Every finding on record at Dulles Health & Rehab Center

Based on observation, resident representative interview, staff interview, clinical record interview, and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for 10 out of 54 residents in the survey sample, Residents #185, #17, #90, #161, #134, #6, #8, #10, #132 and #1. The findings include:1. For Resident #185 (R185), the facility staff failed to implement the comprehensive care plan to provide incontinence care/toileting assistance on night shift 6/28/2024 and 6/30/2024. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 6/22/2024, the resident was assessed as being frequently incontinent of bowel and bladder and being dependent on staff for toileting. The comprehensive care plan for R185 documented in part, Has been assessed as incontinent of bowel and bladder. Date Initiated: 06/24/2024. Under Interventions/Tasks it documented in part, Observe for moisture and incontinence issues and provide care as indicated. Date Initiated: 06/24/2024. Review of the ADL (activities of daily living) documentation for R185 from 6/1/2024-6/30/2024 failed to evidence toileting hygiene provided on night shift on 6/28/2024 and 6/30/2024. The dates were blank. On 3/25/2026 at 9:35 AM, an interview was conducted with licensed practical nurse (LPN) #1 who stated that the care plan purpose was to give the staff direction and help them in the way that they take care of every patient because every patient was different. He stated that the care plan should be implemented because they could not take care of the resident if they did not know what they needed. On 3/25/2026 at 9:50 AM, an interview was conducted with registered nurse (RN) #2 who stated that he did not remember R185 or any conversations with the family about any concerns. He stated that incontinence care should be provided every two hours and more often as needed. On 3/25/2026 at 10:39 AM, an interview was conducted with certified nursing assistant (CNA) #1 who stated that incontinence care was provided every two hours or anytime the resident called them. She stated that they evidenced the care they provided by documenting it in the medical record every shift. On 3/25/2026 at 11:31 AM, an interview was conducted with CNA #5 who stated that incontinence care was provided every two hours at a minimum and there were some residents who required it more often. She stated that they evidenced the care they provided by their documentation in the medical record each shift. The facility policy Comprehensive Care Planning Process revised 1/2026 documented in part, The facility must develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. An interdisciplinary assessment team shall develop a comprehensive assessment and care plan for each patient based on outcomes of assessments and input from the patient, family, and interdisciplinary team members. The team serves as the authority for overseeing patient care services . On 3/25/2026 at 4:29 PM, the administrator, the director of nursing and the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. 2. For Resident #17, (R17) the facility staff failed to implement the comprehensive care plan for incontinence care. R17 diagnoses include but are not limited to quadriplegia (1) and anoxic brain damage (2). On the most recent minimum data set (MDS), an annual assessment with an assessment reference date (ARD) of 2/5/2026, the resident was assessed as having a BIMs (brief interview for mental status) score of 00 meaning the resident was severely impaired for making daily decisions. R17 was assessed as always being incontinent of bowel and bladder and being dependent on staff for toileting hygiene. On 3/34/2026 at 12:04 AM an interview was conducted by phone with the resident's agent. They stated their concern is that the facility is not taking care of the resident, for example she had been to the facility several times on the weekend and it appeared as if the resident's brief had been wet for hours. The comprehensive care plan for R17 documented in part, resident has been assessed as incontinent of bowel and bladder and will have bowel and bladder continence needs met as indicates for the next 30 days. Date initiated 5/24/2021 and revised on 2/10/2026. 3/25/2026 at 9:36 AM, an interview was conducted with LPN (license practical nurse) #1. He stated the purpose of the care plan, is to provide the direction how to take care of each patient. He stated that the care plan should be implemented because he cannot take care of the patient if he does not know the instructions. On 3/25/2026 at 10:45 AM an interview was conducted with certified nursing assistant (CNA) #1 who stated that incontinence care was provided every two hours and is evidenced by documentation. On 3/25/2026 at 11:37 AM an interview was conducted with CNA #5 who stated that incontinence care was provided every two hours and anytime a resident called to say they needed to be changed. She stated she evidenced care that she provided by documentation at the end of the shift. On 3/26/2026 at 4:30 p.m., the Administrator, DON (director of nursing) and the ADON (assistant director of nursing) were notified of the findings. No further information was provided prior to exit. Reference: 1. Quadriplegia- Quadriplegia is a symptom of paralysis that affects all a person's limbs and body from the neck down. https://my.clevelandclinic.org/health/symptoms/23974-quadriplegia-tetraplegia 2. Anoxic brain injury- is a type acquired brain injury that occurs when cells in the brain do not receive enough oxygen. https://biausa.org/brain-injury/about-brain-injury/nbiic/hypoxic-anoxic-brain-injury 3. For Resident #90, (R90) the facility staff failed to implement the comprehensive care plan for showering. R90 diagnoses include but were not limited to dementia (1), right femur fracture, closed (2), cerebral infarction (3) and weakness. On the most recent minimum data set (MDS), a Medicare - 5 day with an assessment reference date (ARD) of 1/30/2026, the resident was assessed as having a BIMs (brief interview for mental score) score of 12 meaning the resident was moderately impaired for making daily decisions. R90 was assessed as being dependent on showering and bathing. On 3/24/2026 at 10:02 AM, an interview was conducted with R90's authorized representative. They stated they are concerned about the resident not getting showered regularly. Review of the clinical documentation from 2/8/2026-2/22/26 evidenced R90 received two showers in a two-week time frame. The comprehensive care plan for R90 documented in part, resident requires ADL assistance with diagnosis of right femur fracture . and will receive necessary level of ADL assistance. and resident will be provided assistance with bathing and hygiene as required. Date initiated 1/23/2026. 3/25/2026 at 9:36 AM, an interview was conducted with LPN (license practical nurse) #1. He stated the purpose of the care plan, is to provide the direction how to take care of each patient. He stated that the care plan should be implemented because he cannot take care of the patient if he does not know the instructions. On 3/25/2026 at 9:36 a.m., an interview was conducted with CNA (certified nursing assistant) #5 who stated that showers are given at least twice a week but more if the resident asked. She stated they document showers given in the care tech. She stated if a resident refused a shower, the CNA notified the resident's nurse and the nurse verified with the resident the refusal. On 3/26/2026 at 4:30 p.m., Administrator, DON (director of nursing) and the ADON (administrator director of nursing) were notified of the findings. No further information was provided prior to exit. References: 1. Dementia- is a loss of mental functions that is severe enough to affect your daily life and activities. https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=dementia 2. Closed fracture- A break in a bone but your bone doesn't push through your skin. https://medlineplus.gov/fractures.html; https://my.clevelandclinic.org/health/diseases/15241-bone-fractures 3. Cerebral infarction- A stroke happens when there is a loss of blood flow to part of the brain. https://medlineplus.gov/ency/patientinstructions/000132.htm 4a. For Resident #161 (R161), the facility staff failed to follow the comprehensive care plan for the administration oxygen. R161 was admitted to the facility with diagnosis that included but not limited to respiratory failure (1) and chronic obstructive pulmonary disease (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/03/2026, R161 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R161 was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R161 as receiving Oxygen therapy. On 03/23/2026 at approximately 2:49 p.m. an observation revealed R161 receiving oxygen by nasal cannula (3). Observation of the oxygen concentrator (4) flow meter revealed a flow rate between two-and-a-half and three liters per minute. On 03/24/2026 at approximately 8:40 a.m. an observation revealed R161 receiving oxygen by nasal cannula. Observation of the oxygen concentrator flow meter revealed a flow rate between two-and-a-half and three liters per minute. On 03/24/2026 at approximately 1:58 p.m. an observation revealed R161 receiving oxygen by nasal cannula. Observation of the oxygen concentrator flow meter revealed a flow rate between two-and-a-half and three liters per minute. The physician order for R161 documented in part, O2 (oxygen) at 3 (three) L/min (liters per minute) via (by) nasal cannula continuously. Every shift for respiratory failure related to chronic obstructive pulmonary disease. Date Ordered: 9/4/2024. The comprehensive care plan for R161 dated 08/26/2024 documented in part, Focus. (R161) has respiratory problem (s) related to acute illness or chronic condition Chronic lung disease, COPD. Created on: 08/26/2024. Revision on: 03/18/2026. Under Interventions it documented in part, Provide oxygen as ordered. Date Initiated: 03/18/2026. On 03/24/2026 at approximately 2:00 p.m. an observation of the flow meter on R161's oxygen concentrator was conducted with LPN (licensed practical nurse) #2. When asked to describe how to read the flow meter on the oxygen concentrator she stated the liter line should pass through the middle of the float ball. After observing the flow meter, she stated that the oxygen flow rate was between two-and-a-half and three liters per minute. After reviewing the physician's orders for R161's oxygen she stated that the flow rate should have been three liters per minute. When asked to describe the purpose of a resident's care plan she stated that the care plan describes what you should do for the resident. She further stated that R161's care plan was being followed for the use of oxygen at the physician ordered flow rate. On 03/24/2026 at approximately 4:30 p.m. the Administrator, Director of Nursing, and the Assistant Director of Nursing were made aware of the above findings. No further information was provided prior to exit. References: (1) A condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. This information was obtained from the website: https://medlineplus.gov/respiratoryfailure.html. (2) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (3) Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula. (4) A medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen. This information was obtained from the website: https://www.oxygenconcentratorstore.com/help-center/what-is-the-medical-definition-of-an-oxygen-concentrator/. 4b. For R161, facility staff failed to store a nebulizer (1) mask in a sanitary manner when not in use. On 03/23/2026 at approximately 2:49 p.m. an observation revealed R161's nebulizer mask laying on top of the bedside table, uncovered. On 03/24/2026 at approximately 8:40 a.m. an observation revealed R161's nebulizer mask laying on top of the bedside table, uncovered. On 03/24/2026 at approximately 1:58 p.m. an observation revealed R161's nebulizer mask laying on top of the bedside table, uncovered. The physician's order for R161 documented in part, Formoterol Fumarate (2) Inhalation Nebulization Solution 20 MCG (micrograms)/2ML (two milliliters). 2 ml inhale orally via nebulizer two times a day for COPD. Order date: 9/11/2025. On 03/24/2026 at approximately 2:00 p.m. an observation of R161's bedside table was observed with LPN #2. After observing the nebulizer mask laying on top of R161's bedside table uncovered, she stated that the mask should be placed in a plastic bag when it is not in use to prevent contamination. On 03/24/2026 at approximately 4:30 p.m. the Administrator, Director of Nursing, and the Assistant Director of Nursing were made aware of the above findings. No further information was provided prior to exit. References: (1) A small machine that turns liquid medicine into a mist. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000006.htm. (2) Used to control wheezing, shortness of breath, and chest tightness caused by chronic obstructive pulmonary disease. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a602023.html. 5. For R134, the facility staff failed to develop a care plan for the use of TED (thromboembolic-deterrent) [NAME] (1) [NAME] (hosiery – stockings). R135 was admitted to the facility with diagnosis that included but not limited to embolism (blockage in the blood vessel) and thrombosis (blood clot in a vein) of superficial veins (veins close to the surface) of left lower extremity (left lower leg). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/04/2026, R134 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R134 was cognitively intact for making daily decisions. On 03/23/2026 at approximately 3:20 p.m. an observation of R134's lower right and left legs failed to evidence TED [NAME]. On 03/24/2026 at approximately 11:20 a.m. an observation of R134's lower right and left legs failed to evidence TED [NAME]. The physician's order for R134 documented in part, TED [NAME] every day shift for Edema (swelling) ON IN AM (put on during the day). Order Date: 02/03/2026. Start date: 02/04/2026. TED [NAME] every evening shift for Edema OFF IN PM (taken off in the evening). Order Date: 02/03/2026. Start date: 02/04/2026. Review of the comprehensive care plan for R134 dated 11/28/2025 failed to evidence documentation for the use of TED [NAME]. On 03/24/2026 at approximately 2:00 p.m. an interview was conducted with the MDS Director regarding R134's comprehensive care plan for the use of TED [NAME]. The MDS Director stated that she would review the care plan. At 9:24 a.m. the MDS Director stated that after reviewing R134's care plan that there was no care plan developed to address R134's use of TED [NAME]. On 03/26/2026 at approximately 2:00 p.m. the Administrator, Director of Nursing, and the Assistant Director of Nursing were made aware of the above findings. No further information was provided prior to exit. References: (1) Hosiery that prevents blood clots. Patients who have just been through an operation are sometimes at risk for blood clotting. Those who are bed-ridden can also develop blood clots due to lack of movement, which can lead to other serious complications. It provides compression, mimics the act of walking, and keeps blood circulation flowing better. This information was obtained from the website: https://www.veintreatmentclinic.com/blog/what-does-ted-hose-stand-for/. 