placement on R (right) chest, every shift for bruit (a vascular murmur heard through a stethoscope ( a device used to hear sounds in the body) to determine how well a [MEDICAL TREATMENT] fistula - is working) an abnormal connection between an artery and a vein) or thrills (palpation of the fistula site) for presence or absence. On (MONTH) 1, 2019, the central line placement site was not checked on the morning or night shift. A review of the nurses progress notes indicated on (MONTH) 27, (YEAR) stage IV (pressure injury down to the bone) on coccyx (tailbone) 5 cm. x 5 cm. x 0.3 cm. There was no treatment documented on (MONTH) 1, 2019 The Left ischium (back of hip bone) stage II .2 cm x 3 cm x 0.3 cm. A review of the treatment nurse's notes dated (MONTH) 2, 2019 at 2:35 PM indicated a new stage II pressure ulcer on the right ischium 2.2 cm x 3 cm x 0.3 cm. c. Monitor [MEDICAL TREATMENT] shunt on central line (R) chest for signs of infection, [MEDICAL CONDITION], ischemia, bleeding or dislodgement and presence of clogging every shift. On (MONTH) 1, 2019, the site was not checked on the morning and night shift. During a review of Resident 5's Progress Notes dated (MONTH) 1, 2019 at 6:27 PM, indicated, Resident noted to be sleeping more this shift, resident noted to be slightly lethargic, resident responsive to verbal tactile stimuli. Resident is alert and oriented times four. MD made aware and order received for CBC (complete blood count) noted and carried out. A review of the Progress Notes for Resident 5, dated (MONTH) 2, 2019 at 2:00 PM, indicated, Treatment nurse went in to do treatment today and noted a right ischium stage 2 - 2.2 cm x 3.0 cm x 03 cm with no s/s (signs or symptoms) of infection but noted that the coccyx unstageable wound has a slight odor, noted new order for CBC (complete blood count, a blood test) to be done today, notify MD and continue treatment and monitor. During a review of Resident 5's Progress Notes, there was no docum

Based on interview and record review, the facility did not provide Registered Nurse (RN) services to the residents (a universe of 56 Residents) of the facility from (MONTH) (YEAR) through (MONTH) (YEAR), and were unaware of the federal regulation to ensure that a RN is required to be onsite at the facility for eight (8) consecutive hours a day for seven (7) days of the week. This failure resulted in missed doses of intravenous (IV-into a vein) medications and dressing changes for one of two residents (Resident 1) with IV orders and for Licensed Vocational Nurses (LVNs) to go without supervision. Findings: An unannounced visit was made to the facility on (MONTH) 13, (YEAR), to investigate a complaint regarding the facility having one nurse on staff to pass medications. During an interview on (MONTH) 13, (YEAR), at 4:15 PM, with Resident 1, he stated that there were no nurses around to give him his intravenous (IV- medications given through a vein) medications, or to change his PICC line dressing (a peripherally inserted central catheter to gain intravenous access for administration of medications over a prolonged period of time). A clinical record review of Resident 1's face sheet (medical and demographic information), indicated Resident 1 was originally admitted to the facility on (MONTH) 5, (YEAR), with a current admitted (MONTH) 5, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Medication Orders, indicated the following: 1. [MEDICATION NAME] HCL ([MEDICATION NAME]) Solution, reconstituted 1 GM (gram- a unit of measure). Use 1 gram intravenously one time a day for bone and joint infection for 8 (eight) weeks, dated (MONTH) 6, (YEAR). A review of the Medication Administration Record, [REDACTED]. During an interview and concurrent record review with the Director of Nursing (DON) on (MONTH) 27, (YEAR) at 1:45 PM, the DON confirmed the missing doses of medication but was unable to address why Resident 1 did not receive the medication as ordered by the physician, which was to start on (MONTH) 6, (YEAR). During a review of the Progress Notes for nursing, dated (MONTH) 6, (YEAR), at 12:10 PM, RN 2 indicated In facility to admin(ister) Vanco IV. Spoke with Pt (patient) regarding Vanco infusion. Pt refuses Vanco at present but states will maybe receive later (Name) MD notified of Pt refusal and stmt (statement) that he will take later, this RN not staying at present but (Name of Director of Nursing) will be in later and can try again. A review of the Progress Notes, for (MONTH) 6, (YEAR) through (MONTH) 7, (YEAR), did not indicate any documented notes from RNs related to the placement of Resident 1's peripherally inserted central catheter (PICC, a thin, soft, flexible tube inserted into a vein used for long term intravenous antibiotics) line, nor of the DON attempting to administer the prescribed IV antibiotic. Further review of the Progress Notes dated (MONTH) 8, (YEAR), at 9:55 AM, RN 2 indicated, IV Vanco started via PICC with no problems. 2. Change mid line dressing (PICC line), one time a day every day for 7 (seven) days, dated (MONTH) 16, (YEAR). A review of the Medication Administration Record, [REDACTED]. During an interview and concurrent record review with the DON on (MONTH) 27, (YEAR) at 5:30 PM, the DON confirmed the order was not followed and that one dressing change was done. During an interview and concurrent record review on (MONTH) 27, (YEAR) at 4:05 PM, of the facility's Timecard Report by Department, Nursing Staffing Assignment and Sign-In Sheet, and Master Nursing Schedules with the Administrator (ADM) and the Payroll Clerk (PC), the ADM was asked how the facility stays in compliance with the federal regulation of having a RN on staff eight consecutive hours a day, seven days a week. The ADM stated, I don't think I can. He further stated that he did not know who the RN was that worked on the DON's days off. A review of the facility Nursing Schedule dated (MONTH) (YEAR), indicated the DON was scheduled to work Monday through Friday. There were six (6) RN names listed on the schedule with none scheduled to work on Saturdays and Sundays when the DON is off. During a review of the facility Nursing Schedule's dated (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), indicate that no RNs were scheduled to work on the DON's days off. During an interview with the DON on (MONTH) 27, (YEAR) at 5:30 PM, the DON confirmed that the Master Schedules from (MONTH) (YEAR) through (MONTH) (YEAR), did not show any RN coverage on the DON's days off, but could not speak to the issue as the previous DON resigned on (MONTH) 14, (YEAR). The DON stated they would pull a RN from another facility to come to do the IV antibiotics that she could not do during her off hours. During an interview with RN 1 who works at another facility owned by the same company, on (MONTH) 27, (YEAR) at 6:30 PM, RN 1 indicated in (MONTH) the facility has two residents with IV therapy and one current resident with an IV PICC line. RN 1 stated she would come to the facility and administer the medications. RN 1 provided a copy of the State of California Title 22 regulation, Nursing Service- Staff with section (b) highlighted, (b) Facilities are licensed for 59 or fewer beds shall have at least one registered nurse or a licensed vocational nurse, awake and on duty in the facility at all times, day and night. RN 1 stated the ADM has given it to provide as the regulation the facility was following. A review of the facility payroll documents of Time Card (indicate the category and time a person worked in the facility) and the Nursing Staffing Assignment and Sign-In Sheets (SIS - a document where salaried staff are to indicate the date and number of hours worked) indicated for the period of (MONTH) 1, (YEAR) through (MONTH) 28, (YEAR), the following dates where the facility was not in compliance with the 8 hours a day for RN staffing: 1. (MONTH) 1, (YEAR), punch sheet indicates one (1) hour for RN 1. The sign in sheet was not provided by the facility. 