Every finding on record at Cura of Sandstone

Based on interview and document review, the facility failed to ensure the facility staff administered medications without significant medication errors for 4 of 21 residents whose medication error reports reviewed. R4's Order Summary dated 3/01/26, indicated R1 had seizure disorder and diffuse traumatic brain injury with loss of conscious of unspecified duration. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had severe cognitive impairment, received anticonvulsant medications and had seizure disorder. Findings include: R4 R4's Order Summary dated 3/01/26, indicated R4 had seizure disorder and diffuse traumatic brain injury with loss of conscious of unspecified duration. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had severe cognitive impairment, received anticonvulsant medications and had seizure disorder. R4's Physician Orders dated 3/01/26, included Dilantin (anti-seizure medication) give 150 milligrams (mg) via gastrostomy (G)-tube twice daily (BID) for seizure disorder. Lacosamide (anti-convulsant) Solution give 10 milliliters (ml) via G-tube three times daily for post traumatic epilepsy. A Medication Error Report dated 3/18/26, indicated on 3/17/26 R4 had received an omission of Lacosamide 10 ml, at 5:11 p.m. The Report indicated medication was documented as given in the Medication Administration Record (MAR) but was not found until the next shift sitting in medication cabinet in a medication cup. The Medication Error Report indicated the cause was a distraction that caused the error and staff were to be more mindful, and there was no pattern. Plan of correction was to not leave medications in room and to double check prior to leaving before the end of the shift. The report indicated the physician was notified by the portal. An additional medication error for R4 indicated on the same date of 3/17/26, Dilantin 150 mg was to be given at 5:07 p.m., but was found on the next shift sitting on the medication cabinet in a medication cup. The Medication Error Report indicated the cause was a distraction that caused the error and staff were to be more mindful, and there was no pattern. Plan of correction was to not leave medications in room and to double check prior to leaving before the end of the shift. The report indicated the physician was notified by the portal. This resulted in two significant medication errors for R4 related to her seizure medications. R4's Seizure Report indicated the last seizure R4 had in March 2026 was 3/12/2026, which was not when she missed her seizure medication on 3/17/26. During interview on 7/15/26 at 12:45 p.m., the facilities pharmacist consultant stated any medication that involves a seizure medication is considered a significant medication error. R4 Evaluation and Management visit with primary physician dated 3/25/26, did not indicate any mention of the medication errors, or laboratory orders to follow up on the seizure medications missed. R2 R2's Care Plan dated 11/03/25, indicated R2 had subdural hematoma (collection of blood between the brain and it outer covering), traumatic brain injury, craniotomy (a surgical operation where a doctor temporarily removes a piece of the skull to reach the brain) and g-tube placement. Staff were directed to administer medications as ordered. Observe for effectiveness and adverse effects and update doctor (MD) as needed. R2 Hospital admission Orders dated 5/18/26, indicated to give propranolol (affects blood flow through arteries and veins) 20 mg give one tablet every eight (8) hours. R2's Medication Error Report dated 5/14/26 at 5:00 p.m., indicated R2 had an order for propranolol 20 mg oral every 8 hours, hold for systolic blood pressure (BP) <100 or heart rate (HR) <60. Order not given on night (NOC) when scheduled at 5:00 a.m. and BP/HR not assessed to hold dose. Morning (AM) shift administered at 7:09 a.m. During interview on 7/15/26 at 4:51 p.m., the director of nursing (DON) stated she had to work the night shift on 5/14/26 and was up for 24 hours and was tired. The DON stated she did not pass the medications at 5:00 a.m. and left them for the day shift nurse coming on. The DON stated she left a sticky note on the medication cart notifying the day shift nurse and left the facility because she was exhausted. During interview on 7/15/26 at 1:00 p.m., facilities pharmacy consultant stated he was concerned with the medication given late due to the patient's medication history and risk of blood clots and felt this was a significant medication error. R5 R5's quarterly MDS dated [DATE], indicated R5 had hemiplegia (paralysis or severe weakness affecting one side of the body), seizure disorder and received anti-convulsant medications. R5's Medication Error Report dated 4/22/26 at 8:41 p.m., indicated R5 had an order for Klonopin (used to treat panic disorders and certain seizure disorders) 1 mg orally (PO) in the evening (HS). The report indicated the medication was never removed from the medication drawer. The report did indicate the physician was notified and plan of correction was to slow down, review rights, and double check before signing off meds. The report indicated no adverse reaction occurred. R5's MD visit was on 5/05/26, which indicated she had seizure disorder and anxiety and received Klonopin 1 mg at HS and has not had any seizures. R8 R8's quarterly MDS dated [DATE], indicated R8 was cognitively intact, and did not receive anticonvulsant medication. R8's Physician Orders dated 5/01/26, indicated R8 received Keppra 250 mg BID (twice daily) for seizure disorder. R8's Physician summary dated 5/01/26, indicated The patients Epilepsy unspecified, intractable (treatment-resistant, refractory or poorly controlled), without status epilepticus as evaluated today. Diagnosis puts at high risk for decompensation (rapid functional decline). Diagnosis for morbidity and mortality. And received Keppra (anti-epileptic) and was overall stable, no recent seizure activity. R8's Medication Error Report dated 4/24/26 at 6:27 p.m., indicated R8 received Keppra 150 mg documented in medication administration record (MAR) as administered, but not punched out of bubble pack. The report indicated the physician was notified and no adverse reactions occurred. What occurred was trying to go too fast and staff needed to slow down, make sure checks are done properly, review the seven rights and do double checks. During interview on 7/15/26 at 1:20 p.m., the pharmacy consultant stated he was not provided with the medication errors in the quarterly QAPI meeting and was informed he will in the July 2026 meeting. The Pharmacist stated there have been changes in the staff and figured that was why, but he also stated this facility has had a history of medication errors and felt all of the medication errors were felt to be significant medication errors. During interview on 7/16/26 at 12:28 p.m., the regional nurse consultant stated there is room for improvement for tracking, trending and the follow up for the charting of medications errors. In addition, the nurse consultant stated the charting for medication needs to be better. Facility policy, Medication Error-Long Term Facility effective 4/2025, indicated A detailed account of the incident must be recorded in facility approved format such documentation must include, but is not limited to, the time the incident the name strength and dosage of the medication, the residents reaction to the medications, any treatment administered the provider name date and time they were notified, notification of resident and/or representative, and known or suspected contributing factors that led to the incident, resident receiving incorrect medication. Medication errors will be considered for the need for additional reporting under vulnerable adult reporting. All medication error reports will be reviewed by DON and quarterly at Quality Assurance meeting.

Based on observation, interview and document review, the facility failed to ensure appropriate infection control while providing laundry services, as well as failing to maintain an effective Infection Prevention and Control Program specific to infection surveillance. The facility's system did not track culture results, organisms identified, or transmission-based precautions (TBP) initiated to ensure residents received appropriate treatment and infection control measures were maintained. This had the ability to affect all 36 residents. In addition, the facility failed to ensure proper glove use and hand hygiene during care for 1 of 1 resident (R8) during completion of ADL cares.Findings include: Laundry Tour: During a laundry room tour on 4/8/26 at 7:16 a.m., other staff (O)-B was observed sorting dirty laundry without wearing gloves and a gown. O-B lifted dirty laundry from a bin, holding the laundry against themselves, and putting the laundry in a washing machine. During a laundry room tour on 4/8/26 at 7:25 a.m., O-B was observed removing clean laundry from a dryer, folding and hanging resident clothing. During an interview on 4/8/26 at 7:25 a.m., the laundry manager stated that staff should be wearing gloves and a gown when handling dirty laundry. They stated a concern for cross contamination with clean laundry. Facility Departmental (Environmental Services) Policy – Laundry and Linen dated 4/2026 instructed employees sorting or washing laundry must wear a gown and gloves and to consider all dirty laundry to be potentially infectious. Infection Surveillance Program: Review of the Infection Surveillance Reports (ISR) dated 1/26, 2/26, and 3/26 showed documentation included resident name, room number, onset date, infection type, such as urinary tract infection (UTI), signs and symptoms, status, and pharmacy order. However, the log lacked documentation of the date cultures were obtained, organisms identified from culture results, whether organisms were resistant to prescribed antibiotics, and any TBP initiated. Review of R13's urine culture results dated 3/2/26, identified the susceptibility profile was consistent with probable extended-spectrum beta-lactamases (ESBL), an infection that is resistant to common antibiotics. During an interview with the infection preventionist (IP) and registered nurse (RN)-C, both working as assistant directors of nursing, on 4/8/26 at 10:25 a.m., the infection preventionist (IP) stated the facility did not track organisms on their ISRs and that cultures results were in the resident's record. The IP stated they were not aware that R13's culture results dated 3/2/26 indicated probable ESBL and indicated knowing the organism was important to place the resident on the appropriate precautions to prevent the spread of infection to others. RN-C reviewed R13's record, confirmed the culture results, and that according to the culture results R13 should have been put on contact precautions. During an interview on 4/8/26 at 3:55 p.m., the director of nursing (DON) stated they expected that the infection organism was tracked with their infection surveillance program. They stated it was important to track the organism to prevent the spread of infection. Facility Transmission-Based Precautions policy dated 1/26, instructed that contact precautions were implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact, including ESBL. Facility Surveillance for Infections policy dated 1/2026, identified gathering surveillance data as part of the facility's Infection Control Program. R8: R8's annual Minimum Data Set (MDS) dated [DATE] indicated R8 had moderate cognitive impairment. Diagnoses included dementia and epilepsy. The MDS indicated R8 was always incontinent of bowel and bladder, and dependent of staff for toileting hygiene. R8's care plan undated, indicated R8 had an alteration in elimination r/t incontinent of urine and bowel. interventions included to check and change every two hours and as needed, along with provide peri cares with incontinence episodes. During an observation on 4/7/26 at 2:50 p.m., nurse assistant (NA)-G entered R8's room and told R8 he was going to check to see if he was dirty and if so, change his brief and clean him up. NA-G washed his hands and placed his gloves on. NA-G gathered wipes, cream, and a new brief from the bedside table. R8's Pants were lowered, the brief was opened up and confirmed R8 was dirty with urine. NA-G removed R8's old dirty brief and washed the front of his peri area with wipes. R8 was rolled to the right side and NA-G cleaned the buttock region. Rolled to the right side. Barrier cream was then applied to R8's buttock. With the contaminated gloves still on, NA-G then placed the new brief on R8 and secured it in place and pulled pants back up. NA-G then opened the bedside drawer and returned the cream back the drawer with the contaminated gloves still on. Finally, NA-G gathered all the trash and walked out of the room, to the trash room, threw away the trash and finally removed the contaminated gloves and washed his hands. During an interview on 4/7/26 at 3:00 p.m., NA-G stated the only time he changed his gloves when going from dirty to clean parts of peri care was when stool had gotten on the gloves. Otherwise, the gloves would be wiped down when peri wipes and finish the job without changing the gloves. Gloves were removed and hands were washed after all the dirty items were thrown into the trash. During an interview on 4/8/26 at 11:23 a.m. the infection preventionist (IP) stated the facility had started hand hygiene audits about a 1.5 weeks ago. Staff were expected to remove gloves after completing peri-care and use hand sanitizer. They should take off their gloves before touching clean items and sanitize. Soap and water were to be used for enteric precautions, before/after using the bathroom, c. diff and before/after eating. To prevent the spread infection. During an interview on 4/8/26 at 2:43 p.m., the DON stated all staff should change gloves when doing cares anytime they change from dirty parts of the process to clean parts of the process.