6. For Resident #6 (R6), the facility staff failed to implement contact transmission-based precautions. (1) A review of R6's clinical record revealed a physician's order dated 3/23/26 for Contact Isolation for a diagnosis of CRE. (2) On 3/23/26 at 3:35 p.m., R6 was observed lying in bed and the resident's call light was ringing. A sign from the Centers for Disease Control was posted outside of R6's room door and documented, CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 3/23/26 at 3:37 p.m., CNA (Certified Nursing Assistant) #1 entered R6's room and turned off the resident's call light without donning a gown or gloves. On 3/25/26 at 9:33 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated the care plan gives staff direction of all they are supposed to do for a particular resident; what staff needs to know about a resident, and information needed to take care of the resident. In regard to care plan implementation, LPN #1 stated he reviews the care plan and follows instructions regarding the residents he cares for on that particular day. On 3/25/26 at 10:39 a.m., an interview was conducted with CNA #1. CNA #1 stated that usually there is a sign posted outside of the room door of residents who require contact precautions. CNA #1 stated that if a resident requires contact precautions, staff should put on a gown and gloves if they are going to touch the resident or items in the resident's room. CNA #1 could not explain why she did not donn a gown or gloves prior to entering R6's room and turning the resident's call light off. On 3/25/26 at 2:12 p.m., the Administrator and Director of Nursing were made aware of the above concern. No further information was presented prior to exit. References: (1) Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. This information was obtained from website: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html (2) Enterobacterales are a group of bacteria (germs) that are a normal part of the human and animal gut but can also cause infections. Carbapenem-resistant Enterobacterales (CRE) are germs resistant to one or several antibiotics called carbapenems. This information was obtained from the website: https://www.cdc.gov/cre/about/index.html. 7.The facility staff failed to implement the comprehensive care plan for anticoagulation monitoring for Resident #8 (R8). R8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident), hemiplegia/hemiparesis, DM (diabetes mellitus) and ESRD (end stage renal disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/19/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for locomotion/transfer/dressing/toileting and hygiene. A review of the comprehensive care plan dated 7/9/21 revealed, FOCUS: Resident is on Anticoagulant therapy/Blood thinner placing patient at risk for bleeding/bruising. INTERVENTIONS: Report signs/symptoms of new/unusual bleeding or bruising for further assessment and treatment. A review of R8's MAR-TAR (medication administration record-treatment administration record) for December 2025, January-February-March 2026 revealed no evidence of anticoagulation monitoring. On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the process of monitoring residents on anticoagulation therapy as observing them for bruising and bleeding. Asked where the evidence of this monitoring is found, LPN #8 stated, there is no documentation or evidence that there is any monitoring. LPN #8 described the purpose of the care plan is to guide the specific care for the resident including goals and interventions. Asked if the interventions were not implemented was the care plan followed/implemented LPN #8 replied, no, it was not. On 3/25/26 at 4:30 PM, the administrator, the director of nursing and the administrative intern were made aware of the findings. No further information was provided prior to exit. 8.A. The facility staff failed to implement the comprehensive care plan for ADL care for Resident #10 (R10). R10 was admitted to the facility on [DATE] with diagnosis that included but were not limited to osteoarthritis, dementia, atrial fibrillation and chronic obstructive pulmonary disease (COPD). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 2/17/26, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting and hygiene. A review of the comprehensive care plan dated 9/29/23 revealed, FOCUS: Resident has bladder & bowel incontinence related to impaired bed mobility and weakness. INTERVENTIONS: Observe for moisture and incontinence issues and provide care as indicated. A review of R10's ADL (activities of daily living) record reveals missing evidence of incontinence care, turning and positioning being provided on following dates and shifts: Day shift- 12/21/25, 12/26/25, 1/20, 1/26, 1/27, 2/2, 2/3, 2/4, 2/10, 2/15, 2/16, 2/17, 2/24, 3/10, 3/19 NS 3/22 and Night shift-12/31, 1/31 and 2/28. On 3/24/26 at 11:00 AM an interview was conducted with CNA (certified nursing assistant) #6. CNA #6 described the process to provide incontinence care and turning / positioning as follows: the resident rounding starts at the beginning of our shift and then it is every two hours, unless the resident needs incontinence care more frequently. This is all documented in our section of point click care. That is the evidence it was completed, if it is not documented there is no evidence that it was done. On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the purpose of the care plan is to guide the specific care for the resident including goals and interventions. Asked if the interventions were not implemented was the care plan followed/implemented LPN #8 replied, no, it was not. On 3/25/26 at 4:30 PM, the administrator, the director of nursing and the administrative intern were made aware of the findings. No further information was provided prior to exit. 8.B. The facility staff failed to develop the comprehensive care plan for anticoagulation monitoring for Resident #10 (R10). R10 was admitted to the facility on [DATE] with diagnosis that included but were not limited to osteoarthritis, dementia, atrial fibrillation and chronic obstructive pulmonary disease (COPD). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 2/17/26, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting and hygiene. There is no evidence of anticoagulant on R10's care plan till 3/24/26. On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the process of monitoring residents on anticoagulation therapy as observing them for bruising and bleeding. Asked where the evidence of this monitoring is found, LPN #8 stated, there is no documentation or evidence that there is any monitoring. LPN #8 described the purpose of the care plan is to guide the specific care for the resident including goals and interventions. Asked if the interventions were not implemented was the care plan followed/implemented LPN #8 replied, no, it was not. On 3/25/26 at 4:30 PM, the administrator, the director of nursing and the administrative intern were made aware of the findings. No further information was provided prior to exit. 9.The facility staff failed to implement the comprehensive care plan for ADL care for Resident #132 (R132). R132 was admitted to the facility on [DATE] with diagnosis that included but were not limited to epilepsy, traumatic brain injury, schizophrenia and psychotic delusions. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/3/26, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting and hygiene. Resident is non-functioning on her right side. A review of the comprehensive care plan dated 3/2/23 revealed, FOCUS: Resident has bladder & bowel incontinence related to functional incontinence. Resident is at risk for pressure ulcer development related to immobility and incontinence, INTERVENTIONS: Encourage and/or assist resident with cleansing perineal area after each incontinence episode. Provide assistance with toileting and peri-care as requested and/or needed. Educate and encourage resident to change positions for pressure relief frequently. A review of R132's ADL (activities of daily living) record reveals missing evidence of incontinence care, turning and positioning being provided on following dates and shifts: Day shift- 1/20, 1/26, 1/27, 2/2, 2/3, 2/4, 2/10, 2/15, 2/16, 2/17, 2/24, 3/10, 3/19 NS 3/22 and Night shift- 1/31 and 2/28. On 3/24/26 at 11:00 AM an interview was conducted with CNA (certified nursing assistant) #6. CNA #6 described the process to provide incontinence care and turning / positioning as follows: the resident rounding starts at the beginning of our shift and then it is every two hours, unless the resident needs incontinence care more frequently. This is all documented in our section of point click care. That is the evidence it was completed, if it is not documented there is no evidence that it was done. On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the purpose of the care plan is to guide the specific care for the resident including goals and interventions. Asked if the interventions were not implemented was the care plan followed/implemented LPN #8 replied, no, it was not. On 3/25/26 at 4:30 PM, the administrator, the director of nursing and the administrative intern were made aware of the findings. No further information was provided prior to exit. 10.The facility staff failed to develop the comprehensive care plan for anticoagulation monitoring for Resident #1 (R1). R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus), CHF (congestive heart failure) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/19/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for locomotion/transfer/dressing/toileting and dependent for bathing. There is no evidence of anticoagulant on R1's care plan till 3/24/26. A review of R1's MAR-TAR (medication administration record-treatment administration record) for December 2025, January-February-March 2026 revealed no evidence of anticoagulation monitoring. On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the process of monitoring residents on anticoagulation therapy as observing them for bruising and bleeding. Asked where the evidence of this monitoring is found, LPN #8 stated, there is no documentation or evidence that we do the monitoring. LPN #8 described the purpose of the care plan is to guide the specific care for the resident including goals and interventions. Asked if the interventions were not implemented was the care plan followed/implemented LPN #8 replied, no, it was not. On 3/25/26 at 4:30 PM, the administrator, the director of nursing and the administrative intern were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor side effects to prevent unnecessary medication administration for four of 54 residents in the survey sample, Residents #2, #8, #10, and #1.The findings include:1. For Resident #2 (R2), the facility staff failed to monitor for side effects of Enoxaparin (1). A review of R2's clinical record revealed the following order dated 2/12/26: Enoxaparin Sodium Injection Solution Prefilled Syringe 100 MG/ML (milligram per milliliter) Inject 1 ml.every 12 hours. A review of R2's February and March 2026 MARs (medication administration record) revealed she had received the medication as ordered each day. Further review of R2's clinical record failed to reveal evidence of monitoring for the side effects of Enoxaparin. On 3/25/26 at 9:23 a.m., LPN (licensed practical nurse) #1 was interviewed. He stated if a resident is receiving an anticoagulant such as Enoxaparin, the resident has a higher risk of bleeding or bruising. He stated the nursing staff should be always monitoring for these side effects, and the monitoring should be documented each shift on the MAR (medication administration record). On 3/25/26 at 4:28 p.m., the Administrator and Director of Nursing were informed of these concerns. A review of the facility policy, Medication Monitoring, revealed, in part: Interventions shall be identified on the patient's comprehensive plan of care for the systematic monitoring of high-risk medications to facilitate early identification of adverse consequences. No additional information was provided prior to exit. References(1) Enoxaparin is used to prevent and treat deep vein thrombosis (DVT; blood clots that form in the veins, typically in the legs). It is also used to prevent complications from angina (chest pain) and heart attacks. Enoxaparin is in a class of medications called low molecular weight heparins. It works by stopping the formation of substances that cause clots. This information was taken from the website https://medlineplus.gov/druginfo/meds/a601210.html. 2. The facility staff failed to ensure Resident #8 (R8) was free of unnecessary medications by monitoring anticoagulants as ordered. R8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident), hemiplegia/hemiparesis, DM (diabetes mellitus) and ESRD (end stage renal disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/19/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for locomotion/transfer/dressing/toileting and hygiene. A review of the comprehensive care plan dated 7/9/21 revealed, FOCUS: Resident is on Anticoagulant therapy/Blood thinner placing patient at risk for bleeding/bruising. INTERVENTIONS: Report signs/symptoms of new/unusual bleeding or bruising for further assessment and treatment. A review of the physician's order dated 4/16/25 revealed Apixaban (Eliquis) Oral Tablet 2.5 MG (1) Give 1 tablet by mouth two times a day for atrial fibrillation. A review of R8's MAR-TAR (medication administration record-treatment administration record) for December 2025, January-February-March 2026 revealed Apixaban administered as ordered. A review of R8's MAR-TAR for December 2025, January-February-March 2026 revealed no evidence of anticoagulation monitoring. On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the process of monitoring residents on anticoagulation therapy as observing them for bruising and bleeding. Asked why this is important, LPN #8 stated, because it is a patient safety issue. On 3/25/26 at 4:30 PM, the Administrator, the Director of Nursing and the Administrative Intern were made aware of the findings. No further information was provided prior to exit. References: Apixaban is an anticoagulant and direct thrombin inhibitor whose purpose is to reduce embolism / clots. Information from [NAME] Pocket Drug Guide for Nurses. 3. The facility staff failed to ensure Resident #10 (R10) was free of unnecessary medications by monitoring anticoagulants as ordered. R10 was admitted to the facility on [DATE] with diagnosis that included but were not limited to osteoarthritis, dementia, atrial fibrillation and chronic obstructive pulmonary disease (COPD). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 2/17/26, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting and hygiene. There is no evidence of anticoagulant on R10's care plan till 3/24/26. A review of the physician's order dated 11/14/25 revealed Apixaban (Eliquis) Oral Tablet 2.5 MG (1) Give 1 tablet by mouth two times a day for Unspecified Atrial fibrillation blood thinner. A review of R10's MAR-TAR (medication administration record-treatment administration record) for December 2025, January-February-March 2026 revealed Apixaban administered as ordered. A review of R10's MAR-TAR for December 2025, January-February-March 2026 revealed no evidence of anticoagulation monitoring. On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the process of monitoring residents on anticoagulation therapy as observing them for bruising and bleeding. Asked why this is important, LPN #8 stated, because it is a patient safety issue. On 3/25/26 at 4:30 PM, the administrator, the director of nursing and the administrative intern were made aware of the findings. No further information was provided prior to exit. References: Apixaban is an anticoagulant and direct thrombin inhibitor whose purpose is to reduce embolism / clots. Information from [NAME] Pocket Drug Guide for Nurses. 4. The facility staff failed to ensure Resident #1 (R1) was free of unnecessary medications by monitoring anticoagulants as ordered. R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus), CHF (congestive heart failure) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/19/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for locomotion/transfer/dressing/toileting and dependent for bathing. There is no evidence of anticoagulant on R1's care plan till 3/24/26. A review of the physician orders dated 12/12/25 revealed Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for Atrial fibrillation. A review of R10's MAR-TAR (medication administration record-treatment administration record) for December 2025, January-February-March 2026 revealed Eliquis administered as ordered. A review of R1's MAR-TAR (medication administration record-treatment administration record) for December 2025, January-February-March 2026 revealed no evidence of anticoagulation monitoring. On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the process of monitoring residents on anticoagulation therapy as observing them for bruising and bleeding. Asked why this is important, LPN #8 stated, because it is a patient safety issue. On 3/25/26 at 4:30 PM, the Administrator, the Director of Nursing and the Administrative Intern were made aware of the findings. No further information was provided prior to exit. References: Apixaban is an anticoagulant and direct thrombin inhibitor whose purpose is to reduce embolism / clots. Information from [NAME] Pocket Drug Guide for Nurses.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to serve food in a safe and sanitary manner for one of one kitchen.The findings include:On 3/23/2026 at approximately 11:48 AM, an observation was made of the facility kitchen with the food service director. Observation of the dry good storage area revealed a 46 fluid ounce carton of thickened apple juice which documented Use by [DATE]. Observation of the kitchen area revealed a wire shelving rack with 6 stacked pans which the director stated were meatloaf pans and were clean and available for use. Two of the pans were observed to have visible debris adhering to the inside of the pans. An additional wire shelving rack inside the cooking area revealed two stacks of steam tray pans, one with four stacked pans and one with three stacked pans. The director stated that they were half pans and were clean and available for use. One of the inside pans in the stack of three pans was observed with visible water droplets on the outside of the pan. One of the inside pans in the stack of four pans was observed with visible water droplets on the outside of the pan. A 22quart bin was observed sitting on the countertop labeled thickener, the bin was observed to contain approximately 14quarts. A plastic scoop with handle was observed inside the bin resting on the thickener product.On 03/24/2026 at 2:54 PM, an interview was conducted with the food service director who stated that she had pulled the thickened apple juice off the shelf and had questioned why the vendor had sent it to them on 12/5/25 because they should have rejected it. She stated that they had re-washed the meatloaf pans to ensure there was no debris left in them and the staff should be checking them and using the scrubber to clean them. The director stated that she had educated her staff on air drying the pans prior to stacking them and making sure there was no moisture left inside of them and that the scoop for the thickener should be kept container on top of the bin and not inside on the product for infection control purposes.According to the FDA (Food and Drug Administration) Food Code 2022, it documented in Annex 3. Public Health Reasons/Administrative Guidelines, in part, .Manufacturer's use-by dates: It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages . Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow . It further documented in Chapter 3. Food, . In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored . In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food .On 3/24/2026 at 4:32 PM, the administrator, the director of nursing and the assistant director of nursing were made aware of the findings.No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to promote residents highest level of well-being for two of 54 residents in the survey sample, Resident #182 and Resident #134. The findings include:1. For Resident #182 (R182), the facility staff failed to implement treatment to venous wounds identified upon admission. The minimum data set (MDS) was not due at the time of the survey. R182 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cellulitis (1), chronic venous insufficiency (2) and chronic lower extremity ulcers (3). On the nursing admission/readmission assessment for R182 dated 3/20/2026 the skin assessment documented, .cellulitis on bilateral lower extremities and wound to bilateral lower extremities . The assessment further documented R182 being alert and oriented to person, place and time. On 3/23/2026 at 2:43 PM, an interview was conducted with R182 who stated that they had only been at the facility since Friday evening. R182 stated that their compression wraps had slipped down at home and they had developed cellulitis in the lower legs and was at the facility for a 28-day course of antibiotics to treat the infection. R182 stated that they had begun therapy that day and had seen many staff coming in to do multiple assessments and was worn out. A body audit for R182 dated 3/20/2026 documented the findings above on the admission nursing assessment. A body audit for R182 dated 3/21/2026 documented in part, . Cellulitis wound to left posterior calf with necrotic tissue to wound bed, purulent drainage noted to site surrounding skin clustering. 11.5cm x 7.6cm x 0.1cm. Cellulitis wound to right posterior calf with granulation tissue, moderate serous drainage, surrounding skin clustering. 5.0cm x 4.5cm x 0.1cm . The physician orders for R182 documented in part, - Cleanse Cellulitis wound to left posterior calf with wound cleanser, pat dry apply calcium Alginate to wound bed + ABD, wrap with kerlix gauze wrap then tape. change dressing daily and PRN (as needed). every evening shift for cellulitis wound. Order Date: 03/23/2026. Start Date: 03/24/2026. - Cleanse Cellulitis wound to right posterior calf with wound cleanser, pat dry apply calcium Alginate to wound bed + ABD, wrap with kerlix gauze wrap then tape. change dressing daily and PRN. every evening shift for cellulitis wound. Order Date: 03/23/2026. Start Date: 03/24/2026. Review of the electronic treatment administration record (eTAR) for R182 dated 3/1/2026-3/31/2026 documented treatment to the cellulitis wounds on the left and right posterior calf beginning on evening shift 3/24/2026. The clinical record failed to evidence treatment to the wounds described above prior to 3/24/2026. The baseline care plan for R182 initiated 3/20/2026 documented in part, At risk for/actual skin breakdown, patient is admitted with pressure injury to right buttock, pressure injury to left buttock, cellulitis wound to left calf, cellulitis wound to right calf, redness to bilateral under breast. Date Initiated: 03/20/2026. Revision on: 03/23/2026. On 3/25/2026 at 9:26 AM, an interview was conducted with licensed practical nurse (LPN) #5, wound nurse. LPN #5 stated that three body audits were completed on all new admissions. She stated that the first body audit was completed by the admission nurse and the next was done 24 hours later by her or the nurse and she completed the last one. She stated that when a wound was identified on admission the nurse should check the hospital discharge instructions for orders on treatment for the wound and if there were no orders they should contact the physician to obtain orders. LPN #5 stated that the admission nurse normally put in the initial treatment and after she did her assessment she may change it as needed. She stated that any treatment to a wound would be evidenced by the documentation on the eTAR and she would review R182's record and orders to see if there was an order for treatment in place for the wounds prior to 3/23/2026. On 3/25/2026 at 9:35 AM, an interview was conducted with LPN #1 who stated that on admission, a skin assessment was performed to identify any wounds. He stated that any wounds were documented on the skin assessment and the physician and the wound team was notified. LPN #1 stated that if it was after hours and the wound nurse was not in the building they called the physician to get an order for a treatment until the wound nurse could assess the wound. On 3/25/2026 at 9:50 AM, an interview was conducted with registered nurse (RN) #2 who stated the admission nurse reviewed the hospital discharge orders for any wound treatment orders and enter those into the medical record. He stated that if there were no wound treatment orders the nurse should call the physician to get an order for the wound. RN #2 stated that the wound nurse would come to assess the resident the next day and ensure the correct treatment was in place. On 3/25/2026 at 11:16 AM, an interview was conducted with LPN #6 who stated that they did not recall admitting R182 on 3/20/2026 or the skin assessment because they floated all over the facility. She stated that when a resident was admitted they did a full body skin assessment and documented any wounds. LPN #6 stated that any wounds were reported to the physician and they discussed any treatment orders sent from the hospital to obtain orders for treatment of the wounds at the facility. She stated that the next day the wound nurse came in to do a skin assessment and updated the orders as needed. The facility policy Documentation of Wound Treatments revised 2/26/2026 documented in part, The Center completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment . On 3/25/2026 at 4:29 PM, the Administrator, the Director of Nursing and the Assistant Director of Nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) Cellulitis is an infection of the skin and deep underlying tissues. Group A strep (streptococcal) bacteria are the most common cause. The bacteria enter your body when you get an injury such as a bruise, burn, surgical cut, or wound. Symptoms include: Fever and chills, Swollen glands or lymph nodes, A rash with painful, red, tender skin. The skin may blister and scab over. Your health care provider may take a sample or culture from your skin or do a blood test to identify the bacteria causing infection. Treatment is with antibiotics. They may be oral in mild cases, or intravenous (by IV) for more severe cases . This information was obtained from the website: Cellulitis | Cellulitis Treatment | MedlinePlus (2) Chronic venous insufficiency occurs when your leg veins don't allow blood to flow back up to your heart. Normally, the valves in your veins make sure that blood flows toward your heart. But when these valves don't work well, blood can also flow backwards. This can cause blood to collect (pool) in your legs. If this condition is not treated, you may have: Pain; Swelling; Cramps; Skin changes; Varicose veins; Leg ulcers. Chronic venous insufficiency is not a serious health threat. But it can be painful and disabling . This information was obtained from the website: Chronic Venous Insufficiency | John Hopkins Medicine (3) Venous ulcers (open sores) can occur when the veins in your legs do not push blood back up to your heart as well as they should. Blood backs up in the veins, building up pressure. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form. Most venous ulcers occur on the leg, above the ankle. This type of wound can be slow to heal . This information was obtained from the website: Venous ulcers - self-care: MedlinePlus Medical Encyclopedia 2. For Resident #134 (R134), the facility staff failed to apply TED (thromboembolic-deterrent) [NAME] (hosiery – stockings) (1) according to the physician's order. R135 was admitted to the facility with diagnosis that included but not limited to embolism (blockage in the blood vessel) and thrombosis (blood clot in a vein) of superficial veins (veins close to the surface) of left lower extremity (left lower leg). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/04/2026, R134 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R134 was cognitively intact for making daily decisions. On 03/23/2026 at approximately 3:20 p.m. an observation of R134's lower right and left legs failed to evidence TED [NAME]. On 03/24/2026 at approximately 11:20 a.m. an observation of R134's lower right and left legs failed to evidence TED [NAME]. The physician's order for R134 documented in part, TED [NAME] every day shift for Edema (swelling) ON IN AM (put on during the day). Order Date: 02/03/2026. Start date: 02/04/2026. TED [NAME] every evening shift for Edema OFF IN PM (taken off in the evening). Order Date: 02/03/2026. Start date: 02/04/2026. Review of the comprehensive care plan for R134 dated 11/28/2025 failed to evidence documentation for the use of TED [NAME]. On 03/24/2026 at approximately 2:00 p.m. an observation of R134 was conducted in her room with LPN (licensed practical nurse) #2. While R134 was sitting on the edge of the bed, LPN #2 asked R134 if she could look at her legs to determine if R134 was wearing TED [NAME]. After examining R134's legs LPN #2 stated that R134 was not wearing TED [NAME] on either the right or left leg. When asked why it was important for R134 to wear the TED [NAME] as ordered by the physician she stated it was to prevent swelling in R134's legs. The facility's policy Antiembolism Stockings Application documented in part, Antiembolism stockings are to be applied to the patient's legs by nursing personnel in accordance with physician/physician-extender orders. Antiembolism stockings are placed to prevent, to the extent possible, venous stasis and improve venous return to the heart. ROUTINE CHECKS: 1. Each day the patient should be checked to see that the stockings are being worn correctly. On 03/26/2026 at approximately 2:00 p.m. the Administrator, Director of Nursing, and the Assistant Director of Nursing were made aware of the above findings. No further information was provided prior to exit. References: (1) Hosiery that prevents blood clots. Patients who have just been through an operation are sometimes at risk for blood clotting. Those who are bed-ridden can also develop blood clots due to lack of movement, which can lead to other serious complications. It provides compression, mimics the act of walking, and keeps blood circulation flowing better. This information was obtained from the website: https://www.veintreatmentclinic.com/blog/what-does-ted-hose-stand-for/

Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide care and services for a gastrojejunostomy stoma site consistent with professional standards of practice for 1 of 54 residents in the survey sample, Resident #17. The findings include: For Resident #17 (R17), the facility staff failed to evidence care of a gastrojejunostomy (GJ) tube (1) stoma site.On the most recent MDS (minimum data set) assessment, annual assessment with a reference date of 2/5/2026, the resident was assessed as having a feeding tube and receives 51% or more of calories from enteral feeding.The physician's orders for R17 documented in part, tube feeding and water flushes but failed to evidence orders for GJ stoma site care.The discharge instructions for R17 dated 12/12/2025 documented in part, Discharge instructions for Gastrostomy/Gastrojejunostomy Tube . Cleanse the skin around the tube and under the skin disk daily with soap and water then dry thoroughly .The comprehensive care plan for R17 documented in part, R17 insertion site will be free of s/sx (signs/symptoms) of infection and provide stoma site care per MD (medical doctor) order or facility policy; see TAR (treatment administration record). Date Initiated: 05/24/2021.On 03/25/2026 3:03 PM, an interview was conducted with LPN (licensed practical nurse) #9. When asked what the procedure for stoma care is, she stated that she changed the dressing and wrote on the dressing the date the dressing was changed. She added that night shift usually changes the dressing.On 03/25/2026 3:38 PM an interview was conducted with RN (registered nurse) #2. When asked what is the procedure for stoma care? He stated care is done daily at 6:00 AM and as needed. He added he would follow the doctor's orders. The facility's policy, Care of a Patient with a Feeding Tube, revised 2/26/2026, documents in part, the stoma area will be cleaned and a dressing applied by a licensed nurse as indicated in accordance with the medical provider's order. In general, the following may be performed unless otherwise specified: a. Cleanse the peristomal area with soap and water using a spiral pattern, moving from the proximal stoma area outward.On 3/26/2026 at 4:30 p.m., the Administrator, DON (director of nursing) and the ADON (assistant director of nursing) were notified of the findings. No further information was provided prior to exit. Reference:(1) G-J (Gastro-Jejunostomy Tube)A G-J tube is placed when the stomach must be bypassed for dietary reasons or dysmotility (slow stomach emptying). In this situation, a smaller tube (J) is placed through an existing gastrostomy line and clamped into place. The smaller line (longer in length) is then threaded down into the jejunum where the formula (and/or medications) are delivered. Because of the smaller size of the GJ, only liquids may pass through this form of a line. This line will have two ports, one that can deliver to the stomach, the other to bypass the stomach directly into the small intestine . This information was obtained from the website: Feeding Tubes - Apfed

Based on observation, clinical record review and staff interview, the facility staff failed to provide respiratory care and services for one of 54 residents in the survey sample, Resident #161. The findings include:1a. For Resident #161 (R161), facility staff failed to administer oxygen according to the physician's order. R161 was admitted to the facility with diagnosis that included but not limited to respiratory failure (1) and chronic obstructive pulmonary disease (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/03/2026, R161 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R161 was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R161 as receiving Oxygen therapy. On 03/23/2026 at approximately 2:49 p.m. an observation revealed R161 receiving oxygen by nasal cannula (3). Observation of the oxygen concentrator (4) flow meter revealed a flow rate between two-and-a-half and three liters per minute. On 03/24/2026 at approximately 8:40 a.m. an observation revealed R161 receiving oxygen by nasal cannula. Observation of the oxygen concentrator flow meter revealed a flow rate between two-and-a-half and three liters per minute. On 03/24/2026 at approximately 1:58 p.m. an observation revealed R161 receiving oxygen by nasal cannula. Observation of the oxygen concentrator flow meter revealed a flow rate between two-and-a-half and three liters per minute. The physician order for R161 documented in part, O2 (oxygen) at 3 (three) L/min (liters per minute) via (by) nasal cannula continuously. Every shift for respiratory failure related to chronic obstructive pulmonary disease. Date Ordered: 9/4/2024. The comprehensive care plan for R161 dated 08/26/2024 documented in part, Focus. (R161) has respiratory problem (s) related to acute illness or chronic condition Chronic lung disease, COPD. Created on: 08/26/2024. Revision on: 03/18/2026. Under Interventions it documented in part, Provide oxygen as ordered. Date Initiated: 03/18/2026.On 03/24/2026 at approximately 2:00 p.m. an observation of the flow meter on R161's oxygen concentrator was conducted with LPN (licensed practical nurse) #2. When asked to describe how to read the flow meter on the oxygen concentrator she stated the liter line should pass through the middle of the float ball. After observing the flow meter, she stated that the oxygen flow rate was between two-and-a-half and three liters per minute. After reviewing the physician's orders for R161's oxygen she stated that the flow rate should have been three liters per minute. When asked why it was important to set the oxygen flow rate according to the physician's order she stated that the resident could become shorth of breath. The manufacturer's user manual for R161's oxygen concentrator documented in part, Chapter 2: Operating Instructions. 6. Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate. On 03/24/2026 at approximately 4:30 p.m. the Administrator, Director of Nursing, and the Assistant Director of Nursing were made aware of the above findings. No further information was provided prior to exit. References:(1) A condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. This information was obtained from the website: https://medlineplus.gov/respiratoryfailure.html. (2) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (3) Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula. (4) A medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen. This information was obtained from the website: https://www.oxygenconcentratorstore.com/help-center/what-is-the-medical-definition-of-an-oxygen-concentrator/. 1b. For R161, facility staff failed to store a nebulizer (1) mask in a sanitary manner when not in use. On 03/23/2026 at approximately 2:49 p.m. an observation revealed R161's nebulizer mask laying on top of the bedside table, uncovered. On 03/24/2026 at approximately 8:40 a.m. an observation revealed R161's nebulizer mask laying on top of the bedside table, uncovered. On 03/24/2026 at approximately 1:58 p.m. an observation revealed R161's nebulizer mask laying on top of the bedside table, uncovered. The physician's order for R161 documented in part, Formoterol Fumarate (2) Inhalation Nebulization Solution 20 MCG (micrograms)/2ML (two milliliters). 2 ml inhale orally via nebulizer two times a day for COPD. Order date: 9/11/2025. On 03/24/2026 at approximately 2:00 p.m. an observation of R161's bedside table was observed with LPN #2. After observing the nebulizer mask laying on top of R161's bedside table uncovered, she stated that the mask should be placed in a plastic bag when it is not in use to prevent contamination. On 03/24/2026 at approximately 4:30 p.m. the Administrator, Director of Nursing, and the Assistant Director of Nursing were made aware of the above findings. No further information was provided prior to exit. References:(1) A small machine that turns liquid medicine into a mist. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000006.htm. (2) Used to control wheezing, shortness of breath, and chest tightness caused by chronic obstructive pulmonary disease. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a602023.html