2. (MONTH) 3, (YEAR), punch sheets indicate no RN time. No SIS was provided by the facility. 3. (MONTH) 4, (YEAR), punch sheets indicate no RN time. The SIS contains no time or signature of the DON. 4. (MONTH) 5, (YEAR), punch sheets indicate no RN time. The SIS contains no time or signature of the DON. 5. (MONTH) 6, (YEAR), punch sheets indicate no RN time. The SIS contains no time or signature of the DON. 6. (MONTH) 7, (YEAR), punch sheets indicate no RN time. The SIS contains no time or signature of the DON. 7. (MONTH) 8, (YEAR), punch sheets indicates 3 hours for RN 2. The SIS contains no time or signature of the DON. 8. (MONTH) 10, (YEAR), punch sheets indicate no RN time. The SIS contains no time or signature of the DON. 9. (MONTH) 13, (YEAR), punch sheets indicates 1.5 hours for RN 3. The SIS contains no time or signature of the DON. 10. (MONTH) 14, (YEAR), punch sheets indicates no RN time. The SIS contains no time or signature of the DON. 11. (MONTH) 15, (YEAR), punch sheets indicates 1.25 hours for RN 4, who does not appear on the facility staff list. The SIS contains no time or signature of the DON. 12. (MONTH) 16, (YEAR), no punch sheet hours. The SIS shows no time or signature of the DON. 13. (MONTH) 17, (YEAR), no punch sheet hours. The SIS shows the signature of the DON; no hours are noted. 14. (MONTH) 19, (YEAR), no punch sheet hours. The SIS shows the signature of the DON; no hours are noted. 15. (MONTH) 20, (YEAR), no punch sheet hours. The SIS shows the signature of the DON; no hours are noted. 16. (MONTH) 21, (YEAR), no punch sheet hours. The SIS shows the signature of the DON; no hours are noted. 17. (MONTH) 22, (YEAR), no punch sheet hours. The SIS shows the signature of the DON; no hours are noted. 18. (MONTH) 23, (YEAR), no punch sheet hours. The SIS shows the signature of the DON; no hours are noted. 19. (MONTH) 25, (YEAR), no punch sheet hours. The SIS shows no time or signature of the DON. 20. (MONTH) 26, (YEAR), no punch sheet hours. The SIS shows the signature of the DON; no hours are noted. 21. (MONTH) 28, (YEAR), no punch sheet hours. The SIS shows the signature of the DON; no hours are noted. During an interview with the ADM and PC on (MONTH) 27, (YEAR) at 6:45 PM, regarding the Timecard Report by Department, Nursing Staffing Assignment and Sign-In Sheet, the ADM and PC confirmed they provided all documents available to show the facility RN staffing. The facility was not able to provide a procedure related to Registered Nurse Staffing, per the ADM. An Immediate Jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a client) was called for the following reason: An IJ was called under 483.35(b) (1), Registered Nurse on (MONTH) 27, (YEAR), at 7:50 PM, in the presence of the Administrator (ADM), Director of Nursing (DON), Minimum Data Set Nurse, (MDS - a licensed nurse who gathers information of the facility's current residents for future assessment, which includes mental and physical health), Director of Staff Development (DSD - a licensed nurse who provides staff orientation, training, and scheduling), and Payroll Clerk (PC). The facility was informed of the failure to follow federal regulations that requires a facility must use the services of a Registered Nurse (RN) for at least eight (8) consecutive hours a day, seven (7) days a week. The IJ was lifted on (MONTH) 31, (YEAR), at 1:27 PM, in the presence of the ADM, PC and RN Consultant, after the corrective action plan was reviewed and confirmed to be implemented through interview, and record review. The corrective action plan included the following: 1. An attached nursing schedule showing that an RN is scheduled for eight (8) hour shift for everyday for the remaining of (MONTH) and January. 2. A signed contract with a healthcare nursing staffing agency as a backup to cover any potential call offs of any RN that may occur to ensure compliance. 3. The DON or designee will review compliance for the next three months to ensure compliance.

Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature level of 71-81 degrees Fahrenheit (F) in the common area by the nurses station, where residents had congregated, five rooms on the 200 hallway (Rooms 200, 201, 202, 203 and 205) and four rooms (Rooms 300, 301, 303 and 304) on the 300 hallway. This failure had the potential to adversely affect the health and safety of residents by placing them at risk for heat exhaustion (condition of physical weakness accompanied by nausea, muscle cramps, and dizziness, due to exposure to intense heat) and heat stroke (condition with fever and often unconsciousness, when exposed to excessively high temperatures), when the air conditioning unit failed. An immediate jeopardy (IJ) was called on May 23, 2017 at 8:25 PM, in the presence of the facility's Regional Nurse (RN) and the Director of Staff Development (DSD), due to excessive heat, (Facility temperatures ranged from 87 to 92 degrees F), and the facility's inoperable air conditioning unit. Findings: During the initial tour on May 23, 2017 between 6:00 PM and 6:14 PM, the nurses' station, where residents (Resident 14, 22 and 23) congregated, felt hot and uncomfortable. The temperature was taken with the surveyor's laser thermometer gun and determined to be 87 degrees Fahrenheit (F) and verified with the Licensed Vocational Nurse (LVN 1 and 2). During the initial tour, observation revealed no facility staff had been observed to be passing hydration to clients affected by the elevated temperatures in the building. The facility's maintenance personnel were not on site, and no work was being completed on the air conditioning unit. During an observation while conducting the initial tour on May 23, 2017 at 6:06 PM, two residents (Resident 1 and 2) were observed in their room (room [ROOM NUMBER]). They were visibly sweating, and complained of the excessive heat in their room. Their room temperature was 91 degrees F, using the surveyor's laser thermometer gun and verified with Resident 1 and Resident 2, who complained of the elevated temperature. The Director of Staff Development (DSD) was also present to verify the elevated temperature of 91 degrees F. During an observation on May 23, 2017 at 6:19 PM, the hydration cart (cart with fluids available to independently serve individuals in the facility) had been observed in the dining room, unavailable to any residents who were unable to get out of bed independently, or to self-propel in their wheelchair. During additional observations, on May 23, 2017, between 6:00 PM and 7:04 PM, the following area's temperatures were taken with the surveyor's laser thermometer gun, and verified with the DSD. a. Nurses' Station: 87 degrees F. During an interview with Resident 14 on May 23, 2017 at 6:20 PM, she stated, I'm (I am) hot, indicating she had been uncomfortable in the common area located by the nurses' station. The temperature in the common area where Resident 14 was sitting was taken with the surveyor's laser thermometer gun and was 87 degrees F, verified with LVN 1 and 2. b. room [ROOM NUMBER]: 92 degrees F. During an interview with Resident 3, on May 23, 2017 at 6:19 PM, she stated, I'm (I am) hot; it's (it is) always hot (in my bedroom). The temperature in room [ROOM NUMBER] was taken with the surveyor's laser thermometer gun and was 90 degrees F, verified with Resident 3, and the DSD. Resident 3 stated the facility had not provided any means of comfort since the air conditioning unit failed to operate. c. room [ROOM NUMBER]: 91 degrees F. During an interview with Resident 1 on May 23, 2017 at 6:14 PM, he stated, It's (it is) hot, and has been since yesterday (in our room). Resident 1 stated the air conditioning does not work and the fan is Blowing hot air. The temperature was 91 degrees F, taken with the surveyor's laser thermometer gun, verified with Resident 1 and the DSD. During an interview with Resident 2 on May 23, 2017 at 6:16 PM, he stated, I'm (I am) hot (in our room), and the (facility's) air conditioning never works. Resident 2 stated, The heat works just fine, but it is always hot (in our room). The temperature was 91 degrees F, taken with the surveyor's laser thermometer gun, verified with Resident 2 and the DSD. d. room [ROOM NUMBER]: 90 degrees F. During an interview with Resident 15 on May 23, 2017 at 6:23 PM, he stated, 90 degrees (Fahrenheit) is too warm (in room [ROOM NUMBER]). The temperature in room [ROOM NUMBER] was 90 degrees F and was taken with the surveyor's laser thermometer gun, verified with Resident 15, and the DSD. During an interview with the Director of Staff Development (DSD) on May 23, 2017 at 6:42 PM, she