Based on observation, interview and document review, the facility failed to follow care planned interventions necessary to prevent an avoidable accident from occurring for 2 of 5 (R30, R14) residents reviewed for falls and accidents. In addition, the facility failed to ensure the safety of a resident with suicidal ideations and not following provider orders for safety precautions for 1 of 5 residents (R2) reviewed for accident hazards. Finally, the facility failed to evaluate a resident with an increased risk of aspiration for 1 of 1 residents (R8) reviewed for accident hazards.Findings include: R30: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had moderate cognition, and diagnoses included cerebral infarct (stroke). R30 required assist of 1 staff, gait belt (a belt used as a safety device to support patients when walking) and a 4-wheeled walker for ambulation to/from the bathroom. R30 did not ambulate outside of the bedroom or bathroom. R30's undated Care Plan, identified R30 had potential for injury related to impaired mobility, impaired cognition. R30 was impulsive and consistently wouldn't ask for assistance or use the call light, had poor safety awareness, self-transferred and self-toileted. Interventions included anti-slip strips on the floor in front of the recliner, dycem under wheelchair cushion and on recliner chair, for slipping and fall prevention, encourage to wear appropriate footwear and keep call light within reach. The plan identified R30 had a self-care deficit related to diagnosis of stroke. Interventions included PER THERAPY R30 [NAME] be an assist of 1 for transfers and ambulation with a 4 wheeled walker. Staff were to always use a gait belt when transferring or ambulating R30. R30's Therapy Communication dated 2/12/26, identified R30 may be assist of 1 staff for transfers and ambulation with a 4 wheeled walker. Gait belt at all times when transferring or ambulating. Patient requires extra time to complete tasks and max cues for safety. During observation on 4/7/26 at 6:53 p.m., the director of nursing (DON) and R30 exited the bathroom and were walking towards R30's recliner. DON was walking alongside and not touching R30. R30 was pushing a 4 wheeled walker. R30 was not observed wearing a gait belt around his waist. During interview on 4/7/26 at 7:08 p.m., the DON stated a resident's transfer status is listed on their care plan and Kardex and staff can view them in the computer system. DON stated during R30's transfer, R30 used a 4 wheeled walker, although staff had not used a gait belt. The DON stated R30's care plan identified staff were to use a gait belt with R30 during all mobility/transfers. The facilities Transferring/Ambulating A Resident policy dated 1/26, identified a transfer belt (gait belt) should be used when assisting a resident who requires physical assistance with a transfer unless another piece of equipment such as a standing lift or full mechanical lift is used. R14: R14's Significant Change MDS dated [DATE] indicated R14 was significantly cognitively impaired. R14's diagnoses included unspecified dementia, unspecified disorientation, atrial fib, and hypertension. MDS section GG indicated R14 needs moderate assistance with dressing and minimal assistance with walking. R14's care plan dated 4/8/26, identified: Self-care deficit related to diagnosis of dementia, interventions included: ambulation: 1 staff assist with belt and walker. R14 was not safe to ambulate independently. dressing: 1 staff assist R14 had impaired cognitive function related to diagnoses of dementia, disorientation, and forgetfulness, interventions included: Remove from harmful situations. Repeat instructions several times, as needed Potential for falls related to diagnosis of dementia, and use of cardiac, antidepressant, narcotic, and diuretic medications. R14 was impulsive, didn't consistently ask for help or use call light, had poor safety awareness, self-transfers, and self-toilets despite not being safe to do so. Interventions included to encourage R14 to wear appropriate footwear/shoes. During an observation on 4/8/26 at 7:10 a.m., R14 was ambulating in the hallway to a chair in the dining room with nursing assistant (NA)-B. R14 was wearing black socks without grippers and no shoes. During an interview on 4/8/26 at 7:42 a.m., nursing assistant (NA)-B stated they had helped R14 get dressed and walked with R14 to the dining room, and they had not noticed that R14 just had socks on their feet. NA-B stated R14 should wear shoes when walking, and they were concerned R14 could slip if not wearing shoes or non-slip socks. NA-B stated they would apply non-slip footwear to R14's feet immediately. During an interview on 4/8/26 at 11:35 a.m., registered nurse (RN)-C stated R14 was at risk for falls and should wear gripper socks or shoes when walking to prevent slipping. RN-C stated they would expect staff to be aware of R14's footwear prior to a walk. During an interview on 4/8/26 at 3:14 p.m., the DON stated when staff provided minimal assistance with walking per R14's care plan, they expected staff would ensure R14 had shoes or non-slip socks on and used their walker, and that staff remained close to R14 and provided verbal cuing. The DON stated concerns for slipping and increased fall risk if R14 was not using non-slip footwear when walking. Facility policy Safety and Supervision of Residents dated 11/2021, instructed staff to identify any specific accident hazards or risks for individual residents and ensure interventions were implemented consistently to reduce accident risks. Facility policy Fall Management - Long Term Care dated 6/2025, instructed staff to implement interventions on the resident's care plan to minimize the risk of falls. R2: R2's quarterly MDS dated [DATE], identified intact cognition and diagnoses of major depressive disorder with psychotic symptoms, bipolar disorder, hallucinations, parkinsonism, insomnia, chronic pain syndrome, and mild cognitive impairment. R2's MDS also indicated delusions, physical and verbal behavior toward others, and wandering behavior. R2 was dependent for transfers and was able to propel his own wheelchair with partial assist. R2's care plan included a focus statement dated 3/6/26, indicating R2 was at risk for alteration in mood related to suicide ideation and thoughts they would be better off dead. The care plan didn't include interventions for keeping cords from R2's reach. R2's electronic medical record (EMR) identified the following timeline: 6/20/25, a provider order to monitor for suicidal ideations and verbalizations of self-harm. 2/1/26, a progress note identified R2 was making comments about getting guns, shooting people, comments about finding a cord to commit suicide. Provider notified and gave order to send to the emergency department if making suicidal ideations. 2/1/26, a provider order to keep all cords out of resident's reach due to suicidal ideation every shift. 4/6/26, a care plan and Kardex update identified to keep cords out of R2's reach. During an observation 4/6/26 at 3:03 p.m., R2 had two soft-touch, pancake-style call lights with cords approximately 15 feet long plugged into the wall and draped to his chair room, there were several electric cords plugged into two televisions and a cable box, on the windowsill there was a small fan plugged in, and a cellphone-style charging cord. Next to R2's bed on a bedside table, there was a charging strip with a cord charging an electric razor, another cellphone-style charging cord, and a refrigerator plugged in. On the wall on the other side of the bed there was a cord hanging from a light fixture at the head of the bed down to about the level of the mattress. R2 was observed in his wheelchair rolling around the room with the ability to reach all of the 11 different cords. During an interview on 4/6/26 at 6:56 p.m., NA-E stated she was familiar with R2 and his care, she stated she was aware of him making suicidal statements because she had heard in report the other weekend. NA-E stated R2 had safety checks for self-transferring. On 4/6/26 at 7:02 p.m., licensed practical nurse (LPN)-B demonstrated in the EMR that R2 had hourly safety checks for behavior, items he shouldn't have, like trash bags and watching him with the cords, and recent suicidal ideation. LPN-B stated it was normally the aids who do more of the rounding, she tried to help out when she could. During an interview on 4/6/26 at 7:06 p.m., RN-B stated they didn't know of R2 having recent suicidal ideations or threats. RN-B confirmed the treatment administration record (TAR) identified to keep all cords out of R2's reach due to suicidal ideation, and to monitor for suicidal ideation. During an observation on 4/6/26 at 7:27 p.m., R2 was in his room in a wheelchair, moving about his room and all 11 cords were still in the same places. During an interview on 4/6/26 at 7:33 p.m., the DON stated they have had residents who have made suicidal statements, but they currently didn't have any. The DON stated she was familiar with R2's behaviors, he wasn't suicidal any longer, adding he could hallucinate about things and people, was paranoid and thought people were stealing his things, or that they're out to get him, R2 did have a diagnosis of bipolar disorder, and was followed by in-house psychiatric service. The DON stated she thought R2's mood lately had been good, and after reviewing the EMR stated the last time R2 had made suicidal statements was 2/1/26, and they did get an order for him to be evaluated in the emergency room if he continued to make statements. Immediate interventions were to initially place him on one-to-one supervision, then 30-minute checks, and to remove all cords from his room, except for the call cords. The DON stated she supposed you could wrap a call cord around yourself; they were pretty long. The DON stated they should be having ongoing interventions for a resident who makes suicidal statements. At 8:29 p.m., the DON stated the order to remove cords from his room was active and didn't have an end date, the nurses were signing off on the TAR that he shouldn't have cords within his reach. The DON added that the aids wouldn't know he shouldn't have cords because it wasn't on the care plan. The DON confirmed an active order should be followed. During an interview on 4/6/26 at 8:38 p.m. NA-D stated R2 can't have a phone charging cord, electric razor cords, or electric recliner cord. During an observation on 4/7/26 at 12:02 p.m., R2 was in his room in a recliner with the footrest up. A trash can with no liner was observed in R2's room, as well as all 11 cords observed yesterday with an additional item, a corded telephone with an approximately eight-foot-long cord had been plugged in and set on the windowsill. Both soft-touch call cords are plugged into the wall and strung over a wire shelving unit next to R2 in the recliner. During an interview on 4/7/26 at 1:34 p.m., NA-C stated she knew R2 was on suicide watch and 30-minute checks, but he's never made any statements to her, and she really didn't know why he was on suicide watch. During an interview on 4/7/26 at 1:39 p.m., NA-A stated she was familiar with R2 and knew he was on suicide watch because a while ago, he had said something, but she wasn't sure what. NA-A stated no one had ever told her R2 had said anything about cords, she didn't know anything about it. During an interview on 4/7/26 at 5:34 p.m., NA-A stated she knew how to care for residents by looking at their Kardex and care plan and under the communication tab to review for new resident changes before she started her shift. NA-A confirmed she had done that today when she started her shift at 2 p.m. and didn't see anything new for R2. NA-A stated R2 was on half-hour safety checks, she would just make sure he was doing ok and not agitated and talk with him. NA-A reviewed the Kardex and stated it said to keep cords out of his reach, NA-A stated this was new and she didn't know about this. NA-A stated she wanted to go check R2's room, upon entering NA-A stated there were lots of cords in here, and started to remove the fan and R2 said, hey what are you doing?. NA-A stated she was going to check with management before he got too upset. At 5:47 p.m., NA-A stated the corporate administrator would be checking into it. At 6:08 p.m., NA-A stated the administration removed most of R2's cords and was doing some research on the bed cords. During an observation on 4/8/26 at 11:51 a.m., all the cords except the television cords and one call light have been removed from R2's room. The 15-foot-long call light cord had been wrapped with a pool noodle and duct tape, which was clean and in good repair. During an interview on 4/8/26 at 3:28 p.m., RN-C, an assistant director of nursing, stated R2 was living in a different room at the time they got the order to keep cords out of his reach and she had modified his previous room but wasn't sure what happened with the cords after he moved to the new room. RN-C stated she wouldn't expect to find cords in his reach when staff were signing off that they were keeping them out of his reach. During an interview on 4/8/26 at 4:17 p.m., the DON stated staff could see the care plan and orders and would have expected they would have taken them out of R2's reach, the risk would be R2 could get a hold of a cord and hurt himself if he were in that mindset. R8: R8's annual MDS dated [DATE] indicated R8 had moderate cognitive impairment. Diagnoses included dementia and epilepsy. The MDS indicated R8 was on a mechanically altered diet as a resident. R8's care plan undated, indicated a potential for altered nutritional status due to hospice. interventions included serve a mechanically altered textured diet and to observe, document, and report and signs or symptoms of dysphagia like pocketing, choking, coughing and holding food in mouth. The care plan lacked interventions of monitoring and assist with meals. R8's provider order dated 3/17/25, indicated to discontinue (DC) regular diet with thin liquids and start mechanical soft diet with slightly thickened liquids R8's provider orders dated 3/19/25, indicated to DC the slightly thickened liquids and start a mechanical soft textured solid food diet with thin liquids. Review of R8's progress notes from 3/10/25 to 3/27/26, were reviewed and indicated the following: on 3/14/25 at 5:38 p.m., R8 took a drink and choked immediately after the drink. Resident placed on meal monitoring until evaluation by administration could be completed. on 3/18/25 at 3:18 p.m., a new order received from hospice to start a mechanical soft with slightly thickened liquids. on 3/19/25 at 5:15 p.m., R8 refused thickened liquids hospice notified of resident complaint of thick liquids. The chart lacked documentation to why thickened liquids were needed or what could happen if the liquids were not thickened. on 3/20/25 at 1:48 p.m., a new order received to DC slightly thickened liquids and start thin liquids. The chart lacked any documentation education occurred related to the need for thickened liquids or a risk verses benefit form was completed by either the resident or the representative. on 1/12/26 at 12:14 p.m., R8 was eating lunch and started choking/coughing on a piece of meat and then ended up vomiting. Staff would monitor for signs and symptoms (S/S) of aspiration. the notes lacked information the guardian was notified of the choking and change of condition. on 2/26/26 at 12:20 p.m., resident coughed with food in his mouth at mealtime. Resident to be monitored at mealtime and assisted until speech/swallow eval could be completed. On 2/26/26 at 12:52 p.m., R8 started coughing with food in his mouth. at the mealtime. R8's face became red and appeared to be having difficulty chewing and swallowing. Attempted to listen to his lung sounds as it had sounded like R8 had aspirated, but R8 was making bear growling noise, which made it hard to listen. Hospice was notified. The documentation lacked information related to notifying the guardian of the change in condition. During an observation on 4/7/26 at 12:32 p.m. R8 was observed in the dining hall eating lunch. There were no staff with him to monitor and assist him to eat his meal. During an interview on 4/8/26 at 9:38 a.m., NA-B stated R8 frequently coughed when he eats. They get the nurse when it happens, but it does seem like they are not changing anything to stop it. NA-B stated the staff was not aware of a need to monitor and assist R8 with meals. During an interview on 4/8/26 at 10:18 a.m., hospice RN-E stated if a resident had concerns about aspiration, then we would work with the facility to either have a dietician or speech therapy evaluate the resident for diet and aspiration concerns. Hospice was aware R8 had an increased risk of aspiration and there were current concerns of aspiration when he ate. RN-E reviewed the notes from visits on 1/12/26 and 2/26/26 and confirmed they had been called to perform a visit due to concerns with aspiration and choking when he ate. There had been no conversation related to dietician consults or speech therapy consults to get an appropriate diet ordered for resident safety but there should have been. During an interview on 4/8/26 at 10:46 a.m., licensed practical nurse (LPN)-E stated She started working with R8 when the choking occured on 2/26/26. I was not R8's primary care nurse and the primary care nurse was the one who communicated with the hospice team. I am not sure if there was a request for speech therapy eval. During an interview on 4/8/26 at 12:28 p.m., RN-C stated if there was a resident with concerns related to aspiration and choking then a speech eval should be obtained to make sure the appropriate diet is ordered to keep the resident safe from choking. If the resident was on hospice then either hospice or the facility staff could obtain the order for speech therapy. RN-C reviewed R8's order history and stated there had never been an order for speech therapy to evaluate swallowing since arrival in the facility. During 4/8/26 at 2:43 p.m., the director of nursing stated anytime there was a concern of choking and aspiration, the expectation was the staff would obtain a speech therapy evaluation order for the resident safety. Facility aspiration precautions policy was not received.