Based on resident, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 54 residents in the survey sample, Resident #8.The findings include:The facility failed to provide evidence of communication with dialysis facility for Resident #8 (R8).R8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident), hemiplegia/hemiparesis, DM (diabetes mellitus) and ESRD (end stage renal disease).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/19/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for locomotion/transfer/dressing/toileting and hygiene.A review of the physician's order dated 7/1/22 revealed, DIALYSIS: Pick up at 0645 AM on Mondays, Wednesdays and Fridays.A review of the comprehensive care plan dated 7/1/21 revealed, FOCUS: Resident has Renal Disease requiring dialysis due to ESRD and has Shunt to Left Arm. INTERVENTIONS: Coordinate with Dialysis center for dialysis treatments as ordered. Communicate with dialysis provider regularly via pre/post treatment notes.A review of R8's dialysis communication book revealed missing dialysis communication- pre / post weights on 2/20, 2/23, 2/25, 2/27, 3/2, 3/6, 3/9, 3/13 and 3/16.On 3/25/26 at 11:15 AM an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 described the process of caring for residents receiving dialysis therapy: check their fistula for bruit and thrill, send a snack/meal with them depending on time of dialysis, and monitor site for bleeding, information is also sent to the dialysis center with the resident. Upon review of R8's dialysis communication book, LPN #8 noted the missing documentation and stated it is not complete, the weights are to be documented. On 3/25/26 at 4:30 PM, the Administrator, the Director of Nursing and the Administrative Intern were made aware of the findings. A review of the facility's Care Planning Special Needs-Dialysis policy revealed, Interventions and related communication between the Center and the dialysis center may include but are not limited to: Pre-and post-weights.No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to store medications in a safe manner for one of 54 residents in the survey sample, Resident #132, and for one of ten medication carts. The findings include: For Resident #132 (R132), the facility staff failed to store the liquid medication cimetidine (a stomach acid reducing medication) in a safe manner. The medication was labeled with an expiration date of 3/15/26. A review of R132's clinical record revealed a physician's order dated 10/21/25 for cimetidine 300 milligrams/five milliliters-give 2.5 milliliters two times a day for gastroesophageal reflux disease. On 3/24/26 at 10:54 a.m., an observation of the Chesapeake unit medication refrigerator was conducted. R132's bottle of liquid cimetidine was labeled with an expiration date of 3/15/26. On 3/25/26 at 10:55 a.m., R132's bottle of liquid cimetidine was observed with LPN (Licensed Practical Nurse) #2. LPN #2 stated the nurses should check the medication refrigerator for expired medications every day. LPN #2 stated R132's bottle of liquid cimetidine was expired and should have been discarded. On 3/24/26 at 4:34 p.m., the Administrator and Director of Nursing were made aware of the above concern. The facility policy titled, Medication Storage documented, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. No further information was presented prior to exit. 2. The LPN (licensed practical nurse) left the medications for two resident's medications on top of medication cart #1 on the Chesapeake Unit. On 03/24/2024 at approximately 8:05 a.m. an observation of LPN (licensed practical nurse) #1 during the facility's medication administration, revealed he was standing at his medication cart preparing medications for a resident in a room that was kiddie-corner across the hall from the medication cart. Observation of the top of the medication cart revealed two medication cups, each containing several pills and tablets. The medication cups containing the pills and tablets were each covered with a clear plastic drinking cup which was turned upside-down over the medication cups. At approximately 8:10 a.m. LPN #1 walked from behind the medication cart and entered a resident's room kiddie-corner across the hall from the medication cart leaving the medication cups containing the pills and tablets on the top of the medication cart. The surveyor followed LPN #1 into the resident's room to observe the administration of medications. After entering the resident's room, the medication cart was out of line of sight and could not be seen from inside the resident's room. At approximately 8:18 a.m. LPN #1 left the resident's room and returned to the medication cart and began preparing medications for another resident in the same room he was just in. At approximately 8:24 a.m. LPN #1 re-entered the same room again and administered medications to the other resident leaving the medication cups containing the pills and tablets on the top of the medication cart. Once again, the surveyor followed LPN #1 into the resident's room to observe the administration of medications. After entering the resident's room, the medication cart was out of line of sight again and could not be seen from inside the resident's room. On 03/24/2026 at approximately 2:16 p.m. an interview was conducted with LPN #1 regarding the resident's medication being left unattended on top of the mediation cart during his medication administration. He stated that the medications should not have been left on top of the medication cart and should have been placed inside the cart. When asked why it was important not to leave medication on the cart unattended, he stated that someone could come by and take the medications. On 03/24/2026 at approximately 4:30 p.m. the Administrator, Director of Nursing, and the Assistant Director of Nursing were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to honor dietary preferences for one of 54 residents in the survey sample, Resident #1.The findings include:The facility staff failed to honor dietary preferences by serving Resident #1 (R1) fish.R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus), CHF (congestive heart failure) and MI (myocardial infarction).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/19/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for locomotion/transfer/dressing/toileting and dependent for bathing.A review of the comprehensive care plan dated 3/18/26 revealed, FOCUS: Altered nutritional needs related to class II obesity and DM. Liberalized diet in place for optimal oral intake. INTERVENTIONS: Discuss food preferences with resident/family and honor food requests as possible.A review of the dietary progress note dated 2/16/26 at 5:50 PM revealed, Met with patient to discuss food preferences. Preferences obtained and relayed to the kitchen.During the initial resident screening on 3/23/26 at approximately 2:15 PM, R1 stated, Everything is great here, except there is food on my meal trays that are on my dislike preference list. A review of the 3/24/26 lunch meal tray ticket noted Dislikes: vegetables (cooked spinach, green beans, lima beans, peas). No fruit cocktail. No rice. No hot dogs. No fish.R1's lunch tray for 3/24/26 included fish. On 3/25/26 at 11:50 AM, CNA (certified nursing assistant) #6 described meal tray delivery as checking the meal ticket with the food that is on the tray to make sure it is correct, placing the tray in front of the resident and assisting them with meal set up if needed.On 3/26/26 at 7:50 AM an interview was conducted with the dietary manager. Asked to describe the meal tray prep and delivery process, the dietary manager described the process as using the meal ticket to identify which foods to put on the resident trays based on their food preferences; it is a two-step process, the trays are made in the kitchen based on the meal ticket and the aides on the units are to compare the food on the tray with the ticket before it is given to the resident.On 3/25/26 at 4:30 PM, the Administrator, the Director of Nursing and the Administrative Intern were made aware of the findings. A review of the facility's Nutrition Orders and Recommendations policy revealed, The Registered Dietitian maintains communication with the interdisciplinary team regarding nutrition care and recommendations.No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain an accurate medical record for one of 54 residents in the survey sample, Resident #182. The findings include:For Resident #182 (R182), the facility staff failed to maintain an accurate medical record by failing to accurately document resident information in the skilled nursing notes on 3/22/26, 3/23/26 and 3/24/26. R182 was admitted to the facility with diagnoses that included but were not limited to cellulitis of the right and left lower limb (1), chronic lower extremity ulcers (2) and long-term use of anticoagulants (3). The nursing admission/readmission assessment for R182 dated 3/20/2026 documented cellulitis with wounds present on both lower extremities, open areas on both buttocks and the resident taking anticoagulant medication. A body audit for R182 dated 3/21/2026 documented in part, . Cellulitis wound to left posterior calf with necrotic tissue to wound bed, purulent drainage noted to site surrounding skin clustering. 11.5cm x 7.6cm x 0.1cm. Cellulitis wound to right posterior calf with granulation tissue, moderate serous drainage, surrounding skin clustering. 5.0cm x 4.5cm x 0.1cm . The physician orders for R182 documented in part, - Apixaban (4) Oral Tablet 5 MG (milligram) (Apixaban) Give 1 tablet by mouth every 12 hours for DVT (deep vein thrombosis). Order Date: 03/20/2026. Start Date: 03/21/2026.- DAPTOmycin Intravenous Solution (5) Reconstituted (Daptomycin) Use 600 mg intravenously in the evening for Cellulitis for 28 Days. Order Date: 03/21/2026.- Piperacillin-Tazobactam-NaCl Intravenous Solution (6) Reconstituted 4-0.5 GM/100ML (Piperacillin Sodium- Tazobactam Sodium-Sodium Chloride) Use 4.5 gram intravenously every 8 hours for Cellulitis for 28 Days. Order Date: 03/21/2026. The baseline care plan for R182 initiated 3/20/2026 documented in part, At risk for/actual skin breakdown, patient is admitted with pressure injury to right buttock, pressure injury to left buttock, cellulitis wound to left calf, cellulitis wound to right calf, redness to bilateral under breast. Date Initiated: 03/20/2026. Revision on: 03/23/2026. The care plan further documented, Is on Anticoagulant therapy/Blood thinner placing patient at risk for bleeding/bruising. Date Initiated: 03/20/2026. Review of the Daily Skilled Observation and Assessment for Management of Medical Status document for R182 dated 3/22/2026, 3/23/2026 and 3/24/2026 documented the following in part, Is the resident on anticoagulants that increase the risk for bleeding? No . Is the resident receiving care related to recent or ongoing infection? No . Does the resident have impaired skin and/or a wound that is being monitored or treated? No . On 3/25/2026 at 9:50 AM, an interview was conducted with registered nurse (RN) #2 who stated that the nurses completed the skilled notes. He stated that the computer prompted them for some of the documentation in them and they needed to be accurate because the purpose of the skilled note was to keep everyone informed on the progress the resident was making. RN #2 stated that the physicians and the managers reviewed the notes and they should be accurate. He reviewed the skilled notes for R182 and stated that he could not say they were accurate.The facility policy Documentation in Medical Record implemented 6/1/2021 documented in part, Each resident's medical record should contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation On 3/25/2026 at 4:29 PM, the administrator, the director of nursing and the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) Cellulitis is an infection of the skin and deep underlying tissues. Group A strep (streptococcal) bacteria are the most common cause. The bacteria enter your body when you get an injury such as a bruise, burn, surgical cut, or wound. Symptoms include: Fever and chills, Swollen glands or lymph nodes, A rash with painful, red, tender skin. The skin may blister and scab over. Your health care provider may take a sample or culture from your skin or do a blood test to identify the bacteria causing infection. Treatment is with antibiotics. They may be oral in mild cases, or intravenous (by IV) for more severe cases . This information was obtained from the website: Cellulitis | Cellulitis Treatment | MedlinePlus (2) Venous ulcers (open sores) can occur when the veins in your legs do not push blood back up to your heart as well as they should. Blood backs up in the veins, building up pressure. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form.Most venous ulcers occur on the leg, above the ankle. This type of wound can be slow to heal . This information was obtained from the website: Venous ulcers - self-care: MedlinePlus Medical Encyclopedia (3) Blood thinners are medicines that prevent blood clots from forming. They do not break up clots that you already have. But they can stop those clots from getting bigger. It's important to treat blood clots, because clots in your blood vessels and heart can cause heart attacks, strokes, and blockages . Anticoagulants, such as heparin or warfarin (also called Coumadin), slow down your body's process of making clots . This information was obtained from the website: Blood Thinners | Anticoagulants | MedlinePlus (4) Apixaban is used to:prevent strokes or blood clots in people who have atrial fibrillation (a condition where the heart beats irregularly and can lead to clots and stroke) in adults.prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in certain situations.treat DVT and PEApixaban is in a class of medications called factor Xa inhibitors. It works by blocking a natural substance that helps blood clots to form . This information was obtained from the website: Apixaban: MedlinePlus Drug Information (5) Daptomycin injection is used to treat certain blood infections or serious skin infections caused by bacteria in adults and children 1 year of age and older. Daptomycin injection is in a class of medications called cyclic lipopeptide antibiotics. It works by killing bacteria. Antibiotics such as daptomycin injection will not work for treating colds, flu, or other viral infections. Using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment . This information was obtained from the website: Daptomycin Injection: MedlinePlus Drug Information (6) Piperacillin and tazobactam injection is used to treat pneumonia and skin, gynecological, and abdominal (stomach area) infections caused by bacteria. Piperacillin is in a class of medications called penicillin antibiotics. It works by killing bacteria that cause infection. Tazobactam is in a class called beta-lactamase inhibitor. It works by preventing bacteria from destroying piperacillin.Antibiotics such as piperacillin and tazobactam injection will not work for colds, flu, or other viral infections. Taking or using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment . This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694003.