stated the air conditioning was not working and had not worked since yesterday (May 22, 2017). The DSD stated, The air conditioner repair person will not repair the air conditioner until tomorrow (May 24, 2017). The DSD stated, I don't (do not) know, why the repairs are not being done. The DSD confirmed the maintenance personnel and the air conditioning unit repair person were not at the facility. During an interview with the Director of Maintenance (DM) on May 23, 2017 at 7:22 PM, he stated the air conditioning was not working when he had left the facility today (May 23, 2017). The DM stated the air conditioner repair person was not scheduled to come back here until tomorrow (May 24, 2017). The DM confirmed that he called the air conditioning unit repair person to come to the facility, after the surveyor arrived on site. A review of the facility's policy and procedure titled, Policy, (undated), indicated, It is our policy to keep the room temperatures between 72 and 81 degrees (Fahrenheit) . If the situation cannot be addressed in a timely manner, more aggressive steps must be taken . A review of the facility's policy and procedure titled, Maintenance Service, (undated), indicated, 2. Functions of maintenance personnel include .d. Maintaining the heat/cooling system .f. Establishing priorities in providing repair service . The IJ was lifted on May 24, 2017 at 11:42 AM, in the presence of the RN and the Director of Maintenance, after the corrective action plan was verified to have been implemented through observation, temperature checks in residents rooms and common areas, interviews with residents and staff and review of in-services with the following: a. Fans were placed in residents rooms and in common corridors, with ice buckets in front of fan to cool the air. b. Air conditioning was repaired. c. Staff were in-serviced on interventions for high temperatures, and reporting any change of conditions to the facility's supervisors. d. Staff to provide rounds with hydration every hour to residents unable to get to hydration cart in the dining room. e. Temperature logs implemented and will continue until room temperatures are 72-81 degrees Fahrenheit (F). f. Staff will have in-service training regarding reporting life safety issues to administrative staff and administrative staff reporting to California Department of Public Health (CDPH).

Based on interview and record review, the facility failed to provide a two person assist for safety precautions while providing toileting care on December 28, 2015 for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling to the floor and sustaining a fracture to her left knee. Finding: During a review of Resident 1's admission clinical record documented Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's quarterly Resident Assessment Instrument (RAI, a tool used to assess a resident from head to toe) completed on December 5, 2015 indicated under transfers that Resident 1 was totally dependent on staff and required a two person assist for transfers. The plan of care for Resident 1, developed on June 9, 2014, and verified by staff as most current plan of care documented Resident 1 required a two person assist with turning and repositioning. During an interview with the Administrator (Admin) on January 5, 2016 at 9:45 AM, the Admin stated on December 28, 2015 Resident 1 was being transferred from the Hoyer lift e-z stand (equipment used to lift a resident to assist with transfers) to the bedside commode by Certified Nursing Assistant 1 (CNA 1) and (CNA 2). The Admin further stated that while Resident 1 was being transferred CNA 1 left to go retrieve batteries for the Hoyer lift e-z stand. The Admin stated that when CNA 1 left Resident 1's room to get batteries, CNA 2 was left with Resident 1 and during that time Resident 1 fell to the floor. During an interview with CNA 1 on January 5, 2016 at 10:30 AM, CNA 1 stated on December 28, 2015 she and CNA 2 were assisting Resident 1 to the bedside commode with the e-z stand Hoyer lift. Suddenly the Hoyer lift began to blink indicating that batteries were needed. CNA 1 stated Resident 1 was partially positioned on the bedside commode. CNA 1 stated she left the room to retrieve new batteries. CNA 1 stated when she returned she saw Resident 1 halfway on the lift with lower half of body sitting on the floor. During an interview with CNA 2 on January 5, 2016 at 10:45 AM, CNA 2 stated on December 28, 2015 at 10:00 AM, she and CNA 1 were assisting Resident 1 to the bedside commode. CNA 2 stated Resident 1 required a Hoyer lift for transfers. CNA 2 stated Resident 1 required two people to transfer. CNA 2 