Based on interview and document review the facility failed to notify family/guardian when a resident had a change of condition. This affected 1 of 1 (R8) resident reviewed for change of condition.Findings Include: R8's annual Minimum Data Set (MDS) dated [DATE] indicated R8 had moderate cognitive impairment. Diagnoses included dementia and epilepsy. The MDS indicated R8 was on a mechanically altered diet.R8's care plan undated, identified a potential for altered nutritional status due to hospice. Interventions included a mechanically altered textured diet and to observe, document, and report and signs or symptoms of dysphagia like pocketing, choking, coughing and holding food in mouth.R8's provider orders dated 3/19/25, identified a mechanical soft textured solid food diet with thin liquids.Review of R8's progress notes from 3/19/25 to 3/27/26 were reviewed and indicated the following:From 3/19/25 to 1/11/16, there was no documentation of concerns related to aspiration.on 1/12/26 at 12:14 p.m., R8 was eating lunch and started choking/coughing on a piece of meat and then ended up vomiting. Staff would monitor for signs and symptoms (S/S) of aspiration. The notes lacked information the guardian was notified of the choking and change of condition.On 2/26/26 at 12:52 p.m., R8 started coughing with food in his mouth at the mealtime. R8's face became red and appeared to be having difficulty chewing and swallowing. Attempted to listen to his lung sounds as it had sounded like R8 had aspirated, but R8 was making bear growling noise, which made it hard to listen. Hospice was notified. The documentation lacked information related to notifying the guardian of the change in condition.During an interview on 4/8/26 at 10:46 a.m., licensed practical nurse (LPN)-E stated anytime there was a change in condition such as change in vital signs, mental state, or breathing the family member/guardian should be notified related to a change in condition of the resident. LPN-E stated choking on food and concerns related to aspiration were included on the list of items that would trigger a call to family member or guardian. LPN-E confirmed she was the staff member in the dining hall on 2/26/26 at 12:52 p.m., when R8 had the observed choking and concerns related to possible aspiration. LPN-E stated hospice was called but that the guardian was not called at that time.During an interview on 4/8/26 at 12:10 p.m., LPN-D stated nursing staff should call and notify both the hospice team and the guardian when there is a change in condition such as breathing issues or aspiration/choking on food while eating.During an interview on 4/8/26 at 12:54 p.m., registered nurse (RN)-B stated both family and hospice should be called when there is any kind of change of condition in the resident so they are aware of the situation and can be part of the care planning for the resident. Conversations would occur related to change in diets and possibly the need to send to emergency room for evaluation.During an interview on 4/8/26 at 2:43 p.m., the director of nursing stated when a resident had a choking episode and concerns with possible aspiration, after the resident is stable, the nurse should notify the provider, the guardian/family member, and hospice if the resident is on hospice.Facility policy Change in a Resident's Condition or Status dated 7/25, indicated when a change in resident condition occurred the nurse would notify the resident's provider on call and the resident's representative when there was a significant change in the resident's physical, emotional, or mental health or when there was a need to alter the resident's medical treatment significantly.

Based on interview and document review, the facility failed to ensure residents with constipation received assessment, effective intervention and notification of the provider for 2 of 5 residents (R2, R3) reviewed for unnecessary medications. This deficient practice had the potential for resident discomfort and medical complications related to constipation. Findings include:R2:R2's quarterly minimum data set (MDS) dated [DATE], identified intact cognition, a diagnosis of slow-transit constipation and occasional bowel incontinence. R2 was dependent for transfers to the toilet and for toilet hygiene.R2's provider orders included 3/3/26, sennosides-docusate sodium (a stool softener) 8.6/50 milligrams (mg) one tab daily for constipation. Orders activated from facility Standing Orders included prunes, prune juice or bananas apples and pears (BAP) as-needed (PRN) for bowel protocol for three days, milk of magnesia (MOM) 30 milliliters (mL) by mouth one time only for constipation, and Dulcolax suppository (a stimulant laxative)10 milligrams (mg) insert rectally every evening shift for constipation for bowel protocol day one.R2's medication administration record (MAR) for March 2026 identified PRN bowel medications and dietary interventions from Standing Orders were utilized 19 times. R2's MAR from 4/1 to 4/8/26 identified they were utilized seven times.R2's electronic medical record (EMR) from 4/1 to 4/8/26 identified one bowel movement (BM) on 4/5/26. R2's EMR didn't contain evidence of a nurse assessment or notification of provider regarding repeated unsuccessful constipation interventions.During an interview on 4/8/26 at 11:51 a.m., nursing assistant (NA)-B stated R2 needed assistance on and off the toilet, and the aids were responsible for documenting the BM. During an interview on 4/8/26 at 12:36 p.m., registered nurse (RN)-B stated the night shift nurses would run a bowel report and give the day shift a BM list, for example today she had R2 and another resident. RN-B stated the bowel protocol started after two days on no BM, but she will talk to the resident, like R2 today, he will go three days without intervention and has said it was normal for him to go a couple days without going and R2 will also tell her if he thinks he needs something, today he didn't want an intervention. If it had been longer, RN-B stated she would check the orders to see the progressive interventions, and by day five probably administer a suppository.R3:R3's quarterly MDS dated [DATE], identified intact cognition, ability to make her needs known and diagnoses of need medical record. R3 was always continent of bowel and independent with toileting hygiene, and a stand-by assist for transfers.R3's undated care plan, identified a focus statement for altered elimination with interventions to give medications as ordered, observe for effectiveness and adverse effects. To follow the bowel protocol as directed for bowel movements, observe for effectiveness of toileting program, offer toilet every two to three hours, record bowels every shift, and update provider with changes to bowel pattern. R3's care plan also indicated she needed stand-by assist of one as needed for transfers and walked independently with a walker. R3's provider order dated 12/15/22, identified polyethylene glycol powder 17 grams by mouth every 12 hours PRN for constipation. R3's MAR for March and April 2026, identified the medication wasn't used.R3's MAR and bowel monitoring record for March and April 2026, identified the following pattern:3/9, milk of magnesia (MOM) 30 mL by mouth as needed (PRN) for constipation for 3 days daily.3/11, BM documented3/13, prunes, prune juice or BAP one time only for bowel protocol for one day.3/14, MOM 30 mL by mouth PRN for constipation for 3 days daily.3/15, BM documented3/18, prunes, prune juice or BAP one time only for bowel protocol for one day.3/19, MOM 30 mL by mouth one time only for constipation per bowel protocol for one day.3/20, day 4 no BM, utilize PRN medications and dietary interventions for constipation as able until adequate results achieved every day and evening shift for bowel protocol for one day.3/21, day 5 no BM, utilize PRN medications and dietary interventions for constipation as able until adequate results achieved every day and evening shift for bowel protocol for one day.3/23, day 7 no BM, utilize PRN medications and dietary interventions for constipation as able until adequate results achieved every day and evening shift for bowel protocol for one day.3/29, prunes, prune juice or BAP one time only for bowel protocol for one day.3/29, BM recorded3/31, BM recorded4/1, BM recorded4/3, prunes, prune juice or BAP one time only for bowel protocol for one day.4/5, MOM 30 mL by mouth one time only for constipation per bowel protocol for one day.4/6, day 5 no BM, utilize PRN medications and dietary interventions for constipation as able until adequate results achieved every day and evening shift for bowel protocol for one day.4/7, BM recordedR3's EMR didn't contain evidence of bowel assessments or provider notification for on-going constipation and PRN use.During an interview on 4/6/26 at 1:57 p.m., R3 stated she thought she was backed up and hadn't gone since last Monday. During an interview on 4/8/26 at 7:41 a.m., NA-B stated she was caring for R3 today, she had just transferred R3 off the bed so she could take her walker and go to the bathroom. R3 would put her light on when she was done. NA-B confirmed she would be responsible for documenting resident BMs.During an interview on 4/8/26 at 9:05 a.m., licensed practical nurse (LPN)-C stated for residents who took themselves to the bathroom the aids or nurses would ask them each shift if they have had a BM and then document it. LPN-C stated only the nurses could see how many days it had been since the last BM.During an interview on 4/8/26 at 1:30 p.m., RN-C, an assistant director of nursing (ADON) stated it was the responsibility of the overnight nurse to run the bowel report and then enter the orders for day shift. RN-C stated their bowel protocol started on day two of no BM, and if a resident had gone five or six days without then she believed you would do the enema, but added the residents had the right to refuse as well. The nurses are pretty good about updating the doctor if they are having constipation issues, she hasn't performed assessments as part of that protocol. It is noted in the care plan that she does also take herself to the bathroom. [NAME] doesn't see the provider was notified. Would expect a prescription PRN to be used. She is known to refuse some meds. RN-C stated there was always the risk of impaction or obstruction, leading to perforation or infection.During an interview on 4/8/26 at 2:07 p.m., the director of nursing (DON) stated her expectation was if staff were using the bowel protocol, and things weren't working they should be reaching out to the provider to update them to see if they need further intervention and would expect them to do an assessment as they were going on without effectiveness.A review of Facility Standing Orders, undated, identified on day two of no BM to give prunes, prune juice or bananas, apples and pears (BAP). On day three, give milk of magnesia (MOM) or lactulose. On day four, give bisacodyl suppository followed by tap water enema if no results. Dosages for the above are, MOM give 30 milliliters (mL) orally as needed daily with a warning not to give if the resident has end-stage renal disease or dialysis, give lactulose instead. For lactulose, give 30 mL by mouth daily as needed. For bisacodyl, give 10 milligrams (mg) suppository rectally daily as needed. For tap water enema, give 500 mL rectally as needed daily.A policy regarding the facility's procedures for bowel management was requested but not received.

Based on interview and document review, the facility failed to perform a passive range of motion (PROM) program for 1 of 2 (R13) residents reviewed for restorative care.Findings include: R13's annual Minimum Data Set (MDS) dated [DATE] indicated R13 was cognitively intact. Diagnoses included multiple sclerosis (MS) and paraplegia. Section GG indicated R13 had impairment to one upper extremity and both lower extremities. R13's Care Plan undated, indicated a potential for injury related to impaired mobility from paraplegia and MS. Interventions included complete PROM/stretching program once a shift (1 time in morning and 1 time in evening). Copies of PROM program were available at the nurse station 3. R13's PROM documentation from 3/10/26 to 4/8/26 were reviewed and indicated the following:10 shifts were documented as no not performed.14 shifts were documented as not applicable.6 shifts had nothing documented.During an observation on 4/6/26 at 4:23 p.m., R13 was observed to have contractures to her right upper extremity and both of her lower extremitiesDuring an interview on 4/06/26 at 4:23 p.m., R13 stated the staff were always forgetting to do here PROM to her right upper and both lower extremities There have been contractures to those three extremities for some time due to her MS.During an interview on 4/7/26 at 6:18 p.m., nurse assistant (NA)-A stated the care plan told the staff which residents had PROM programs, when they had to be done, and how often. NA-A confirmed R13 was on a PROM program that needed to be done daily during the day shift and evening shift. R13 would refuse the PROM program sometimes. All PROM program documentation was documented on the plan of care and either yes or refused. If the resident refused, the charge nurse needed to be notified. There was no reason to ever document under no or not applicable.During an interview on 4/8/26 at 2:43 p.m., the director of nursing (DON) stated an expectation the NA would perform the PROM program when it was scheduled. A yes or refused would be documented in the plan of care when completed. If the resident refused, then the NA should report that to the charge nurse.Facility policy Restorative Nursing Services last approved 1/14, indicated residents would receive restorative nursing care to help promote optimal safety and independence.

Based on observation, interview, and document review, the facility failed to attempt to elevate the head of bed (HOB) to prevent aspiration for a resident laying flat with tube feeding (TF) running. This effected 1 of 1 (R28) residents reviewed for TFFindings Include: R28's annual Minimum Data Set (MDS) dated [DATE] indicated R28 had moderate cognitive impairment. Diagnoses included abdominal distention and hemiplegia (complete to total muscle loss to one side of the body). R28 received TF with 51% or greater intake received through TF. R28's care plan undated, indicated a nutritional problem related to a diagnosis of hemiplegia. Interventions included to provide TF and water flushes as ordered. R28's care plan also indicated a risk for aspiration related to TF and inconsistent maintenance of HOB greater than 30 degrees secondary to resident preference/refusal. Interventions included ensure resident is positioned with head elevated greater than 30 degrees with feedings, if refusal for HOB elevation is found then hold the tube feeding and resume when safe, staff need to educate on aspiration risk and implement risk-reduction strategies and inform the charge nurse. R28's Order Summary Report dated 2/4/26, indicated an order for Jevity 1.2 vial gastric tube at 30 milliliters per hour. During an observation on 4/7/26 at 1:17 p.m., R28 was observed in bed laying on her back with the HOB flat. The TF was observed running at 30 milliliters per hour continuously. During an interview on 4/7/26 at 1:20 p.m., nurse assistant (NA)-F confirmed R28 was lying flat in bed with the TF running continuously. NA-F stated R28 needed to have the HOB greater than 30 degrees to prevent aspiration, but R28 liked to play with the controls and always lowered her own HOB below the 30-degree mark on her own. NA-F then entered a different resident room without going into R28's room to attempt to raise the HOB greater than 30 degrees or report findings to the charge nurse. During an interview on 4/7/26 at 3:37 p.m., licensed practical nurse (LPN)-D stated all residents with TF were to have the HOB elevated over 30 degrees to decrease the risk of aspiration of the TF. If staff saw the resident with the HOB below the 30-degree level, they should attempt to raise the HOB over 30 degrees and report it to the charge nurse so the resident could be educated. During an interview on 4/7/26 at 3:53 p.m. the director of nursing (DON) stated an expectation was for the staff to attempt to raise the HOB over 30 degrees if the resident was found with the HOB to low. If the resident refused, then the staff should report the refusal to the charge nurse so the charge nurse could educate the resident and if needed do a risk verses benefit. Facility policy Enteral Nutrition last approved on 1/26, indicated possible complications included aspiration and esophageal swelling. The policy did not mention safety precautions to decrease the risk of complications.