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control practices for two of 54 residents in the survey sample, Residents #6, and #115, and for one of five residents in the medication administration observation, Resident #2. The findings include: For Resident #6 (R6), the facility staff failed to implement contact transmission-based precautions. (1) A review of R6's clinical record revealed a physician's order dated 3/23/26 for Contact Isolation for a diagnosis of CRE. (2) On 3/23/26 at 3:35 p.m., R6 was observed lying in bed and the resident's call light was ringing. A sign from the Centers for Disease Control was posted outside of R6's room door and documented, CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 3/23/26 at 3:37 p.m., CNA (Certified Nursing Assistant) #1 entered R6's room and turned off the resident's call light without donning a gown or gloves. On 3/25/26 at 10:39 a.m., an interview was conducted with CNA #1. CNA #1 stated that usually there is a sign posted outside of the room door of residents who require contact precautions. CNA #1 stated that if a resident requires contact precautions, staff should put on a gown and gloves if they are going to touch the resident or items in the resident's room. CNA #1 could not explain why she did not donn a gown or gloves prior to entering R6's room and turning the resident's call light off. On 3/25/26 at 2:12 p.m., the Administrator and Director of Nursing were made aware of the above concern. The facility policy titled, Transmission Based Precautions documented, 3. Contact Precautions. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. No further information was presented prior to exit. References: (1) Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. This information was obtained from website: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html (2) Enterobacterales are a group of bacteria (germs) that are a normal part of the human and animal gut but can also cause infections. Carbapenem-resistant Enterobacterales (CRE) are germs resistant to one or several antibiotics called carbapenems. This information was obtained from the website: https://www.cdc.gov/cre/about/index.html 2. For Resident #115 (R115), the facility staff failed follow infection control practices when entering a contact precautions (1) room on 3/24/2026. On 3/24/2026 at 9:04 AM, an observation was made of R115's doorway to their room. A sign outside of the entrance documented contact precautions in place instructing those who enter to wash hands and don gown and gloves prior to entrance. A storage unit hanging on the door contained gloves, gowns and hand sanitizer. On 3/24/2026 at 9:38 AM, a facility staff member was observed entering R115's room without washing their hands or donning gown or gloves and going to the bedside table to pick up the breakfast tray. The staff member then went to R115's roommates bedside and retrieved the breakfast tray and delivered them out of the room to a waiting dietary staff member. The staff member was observed to sanitize their hands afterwards. The physician orders for R115 documented in part, Contact Isolation DX (diagnosis): UTI (urinary tract infection) Duration: 3/29/26 every shift until 03/29/2026 23:59 (11:59 PM). On 3/25/2026 at 9:50 AM, an interview was conducted with registered nurse (RN) #2 who stated that when a resident was on contact precautions it meant that staff could not go in the room without PPE (personal protective equipment) on which included gown and gloves. He stated that it did not matter what the staff were doing and it included if they were picking up the meal trays. RN #2 stated that this was to avoid transmission of infection and prevent spreading any infection from resident to resident. On 3/25/2026 at 10:39 AM, an interview was conducted with certified nursing assistant (CNA) #1 who stated that when a resident was on contact precautions they put on gown and gloves. She stated that they knew the resident was on contact precautions by the sign on the door and they put the gown and gloves on if they touched anything in the room. The facility policy Transmission-Based Precautions revised 2/9/2026 documented in part, . Contact Precautions . Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, MRSA, Acinetobacter baumanni, ESBL producing organisms, etc.) . On 3/25/2026 at 4:29 PM, the administrator, the director of nursing and the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens . This information was obtained from website: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html 3. For Resident #2 (R2), the facility staff failed to administer eye drops and an injection in a sanitary manner on 3/23/26. On 3/23/26 at 8:13 a.m., RN (registered nurse) #1 was observed preparing and administering medications to R2. RN #1 placed all medications to be administered on a tray on the medication cart. She sanitized her hands and donned gloves. She closed two drawers on the medication cart, touched the surface of the medication cart, and pressed the lock on the medication cart. She took the tray of medications to the resident, who was sitting up in a chair. She pressed each individual oral medication out of its blister packaging into a medication cup. Without changing gloves or sanitizing her hands, she administered one drop of Olopatadine 0.1% ophthalmic solution (1) into each eye. Without changing gloves or sanitizing her hands, she administered Enoxaparin 100 mg (milligrams) (2) into R2's subcutaneous tissue on her right hip. A review of R2's clinical record revealed the following orders:Olopatadine HCl Ophthalmic Solution 0.1 % Instill 1 drop in both eyes in the morning for antihistamine. Enoxaparin Sodium Injection Solution Prefilled Syringe 100 MG/ML (milligram per milliliter) Inject 1 ml.every 12 hours. On 3/25/26 at 9:23 a.m., LPN (licensed practical nurse) #1 was interviewed. He stated if a nurse dons gloves prior to administering any medications, the gloves should be changed and the nurse's hands should be sanitized if the gloves become contaminated. He stated the nurse should always sanitize hands and put on clean gloves between administering oral medications and giving eye drops. He stated this helps prevent eye infections. He explained that between administering eye drops and administering an injection, the gloves should also be removed and hands sanitized prior to donning new gloves and giving the injection. He stated this is basic nursing care to prevent residents from becoming contaminated with bacteria or other germs. On 3/25/26 at 4:28 p.m., the Administrator and Director of Nursing were informed of these concerns. A review of the facility policy, Hand Hygiene, revealed, in part: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Change gloves during patient care when moving from a contaminated body site to a clean body site. No additional information was provided prior to exit. References(1) Prescription ophthalmic olopatadine (Pazeo) and nonprescription ophthalmic olopatadine are used to relieve itchy eyes caused by allergic reactions to pollen, ragweed, grass, animal hair, or pet dander. Olopatadine is in a class of medications called mast cell stabilizers. It works by preventing the release of substances that cause eye itching. This information is taken from the website https://medlineplus.gov/druginfo/meds/a602025.html. (2) Enoxaparin is used to prevent and treat deep vein thrombosis (DVT; blood clots that form in the veins, typically in the legs). It is also used to prevent complications from angina (chest pain) and heart attacks. Enoxaparin is in a class of medications called low molecular weight heparins. It works by stopping the formation of substances that cause clots. This information was taken from the website https://medlineplus.gov/druginfo/meds/a601210.html.

Based on resident representative interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for five of 54 residents in the survey sample, Residents #17, # 90, #185, #10, and #132. The findings include: 1. For Resident #17 (R17) the facility staff failed to provide incontinence care/toileting assistance on multiple dates in 1/2026, 2/2026, 3/2026. On the most recent minimum data set (MDS), an annual assessment with an assessment reference date (ARD) of 2/5/2026, the resident was assessed as having a BIMs (brief interview for mental status) score of 00 meaning the resident was severely impaired for making daily decisions. R17 was assessed as always being incontinent of bowel and bladder and being dependent on staff for toileting hygiene. On 3/34/2026 at 12:04 AM an interview was conducted by phone with the resident's representative. They stated their concern is that the facility is not taking care of the resident, for example she had been to the facility several times on the weekend, and it appeared as if the resident's brief had been wet for hours. Review of the ADL documentation for R17 from 1/5/2026-1/31/2026 failed to evidence incontinence care provided on day shift on 1/7/26, 1/14/26, 1/18/26, 1/19/26, 1/21/26, 1/23/26, 1/28/26, 1/30/26, on evening shift on 1/5/26, 1/12/26, 1/18/26, and on night shift on 1/25/26, 1/31/26. The date blocks were blank. Review of the ADL documentation for R17 from 2/4/2026-2/15/2026 and 2/23/2026-2/28/2026 failed to evidence incontinence care provided on day shift on 2/5/26, 2/7/26, 2/8/26, 2/14/26, 2/15/26, 2/24/26, 2/25/26, 2/26/26, on evening shift on, 2/4/26, and on night shift on, 2/14/26, 2/15/26, 2/25/26, 2/27/26, 2/28/26. The date blocks were blank. Review of ADL documentation for R17 from 3/1/2026-3/7/2026 and 3/13/2026-3/22/2026 failed to evidence incontinence care provided on day shift on 3/1/26, 3/2/26, 3/4/26, 3/5/26, 3/14/26, 3/15/26, 3/19/26, 3/20/26, on evening shift on, 3/4/26, and on night shift on, 3/1/26, 3/2/26, 3/3/26, 3/14/26, 3/17/26, 3/18/26, 3/21/26, 3/22/26. The date blocks were blank. The comprehensive care plan for R17 documented in part, resident has been assessed as incontinent of bowel and bladder and will have bowel and bladder continence needs met as indicates for the next 30 days. Date initiated 5/24/2021 and revised on 2/10/2026. On 3/25/2026 at 10:45 AM an interview was conducted with certified nursing assistant (CNA) #1 who stated that incontinence care was provided every two hours and is evidenced by documentation. On 3/25/2026 at 11:37 AM an interview was conducted with CNA #5 who stated that incontinence care was provided every two hours and anytime a resident called to say they needed to be changed. She stated she evidenced care that she provided by documentation at the end of the shift. The facility policy ADL Care of Patients CL. 1301 dated 2.6.2026 documented in part, .Each patient will be provided with daily personal attention and care.daily personal care provided will be documented in the patient's medical record. patients who are incontinent will receive. clean clothing and linens each time their clothing or bed linen is soiled/wet with bodily fluids (urine, feces). On 3/26/2026 at 4:30 p.m., the Administrator, DON (director of nursing) and the ADON (assistant director of nursing) were notified of the findings. No further information was provided prior to exit. 2. For Resident #90 (R90) the facility staff failed to provide showers for the resident twice a week between the dates of 2/8/2026-2/22/2026. On the most recent minimum data set (MDS), a Medicare - 5 day with an assessment reference date (ARD) of 1/30/2026, the resident was assessed as having a BIMS (brief interview for mental score) score of 12 meaning the resident was moderately impaired for making daily decisions. R90 was assessed as being dependent for showering and bathing. On 3/24/2026 at 10:02 AM, an interview was conducted with R90's authorized representative. They stated they are concerned about the resident not getting showered regularly. Review of the clinical documentation from 2/8/2026-2/22/26 evidenced R90 received two showers in a two-week time frame. The comprehensive care plan for R90 documented in part, resident requires ADL assistance with diagnosis of right femur fracture . and will receive necessary level of ADL assistance. and resident will be provided assistance with bathing and hygiene as required. Date initiated 1/23/2026. On 3/25/2026 at 9:36 a.m., an interview was conducted with CNA (certified nursing assistant) #5 who stated that showers are given at least twice a week but more if the resident asked. She stated they document showers given in the care tech. She stated if a resident refused a shower, the CNA notified the resident's nurse and the nurse verified with the resident the refusal. The facility policy ADL Care of Patients CL. 1301 dated 2.6.2026 documented in part, .patients will receive a tub/shower bath as often as needed, but not less than twice weekly. On 3/26/2026 at 4:30 p.m., Administrator, DON (director of nursing) and the ADON (administrator director of nursing) were notified of the findings. No further information was provided prior to exit. 3. For Resident #185 (R185), the facility staff failed to provide incontinence care/toileting assistance on night shift 6/28/2024 and 6/30/2024. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 6/22/2024, the resident was assessed as being frequently incontinent of bowel and bladder and being dependent on staff for toileting. Review of the ADL (activities of daily living) documentation for R185 from 6/1/2024-6/30/2024 failed to evidence toileting hygiene provided on night shift on 6/28/2024 and 6/30/2024. The dates were blank. The comprehensive care plan for R185 documented in part, Has been assessed as incontinent of bowel and bladder. Date Initiated: 06/24/2024. Under Interventions/Tasks it documented in part, Observe for moisture and incontinence issues and provide care as indicated. Date Initiated: 06/24/2024. On 3/25/2026 at 9:50 AM, an interview was conducted with registered nurse (RN) #2 who stated that he did not remember R185 or any conversations with the family about any concerns. He stated that incontinence care should be provided every two hours and more often as needed. On 3/25/2026 at 10:39 AM, an interview was conducted with certified nursing assistant (CNA) #1 who stated that incontinence care was provided every two hours or anytime the resident called them. She stated that they evidenced the care they provided by documenting it in the medical record every shift. On 3/25/2026 at 11:31 AM, an interview was conducted with CNA #5 who stated that incontinence care was provided every two hours at a minimum and there were some residents who required it more often. She stated that they evidenced the care they provided by their documentation in the medical record each shift. On 3/25/2026 at 4:29 PM, the administrator, the director of nursing and the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to provide ADL (activities of daily living) specifically incontinent care for a dependent resident, Resident #10 (R10). R10 was admitted to the facility on [DATE] with diagnosis that included but were not limited to osteoarthritis, dementia, atrial fibrillation and chronic obstructive pulmonary disease (COPD). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 2/17/26, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting and hygiene. A review of the comprehensive care plan dated 9/29/23 revealed, FOCUS: Resident has bladder & bowel incontinence related to impaired bed mobility and weakness. INTERVENTIONS: Observe for moisture and incontinence issues and provide care as indicated. A review of R10's ADL (activities of daily living) record reveals missing evidence of incontinence care, turning and positioning being provided on following dates and shifts: Day shift- 12/21/25, 12/26/25, 1/20, 1/26, 1/27, 2/2, 2/3, 2/4, 2/10, 2/15, 2/16, 2/17, 2/24, 3/10, 3/19 NS 3/22 and Night shift-12/31, 1/31 and 2/28. On 3/24/26 at 11:00 AM an interview was conducted with CNA (certified nursing assistant) #6. CNA #6 described the process to provide incontinence care and turning / positioning as follows: the resident rounding starts at the beginning of their shift and then it is every two hours, unless the resident needs incontinence care more frequently. This is all documented in their section of point click care. That is the evidence it was completed, if it is not documented there is no evidence that it was done. On 3/25/26 at 4:30 PM, the Administrator, the director of nursing and the administrative intern were made aware of the findings. No further information was provided prior to exit. 5. The facility staff failed to provide ADL (activities of daily living) specifically incontinent care for a dependent resident, Resident #132 (R132). R132 was admitted to the facility on [DATE] with diagnosis that included but were not limited to epilepsy, traumatic brain injury, schizophrenia and psychotic delusions. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/3/26, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting and hygiene. Resident is non-functioning on her right side. A review of the comprehensive care plan dated 3/2/23 revealed, FOCUS: Resident has bladder & bowel incontinence related to functional incontinence. Resident is at risk for pressure ulcer development related to immobility and incontinence, INTERVENTIONS: Encourage and/or assist resident with cleansing perineal area after each incontinence episode. Provide assistance with toileting and peri-care as requested and/or needed. Educate and encourage resident to change positions for pressure relief frequently. A review of R132's ADL (activities of daily living) record reveals missing evidence of incontinence care, turning and positioning being provided on following dates and shifts: Day shift- 1/20, 1/26, 1/27, 2/2, 2/3, 2/4, 2/10, 2/15, 2/16, 2/17, 2/24, 3/10, 3/19 NS 3/22 and Night shift- 1/31 and 2/28. On 3/24/26 at 11:00 AM an interview was conducted with CNA (certified nursing assistant) #6. CNA #6 described the process to provide incontinence care and turning / positioning as follows: the resident rounding starts at the beginning of our shift and then it is every two hours, unless the resident needs incontinence care more frequently. This is all documented in our section of point click care. That is the evidence it was completed, if it is not documented there is no evidence that it was done. On 3/25/26 at 4:30 PM, the administrator, the director of nursing and the administrative intern were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the baseline care plan for one of 54 residents in the survey sample, Resident #182. The findings include:For Resident #182 (R182), the facility staff failed to implement the baseline care plan to implement treatment to wounds identified upon admission. The minimum data set (MDS) was not due at the time of the survey. R182 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cellulitis (1) and chronic lower extremity ulcers. The baseline care plan for R182 initiated 3/20/2026 documented in part, At risk for/actual skin breakdown, patient is admitted with pressure injury (2) to right buttock, pressure injury to left buttock, cellulitis wound to left calf, cellulitis wound to right calf, redness to bilateral under breast. Date Initiated: 03/20/2026. Revision on: 03/23/2026. Under Interventions/Tasks it documented in part, Assess skin thoroughly and implement precautions and/or treatment as indicated. Date Initiated: 03/20/2026 . On the nursing admission/readmission assessment for R182 dated 3/20/2026 the skin assessment documented, .cellulitis on bilateral lower extremities and wound to bilateral lower extremities . excoriation to the sacrum and open area on bilateral buttocks . A body audit for R182 dated 3/20/2026 documented the findings above.A body audit for R182 dated 3/21/2026 documented in part, . Right buttock: DTI (deep tissue injury) (3) to right buttock with dark maroon/purple tissue to wound bed, no drainage surrounding skin redness. 4.0cm (centimeter) x 3.5cm x 0.1cm. Left buttock: DTI to left buttock with dark maroon/purple tissue to wound bed, no drainage noted, surrounding skin redness. 4.5cm x 4.0cm x 0.1cm . Cellulitis wound to left posterior calf with necrotic tissue to wound bed, purulent drainage noted to site surrounding skin clustering. 11.5cm x 7.6cm x 0.1cm. Cellulitis wound to right posterior calf with granulation tissue, moderate serous drainage, surrounding skin clustering. 5.0cm x 4.5cm x 0.1cm . The physician orders for R182 documented in part, - Cleanse Cellulitis wound to left posterior calf with wound cleanser, pat dry apply calcium Alginate to wound bed + ABD, wrap with kerlix gauze wrap then tape. change dressing daily and PRN (as needed). every evening shift for cellulitis wound. Order Date: 03/23/2026. Start Date: 03/24/2026.- Cleanse Cellulitis wound to right posterior calf with wound cleanser, pat dry apply calcium Alginate to wound bed + ABD, wrap with kerlix gauze wrap then tape. change dressing daily and PRN. every evening shift for cellulitis wound. Order Date: 03/23/2026. Start Date: 03/24/2026.- Cleanse pressure injury to left buttock with wound cleanser, pat dry apply zinc oxide paste to site daily and PRN. notify MD/NP (medical doctor/nurse practitioner) for any changes. every shift for Pressure injury. Order Date: 03/23/2026. Start Date: 03/23/2026. Review of the electronic treatment administration record (eTAR) for R182 dated 3/1/2026-3/31/2026 documented treatment to the pressure injury on the left and right buttock pressure injuries beginning on night shift 3/23/2026 and treatment to the cellulitis wounds on the left and right posterior calf beginning on evening shift 3/24/2026. The clinical record failed to evidence treatment to the wounds described above prior to 3/23/2026. On 3/25/2026 at 9:35 AM, an interview was conducted with licensed practical nurse (LPN) #1 who stated that the care plan purpose was to give the staff direction and help them in the way that they take care of every patient because every patient was different. He stated that the care plan should be implemented because they could not take care of the resident if they did not know what they needed. LPN #1 stated that on admission, a skin assessment was performed to identify any wounds and wounds were documented on the skin assessment with notification of the physician and the wound team. LPN #1 stated that if it was after hours and the wound nurse was not in the building they called the physician to get an order for a treatment until the wound nurse could assess the wound. On 3/25/2026 at 11:16 AM, an interview was conducted with LPN #6 who stated that they did not recall admitting R182 on 3/20/2026 or the skin assessment because they floated all over the facility. She stated that when a resident was admitted they did a full body skin assessment and documented any wounds. LPN #6 stated that any wounds were reported to the physician and they discussed any treatment orders sent from the hospital to obtain orders for treatment of the wounds at the facility. She stated that the next day the wound nurse came in to do a skin assessment and updated the orders as needed.On 3/25/2026 at 4:29 PM, the administrator, the director of nursing and the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) Cellulitis is an infection of the skin and deep underlying tissues. Group A strep (streptococcal) bacteria are the most common cause. The bacteria enter your body when you get an injury such as a bruise, burn, surgical cut, or wound. Symptoms include: Fever and chills, Swollen glands or lymph nodes, A rash with painful, red, tender skin. The skin may blister and scab over. Your health care provider may take a sample or culture from your skin or do a blood test to identify the bacteria causing infection. Treatment is with antibiotics. They may be oral in mild cases, or intravenous (by IV) for more severe cases . This information was obtained from the website: Cellulitis | Cellulitis Treatment | MedlinePlus (2) Pressure sores occur when there is too much pressure on the skin for too long. This reduces blood flow to the area. Without enough blood to nourish the skin, the skin can die and a sore may form . This information was obtained from the website: How to care for pressure sores: MedlinePlus Medical Encyclopedia (3) There are two other types of pressure sores that don't fit into the stages.Sores covered in dead skin that is yellow, tan, green, or brown. The dead skin makes it hard to tell how deep the sore is. This type of sore is unstageable.Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore .This information was obtained from the website: How to care for pressure sores: MedlinePlus Medical Encyclopedia

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide a written notice of transfer for one of 54 residents in the survey sample, Resident #6. The findings include:For Resident #6 (R6), the resident was transferred to the hospital on 2/28/26. The facility staff failed to provide a written notice of transfer to the resident, resident representative, or ombudsman. A review of R6's clinical record revealed the resident was transferred to the hospital on 2/28/26 for a fever, low oxygen, and a slow response. Further review of R6's clinical record and a review of a facility binder containing ombudsman notices failed to reveal the facility staff provided a written notice of transfer to R6, the resident's representative, or the ombudsman. On 3/24/26 at 2:47 p.m., an interview was conducted with the Director of Social Services. The Director of Social Services stated that when a resident is transferred to the hospital, she sends written notification of the transfer to the resident's family via mail, documents the date this is done on a written notification form, and sends a weekly encrypted email of all transfers to the ombudsman. The Director of Social Services stated she provides the written notification form to the resident, if and when the resident returns to the facility. The Director of Social Services stated she was on leave when R6 was transferred to the hospital and her social services team was new. On 3/24/26 at 4:34 p.m., the Administrator and Director of Nursing were made aware of the above concern. The facility policy titled, Notification of Discharge documented, Discharge notices for emergent discharges will be provided to the patient/representative as soon as practicable. Copies of notices for emergency transfers must also be sent to the ombudsman, but they may be sent when practicable and may be provided in the form of a list of residents monthly. No further information was presented prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician of medication not administered for one of 54 residents in the survey sample, Resident #182. The findings include: For Resident #182 (R182), the facility staff failed to notify the physician that the Daptomycin Intravenous Solution (1) was not administered as ordered on 3/21/2026 at 5:00 PM. The minimum data set (MDS) was not due at the time of the survey. R182 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cellulitis (2) and chronic lower extremity ulcers. The physician orders for R182 documented in part, Daptomycin Intravenous Solution Reconstituted (Daptomycin) Use 600 mg (milligram) intravenously in the evening for Cellulitis for 28 Days. Order Date: 03/21/2026. Start Date: 03/21/2026. Review of the electronic medication administration record (eMAR) for R182 dated 3/1/2026-3/31/2026 documented the Daptomycin order listed above. For the 3/21/2026 5:00 PM dosage it documented a 9. The eMAR Chart Codes documented in part, .9=Other/See Nurses Notes. The progress notes for R182 documented in part,- 3/20/2026 22:12 (10:12 PM) Note Text: Patient is [age and sex of R182], admitted from [Name of hospital] arrived to facility at around 2015 (8:15 PM) via stretcher accompanied by transportation staff. Patient is alert and oriented to person, place and time. Able to follow all commands . Patient has central line on Right upper chest with double lumen. Patient is on IV (intravenous) ABT (antibiotic) Daptomycin Intravenous Solution Reconstituted (Daptomycin) one time a day in the evening for Cellulitis . - 3/21/2026 18:13 (6:13 PM) Note Text: Daptomycin Intravenous Solution Reconstituted Use 600 mg intravenously in the evening for Cellulitis for 28 Days. waiting for pharmacy arrived [sic]. The clinical record failed to evidence notification of the physician that the 3/21/2026 dose of the Daptomycin was not administered. On 3/25/2026 at 9:35 AM, an interview was conducted with licensed practice nurse (LPN) #1 who stated that if a medication had not arrived from the pharmacy the nurse should call the physician to let them know that it had not arrived to follow any instructions they gave. He stated that they should document that they notified the physician and the resident that the medication was not given as scheduled because it had not arrived from the pharmacy. On 3/25/2026 at 9:50 AM, an interview was conducted with registered nurse (RN) #2 who stated that they reviewed when a resident received their last doses of any antibiotics from the hospital discharge information upon admission and tried not to miss any doses. He stated that they faxed the prescriptions over to the pharmacy right away and if the medication had not arrived they notified the physician to see if they wanted to extend the treatment time and to let them know that a dose was not available. RN #2 stated that this would be documented in the medical record. The facility policy Medication Ordering and Receipt documented in part, .Information provided to the Pharmacy regarding new admissions must be transmitted immediately using the admission process as established by the pharmacy/facility . On 3/25/2026 at 4:29 PM, the administrator, the director of nursing and the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. Reference:(1) Daptomycin injection is used to treat certain blood infections or serious skin infections caused by bacteria in adults and children 1 year of age and older. Daptomycin injection is in a class of medications called cyclic lipopeptide antibiotics. It works by killing bacteria. Antibiotics such as daptomycin injection will not work for treating colds, flu, or other viral infections. Using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment . This information was obtained from the website: Daptomycin Injection: MedlinePlus Drug Information (2) Cellulitis is an infection of the skin and deep underlying tissues. Group A strep (streptococcal) bacteria are the most common cause. The bacteria enter your body when you get an injury such as a bruise, burn, surgical cut, or wound. Symptoms include: Fever and chills, Swollen glands or lymph nodes, A rash with painful, red, tender skin. The skin may blister and scab over. Your health care provider may take a sample or culture from your skin or do a blood test to identify the bacteria causing infection. Treatment is with antibiotics. They may be oral in mild cases, or intravenous (by IV) for more severe cases . This information was obtained from the website: Cellulitis | Cellulitis Treatment | MedlinePlus

Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for one of 54 residents in the survey sample, Resident #132. The findings include:The facility staff failed to maintain the call light in a position where Resident 132 could access it. Observation on 3/24/26 at 8:40 AM revealed R132 in her wheelchair with her right side parallel to her bed. Resident #132's (R132) touch pad call bell cord was clipped to the edge of the bed with the TV (television) remote control. R132 was admitted to the facility on [DATE] with diagnosis that included but were not limited to epilepsy, traumatic brain injury, schizophrenia and psychotic delusions.The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/3/26, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting and hygiene. Resident is non-functioning on her right side.A review of the comprehensive care plan dated 8/5/24 revealed, FOCUS: Resident has had actual fall with no injury which increases risk of falling in the future. INTERVENTIONS: Place personal items, water, etc. within reach of resident.During the observation of R132 on 3/24/26 at 8:40 AM, resident was asked to reach the call bell. R132 reached across her body with her left hand and was unable to reach the call bell clipped to the edge of the bed on her right side. R132 communicates 'no' by shaking her head and 'yes' by lifting left thumb up. Asked if she was able to reach her touch pad call bell, R132 shook her head 'no'.On 3/24/26 at 8:50 AM an interview was conducted with LPN (licensed practical nurse) #1. Asked to observe R132's call bell, LPN #1 went into room and asked resident if she could reach her touch pad call bell, she showed him she could not reach it across her body with her left hand. LPN #1 relocated the call bell to her wheelchair tray and asked if her call bell was in reach. R132 showed LPN #1 that she could reach the call bell once moved to her wheelchair tray. LPN #1 stated, it is a safety issue if she cannot call us for assistance, as her call bell was not initially within her reach.On 3/25/26 at 4:30 PM, the administrator, the director of nursing and the administrative intern were made aware of the findings. A review of the facility's Call Lights: Accessibility and Timely Response policy, revealed, The purpose of this policy is to ensure the Center is adequately equipped with a call light at each patients' bedside, toilet, and bathing area to allow patients to call for assistance. Call lights will directly relay assistance is needed to an employee(s) or centralized location to facilitate prompt response/intervention for the patient.No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for a pressure injury for one of 54 residents in the survey sample, Resident #182. The findings include:For Resident #182 (R182), the facility staff failed to implement treatment to a pressure injury (1) identified upon admission. The minimum data set (MDS) was not due at the time of the survey. R182 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cellulitis (2) and chronic lower extremity ulcers. On the nursing admission/readmission assessment for R182 dated 3/20/2026 the skin assessment documented, . excoriation to the sacrum and open area on bilateral buttocks . The assessment documented R182 being alert and oriented to person, place and time. On 3/23/2026 at 2:43 PM, an interview was conducted with R182 who stated that they had only been at the facility since Friday evening. R182 stated that their compression wraps had slipped down at home and they had developed cellulitis in the lower legs and was at the facility for a 28-day course of antibiotics to treat the infection. R182 stated that they had begun therapy that day and had seen many staff coming in to do multiple assessments and was worn out. A body audit for R182 dated 3/20/2026 documented the findings above.A body audit for R182 dated 3/21/2026 documented in part, . Right buttock: DTI (deep tissue injury) (3) to right buttock with dark maroon/purple tissue to wound bed, no drainage surrounding skin redness. 