stated that while transferring Resident 1 to the bedside commode, the Hoyer lift started to blink indicating new batteries were needed. CNA 2 stated that Resident 1 had gotten on the bedside commode, but was not securely positioned all the way back on the commode. CNA 2 stated CNA 1 left to go retrieve batteries for the Hoyer lift. CNA 2 stated she attempted to change Resident 1's diaper by herself, Resident 1 began to fall forward. CNA 2 stated Resident 1 fell forward to the floor and fell on her knees. CNA 2 stated that she should have waited for CNA 1 to return before she attempted to change Resident 1. CNA 2 stated Resident 1 should have been secured on the bedside commode before CNA 1 left the room to retrieve batteries to ensure a safe transfer occurred. During an interview with Licensed Vocational Nurse 1 (LVN 1) on January 5, 2016 at 11:00 AM, LVN 1 stated she assessed Resident 1 after a fall from the easy stand Hoyer lift. LVN 1 stated Resident 1 had two lacerations (cuts to skin) to the right knee. LVN 1 stated that the physician was notified and Resident 1 was assisted back to bed. LVN 1 stated that on December 31, 2015 (three days after the fall incident), Resident 1 was complaining of severe left knee pain. LVN 1 stated Resident 1 had a pain score of 8 out of 10 (pain scale 0-10, 0 is no pain, 10 is severe pain). LVN 1 stated the physician was notified and orders were received to obtain an x-ray (picture of bone) of Resident 1's left knee. Review of the x-ray report from December 31, 2015 revealed that Resident 1 had a non-displaced fracture of the left knee. During an interview with the Administrator on January 5, 2016 at 11:15 AM, the Admin stated that it was the policy of the facility that staff follow the plan of care for all residents to ensure residents safety would not be affected.

Based on observation, interview, and record review, the facility failed to ensure that all resident areas were maintained to ensure a safe and secure environment for a universe of 45 residents, staff and visitors. The following issues were identified at the facility on October 10, 2013: 1) For 2 of 2 sampled residents (Resident A and B) the facility failed to ensure that all residents were removed from the affected area (residents' room) when a rain water leak was discovered from the ceiling and on to the floor. 2) For all residents, staff and visitors, the facility failed to ensure that there were no rain water leaks from the roof, and that all areas of the facility (200 hallway ceiling and floor, and the area in front of the Nurses' Station) were safe and dry. Because of the facility's failure to ensure a well maintained and safe environment ( damage to the roof and ceiling from rain), all residents, staff, and visitors were at risk for injury, serious harm, or death, due to potential falls, including fractures, and potential mold inhalation. Immediate Jeopardy was called on October 10, 2013 at 6:00 PM with the Administrator and the Company President. Findings: 1. a) During an observation of the facility on October 10, 2013 at 11:05 AM, water was observed dripping from the ceiling in several places in a room by beds B and C. The leak by bed B was observed dripping on the resident ' s oxygen concentrator and on to the floor. During an interview with the facility Administrator on October 10, 2013 at 11:06 AM, the Administrator confirmed that there were leaks from the roof due to the pitch (the angle) of the roof and pooling of rain in certain spots from current and past rain storms. She further requested that the Maintenance Director get some buckets to catch the water. The residents in the room (Residents A and B) had not been moved by facility staff for their safety. During a review of the facility's last survey conducted 11/2/12, a finding was documented at this tag regarding water stains on the ceiling in a resident room. The staff confirmed that there were problems when it rained and the stains were from water damage. During a review of the maintenance log for the year 2013, a previous request for repairs to the " roof from rain" was noted for the room of Residents A and B, dated September 2, 2013. b) During an interview with Resident A on October 10, 2013 at 5:45 PM, Resident A stated that the ceiling in the room, began leaking last night. During a review of the clinical record for Resident A, it was documented that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the H&P (History and physical a yearly exam by the physician) dated May 29, 2013, documented that the resident did not have the capacity to make or understand health care decisions. During an interview with Resident B on October 10, 2013 at 5:50 PM, Resident B stated that the ceiling in the room, had been leaking for months now, anytime it rained. This time the leaking started last night. During a review of the clinical record for Resident B, it was documented that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the H&P (History and physical a yearly exam by the physician) dated July 5, 2013, documented that the resident had the capacity to make or understand health care decisions. Review of the physician's order [REDACTED]. 