Number of residents sampled: 1Number of residents cited: 1Based on interview and document review, the facility failed to ensure the facility antibiotic stewardship program was followed for antibiotic use for 1 of 1 resident (R13) reviewed for antibiotic use.Findings include:R13's annual Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact. R13's diagnoses included multiple sclerosis, dysuria, obesity, diabetes mellitus type 2, paraplegia, and dementia. R13's care plan dated 3/18/26, identified R13 had urinary incontinence and an indwelling catheter.A nursing note dated 2/23/26 at 3:01 p.m., indicated a message was sent on portal to the provider with an update on R13's urinary color, vaginal discharge, and increasing confusion and agitation.R13's provider orders dated 2/23/26 at 7:00 p.m., included Macrobid 100 mg capsule Give 100 mg by mouth two times a day for Dysuria for 7 Days: Macrobid 100 mg by mouth two times a day for 7 days. The medication was discontinued on 3/2/26.R13's progress note dated 2/23/26 at 9:57 p.m., identified that a message was sent on portal to update the provider that R13's symptoms included urinary odor, vaginal discharge, increasing confusion and agitation.R13's Urine Culture Result dated 3/2/26 at 4:06 a.m., identified susceptibility profile is consistent with a probable extended-spectrum beta-lactamases (ESBL), a multi-drug-resistant organism greater than 100,000 colony forming units per milliliter (ml). The antimicrobial susceptibility identified the organism was resistant to cefuroxime. R13's medical record lacked evidence of any established criteria (such as McGreer) being used to determine the presence of infection before an antibiotic was initiated. R13's medical record lacked documentation that non-pharmaceutical interventions were initiated prior to requesting an order for antibiotics.During an interview on 4/8/26 at 10:25 a.m., the infection preventionist (IP) stated nurses needed to identify a minimum of three symptoms, such as fever, change in cognition, or urinary symptoms when suspecting a urinary tract infection (UTI). IP stated R13's medical record reported R13's symptoms were foul smelling urine, discharge, and increased confusion/agitation when staff called the provider on 2/23/26. The IP stated they usually complete a tool such as McGreer's criteria and confirmed there was no documentation that this occurred prior to obtaining antibiotic orders for R13 on 2/23/26.During an interview on 4/8/26 at 10:39 a.m., registered nurse (RN)-C stated the order for the antibiotic Macrobid was received 2/23/26, and they obtained R13's urine sample on 2/25/26, the same day they received the order for the urinalysis. RN-C stated they typically would obtain a urine specimen prior to starting an antibiotic but R13 had a history of refusals and had refused a urine sample.During an interview on 4/8/26 at 3:55 p.m., the director of nursing (DON) stated when a UTI was suspected, they expected staff to monitor symptoms, assess, follow McGreer's criteria, initiate standing orders to start UTI-stat and increase fluids, and update the provider. The DON expected nurses to question a provider ordering antibiotics prior to specimen collection, document the discussion, and report concerns to the DON or IP nurse.The facility policy Antibiotic Stewardship dated 4/2024, identified that inappropriate use of antibiotics affects individual residents and the overall community with the potential for opportunistic infections, drug interactions, and drug-resistant pathogens.

Based on observation, interview and document review the facility failed to develop care plans to include enhanced barrier precautions (EBPs) for 2 of 3 residents when nursing assistant (NA)-A was observed lacking required personal protective equipment (PPE) while performing high contact care for R2 who required EBPs.Findings include: During observations on 3/4/26 at 1:05 p.m., an Enhanced Barrier Precautions sign was observed on the door for R2's room, with a personal protective equipment (PPE) cart outside the door. NA-A was observed at the side of R2's bed, wearing only gloves and a mask as PPE. Registered Nurse (RN)-A, an agency nurse, entered the room with a mask, gloves, and a gown. RN-A failed to inform NA-A a gown was also required as a part of the necessary PPE during high-contact cares for R2. NA-A proceeded to assist RN-A with positioning R2. NA-A reached over R2 to turn her to her right side, as R2 did not participate in her own bed mobility. NA-A held R2 on her side while RN-A performed wound care to her coccyx (tailbone area). R2's admission minimum data set (MDS), dated [DATE], indicated R2 had diagnoses of Alzheimer's Disease and a stage IV pressure ulcer. Her MDS also indicated she had severely impaired cognition, was dependent on staff for all cares and mobility. R2's care plan, dated 2/17/26, directed assistance of 1-2 staff for all cares, but lacked direction to use EBPs with high-contact care. During an interview on 3/4/26 at 9:52 a.m., nursing assistant (NA)-A, an agency aide, stated she was provided with verbal instructions to properly care for each resident when she started at the facility on 2/23/26. NA-A stated she had not been shown how to access each residents' care plans. During an interview on 3/4/26 at 1:20 p.m., RN-A stated, I should have probably told her to gown up, when asked if NA-A was lacking required PPE during R2's care. During an interview on 3/4/26 at 1:25 p.m., NA-A stated she noticed RN-A entered the room with a blue gown on but did not know she was supposed to wear a gown. NA-A stated she did not see the EBP sign on R2's door. She stated she saw the PPE cart, in the hall next to R2's door, but was not aware it was intended for R2. NA-A stated she was aware of the EBP practice and knew it was to reduce the spread of germs. During an interview on 3/4/26 at 1:35 p.m., the ADON/infection control nurse stated EBPs should be used for residents identified when performing high-contact cares, including gown and gloves. She stated the RN should have said something to the NA regarding the need to wear a gown. She stated the NA's are to reference the Kardex (developed from the care plan) to determine care and precautions required for each resident. ADON stated she missed adding EBPs to the care plan for R2. A facility policy, Enhanced Barrier Precautions (EBPs), dated 1/26 directed EBPs was an infection control intervention designed to reduce transmission of multi-resistant drug organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities. Further the policy indicated the use of EBPs within the facility was recommended by the Center for Disease Control (CDC). A facility policy, Care Plans Comprehensive Person-Centered, dated 2/2025 directed the comprehensive, person-centered care plan will: incorporate identified problem-areas and incorporate risk factors associated with identified problems. The policy indicated that the care plan must reflect currently recognized standards of proactive for problem areas and conditions and identify problem areas and their causes and develop interventions that are targeted and meaningful to the residents.

Based on observation, interview and document review, the facility failed to follow established infection control practices for 3 of 3 residents (R1, R2, R3) on enhanced barrier precautions (EBPs) while performing high-contact care.Findings include: During an observation on 3/4/26 at 7:05 a.m., licensed practical nurse (LPN)-A and the director of nursing (DON) performed wound care for R1.- The DON removed two dressings on R1's left foot, discarded them and removed her gloves. The DON failed to perform hand hygiene prior to applying new gloves. She used wound cleanser and gauze to clean the stage II (partial thickness skin loss) left heel wound. She applied calcium alginate (a highly absorbent dressing that creates a moist healing environment) and covered with a bordered foam dressing. Following the application of the dressings to the left heel, the DON changed her gloves but failed to perform hand hygiene.- The DON cleansed the stage III (full thickness skin injury that involves full-thickness skin loss, resulting in exposure of the fatty tissue beneath) left lateral foot wound using wound cleanser and gauze. She measured the wound. She failed to change her gloves and perform hand hygiene. The DON proceeded to complete the treatment using skin prep, applied collagen to the wound bed, and covered with a bordered foam dressing. The DON changed her gloves and performed hand hygiene.- The DON observed R1's foley catheter (a flexible indwelling tube inserted into the bladder to drain urine) lying in her bed. The DON discarded her gloves and applied sterile gloves but failed to perform hand hygiene, before attempting to place the foley catheter into R1's urethra (the tube-structure that transports urine from the bladder to outside of the body) with her right hand, as she used her left hand to position R1's genitalia. When there was no urine return, she removed the sterile gloves, opened a new catheter kit, and applied sterile gloves without performing hand hygiene. The DON used her right hand to attempt to place the foley catheter into R1's urethra and her left hand to position R1's genitalia again but was unsuccessful. The DON discarded her gloves and opened a new catheter kit without performing hand hygiene prior to applying the sterile gloves. The DON placed the Foley catheter and inflated the balloon intended to maintain its placement in the bladder.- The DON failed to change her gloves and perform hand hygiene before she removed the abdominal (ABD) pad and gauze packing from R1's stage IV coccyx wound and her stage IV left gluteal (buttocks) fold wound. She discarded the dressings, changed her gloves, and washed her hands.- Then the DON held the paper tape measure to the coccyx wound to determine measurements, then moved the tape measure to the bedside table with the backside of the tape measure touching the table four times, as she documented the wound measurements with the marker. The DON failed to change her gloves or perform hand hygiene, then used another paper tape measure to assess the left gluteal fold wound.- The DON moved all the used paper tape measures on top of an open box of facial tissues. Then she used wound cleanser and gauze to clean the coccyx wound and left gluteal fold wound, failing to change her gloves or perform hand hygiene between cleaning the two wounds. After cleaning the wounds, she discarded her gloves and washed her hands. She applied new gloves and packed the coccyx wound with gauze and covered with a new ABD pad, securing it in place with tape. The DON then placed all the used paper tape measures on the flap of the open box of ostomy bags (medical appliance bags used to collect stool through an opening in the abdominal wall). Then the DON removed her gloves and performed hand hygiene.- The nurses failed to disinfect the over the bed table where the soiled paper tape measures had been placed before exiting the room. R1's quarterly MDS dated [DATE] indicated she had diagnoses of Type 2 Diabetes Mellitus, paraplegia, encephalopathy and had two stage III pressure ulcers, one stage IV pressure ulcer, and one deep tissue injury. Her MDS indicated she was cognitively intact and was dependent on staff for all cares and mobility. R1's care plan dated 2/12/25 indicated R1 was on EBP's per CDC recommendations for wounds with a goal to remain free of multidrug-resistant organisms (MDRO). During an observation on 3/4/26 at 1:05 p.m., an Enhanced Barrier Precautions (EBP) sign was observed on the door for R2's room, with a personal protective equipment (PPE) cart outside the door. NA-A was observed standing at the edge of R2's bed, wearing only gloves and a mask as PPE. Registered Nurse (RN)-A, an agency nurse, entered the room with a mask, gloves, and a gown. RN-A failed to inform NA-A that a gown was also required as a part of the necessary PPE during high-contact cares for R2. NA-A proceeded to assist RN-A with positioning R2, as NA-A's scrubs were in contact with R2/s bedding and handrail. NA-A reached over R2 to turn her to her right side, as R2 was unable to participate in her own bed mobility. NA-A held R2 on her side while RN-A performed wound care to her coccyx (tailbone area). R2's admission minimum data set (MDS), dated [DATE], indicated R2 had diagnoses of Alzheimer's Disease and a stage IV (severe, full thickness wound extending to exposed muscle, tendon, or bone) pressure ulcer. Her MDS also indicated she had severely impaired cognition, was dependent on staff for all cares and mobility. R2's care plan, dated 2/17/26, directed assistance of 1-2 staff for all cares, but lacked direction to use EBPs with high-contact care. During an interview on 3/4/26 at 1:20 p.m., RN-A stated, I should have probably told her [NA-A] to gown up, following R2's care. During an interview on 3/4/26 at 1:25 p.m., NA-A stated she noticed RN-A entered R2's room with a blue gown but did not know she was supposed to wear a gown as well. NA-A stated she had been providing care for R2 for a couple of weeks and had never worn a gown. She stated she did not see the EBP sign on R2's door. She stated she saw the PPE cart, in the hall next to R2's door, but was not aware it was intended for R2. NA-A stated she was aware of the EBP practice and knew it was intended to reduce the spread of germs. During an observation on 3/5/26 at 9:06 a.m., the DON performed wound care, with the assistance of the ADON for her wounds to R3's stage III coccyx wound and her stage IV left gluteal wound. The DON held the paper measuring tape to the coccyx wound, then wrote the measurements with a marker on the tape. Red liquid was observed on the back of the paper measuring tape. The DON placed the tape directly on R3's bedside table, touching her water mug. The DON changed her gloves but failed to perform hand hygiene before she measured the left gluteal wound with a new paper tape measure. She wrote the measurements with a marker. At the completion of the wound care, the DON picked up the marker and paper tape measures with her bare hands and placed the marker and soiled tape measures in the right pocket of her scrubs. The nurses failed to disinfect the bedside table following the wound care. The DON placed the marker and soiled paper tape measures directly on the treatment cart, next to the laptop in the hallway. R3's was admitted on [DATE]. Her minimum data set MDS was incomplete. R3's care plan dated 3/4/26 indicated R3 was on EBP's per CDC recommendations for wounds with a goal to remain free of multidrug-resistant organisms (MDRO). During an interview on 3/4/26 at 9:52 a.m., nursing assistant (NA)-A, an agency aide, stated she was provided with verbal instructions to properly care for each resident when she started at the facility on 2/23/26. NA-A stated she had not been shown how to access each residents' care plan. During an interview on 3/4/26 at 1:35 p.m., the ADON/infection control nurse stated EBPs should be used for residents identified to require EBPs when performing high-contact cares, including gown and gloves. She stated the RN-A should have said something to the NA-A regarding the need to wear a gown. She stated the NA's are expected to reference the Kardex (developed from the care plan) to determine care and precautions required for each resident. The ADON stated she missed adding EBPs to the care plan for R2 when she was admitted with a wound. During an interview on 3/5/26 at 9:30 a.m., the ADON and infection control nurse stated the soiled tape measures had the possibility to spread infection and should not be placed on the treatment cart. She stated hand hygiene should be performed between glove changes, after cleansing each wound, after measuring each wound, and before providing care to the next wound to reduce the spread of infection. During an interview on 3/5/26 at 9:35 a.m., the DON stated it was necessary to change gloves after cleaning each wound and between treatments for each wound. She stated there was potential for contamination from one wound to the other. She stated placing the used tape measures on the treatment cart that could contaminate the surface with germs. During an interview on 3/5/26 at 11:03 a.m., the medical director (MD) stated the importance of infection control measures such as appropriate hand hygiene and proper use of PPE to prevent the spread of infection. A facility policy, Handwashing/Hand Hygiene, dated 9/2025, directed this facility considers hand hygiene the primary means to prevent the spread of infections. Use of an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap and water before performing and non-surgical procedures, before and after handling an invasive device, before donning sterile gloves, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after handling used dressings or contaminated equipment, after removing gloves. Further, the policy indicated the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. A facility policy, Personal Protective Equipment (PPE), dated 1/2026, directed gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other residents or environments. Wash hands after removing gloves (Note: Gloves do not replace handwashing.) A facility policy, Enhanced Barrier Precautions (EBPs), dated 1/2026 directed EBPs was an infection control intervention designed to reduce transmission of multi-resistant drug organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities. Further the policy indicated the use of EBPs within the facility was recommended by the Center for Disease Control (CDC).EBPs are indicated for residents with any of the following:1. Infection or colonization with a CDC targeted (MDRO when Contact Precautions do not otherwise apply; OR2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.EBP of utilizing a minimum of a gown and glove use will be initiated for high-contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use for EBP include Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care for stage 2 pressure ulcers, diabetic ulcers, venous stasis ulcers, arterial ulcers, open surgical wounds.