4.0cm (centimeter) x 3.5cm x 0.1cm. Left buttock: DTI to left buttock with dark maroon/purple tissue to wound bed, no drainage noted, surrounding skin redness. 4.5cm x 4.0cm x 0.1cm . The physician orders for R182 documented in part, - Cleanse pressure injury to left buttock with wound cleanser, pat dry apply zinc oxide paste to site daily and PRN (as needed). notify MD/NP (medical doctor/nurse practitioner) for any changes. every shift for Pressure injury. Order Date: 03/23/2026. Start Date: 03/23/2026.- Zinc Oxide External Paste 20 % (Zinc Oxide (Topical)) Apply to Right buttock topically every shift for Pressure injury Cleanse pressure injury to right buttock with wound cleanser, pat dry apply Zinc Oxide to site daily and PRN. notify MD/NP for any changes. Order Date: 03/23/2026. Start Date: 03/23/2026. Review of the electronic treatment administration record (eTAR) for R182 dated 3/1/2026-3/31/2026 documented treatment to the pressure injury on the left and right buttock pressure injuries beginning on night shift 3/23/2026. The baseline care plan for R182 initiated 3/20/2026 documented in part, At risk for/actual skin breakdown, patient is admitted with pressure injury to right buttock, pressure injury to left buttock, cellulitis wound to left calf, cellulitis wound to right calf, redness to bilateral under breast. Date Initiated: 03/20/2026. Revision on: 03/23/2026. The clinical record failed to evidence treatment to the wounds described above prior to 3/23/2026. On 3/25/2026 at 9:26 AM, an interview was conducted with licensed practical nurse (LPN) #5, wound nurse. LPN #5 stated that three body audits were completed on all new admissions. She stated that the first body audit was completed by the admission nurse, and she completed the next two. She stated that when a wound was identified on admission the nurse should check the hospital discharge instructions for treatment orders for the wound and if there were no orders they should contact the physician. LPN #5 stated that the admission nurse normally put in the initial treatment and after she did her assessment she may change it as needed. She stated that any treatment to a wound would be evidenced by the documentation on the eTAR and she would review R182's record and orders to see if there was anything in place for the wounds prior to 3/23/2026. On 3/25/2026 at 9:35 AM, an interview was conducted with LPN #1 who stated that on admission, a skin assessment was performed to identify any wounds. He stated that any wounds were documented on the skin assessment and the physician and the wound team was notified. LPN #1 stated that if it was after hours and the wound nurse was not in the building they called the physician to get an order for a treatment until the wound nurse could assess the wound. On 3/25/2026 at 9:50 AM, an interview was conducted with registered nurse (RN) #2 who stated the admission nurse reviewed the hospital discharge orders for any wound treatment orders and enter those into the medical record. He stated that if there were no wound treatment orders the nurse should call the physician to get an order for the wound. RN #2 stated that the wound nurse would come to assess the resident the next day and ensure the correct treatment was in place. On 3/25/2026 at 11:16 AM, an interview was conducted with LPN #6 who stated that they did not recall admitting R182 on 3/20/2026 or the skin assessment because they floated all over the facility. She stated that when a resident was admitted they did a full body skin assessment and documented any wounds. LPN #6 stated that any wounds were reported to the physician and they discussed any treatment orders sent from the hospital to obtain orders for treatment of the wounds at the facility. She stated that the next day the wound nurse came in to do a skin assessment and updated the orders as needed.The facility policy Pressure Injury Prevention Guidelines revised 2/26/2026 documented in part, . Interventions will be documented in the care plan. 5. Compliance with interventions will be documented in the medical record . b. For patients who have a pressure injury present: treatment or medication administration records: plan of care . Surveillance will be utilized as a method to prevent and to promote the early identification of pressure injuries, to the extent possible. RNs and LPNs participate in surveillance through the evaluation of patients and reporting changes in condition to the patient's physician/physician extender and other nursing management employees of new or worsened pressure injuries . On 3/25/2026 at 4:29 PM, the administrator, the director of nursing and the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. Reference:(1) Pressure sores occur when there is too much pressure on the skin for too long. This reduces blood flow to the area. Without enough blood to nourish the skin, the skin can die and a sore may form . This information was obtained from the website: How to care for pressure sores: MedlinePlus Medical Encyclopedia (2) Cellulitis is an infection of the skin and deep underlying tissues. Group A strep (streptococcal) bacteria are the most common cause. The bacteria enter your body when you get an injury such as a bruise, burn, surgical cut, or wound. Symptoms include: Fever and chills, Swollen glands or lymph nodes, A rash with painful, red, tender skin. The skin may blister and scab over. Your health care provider may take a sample or culture from your skin or do a blood test to identify the bacteria causing infection. Treatment is with antibiotics. They may be oral in mild cases, or intravenous (by IV) for more severe cases . This information was obtained from the website: Cellulitis | Cellulitis Treatment | MedlinePlus (3) There are two other types of pressure sores that don't fit into the stages.Sores covered in dead skin that is yellow, tan, green, or brown. The dead skin makes it hard to tell how deep the sore is. This type of sore is unstageable.Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore .This information was obtained from the website: How to care for pressure sores: MedlinePlus Medical Encyclopedia

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to administer parenteral medications in a manner to prevent infection for one of five residents in the medication administration observation, Resident #2.The findings include:For Resident #2 (R2), the facility staff failed to administer an intravenous antibiotic in a sanitary manner on 3/23/26. On 3/23/26 at 8:13 a.m., RN (registered nurse) #1 was observed preparing and administering medications to R2. RN #1 placed all medications to be administered on a tray on the medication cart. She sanitized her hands and donned gloves. She closed two drawers on the medication cart, touched the surface of the medication cart, and pressed the lock on the medication cart. She took the tray of medications to the resident, who was sitting up in a chair. Without changing gloves, she administered oral medications, eye drops, and an injection to R2. Without changing gloves, she removed the cap to R2's central venous access, cleaned the access with alcohol, and connected the tubing for the Daptomycin (1) to R2's central venous access. She unclamped the antibiotic so that it could begin infusing.A review of R2's clinical record revealed the following order: Daptomycin Sodium Chloride Intravenous Solution 500-0.9 MG/50ML (milligrams per milliliter) Use 620 mg intravenously one time a day for Wound Infection for 6 Weeks.On 3/25/26 at 9:23 a.m., LPN (licensed practical nurse) #1 was interviewed. He stated if a nurse dons gloves prior to administering any medications, the gloves should be changed and the nurse's hands should be sanitized if the gloves become contaminated. He explained that between administering any other medications and accessing a resident's central venous access, the gloves should be removed and hands sanitized prior to donning new gloves and attaching an antibiotic to a central venous access. He stated this is basic nursing care to prevent residents from becoming contaminated with bacteria or other germs. He stated that central venous accesses are especially critical because the directly affect the resident's bloodstream.On 3/25/26 at 4:28 p.m., the Administrator and Director of Nursing were informed of these concerns.A review of the facility policy, Intravenous (IV) Access Device Care, revealed no information related to these concerns.A review of the facility policy, Hand Hygiene, revealed, in part: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Change gloves during patient care when moving from a contaminated body site to a clean body site.No additional information was provided prior to exit.Reference(1) Daptomycin injection is used to treat certain blood infections or serious skin infections caused by bacteria in adults and children 1 year of age and older. Daptomycin injection is in a class of medications called cyclic lipopeptide antibiotics. It works by killing bacteria. This information is taken from the website https://medlineplus.gov/druginfo/meds/a608045.html.

Based on observation, interview, clinical record review and facility documentation review, the facility staff failed to ensure the Resident's right to privacy for 1 Resident (Resident #3), in a survey sample of 4 Residents. The findings included: For Resident #3, the facility staff failed to ensure Resident #4, who was a Resident with dementia and wandering behaviors, did not wander into Resident #3's room at will. On 11/14/23 at 1:00 PM Resident #4 was observed in the hall self-propelling wheelchair down hall. She was observed to stop and stay in the doorway and look in the rooms. On 11/14/23 at 1:20 PM an interview was conducted with CNA B (certified nursing assistant-B) who stated they try to keep Residents that wander, out of other Residents rooms however it is not always possible. CNA B stated that Resident #4 has had to be redirected on many occasions out of Resident #3's room. CNA B stated that Resident #4 is easily redirected. On 11/15/23 at approximately 10:30 AM an interview was conducted with Resident #3 who was asked about issues with other Residents. Resident #3 stated That a lady wanders in his room from next door. She comes in, but she doesn't knock it makes me mad if I'm using my urinal or if I'm washing up. That's why I keep my door closed all the time. On 11/15/23 a review of the clinical record revealed that Resident #3 has care planned to keep his door closed to deter Resident #4 from entering his room. On 11/15/23 at approximately 11:00 AM an interview was conducted with the Administrator who stated she was aware that Resident #4 had a wander guard as a result of the assessment in August. When asked if it was her expectation that the information on wandering behaviors and placement of a wander guard be in the care plan she stated that it was her expectation. When asked if she expected there to be interventions to protect the privacy of other Residents and she stated that it was. During the end of day meeting on 11/15/23, the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation review, the facility staff failed to ensure care plans were reviewed and revised to accurately reflect changes in care for 1 Resident (Resident #4) in a survey sample of 4 Residents. The findings included: For Resident #4 the facility staff failed to add the wandering risk assessment results, the addition of the wander guard, and interventions for wandering to the comprehensive care plan. On 11/14/23 at 1:00 PM Resident #4 was observed self-propelling the wheelchair down the hallway. She was observed to stop and stay in the doorway and look in the rooms. On 11/14/23 at 1:20 PM an interview was conducted with CNA B (certified nursing assistant-B) who stated they try to keep Residents that wander, out of other Residents rooms however it is not always possible. CNA B stated that Resident #4 has had to be redirected on many occasions out of Resident #3's room. CNA B stated that Resident #4 is easily redirected. On 11/15/23 at approximately 10:30 AM an interview was conducted with Resident #3 who stated he has no issues with the facility. When asked about issues with other Residents he stated That lady wanders in here from next door. She comes in, but she doesn't knock it makes me mad if I'm using my urinal or if I'm washing up. Resident #3's room was next door to Resident #4, and Resident #4 has a dementia diagnosis with wandering behaviors. On 11/15/23 a review of the clinical record revealed that Resident #3 had care planned to keep his door closed to deter Resident #4 from entering his room. A review of the clinical record revealed a wandering risk assessment was completed on 8/14/23. Resident #4 was found to be at risk for wandering and had a wander guard placed on her at that time. A review of the care plan for Resident #4 revealed that her care plan did not address elopement risk or the wandering assessment nor does it have any care planned interventions for wandering. On 11/15/23 at approximately 11:00 AM an interview was conducted with the Administrator who stated she was aware that Resident #4 had a wander guard as a result of the assessment in August. When asked if it was her expectation that the information on wandering behaviors and placement of a wander guard be in the care plan she stated that it was her expectation. When asked if she expected there to be interventions to protect the privacy of other Residents and she stated that it was. During the end of day meeting the Administrator was made aware of the concerns and no further information as provided

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure accurate and timely assessment of the development of pressure ulcers, resulting in harm, for two Residents (Residents' #4 and #2) in a survey sample of 25 Residents. 1. For Resident #2, the facility staff failed to identify a pressure ulcer to the left heel before it reached an unable to stage wound with eschar and slough and; 2. For Resident #4, a right buttock pressure ulcer was initially identified as a Stage III pressure ulcer when diagnosed . The Findings Included: 1. For Resident #2, the facility staff failed to identify a pressure ulcer to the left heel before it reached an unable to stage wound with eschar and slough. Resident #2, was admitted to the facility 3/20/09. [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/25/14 was coded as a quarterly assessment. Resident #2 was coded as having both short and long term memory problems and required total assistance of staff for daily decision making. Resident #2 was also coded as requiring total assistance of one or two staff members to perform activities of daily living, such as bed mobility. Resident #2 was coded as being at risk for the development of pressure ulcers and one pressure ulcer was coded on the MDS assessment as being a stage 3. The Minimum Data Set 3.0 defines the four stages of pressure ulcers. STAGE I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. STAGE II Partial thickness of skin loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact blister. STAGE III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. STAGE IV Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some part of the wound bed. Often includes undermining or tunneling. The MDS also included pressure ulcers that were unstagable due to coverage of the wound bed by slough and/or eschar. Slough is defined as yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. On 4/9/14 at 8:20 AM, Resident #2 was observed lying in bed on a air mattress. Both heels were elevated on a heel elevating pillow. No dressing was on the left heel, and the heel was covered with thick, black, leathery eschar of about 4-5 cm in diameter. The current treatment to the heel was skin prep twice daily. A Braden scale (to determine risk of development of a pressure ulcer) was done 1/16/14 and the resident was scored as a very high risk. Review of the clinical record and wound tracking revealed the following: On 2/14/14 at 4:08 PM, the nurse's note read Resident #2 "has developed a pressure ulcer on his left heel, measuring 2.0 by 2.0 by 0 cm (centimeters), 90 % slough, 10% eschar. Moderate serous exudate (drainage) , no odor." The wound was discovered by the wound care nurse. The resident acquired a sacral ulcer in December, 2013, which was discovered at a stage 2 ulcer. Review of the skin audits done by licensed nursing staff revealed an audit done on 2/10/14 which revealed: right shin and right calf areas. No mention was made of the stage 3 sacral wound found in December. Review of February, 2014's skin observation records done by the CNA's (certified nursing assistant) revealed the following documentation, "None of the other observed or not applicable", meaning nothing was there. And also, the unstageable wound discovered on 2/14/14 was not