2) During an observation of the facility on October 10, 2013 at 11:05 AM, water marks were observed by a light fixture in the 200 hall and a large area of the ceiling in front of the Nurses' Station. Four residents were observed sitting in wheelchairs in front of the Nurses' Station. The area of the Nurses' Station was at the center of the building, and the area where all residents, staff, and visitors must pass through to access other parts of the building, including the entrance, family area, dining room, and outdoor areas. During an interview with the facility Administrator on October 10, 2013 at 11:06 AM, the Administrator confirmed that there were leaks from the roof due to the pitch (the angle) of the roof and pooling of rain in certain spots. The Administrator further stated that anytime it had rained there have been leaks found around the facility. The Administrator stated that the roof leaking was not an unusual occurrence at the facility, it happened all the time. The Administrator stated that 2 years ago there was a big rain storm and when she came in the next morning the ceiling in the dining room was bowed from water damage from a leak. Failure of the facility to repair the roof placed resident, staff and visitors at risk of harm from potential falls. For the elderly, medically compromised resident a fall and its' inherent risks including fracture is great. Possible health risks that could develop due to exposure to mold inhalation is described below: According to the CDC, a) studies of mold growth on building materials, such as plywood, have found that mold grows on materials that remain wet for 48--72 hours (Doll SC. Determination of limiting factors for fungal growth in the built environment. Cambridge, MA: Harvard University School of Public Health; 2002.). b) Building interiors should be assumed to be substantially contaminated with mold in the following circumstances: Signs of water damage are visible or mildew odors are strong. (CDC: Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes and Major Floods--- Atlanta Georgia MMWR June 9, 2006 / 55(RR08);1-27) c) Exposure to materials and structures contaminated with mold should be assumed to present a potential health risk regardless of the type of mold. Risk for illness does not necessarily vary with the type of mold or the extent of contamination. (CDC: Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes and Major Floods--- Atlanta Georgia MMWR June 9, 2006 / 55(RR08);1-27) Because of the facility's failure to ensure a well maintained and safe environment, all residents, staff, and visitors were at risk for injury, serious harm, or death, due to damage to the roof from rain. Immediate Jeopardy was called on October 10, 2013 at 6:00 PM with the Administrator and the Company President. On October 10, 2013 at 7:00 PM, the Administrator presented a corrective action plan to the survey team. The corrective action plan consisted of the following elements: 1) The Residents A and B were relocated. Room will not be occupied until all repairs have been completed. 2) Any further occurrences would be reported to CDPH. 3) The Maintenance Supervisor made a full environmental inspection to ensure no other areas were affected, and would be done after each occurrence of inclement weather to look for leaks in the future. 4) A new facility policy and procedure was adopted to ensure that all residents will, in the future be immediately removed from any area where a leak is discovered. 5) All facility personnel to be in-serviced on the above policy and procedure by October 23, 2013. A new posting of the new policy and procedure will be available for all employees until the in-service is completed. 6) The Maintenance Supervisor will conduct regular environmental rounds and document any roof repairs needed and ensure that the repairs are completed timely. The corrective action plan was accepted on October 10, 2013 at 7:17 PM by the survey team. The survey team met with the facility Administrator and the Company Director of Clinical Services and informed them that the team had abated the Immediate Jeopardy.