Based on interview and document review, the facility failed to ensure safe transfer with a EZ Way smart lift, according to manufacturer's recommendations for 1 of 3 (R1) residents. This resulted in immediate jeopardy (IJ) when R1 fell out of the sling and sustained a contusion to the scalp, closed wedge compression fracture (front part of the vertebrae collapses) of T4 vertebra, and was sent to the Emergency Department (ED). The IJ began on 11/29/25 at 6:00 p.m., when staff, under the age of eighteen, used a full body mechanical lift to transfer R1 from her wheelchair to her bed, did not follow facility policy or manufacturer's instructions, and R1 fell out of the sling. The administrator, director of nursing, corporate nurse, and regional director of operations were notified of the IJ at 11:45 a.m. on 12/4/25. The facility implemented immediate corrective action on 11/30/25, prior to the survey, to prevent recurrence. Therefore, the IJ was issued at past noncompliance.Findings included:R1's care plan dated 3/13/25, indicated R1 needed an EZ Way smart lift with two staff assistance for transfers.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of intellectual disabilities and osteoporosis. R1 was fully dependent on staff for all transfers.R1's ED after visit summary dated 11/29/25, indicated R1 had a contusion to the scalp and a closed wedge compression fracture of T4 vertebra.R1's progress note dated 11/29/25 at 8:43 p.m., written by licensed practical nurse (LPN)-A indicated R1 was being transferred with an EZ Way smart lift by two nursing assistants (NA)s and one of the straps was not connected to the EZ Way smart lift when the nurse entered the room. R1 was sent to the ED. At 9:30 p.m., the ED called and stated R1 had a T4 fracture.During an interview on 12/3/25 at 1:39 p.m., nursing assistant (NA)-A stated on 11/29/25 at around 6:00 p.m., NA-A indicated both she and NA-B were [AGE] years old, and she knew one of them had to be at least 18 to complete a transfer using the lift but it slipped her mind at the time. NA-A stated she placed R1's right upper sling strap to the EZ Way smart lift and was going to place R1's bottom right sling strap to the lift but R1's neighbor needed assistance, NA-A went to the other side of the curtain to assist R1's roommate and NA-B started lifting R1 without NA-A being present. NA-A was not able to check the straps and did not place the right lower strap to the EZ Way smart lift. NA-A heard R1 fall to the floor and saw R1's right leg sling strap was not attached to the EZ Way smart lift.During an interview on 12/3/25 at 2:59 p.m., LPN-A stated on 11/29/25 around 6:00 p.m., unknown NA came to the nurse's office and stated LPN-A was needed in R1's room. LPN-A stated she went to R1's room and found two staff under the age of 18 in R1's room with R1 on the floor. R1's right leg strap was not attached to the EZ Way smart lift.During an interview on 12/3/25 at 3:12 p.m., EZ Way representative stated the EZ Way smart lift and sling used to transfer R1 at the time of the fall did not malfunction and was in working order. Staff under the age of 18 were not to operate the lift but can assist with the transfer. Both staff need to be present during the transfer and need to check all four straps to ensure they are all attached to the EZ Way smart lift correctly.During an interview on 12/4/25 at 7:19 a.m., NA-B confirmed she was [AGE] years old. NA-B indicated there should have been an adult present during the transfer but there was not because she forgot. NA-B stated she entered R1's room on 11/29/25 around 6:00 p.m., to assist NA-A transfer R1 with EZ Way smart lift. NA-B stated she attached both bottom straps then NA-A went to the other side of the curtain to help R1's roommate. NA-B indicated she checked all straps and then started lifting R1 while NA-A was helping R1's roommate behind the curtain. NA-B stated she should not have been running the machine as she is underage, and she should have waited for NA-A to be next to R1 before lifting her in the air. NA-B stated R1 leaned forward and fell out of the lift onto the ground.During an interview on 12/4/25 at 8:34 a.m., the facility medical director (MD)-A stated he looked at R1's imaging and R1's fracture was acute and occurred due to the fall on 11/29/25. MD-A indicated the fall has contributed to R1's decline and did harm R1. He would have expected two staff, one at least [AGE] years old, to be in the room during any full body mechanical lift transfer.During an interview on 12/4/25 at 9:29 a.m., the director or nursing (DON) stated both staff should have been next to R1 before the transfer started and two staff should have put eyes on the sling straps to ensure they were attached. One staff should have been over the age of 18 and that person should have been the one to manage the machine.EZ-Way Smart Life Operator's Instructions revised 5/9/2025, directed staff to do a final check of all four loop attachment points to ensure each loop was sufficiently attached to the respective hook of the hanger bars.Mechanical Lift Transfer Reminders undated, directed two staff to assist with EZ Way smart lift transfers, staff member operating the EZ Way smart lift must be [AGE] years of age. Both staff needed to check all four straps for correct placement on the EZ Way smart lift. At no point when a resident was being transferred should staff members leave the area of the resident or lift. The past noncompliance IJ began on 11/29/25. The immediate jeopardy was removed, and the deficient practice was corrected by 11/30/25, after the facility implemented a systemic plan that included the following actions: Reviewed policies on use of mechanical lifts. The facility re-assessed R1 and all residents who utilize a mechanical lift. The facility re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing. The facility completed audits daily for two weeks observing staff transferring residents with mechanical lifts results would be brought to Quality Assurance and Performance Improvement (QAPI) committee. The facility would develop an ongoing plan for safe transfer education in QAPI meeting on 12/10/25. Verification of corrective action was confirmed by observation, interview, and document review on 12/3/25 and 12/4/25.

Based on interview and document review the facility failed to ensure the right to weekend mail delivery occurred for 5 of 5 residents (R2, R3, R19, R28, R36) who were reviewed for weekend mail delivery. This deficient practice had the potential to impact all 41 residents who resided at the facility. Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was cognitively intact. R3's quarterly MDS assessment dated [DATE], indicated R3 was moderately cognitively impaired. R19's quarterly MDS assessment dated [DATE], indicated R3 was moderately cognitively impaired. R28's quarterly MDS assessment dated [DATE], indicated R28 was moderately cognitively impaired. R36's quarterly MDS assessment dated [DATE], indicated R2 was cognitively intact. During a group interview on 2/11/25 at 10:11 a.m., the following was said: --- R2 confirmed mail was delivered to the facility on the weekend and indicated packages from delivery places like UPS were also delivered to the facility on weekends. R2 went on to say mail and packages did not get delivered to them on the weekends. ---R28 stated it depended on who was working if they got their mail. It seemed like some staff didn't know they were supposed to deliver resident mail. ---R2 stated they ordered things on-line, and they did not get their packages or personal mail on the weekend. Instead of being delivered the packages just sat on the chairs by the door all weekend long. ---R28, R3, R19, and R36, confirmed residents did not always get their packages and/or mail delivered to them on the weekend. During an interview on 2/13/25 at 8:27 a.m., the social worker stated the facility did get mail delivery on Saturdays and they believed it was the activities staff that were responsible for mail delivery on the weekends. During an interview on 2/13/25 at 11:31 a.m., activities aid (AA-B) stated resident mail got delivered to the main office. AA-B indicated one of their responsibilities was to deliver resident mail. They checked for and delivered resident mail that was located on the activity director's desk in their department only. AA-B confirmed they did not go and get newly delivered resident mail on the weekends from the office, they only delivered resident mail that was already on the director's desk when they worked on the weekend. During an interview on 2/13/25 at 11:33 a.m., Activities Aid (AA-A) stated during the week mail was delivered to the office where it was sorted and then delivered to the activities department for delivery to residents. AA-A stated on weekends, they only delivered mail that was already in the activities department. When mail and packages were delivered to the facility on the weekends, they got put in the office. AA-A confirmed they did not go into the office and get resident mail or packages on Saturdays or Sundays, instead they left the mail for the office manager to sort on Monday. During an interview on 2/13/25 at 11:48 a.m., the activities director (AD) on Saturdays, staff should go through the mail and make sure magazines, packages, cards and personal stuff got passed out to residents. AD confirmed residents were not consistently getting their mail delivered to them on the weekend as they should, and indicated they planned to rework things to ensure this happened consistently going forward. The facility policy Resident Mail dated 12/2023, directed mail will be delivered to residents within 24 hours unopened, and unread including magazines and newspapers, unless assistance is requested by the resident or resident representative.

Based on observation, interview and document review the facility failed to ensure alcohol based hand sanitizer was in use in the hand hygiene dispensers throughout the facility. In addition, the facility failed to ensure oxygen tubing was changed timely for 1 of 1 resident (R11) reviewed for oxygen therapy. Findings include: On 2/10/25 at approximately 2:15 p.m., during resident screenings the hand sanitizer dispensed from the hallway wall dispenser and the dispensers in resident rooms felt watery and was odorless. On 2/11/25 at 2:03 p.m., housekeeper (H)-A stated housekeeping was in charge of refilling the hand hygiene dispensers. When the hand sanitizer fluid was no longer visible in the side window of the dispenser, they would open the dispenser, remove the container and take it to a locked room where the container would be refilled. H-A opened the dispenser and showed the refillable bottle in the dispenser, the bottle was undated. On 2/12/25 at 9:26 a.m., H-B stated Ecolab had stopped making the product they were using foam in cans so Ecolab provided a new product. H-B stated it felt watery and the nursing assistants (NAs) didn't like it so the facility also had Purell hand sanitizer in pump bottles and [NAME] hand sanitizer in pocket size bottles. The Ecolab product was in all resident rooms and in the hallway dispensers. The product was benzalkonium chloride 0.89 % and water. H-B stated the bottles in the dispenser should have been dated when they were first filled. H-B stated the dispensers were re-filled when the product was no longer visible in the side window. The product was in a locked room, staff would attach the refillable bottle and press a button, the machine would automatically dispense the product and water in a pre-programmed ratio. During an interview on 2/12/25 at 3:26 p.m., registered nurse (RN)-A reviewed the information on benzalkonium chloride 0.89% and verified this was the product the facility was using and that the product was a non-alcohol based hand sanitizer. RN-A thought it had been in use about one and one half years. RN-A could not verify if nursing had been involved in the change in the hand sanitizer product. During an interview on 2/12/25 at 3:43 p.m., the administrator stated she learned today that the hand sanitizer product was not alcohol based. During an interview on 2/13/25 at 7:53 a.m., the director of nursing (DON) stated hand sanitizer products needed to be alcohol based and until yesterday she was not aware that the product in the hand sanitizer dispensers was not alcohol based. During an interview on 2/13/25 at 9:25 a.m., Ecolab representative stated the hand sanitizer was not alcohol based and said it was quaternary based product. Ecolab product specification document for concentrated foam hand sanitizer dated 2015, identified the product was benzalkonium chloride. The product was concentrated and was to be diluted in a 10 to 1 ratio. Page two of the document dated 6/5/20, identified the following: To help reduce the risk of infection, the US Centers for Disease Control (CDC) and the World Health Organization (WHO) are recommending that standard practices to reduce exposure to and transmission of a range of illnesses be followed. These practices include reinforcing good personal hygiene by performing proper handwashing with soap and water or using an alcohol-based hand sanitizer if soap and water are not available. The Centers for Disease Control (CDC) Handsanitizer guidelines and recommendations dated 3/12/24, identified the following: Hand Sanitizer Guidelines and Recommendations Key points Washing hands with soap and water is the best way to get rid of germs in most situations. If soap and water are unavailable, use a hand sanitizer with at least 60% alcohol to clean your hands. You can tell if the sanitizer contains at least 60% alcohol by checking the product label. Handwashing/Hand Hygiene policy dated 1/2023, identified the facility would use an alcohol-based hand rub containing at least 62 % alcohol. R11 R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included treatment for palliative care, anxiety disorder, chronic obstructive pulmonary disease (COPD[a group of lung disease that block airflow and make it difficult to breathe]), macular degeneration (an eye disorder that causes vision loss), and paroxysmal atrial fibrillation (a type of irregular heartbeat where the heart's upper chambers [atria] beat rapidly and irregularly for a short period of time). R11's MDS identified R11 was moderately cognitively intact and used oxygen. R11's care plan initiated on 11/4/24, identified R11 had an alteration in respiratory status related to a diagnosis of COPD with use of oxygen. Interventions included to administer oxygen as order by medical provider (MD). R11's care plan did not include directing staff to change oxygen tubing. R11's active orders current as of 2/13/25, identified R11 had an order for oxygen at two liters per nasal cannula at bedtime related to COPD. A review of R11's treatment record for December 2024, January 2025, and February 2025, did not identify oxygen tubing changes. On 2/10/25 at 5:20 p.m., R11's oxygen tubing that she was using and was connected to the oxygen concentrator and the oxygen tubing connected to the oxygen tank on her wheelchair were both dated 2/2. On 2/11/25 at 3:16 p.m., licensed practical nurse (LPN)-A checked R11's oxygen tubing and verified it was dated 2/2, and stated the tubing should be changed weekly. On 2/13/25 at 7:54 a.m., the director of nursing (DON) stated oxygen tubing is expected to be changed weekly to minimize the risk for infection. Oxygen Administration - Long Term Care dated 2/2024, identified under infection control Nasal cannulas, mask , or mouth pieces are to be replaced weekly and as needed.