on the record. The facility policy on body audits was presented. The policy reads: "Full body audits will be conducted on all residents at admission, re-admission, and at least weekly by CNA's and/or licensed nursing staff and when a new area is observed. a. When a new area of concern is identified, the CNA will document in EMR (electronic medical record) and notify the nurse for follow up. b. If no new areas are observed, the CNA will document "no new skin issues." Review of the care plan dated 2/19/14 revealed under the heading of Impaired skin integrity to include: "Pressure reduction support to bed or chair, turn and reposition resident, elevate heels off bed, dietary referral, and to notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care." On 4/9/14 at 3:00 PM, RN (registered nurse) C was interviewed. RN (C) stated, "The heel wound was found at an unable to stage. We were floating his heels, and he had a pressure mattress." RN (C) went on to state, "We had him on floater boots and he got a place on his shin and he was changed to a floater (heels up) mattress. We should have found it earlier than an unable to stage." On 4/9/14 at 3:15 PM, CNA(A) was interviewed. She stated, "We can assess the skin while giving baths, showers. If we see a new bruise, sore, changes in color of the skin, any abnormality, would go to the nurse. We can also chart on ADL's." On 4/9/14 at 3:55 PM, The Administrator and DON (director of nursing) were notified of above findings and of a harm level deficiency. On 4/10/14 at 12:55 PM, the DON presented the following from "Guidance to Surveyors, "Because a resident can develop a pressure ulcer within 2-6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers." The DON stated, "This shows a pressure ulcer can happen within 2-6 hours. I know there was nothing there the previous shifts, my nurses would have seen it." According to "www.nursingceu.com <http://www.nursingceu.com> "The compression of soft tissue interferes with the tissue blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers usually occur over bony prominences such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Other factors previously mentioned also contribute to the tissue breakdown. Pressure ulcers can develop within 24 hours of the initial pressure but take as long as 5 days to present themselves." "The prevention of pressure sores depends on inspecting the skin frequently for redness which is the first sign of skin breakdown." http://www.medicinenet.com/prevention/article.htm> ) 2. For Resident #4, a right buttock pressure ulcer was initially identified as a Stage III pressure ulcer. Resident #4, a female, was admitted to the facility 6/27/13. Her [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/29/14 was coded as a significant change assessment. Resident #4 was coded as having no memory deficits and was able to make her own daily life decisions. She was also coded as requiring extensive to total assistance of one to two staff members to perform her activities of daily living. Resident #4 was coded as being at risk to develop pressure ulcers. She was coded as having two stage III pressure ulcers, with one Stage III pressure ulcer being present on readmission. She was also coded as having two Stage IV pressure ulcers, with both areas being present on readmission. Resident #4 was observed during wound care 4/10/14 beginning at 11:45 a.m. She was lying on her back with pillows under her sides. Resident #4 was alert and oriented, verbally responsive with very soft speech. During wound care, her wounds were observed. The wound on her right buttock was pink to red wound base with 20% slough noted in the wound bed. The old dressing was covered with serosangious drainage. No swelling, odor, or abnormal redness was noted. Definitions of pressure ulcers provided by NPUAP (National Pressure Ulcer Advisory Panel): " Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a Stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and these ulcers can be shallow. Stage V ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule), making osteo[DIAGNOSES REDACTED] possible. Exposed bone/tendon is visible or directly palpable.Unstageble: Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed." Resident #4 had been admitted to the facility with pressure ulcers at her sacrum, and both heels. After returning from one of her hospitalization s, a stage III pressure ulcer was identified on her left buttock. Documentation within the nursing notes revealed Resident #4 was identified as, "Late entry 12/11/13 18:25 (6:25 p.m.) Addendum Writer assessed resident to find stage 3 pressure ulcer in the right buttock, measuring 4 x 3 x 0 cm (centimeter). 40 % slough, 60% granulation, with light serous exudate. There is no malodor, surrounding tissue pink and intact with no maceration." The nursing entry prior to the identification of the Stage III pressure ulcer on Resident #4's right buttock, was a note dated 12/9/13 that described Resident #4's urinary output by her catheter. Review of the CNA (certified nursing assistant) ADL (activities of daily living) documentation revealed no documentation that the CNA had observed any new pressure ulcer areas during December, 2013. RN (registered nurse) C, the wound care nurse, stated 4/9/14 at 3:10 p.m., she had been informed on 12/11/13 that the Stage III pressure ulcer had been identified on Resident #4's right buttock. After assessing the area, RN C stated she informed the physician and obtained an order to treat with "Santyl and [MEDICATION NAME] foam dressing daily." "[MEDICATION NAME] SANTYL? Ointment is indicated for [MEDICATION NAME] chronic dermal ulcers and severely burned areas." Information was obtained at http://www.santyl.com/content/pdf/SANTYL_Milne_Reprint_Carrier.pdf Documentation revealed an entry on the eTAR (electronic treatment record) that Resident received treatment to the area from 12/12/13 until the present. Prior to 12/11/13, no wound care was being performed to Resident #4's right buttock. The DON (director of nursing) stated 4/10/14 at 11:10 a.m., Resident #4 had been receiving personal and wound care frequently prior to the identification of the right buttock wound. The DON was emphatic that the pressure ulcer was a stage III area and that was "What it was when we discovered it!" The DON also stated Resident #4's skin would have experienced a head to toe skin assessment weekly since her admission to the facility by a nurse. Review of her skin assessments revealed Resident #4 was not identified as having any areas on her right buttock on 12/4/13, the nursing skin assessment prior to the identification of the Stage III pressure ulcer on 12/11/13. Documentation was evident that Resident #4 had a Foley catheter since her admission to the facility due to her known Stage IV pressure ulcer at her sacrum. Resident #4, while incontinent of bowel, was able to inform the staff when she had a bowel movement. The CNA (certified nursing assistant) ADL (activities of daily living) documentation revealed Resident #4 had a bowel movement on 12/10/13 at 1 a.m., at 11:11 a.m., and 9:34 p.m. On 12/11/13 Resident #4 was documented as having bowel movements at 12:21 a.m., 9:48 p.m., and 9:15 p.m. Documentation on the CNA ADL sheet indicated Resident #4 failed to receive any bathing assistance on 12/10/13 and only received a partial bath at 12:23 a.m. on 12/11/13. No other bathing assistance was performed from 12/11/13 at 12:23 a.m. until Resident #4 was given a shower on 12/16/13 at 11:19 a.m. (5 days). Prior to 12/11/13, Resident #4 had not been bathed from 12/5/13 at 1:13 a.m. until she received a shower on 12/9/13 at 9:41 a.m. Documentation was evident that Resident #4 was receiving wound care to the area on her sacrum twice daily during December, 2013. No documentation was evident that the area on Resident #4's right buttock was identified as having any type of skin breakdown, prior to the identification of the Stage III pressure ulcer on 12/11/13. While the note identifying the area was documented at 6:25 p.m., the DON stated that was "just the time the note was written, not the time the area was actually identified." The DON stated a stage III pressure ulcer could present as soon as "2 to 6 hours" after damage, however was unable to provide written documentation of that fact. Guidance regarding presentation of a pressure ulcer was provided at: " www.ahrq.gov <http://www.ahrq.gov> Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis. Since 1930, we have understood that normal blood pressure within capillaries ranges from 20 to 40mm Hg (millimeter of mercury); 32mm Hg is considered the average.17 Thus, keeping the external pressure less than 32 mm Hg should be sufficient to prevent the development of pressure ulcers. However, capillary blood pressure may be less than 32 mm Hg in critically ill patients due to hemodynamic instability and comorbid conditions; thus, even lower applied pressures may be sufficient to induce ulceration in this group of patients. Therefore, the key to preventing pressure ulcers is to accurately identify at-risk individuals quickly, so that preventive measures may be implemented." And also at: "www.nursingceu.com <http://www.nursingceu.com> The compression of soft tissue interferes with the tissue blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers usually occur over bony prominences such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Other factors previously mentioned also contribute to the tissue breakdown. Pressure ulcers can develop within 24 hours of the initial pressure but take as long as 5 days to present themselves." Review of Resident #4's care plan, in place at the time of the identification, included as preventative and care of her impaired skin, "Observe/document location, size, and treatment of [REDACTED]." The administrator, DON, and corporate consultants were advised of the failure of the staff to identify a pressure ulcer prior to becoming a Stage III, resulting in harm, for Resident #4, 4/9/14 at 5:15 p.m. and 4/10/14 at the end of day meeting.

Based on staff interview, facility documentation, clinical record review and in the course of a complaint investigation, the facility staff failed to respond appropriately to a change in respiratory status and failed to following physician orders to increase the liters of oxygen administered for one resident (Resident #1) of four residents in the survey sample. Resident #1 was in respiratory distress from 9 A.M. until 1:15 P.M. The resident was sent out to an acute care setting (emergency room ); the resident was intubated and then sent to their [MEDICAL CONDITION] Critical Care Unit. The Findings Included: Resident #1 was a [AGE] year-old originally admitted to the facility on [DATE] with a readmission date of [DATE] [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 9/1/10 coded Resident #1 with severe cognitive impairment and recurrent lung aspiration in the last 90 days with shortness of breath. Resident #1 was coded for ADL (Activity of Daily Living) as being totally dependent on staff for personal hygiene. A review was conducted on 12/1/10 of Resident #1's facility documents and clinical record. Resident #1's clinical record indicated on 9/24/10 at 9:00 a.m. LPN #1 assessed the resident and documented, "Resident is wheezing and looking towards cilling (ceiling) Responsive to varbel (verbal) command just looking on one side- neb (nebulizer) treatment given v.s. (vital signs) 112/67, 102, 98.0, 02 (oxygen) on 3 lit (liters) oxigen (oxygen) 89%, R-14 (respiratory rate) continue monitor ". Moreover, LPN #1 documented at 12:00 p.m. "Continue monitored resident looked lethargic, breathing heavely (heavily), sleeping less responsive to sound, responsive to touch. 02 (oxygen) 89 on 3 litt (liters) oxigen (oxygen)". In addition, Resident #1's clinical record revealed LPN #1 attempted to contact the resident's physician regarding the change of condition at 12:15 p.m. and 12:30 p.m. Documentation showed both times she was placed on hold. LPN #1 documented at 12:35 p.m. Resident #1's responsible party was called and notified of the change in condition. LPN #1 notified the facility unit manager and was instructed to "continue monitered (monitoring) resident gave neb (nebulizer treatment) and oxigen (oxygen) eleveted (elevated) head. 02 (oxygen) on 3 lit. (liters) 84% . Resident #1's clinical record documented LPN #1 attempted to call resident's physician once again at 12:50 p.m. and left message for physician to contact the facility regarding Resident #1 change in condition. Subsequently, Resident #1's physician returned the facility call at 1:15 p.m. and the resident was transported at 1:25 p.m. to an emergency medical facility for evaluation. An interview conducted on 12/1/10 at 11:00 a.m. with LPN #1 regarding the stated finding. LPN #1 stated on 9/24/10 at 9:00 a.m. Resident #1 was assessed with [REDACTED]. Resident #1 was looking toward the ceiling and at that time she observed some abnormal behaviors from the resident. Moreover, LPN #1 stated she proceeded to give the resident's nebulizer treatment, but noted his respiratory rate was lower than normal. Resident #1 was assessed at 12:00 p.m. found lethargic, breathing heavily and she observed again abnormal behaviors from the resident. LPN #1 stated she attempted to contact the resident's physician three times, but was placed on hold for 10 minutes. In addition, LPN #1 stated she contacted the resident's responsible party regarding his change in condition and notified the facility unit manager. LPN #1 stated the facility unit manager (Registered Nurse) assessed the resident and instructed her to give another nebulizer treatment and continue to contact resident ' s physician. LPN #1 stated Resident #1's oxygen saturation level continued to decrease and the resident remained on 3 liters of oxygen during his change in condition. Finally, LPN #1 stated again the resident did not "bounce back" after the nebulizer treatment as usual and the resident's physician contacted the facility with orders to transport. The surveyor asked if the unit manager continued to assess the resident with LPN #1 during his change in condition? LPN#1 stated, "No!" "She instructed me to continue monitoring the resident and contact his physician." The surveyor asked, if anyone came to assist her with the resident during his change in condition? LPN #1 stated, "No". Further review of Resident #1's clinical record had documented the following physician's orders regarding his care and treatment: Resident#1 had a PRN order for oxygen. The Resident had two physician's orders regarding oxygen therapy: First, physician's order stated oxygen 4 liters via nasal cannula if oxygen saturation is less than 90% and call MD. Second, Keep oxygen saturation greater than 92 % and call MD if less than 92%. Dates of orders Physician ' s orders 12/22/09 Check oxygen Saturation as needed 12/22/09 Keep oxygen Saturation greater than 92% and call physician if less than 92% 12/22/09 Oxygen at 4 liters per minutes via nasal cannula if oxygen saturation less than 90% and call physician 4/09/10 Oxygen at 10 liters per minute via nebulizer mask as needed for shortness of breath. An interview was conducted on 12/1/10 at 1:20 p.m. with RN #1 the facility unit manager pertaining to the findings. RN #1 stated on 9/24/10 she was the supervisor on duty for the facility. RN #1 stated Resident #1 was having difficulties with breathing and LPN #1 was giving the resident a breathing treatment when she entered into his room. RN #1 stated she did not think the resident's condition was critical because of his past history of breathing difficulties. RN #1 stated she did not document her assessment of Resident #1 and did not question LPN #1 regarding her overall assessment of Resident #1's current condition. RN #1 stated she left the unit and returned to her supervision duties for the facility. The surveyor found no evidence that Resident #1's physician was contacted on 9/24/10 at 9:00 a.m. when LPN #1 initially assessed resident ' s oxygen saturation level at 89%. Furthermore, the surveyor found no physician's order for the use of [REDACTED] The facility Director of Nursing and Clinical Nurse Consultant (CNC) requested at a meeting with the surveyor on 12/2/10 at 8:55 a.m. regarding the findings. The CNC stated the facility agreed with the surveyor that facility staff failed to follow Resident #1 physician's orders. CNC stated the resident had a physician's order to contact the physician when oxygen saturation level fall below 92% and 4 liters of oxygen should have been administered not 3 liters as documented. CNC expressed that LPN #1 and RN #1 did not think the change of condition was critical and they reacted as usual to resident episodes of breathing difficulties. The facility presented the surveyor with copies of Resident #1's clinical record which detailed a history of breathing difficulties since being admitted to the facility. Resident #1's documentation from the emergency medical facility revealed the resident was diagnosed with [REDACTED]. Resident #1 was admitted to the hospital's "Pulmonary Critical Care" service and assigned to the hospital ICU (Intensive Care Unit). The administrator and management team were made aware of the findings during the end-of-day briefings on 12/1/10. COMPLAINT DEFICIENCY