Based on interview and document review, the facility failed to maintain a surety bond (a written agreement to guarantee payment of another company's obligation under a separate contract) to protect the account balance of the resident trust fund. This had the potential to affect 23 of 41 residents at the facility who had a trust account managed by the facility. Findings include: During an interview on 2/12/25 at 9:35 a.m., the office manager (who was responsible for the resident trust funds) pulled up the total balance for the resident trust which was 9,254.77 dollars. The office manager was unable to locate a copy of the surety bond and indicated they would need to follow-up with the corporate office. On 2/13/25 at 10:52 a.m. the administrator stated the corporate office was going to send a copy of the surety bond. On 2/14 /25 at 1:58 p.m., the administrator e-mailed a copy of a document entitled Erisa Dishonesty Bond Edition of 10/1/17, Spring Valley Mutual Insurance Company. The bond indicated it covered employees insured by the employee benefit plans. The document did not include coverage for residents with trust accounts. An additional request for a copy of the surety bond specific to the resident trust accounts was made and additional documents were not received. The facility policy Handling of Resident Finances and Property dated 8/2021, identified the facility must ensure any party responsible for holding or managing residents' personal funds is bonded or obtained insurance in sufficient amounts to specially cover losses of resident funds and provides proof of the bond or insurance.

Based on observation, interview and document review, the facility failed to ensure that temperature-controlled medications were properly stored for 6 of 6 residents (R10, R14, R17, R1, R19, R6) and any resident needing medications from the pharmacy-provided emergency kit, stock vaccine, and tuberculin testing medication. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had diagnoses which included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), diabetes mellitus, and hyperlipidemia. R14's quarterly MDS dated [DATE], identified R14 had diagnoses which included, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), hypertension, diabetes mellitus, hyperlipidemia, arthritis, and dementia. R17's admission MDS dated [DATE], identified R17 had diagnoses which included hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left non-dominant side, hypertension, gastric esophageal reflux disease (GERD), diabetes mellitus, and arthritis. R1's annual MDS dated [DATE], identified R1 had diagnoses which included seizures, GERD, thyroid disease, arthritis, aphasia (a language disorder that affects a person's ability to understand, produce, or use language due to damage to the brain areas responsible for language processing), anxiety, and depression. R19's quarterly MDS dated [DATE], identified R19 had diagnoses which included hemiplegia affecting left non-dominant side, nicotine dependence, hypertension, diabetes mellitus, and depression. R6's quarterly MDS dated [DATE], identified R6 had diagnoses which included, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anemia, hypertension, and seizures. On 2/12/25 at 2:27 p.m., during a tour of station three's medication room with registered nurse (RN)-B the medication refrigerator temperature log was noted to have temperatures recorded that were out of range. RN-D entered the room and verified the morning temperature at 6:30 a.m., was 48 degrees Fahrenheit (F) and at 1:40 p.m., the temperature was 53 degrees F. RN-D stated the refrigerator contained insulins, neurontin, vaccines, and other medications. RN-D stated she had adjusted the temperatures but did not notify anyone. RN-B stated they would obtain a list of medications in the refrigerator. On 2/12/25 at 2:41 a.m., maintenance (M)-A arrived and stated the dial must have been turned the wrong direction, the inside back wall of the refrigerator was wet with water droplets. A review of station three's medication refrigerator temperature record identified the refrigerator was supposed to be checked twice a day. The readings should be reviewed weekly for out-of-range temperatures or temperature trends. The safe range was identified as 36 degrees F to 46 degrees F. October 2024 revealed the following dates out of the safe range: 10/3/24 6:46 a.m., 47 F 10/8/24 6:45 a.m., 35 F and 2:00 p.m., 35 F 10/9/24 6:45 a.m., 47 F and 3:05 p.m., 47 F 10/10/24 6:00 p.m., 35 F 10/14/24 2:20 p.m., 47 F 10/16/24 2:22 p.m., 47 F 10/18/24 6:30 a.m., 35 F 10/20/24 3:00 p.m., 28 F 10/21/24 1:00 a.m., 47 F 10/26/24 2:15 p.m. 35 F 10/27/24 6:30 a.m., 47 F and 3:40 p.m., 47 F 10/28/24 6:30 a.m., 47 F 10/30/24 6:30 a.m., 35 F November 2024 revealed the temperature was out of the safe range five times. December 2024 revealed the temperature was out of the safe range twice. January 2025 revealed the temperature was out of the safe range ten times. February 2025 revealed the following dates out of the safe range: 2/8/25 8:00 p.m., 48 F 2/10/25 8:30 p.m., 48 F 2/11/25 6:30 a.m., 48 F and 1:40 p.m., 53 F. An inventory revealed the following medications were stored in station three's medication refrigerator: liquid gabapentin 90 milliliter and 20 milliliter bottles (used to treat seizures and pain caused by shingles) for R1 Trulicity six pens (a once weekly injectable medication that treats type 2 diabetes) for R14, R10, R19 Semglee (long acting man-made insulin used to control high blood sugars) for R10 Copaxone 17 syringes (a medication used to treat relapsing remitting multiple sclerosis) for R10 Novolog one pen (type of insulin used to treat diabetes) for R17 Lantus seven pens (a type of insulin used to treat diabetes) for R14 Arexvy kit one dose (active immunization for the prevention of lower respiratory tract disease caused by the respiratory syncytial virus (RSV) for R6 Arexvy kit 20 doses stock Aplisol one bottle stock (used for intradermal administration as an aid in the diagnosis of tuberculosis) refrigerated emergency kit: promethazine suppositories four (used to treat nausea) Lantus one pen Novolog one pen Manufacturer's information for the following medications was as follows: liquid gabapentin dated 4/2012, identified the medication should be stored between 36 degrees and 46 degrees F. Trulicity dated 11/2024, identified the medication should be stored between 36 degrees and 46 degrees F. Semglee dated 11/2023, identified the medication should be stored between 36 degrees and 46 degrees F. Copaxone dated 1/2025, identified the medication should be stored between 36 degrees and 46 degrees F. promethazine suppositories no date, identified the medication should be stored between 36 degrees and 46 degrees F. Novolog dated 3/2023, identified the medication should be stored between 36 degrees and 46 degrees F. Lantus dated 11/2018, identified the medication should be stored between 36 degrees and 46 degrees F. Arexvy dated 2025, identified the medication should be stored between 36 degrees and 46 degrees F. Aplisol dated 11/2013, identified the medication should be stored between 36 degrees and 46 degrees F. During an interview on 2/13/25 at 7:56 a.m., the director of nursing (DON) stated she would expect staff to notify maintenance if the medication refrigerator was out of the temperature range. The DON stated it was important to keep the refrigerator in range so the medications stored in the refrigerator did not lose their effectiveness. During an interview on 2/13/25 at 9:53 a.m., the consultant pharmacist (CP)-C stated staff were supposed to check the medication refrigerators twice a day if they were storing vaccines and stated 50 degrees F was too warm. CP-C stated he would expect the facility to call the pharmacy the medications came from and to adjust the temperature and check every one to two hours to see if the temperature returned to a safe range. CP-C stated it was a concern for the viability of medications if the refrigerator had been out of the safe range for months. CP-C stated the medications should have been treated like they had been at room temperature and dated as opened for the date the refrigerator was out of the safe temperature range. On 2/13/25 at 10:33 a.m., during an interview, M-A stated he could not recall being notified that the medication refrigerators were out of the safe range. M-A stated he checked the medication refrigerators monthly. On 2/13/25 at 10:40 a.m., with RN-B during a tour of station two the medication room temperature log did not show any temperatures out of the safe range, the temperature in the refrigerator was 39 degrees F. On 2/13/25 at 10:48 a.m., RN-B stated she would expect staff to alert someone in upper management or maintenance if the temperatures in the medication refrigerators were out of range. On 2/13/25 at 11:02 a.m., the administrator stated she would expect staff to correct temperatures in the medication refrigerator that were out of range, then re-check the temperature and involve maintenance if needed. The administrator stated medications needed to be kept in a specific range to make sure they remained usable. Medication Guidelines - Long Term Care dated 2/2025, identified Medication requiring refrigeration must be stored in the refrigerator located in the medication room and kept within standard temperature parameters based on Centers for Disease Control (CDC) recommendations.

Based on observation, interview, and record review, the facility failed to ensure provider orders for medication parameters were followed for 1 of 5 residents (R18) reviewed for unnecessary medications. In addition, the facility failed to ensure provider orders for a fluid restriction and daily weights were followed for 1 of 2 (R142) residents reviewed for hydration. Findings include: R18's admission Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and diagnoses of hypertension (high blood pressure) and repeated falls. R18's care plan dated 2/3/25, identified potential for drug interactions and adverse effects related to the use of multiple medications, and listed interventions to administer medications as ordered and observe for effectiveness and adverse side effects. R18's provider orders contained an order for furosemide (a medication used to help rid the body of water) 20 mg to be given one time per day for hypertension and to hold the medication if R18's systolic blood pressure (SBP, the top number of a blood pressure which represents the pressure in the arteries when the heart beats) was below 110. Review of R18's medication administration record (MAR) revealed furosemide was administered to R18 on 2/5/25 when her SBP was 94, and on 2/7/25 when her SBP was 90. During an interview on 2/13/25 at 7:55 a.m., assistant director of nursing, registered nurse (RN)-A stated she would expect the provider order was followed and if it wasn't it needed to be followed up with the provider. RN-A stated the risk for R18 receiving this medication when the SBP was below 110 could be even lower blood pressure and more electrolyte imbalance. During an interview on 2/13/25 at 11:43 a.m., the director of nursing (DON) stated she would expect the order would be followed, and not following the order could put R18 at risk for even lower blood pressure and possibly becoming dehydrated. R142's admission record identified an admitted [DATE] and diagnoses of heart failure, stomach cancer, anemia, and hypertension. R142's care plan dated 2/3/25, didn't contain information regarding a fluid restriction. R142's provider orders dated 2/4/25, identified orders for: -furosemide (a medication used to help rid the body of water) 20 milligrams (mg) daily -spironolactone (a medication used to help rid the body of water) 50 mg daily -fluid restriction of 64 ounces (oz) daily, with 46 oz from dietary and 18 oz from nursing with medications. Document the amount of fluids given from nursing every shift. -on 2/6/25 a nursing order for daily weight monitoring related to a diagnosis of ascites (the accumulation of extra fluid around the abdomen). During a review on 2/10/25, it was noted R142's medication administration record (MAR) for February 2025 didn't reflect R142's weight was taken and recorded in the record for 2/9, 2/10, 2/11 or 2/12. Review of R142's progress notes identified a note from 2/7/25 indicating a nurse's order was placed to weigh R142 daily due to a diagnosis of ascites. The notes didn't reflect any refusals from R142 to have his weight taken. During an interview on 2/10/25 at 5:45 p.m., R142 was complaining to an unknown nursing assistant (NA) that he had asked for water this morning but hadn't gotten any. The NA explained to R142 he was on a fluid restriction and only got two eight ounces (oz) glasses of water from nursing staff, which was on his over-the-bed table. During an interview on 2/11/25 at 10:59 a.m., R142 was looking at a large pitcher of water that was brought to him this morning, he didn't know who brought it. R142 picked up the pitcher and said it was full, and then said, isn't that stupid, yesterday I could only get a little glass of water and now I get this, R142 shook his head and stated he didn't understand. R142 also had a 20 oz bottle of orange soda which he said he had brought here himself; the bottle was about half gone. During an observation on 2/11/25 at 1:57 p.m., R142 was sleeping in his room. The bottle of orange soda was two-thirds empty. During an interview on 2/11/25 at 3:30 p.m., nursing assistant (NA)-A stated staff looked at the Kardex (a care plan summary) or care plan to know how to care for residents, and if it weren't clear she would ask the supervisor. NA-A stated she knew R142 had a fluid restriction because she heard about it, but it wasn't on his Kardex. During an interview on 2/11/25 at 3:42 p.m., an assistant director of nursing, RN-A confirmed the Kardex for R142 didn't contain a fluid restriction. RN-A explained any RN in management could update the care plan, which would flow to the Kardex, but she wasn't sure if it was a nursing or dietary responsibility. RN-A stated it would be important to follow fluid restrictions because R142 could get fluid overload. During an interview on 2/12/25 at 11:20 a.m., NA-B stated they could look at the Kardex to know how to care for the residents. NA-B wasn't aware of any residents with a fluid restriction. NA-B stated dietary had slips that came out with the trays and indicated if there was a special diet, allergies, or special equipment needed. NA-B stated the NAs were responsible for getting the weekly and daily weights done in the morning before breakfast. During an interview on 2/12/25 at 11:30 a.m., NA-C stated they could look at the care plan to know how to care for the residents. NA-C wasn't aware of any resident with a fluid restriction. NA-C looked at R142's Kardex and confirmed there was a 64 oz fluid restriction. NA-C stated they hadn't weighed R142 today, LPN-B had weighed him. During an interview on 2/12/25 at 12:34 p.m., LPN-B stated the NAs were responsible for getting resident's weight, but she had weighed him today. LPN-B confirmed R142 had an order for daily weights, and she had weighed him yesterday and today, but hadn't documented it yet. LPN-B stated it would be important to take his daily weight because he had ascites and was at risk for retaining fluid. During an interview on 2/13/25 at 11:32 a.m., the DON stated daily weights needed to be completed, and it would be important for R142 because he had ascites and too much fluid could lead to complications. The DON would also expect fluid restrictions be on the Kardex. A policy, Medication Guidelines - Long Term Care dated 2/2025, identified its purpose was to ensure the accurate storage and safe and effective administration of medications by qualified personnel. The medication administration guidelines indicated provider orders would be followed, and medications would be given following the six rights of medication administration, including the right resident, drug, dose, route, time and documentation.

Based on observation, interview and document review the facility failed to ensure aspiration precautions were followed for 1 of 2 residents (R24) reviewed for accidents. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had diagnoses which included cerebral infarction (stroke), dysphagia (difficulty swallowing foods or fluids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). R24's MDS identified R24 had no rejections of care and was cognitively intact. R24's kardex as of 2/11/25, identified Special Instructions : No straws (per speech therapy). R24's order review report identified tube feeding diet, no straws per speech therapy dated 3/26/24. On 2/11/25 at 2:49 p.m., R24 was seated in the recliner and on a bedside table next to the chair was a large plastic cup with a straw in the cup. On 2/11/25 at 2:55 p.m., R24 stated they always had a straw in the water cup. On 2/11/25 at 2:57 p.m., registered nurse (RN)- A reviewed R24's orders and verified R24 was not supposed to have straws per speech therapy and per her current orders. RN-A stated the nursing assistants would know not to give R24 a straw with her water based on the kardex. RN-A verified the use of a straw would increase the risk for aspiration. A policy on aspiration precautions was requested but not provided.

Based on observation, interview, and document review, the facility failed to ensure oxygen was administered as ordered for 1 of 1 residents (R11) reviewed for oxygen therapy. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included treatment for palliative care, anxiety disorder, chronic obstructive pulmonary disease (COPD[a group of lung disease that block airflow and make it difficult to breathe]), macular degeneration (an eye disorder that causes vision loss), and paroxysmal atrial fibrillation (a type of irregular heartbeat where the heart's upper chambers [atria] beat rapidly and irregularly for a short period of time). R11's MDS identified R11 was moderately cognitively intact and used oxygen. R11's care plan initiated on 11/4/24, identified R11 had an alteration in respiratory status related to a diagnosis of COPD with use of oxygen. Interventions included to administer oxygen as order by medical provider (MD). R11's active orders current as of 2/13/25, identified R11 had an order for oxygen at two liters per nasal cannula at bedtime related to COPD. R11's treatment record for the past three months identified R11 had oxygen flowing at 3 liters per minute on the following dates: 1/1/25 1/2/25 12/17/24 12/20/24 12/21/24 12/22/24 12/23/24 12/24/24 12/25/24 12/26/24 12/27/24 12/28/24 12/29/24 12/30/24 12/31/24 A review of the past three months of progress notes did not include any notes on increased oxygen needs or communication to the MD about an increased need for oxygen. On 2/10/25 at 5:20 p.m., R11's oxygen flow meter was at 2.5 liters per min (LPM). On 2/11/25 at 3:16 p.m., licensed practical nurse (LPN)-A verified R11's oxygen was at 2.5 LPM and said it should have been at 2 LPM. LPN-A stated it works opposite if the LPM are set too high and the resident might start retaining carbon dioxide which could lead to respiratory failure. LPN-A stated R11 had recently been using her oxygen during the day and not just at night. During an interview on 2/13/25 at 7:54 a.m., the director of nursing (DON) stated she would expect staff to check a resident's oxygen flow meter daily to ensure it was at the correct LPM and to document oxygen saturations daily. The DON verified it was important to follow the MD's orders especially with residents with COPD because a higher flow rate could contribute to breathing difficulties. The Oxygen Administration - Long Term Care policy dated 2/2024, identified a provider order was needed for oxygen administration. The policy identified the order should be verified to ensure the amount of liter flow, method of administration and duration of therapy.

Based on observation, interview, and document review, the facility failed to ensure use of an as-needed (i.e., PRN) psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medication for 1 of 5 residents (R11) reviewed for unnecessary medication use. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included treatment for palliative care, anxiety disorder, chronic obstructive pulmonary disease (COPD [a group of lung diseases that block airflow and make it difficult to breathe]), macular degeneration (an eye disorder that causes vision loss), and paroxysmal atrial fibrillation (a type of irregular heartbeat where the heart's upper chambers [atria] beat rapidly and irregularly for a short period of time). R11's MDS identified R11 was moderately cognitively intact and had no behaviors or rejections of care. R11's MDS identified R11 used scheduled and PRN pain medications, used anti-anxiety, anti-depressant, and opioid medications during the review period. On 2/11/25 at 10:33 a.m., R11 was seated on her bed wearing oxygen at two liters per minute, the television was on she was finishing her breakfast and said she would like something other than boiled eggs all the time. No other concerns. R11's active orders as of 2/13/25, identified the following order: lorazepam oral tablet 0.5 milligrams (mg) give 0.5 mg by mouth every two hours as needed for anxiety/dyspnea orders valid through end of life. A review of the monthly pharmacy reviews identified the following: 11/12/24, Pharmacist Recommendations to Providers: Order - lorazepam 0.5 mg every two hours PRN. PRN orders for psychotropic drugs anti-psychotic, anti-depressant, anti-anxiety, and hypnotics are limited to 14 days. If believe that it is appropriate for the PRN order to be extended beyond 14 days, should document the rationale in the resident's medical record and indicate the duration for the PRN order. No response from the physician was received. 12/10/24, Medical Director summary from the pharmacist. PRN psychoactive (non-anti-psychotics) without end date. Lorazepam 0.5 mg every two hours PRN. Rationale/indication for requiring PRN order past 14 days. No response was received. 2/7/25, Pharmacist Recommendations to Providers: Order - lorazepam 0.5 mg every two hours PRN. PRN orders for psychotropic drugs anti-psychotic, anti-depressant, anti-anxiety, and hypnotics are limited to 14 days. If believe that it is appropriate for the PRN order to be extended beyond 14 days, should document the rationale in the resident's medical record and indicate the duration for the PRN order. No response from the physician was received. Hospice Order date 2/5/25, start lorazepam 0.5 mg one tab oral every two hours PRN for anxiety/dyspnea. Order valid through end of life. During an interview on 2/11/25 at 11:27 a.m., hospice registered nurse (RN)-C stated they were told it was okay to write orders for lorazepam until end of life, then stated there was current discussion about the need for a stop date. During an interview on 2/13/25 at 7:54 a.m., the director of nursing (DON) stated PRN lorazepam should only be ordered for 14 days, the DON added for hospice residents the order could be ordered for up to six months. The DON was not sure if the medical director had talked with the hospice physician about a stop date for R11's PRN lorazepam. During an interview on 2/13/25 at 9:35 a.m., consultant pharmacist (CP)-C stated he requested a stop date in November for R11 and received no response. The request was re-issued in December and now again in February. CP-C stated this was discussed at the quality meeting on 1/7/25 and believed the medical director had reached out to the hospice medical doctor regarding this concern. Psychotropic Medication Management - Long Term Care dated 10/2023, identified the following; As needed orders for psychotropic drugs (with the exception of anti-psychotics, see below) are limited to 14 days. Unless, the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days in which case he/she should document their rationale in the resident's medical record and indicate the duration of the as needed order.

Based on observation, interview, and document review the facility failed to ensure resident call lights were within reach from the bathroom floor in multi-resident bathrooms for 3 of 3 residents (R24, R11, R30) reviewed for call light accessibility. Findings include: On 2/10/25 at 1:58 p.m., R24's shared bathroom call light was checked to see if it worked and if it was accessible from the floor. The call light was a white cord that was looped and attached to a hook approximately four feet from the floor. On 2/10/25 at 5:24 p.m., R11's shared bathroom call light was checked to see if it was in working order and if it was accessible from the floor. The call light cord was approximately 10 inches from the floor. On 2/10/25 at 6:42 p.m., R30's bathroom call light was checked to see if it was in working order and for accessibility from the floor. The call light was approximately 14 inches from the floor. On 2/12/25 at 9:10 a.m., maintenance (M)-A checked R11's bathroom call light and removed it from the hook in the wall and measured. When the call light was freed from the hook in the wall the bottom of the cord was 18 inches from the floor. M-A stated it makes sense that the call lights should be able to be reached from the floor. On 2/12/25 at 9:11 a.m., R11 stated the call light had always been hooked to the wall, she stated she did not ask for it to be looped and hooked to the wall. On 2/12/25 at 9:17 a.m., R11's bathroom call light was measured by M-A and found to be 18 inches from the floor. On 2/12/25 at 9:19 a.m., R30's bathroom call light was measured by M-A and found to be 17 inches from the floor. During an interview on 2/13/25 at 10:56 a.m., the administrator stated if a resident fell in the bathroom and the call light cord reached almost to the floor they would have a better chance to reach the call light. A policy on call lights was requested but not provided.

Based on observation, interview, and document review, the facility failed to ensure 1 of 3 residents (R10) with pressure ulcers, were assessed, monitored and/or provided care to promote healing of current pressure ulcers and to prevent the development of new pressure ulcers. R10 developed recurrent pressure ulcers to the buttocks/coccyx area which caused actual harm for R10. Findings include: R10's Minimum Data Set ((MDS) dated [DATE], indicated R10 was cognitively impaired, required extensive assistance with transferring and repositioning in bed and in wheelchair, and was at risk for pressure ulcer (PU) development. The MDS also identified R10 had [DIAGNOSES REDACTED]. The Skin Risk Assessment (with Braden Scale) dated 5/26/15, identified R10 was at risk for the development of PU's. R10's assessment indicated she currently had a DTI (deep tissue injury) to left heel, open area to left gluteal fold near coccyx, dry scab to right outer ankle, moisture to abdominal folds. The assessment also indicated she had limited mobility, with potential problems of friction and shearing. Maintains relatively good position in chair or bed most of time but occasionally slides down. Interventions included tissue off loading while in w/c (wheelchair), scheduled times to stay in bed off of buttocks, floating heel while in bed, and a heel protector. The 5/27/15, tissue tolerance assessment (determines skins ability to withstand pressure and determine appropriate repositioning intervals) indicated non blanchable redness was noted after a two hour observation. The nutritional high risk assessment completed on 5/28/15, identified a regular diet. The assessment indicated R10 had lost 10 pounds in the previous six months so was receiving glucerna (oral nutritional supplement) twice a day. R10's care plan reviewed 5/28/15, identified at risk for skin breakdown. The care plan directed staff to place a cushion in the w/c and recliner, apply barrier cream with pericares, pressure relieving honeycomb cushion in w/c, off load (relieving pressure to area to allow for tissue perfusion) every hour when in the w/c, reposition/offload every hour, w/c with lateral side supports for positioning, small piece of honeycomb to the inside heel of left shoe, float heel while in bed. The nursing assistant care sheet indicated hourly tissue offloading, leave sling behind her in w/c, toilet every hour when in the w/c. The medication administration history dated 4/15/15 to 4/30/15, indicated the nurses were monitoring three open areas on left buttocks until they resolved. Laboratory results on 5/8/15 were as follows: [MEDICATION NAME] (the level of protein in the blood) 3.0 gram/deciliter (g/dL), normal was 3.5-5.0 g/dL; transferrin (plasma protein that transports iron through the blood) was 154 milligrams/deciliter (mg/dL), normal was 190-350 mg/dL. On 8/25/15, at 4:27 p.m. R10 was sitting in her wheelchair in the day room. The sling from her mechanical lift remained underneath her in the wheelchair. Observation on 8/26/15, at 6:21 p.m. R10 was sitting in the wheelchair in the hallway. The mechanical lift sling which is purple in color with a green ribbing around it remained under her in the chair. Below the sling was the pressure relieving cushion in the wheelchair. An interview on 8/26/15, at 7:32 a.m. licensed practical nurse (LPN)-B stated she had seen three open areas on R10's coccyx area the previous weekend. The treatment was to cleanse the area and apply sensicare. Observation on 8/26/15, at 10:20 a.m. registered nurse (RN)-A, RN-B, and nursing assistant (NA)-A were all present. The mechanical lift (maxi move lift) sling was observed to cross over R10's coccyx area. As R10 was lifted, the sling slid downward which created shearing over the coccyx area. The wound nurse measured the open area on R10's coccyx to be 1.2 centimeters (cm) long and 0.7 cm wide. The two other wounds were healed. R10 was assisted back to the wheelchair with a mechanical lift and the sling was left under R10. Under the sling was dycem, a thick plastic like sheet that reduces slipping. The pressure reducing cushion for the wheelchair was under the dycem. On 8/26/15, at 1:03 p.m. RN-A measured R10's heel and ankle PUs. R10's left heel measured 1 cm in length and 1.8 cm width with 0.5 cm depth. RN-A stated the PU was slough filled. The PU was cleansed and hydrogell with [MEDICATION NAME] was applied. R10's shoe had a sheet of honey comb under the heel. RN-A measured the ankle PU to be 1.3 cm long and 1.1 cm wide with less than 0.1 cm depth. The PU was cleansed and a duoderm dressing was reapplied. Skin prep was applied to the surrounding skin. An interview with NA-A on 8/26/15, at 6:28 a.m. who stated the sling size was color coded. It was care planned to leave the sling under the resident. NA-A did not know how it was determined to leave a sling under a resident. During an interview on 8/26/15, at 7:23 a.m. LPN-C stated R10 had an open area on her left heel, an open area on the lateral ankle and three on her coccyx area. She said they apply sensicare cream with every change of her brief. A protective bandage was on her right inner thigh. LPN-C indicated the staff was not sure if the brief or the mechanical lift sling was causing that pressure ulcer, so the area was protected. During an interview on 08/26/2015, at 9:46 a.m. RN-A stated R10's last pressure ulcer was healed on 8/4/15, but the LPN found three open areas on the weekend of 8/22/15. RN-A measured them 8/24/15, which indicated writer was alerted by staff that (R10) had 3 (three) open areas that were discovered over weekend on her coccyx/buttocks area.right upper buttock there is a 0.5 cm x 0.6 cm x 0.1 cm stage 2 pressure ulcer with light red wound base & on left buttock there is a 0.8 cm x 0.2 cm x 0 cm superficial red wound base stage 2 pressure ulcer, just superior to this is another 0.5 cm x 1 cm x 0 cm stage 2 superficial red wound base. RN-A stated the three PU on the coccyx were related to friction, and the heel was pressure related. RN-A indicated no changes in care planned interventions were made at that time. During an interview on 8/27/15, at 7:59 a.m. RN-B stated the history of R10's PU since 5/15 was as follows: -5/5/15, there was a stage 2 PU (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) on the interior aspect of the gluteal fold 0.5 cm x 0.5 cm. Off loading was done hourly during the day and every two hours at night. Dietary was updated. R10 was on glucerna (supplement for diabetics) since 11/14. She was started on Juven (protein supplement) and due to side effects it was discontinued. No further dietary consults were made. At that time the left heel was a 6 cm x 7 cm deep tissue injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). The skin was intact and skin prep was applied and a piece of honey comb was placed under her heel, inside her shoe. There was also a 2 cm x 2 cm mushy area on her right ankle. The area was covered with pilex for protection. Honey comb was placed on the end of her bed for heel and ankle protection. She has a pressure relieving mattress on her bed. Float heels at night. -5-13-15, a stage 2 pressure ulcer on top of gluteal fold was found measuring 0.4 cm diameter and superficial. An occupational therapy (OT) consult for w/c positioning was made. No other intervention changes were made. (OT consult dated 5-14-15, indicated that current foot positioning is impacting or contributing to wounds.) -5-19-15, one open area on coccyx measured 0.3 x 0.5. cm. The left heel was 3 cm x 4 cm dark purple deep tissue injury. The ankle area measured 0.2 cm x 0.3 cm. Will continue current treatment and continue tissue off loading. No change in assessment or intervention was made. -5-26-15, coccyx was a 0.3 cm x 0.5 cm stage 2 area. The area on the ankle was 0.2 cm x 0.3 cm area. The left heel area was 3.0 cm x 4.0 cm area. There was no change in interventions. -5-28-15, medical doctor (MD)-L saw R10's wounds and did not make any changes or write orders. No change in assessments or interventions. -6-4-15, coccyx stage 2 pressure ulcer is 0.3 cm x 0.3 cm wound bed was pink skin protector continued. Deep tissue injury to left heel was 2.8 cm x 4 cm with black eschar and mushy (per RN-B it is a change for the worse. It was firm but now mushy) MD-L recommended to let the ankle area dry out. No new skin assessments or changes in interventions were made. -6-10-15, was started on jueven, due to side effects it was discontinued and no replacement was started. R10 had received glucerna since 10/2014, and a multivitamin since 2014. -6-12-15, the PU on the coccyx was pinpoint but stage 2. The heel deep tissue area was 2.4 cm x 3.5 cm. The right ankle was 1 cm x 0.7 cm x 0.1 cm, the scab fell off leaving a slough filled wound bed. No change in assessment or intervention was initiated. -6-19-15, the coccyx measured 0.1 cm x 0.1 cm and superficial for depth. The deep tissue injury to heel 2.0 cm x 2.5 cm with black eschar. The right ankle area measured 0.8 cm x 0.8 cm x 0.1 cm. wound bed 100% slough. No change in assessment or intervention. -6-26-15, stage 2 pressure ulcer was less than 0.1 cm diameter. The deep tissue injury of left heel was 1.4 cm x 2.0 cm. The right ankle was 1.2 cm x 1.2 cm x 0.2 cm bed 50 % white slough and 50% granulation. No change in assessments or interventions were made. -6-30-15, the stage 2 coccyx area was resolved and closed. -7-2-15, a new pressure ulcer measuring 1 cm x 1.5 cm to right buttocks within 1/2 inch of previous wound. A 0.5 cm x 0.6 cm to left medial upper buttock area. The deep tissue injury left heel 1 cm x 2 cm eschar firm dry. The right ankle was 1.3 cm x 1.3 cm x 0.1 cm with a wound bed 20 % slough 80% granulation. There were no changes made in skin assessment or interventions. -7-6-15, a change for nursing to be present during the nursing assistants off loading was added per RN-B. This intervention was not on the care plan nor was the practice observed during the survey process. No new skin assessments or interventions were initiated. -7-7-15, the right upper coccyx stage 2 PU measured 1.0 cm x 1.8 cm . The left heel is 1 cm x 2 cm. The right ankle was 1.3 cm x 1.2 cm x 0.1 cm wound bed 20 % slough 80% granulation. There was no change to skin assessments or interventions. -7-12-15, another OT eval for wc positioning was sent. The results in the evaluation were . Pt does not require skilled OT services at this time however will attempt to trial new pressure reliving cushion and continue to assist in position needs as able moving forward. (No documentation of the new cushion being trialed.) -7-13-15, a stage 2 pressure ulcer to right buttocks wound measured 0.8 cm x 1 cm x 0.1 cm. RN-A changed dressing from [MEDICATION NAME] to [MEDICATION NAME] dressing. To be changed every five days and as needed. The deep tissue injury to left heel is 0.9 cm x 2 cm. The right ankle is 1.3 cm x 1 cm x 0.1 cm wound bed 20 % slough 80 % granulation scant amount drainage yellow on dressing. No change in skin assessments or interventions. -7-21-15, the right buttock measures 0.3 cm x 0.5 cm x 0 cm with no drainage. The left heel had the deep tissue injury measuring 1.3 cm x 2 cm. The ankle right was 1.4 cm x 1 cm x 0.2 cm with 20 % slough 80 % granulation. There was a scant amount of yellow drainage No change in assessment or intervention was initiated. -7-28-15, the right buttock PU was resolved and intact. The left heel was 1.5 cm x 2 cm dark brown mushy soft escar on top adhered to wound bed. The treatment to the heel was changed to periwound cleanser instead of skin prep. The right ankle was 1.4 cm x 1 cm x 0.1 cm with 20 % slough, 80 % granulation, and a scant amount yellow drainage. There were no changes in skin assessment or interventions. -8-4-15, the right buttock remained intact. The deep tissue PU on the left heel was 1.3 cm x 2.0 cm dark brown mushy on top 100% slough. The right ankle measured 1 cm x 1 cm x 0.1 cm and was 20 % slough. There were no changes in the intervention. -8-14-15, the left heel is 100% slough wound bed measured 1 cm x 2 cm. The right ankle was 1.2 cm x 1 cm by less than 0.1 cm. 100% granulation no drainage. There was no change in treatment. -8/19/15, the left heel was 1.2 cm x 1.5 cm depth 0.4 cm 100% stringy slough. The right ankle was 1 cm x 1 cm less 0.1 cm depth and the wound bed was 100% granulation with no drainage. There was no change in treatment. -8/22/15, the night nurse found 3 small open areas on upper buttock; the first was 0.8 cm x 0.6 cm, the second was 0.5 cm x 0.5 cm, and the third was 0.4 x 0.4 cm. The area was cleansed and skin protectant applied. -8/24/15, the wound nurse measured the wounds and noted the right upper buttock stage 2 PU to be 0.5 x 0.6 cm, less than 0.1 cm depth, with a red wound base. The left buttock stage 2 PU measured 0.8 cm x 0.2 cm, had no depth, and was superior to the third stage 2 PU that measured 0.5 cm x 1 cm, and had no odor or drainage. RN-B said, We think its from friction . (R10) rocks sometimes. An air mattress on bed. The current pad in the wheelchair was the same honeycomb pad. There was no documentation indicating why the pad was not changed to ROHO as suggested by OT. There was no reassessment or change in interventions despite the reoccurrence of pressure ulcers to the buttocks/coccyx area. During an interview on 08/27/2015, at 9:41 a.m. RN-B said she didn't have any ideas of what to change for interventions. During an interview on 08/27/2015, at 10:00 a.m. registered dietician (RD)-C stated R10 was on a glucerna supplement since October 2014. She said they attempted to give her jueven (to add additional protein for healing) but R10 was unable to take it due to side effects and no other change in supplement has been attempted. During an interview on 08/27/2015, at 11:20 a.m. RD-E stated R10 was not getting any protein fortified foods. She said R10 eats well. During an interview on 8/27/15, at 1:15 p.m. RD-C stated she looks at the percentage of eaten food, which was monitored but had not calculated the protein intake for a while. She said the protein measure is a poor indicator of nutritional status. She said that after reviewing R10's intake she needed more protein added and stated [MEDICATION NAME] would be added to her diet. RD-C also agreed R10 was high risk for nutrition and PU. RD-C also acknowledged there was no nutritional assessment note since 5/28/15. During an interview on 08/27/2015, at 11:06 a.m. occupational therapist (OT)-D said R10 tends to lean to the side. She did an evaluation on April 17, 2015. At that time she added a bolster cushion over the arm rest, and she put a foam cushion insert on both sides of R10 to minimize leaning to the sides. She said there was no documentation that suggested a ROHO pad was put into the wheelchair, how the honey comb was restarted, or if it had ever been changed. OT-D said she made a recommendation to not have the sling under R10. OT-D was not aware of any assessment that was completed to determine the sling could safely stay under R10 when sitting. During an interview on 08/27/2015, at 10:04 a.m. the director of nurses (DON) said they have tried all of the interventions to minimize PU they can think of. She said she was not aware of any assessment to determine if it is safe to have the sling under the resident but they did care plan it. She said it is also care planned to offload every hour. She also stated her expectation is for assessments quarterly, annual and when significant change has occurred on the residents. She was not aware of why there was no recent dietary or nursing assessment. She was not aware there were no recent laboratory results. She verified there were no assessments of the efficacy of having the extra green sheet on top of the wheelchair pad and under the sling, which are all under the resident. During an interview on 08/27/2015, at 1:33 p.m. RN-B stated they normally do a tissue tolerance when there is any new skin breakdown. She said she did one yesterday because it was due for the quarter, not because of new skin breakdown. She went on to say they are suppose to do skin assessments whenever there is new skin breakdown. RN-B stated they usually get new laboratory tests completed when there is new skin breakdown and acknowledged there had not been any new tests since last May. RN-B further verified R10 had not received any new protein supplements. A policy entitled: Pressure Ulcer and Non-Surgical Wound Documentation, revised 2/15, indicated a dietician to review nutrition/hydration status and make recommendations to promote healing. Monitor and document as needed.