Every finding on record at Fountain View Subacute and Nursing Center

Based on record review and interview, the facility failed to ensure that a necessary medical appointment with a neurologist (a medical doctor who diagnoses and treats problems in the brain, spinal cord, and nerves) was scheduled and executed for one of three sampled residents (Resident 1) who was had a diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and epilepsy (a common brain disorder that causes a person to have repeated seizures- a sudden, temporary burst of abnormal electrical activity in the brain). This deficient practice could have resulted in worsening conditions such as increased seizure (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in movement, behavior, feelings, or awareness) frequency.During a review of Resident 1's admission record indicated that Resident 1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses Including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial loss of control on just one side of the body) following cerebral infarction affecting left non-dominant side, epilepsy, and hypertension (HTN-high blood pressure). During a review of Resident 1's order dated [DATE], indicated, Status post Neurosurgery operation [specialized medical surgery to treat problems in the brain, spinal cord, or nerves] follow-up. During a review of Resident 1's physician's orders dated [DATE] indicated, Neuro-rehabilitation consultation on [DATE] @ 4:00PM. During a review of Resident 1's Social Services (SS) notes dated [DATE] indicated, Resident [Resident 1] had a neurology appointment today, once [Resident 1] arrived to appointment, she [Resident 1] was not seen due to authorization being expired on [DATE], SSD [Social Services Director] placed a call to authorization department and was able to get an extension for authorization until [DATE]. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 1 cognitively intact (can think, learn, remember, and make good choices without any problems). The MDS indicated Resident 1 required between partial/moderate assistance to complete dependence on staff Activities of Daily Living (ADLs such as oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, putting on/taking off footwear, chair/bed-to-chair transfer, and personal hygiene). During an interview with Family Member (FM) 1 on [DATE] at 2:49 pm, FM 1 stated that Resident 1 had a history of a stroke of which she needed to keep appointments with neurology to make sure that she was receiving neurological rehabilitation treatments. FM 1 stated that the facility had not been able to get her in to see the neurologist since she was admitted to the facility in 2024. FM 1 stated that she had been communicating with facility staff including the Social Worker (SW) but felt that the facility was failing to go through with what they were promising herself (FM 1) and Resident 1. During an interview with the SW on [DATE] at 10:48 am, the SW stated that some of her responsibilities included assisting with appointments set-up for the residents along with transportation services. The SW stated that Resident 1 was pending a neurology appointment whom she had visited [DATE]. The SW stated that an authorization requested had been submitted to Resident 1's health insurance on [DATE]. The SW was unable to locate the neurologist's notes for the [DATE] appointment stating that she (SW) would follow up with the Medical Records Director (MRD). During an interview with the MRD on [DATE] at 2:20 pm, the MRD confirmed that there were no neurology noted for the [DATE] because even though Resident 1 had gone to the appointment, she (Resident 1) was not seen because the authorization had expired in [DATE]. The MRD stated Importance of getting the resident the resident seen was for continuity of care and prevent Resident 1's condition from worsening. During a follow up interview with the SW on [DATE] at 2:45 pm, the SW confirmed that there was no set neurology appointment Resident 1. The SW stated that she (SW) was working on getting authorization for the neurology appointment. The SW stated that the importance of ensuring that Resident 1 followed up with neurology was to ensure continuity of care. During a review of the facility's policy and procedure (P&P) titled, AppointmentsAdministrative Policies, reviewed [DATE], indicated, This policy and procedure document outlines the support a facility provides to residents in accessing specialty healthcare services to enhance their health and wellbeing. Here's a summary of key points:Policy Highlights: Access to Specialty Providers: The facility will help residents contact specialty providers as needed, based on health recommendations. Appointment Assistance: The facility will assist in scheduling appointments and arranging necessary transportation for residents to ensure they can attend their appointments. Resource Utilization: The staff will help residents and their representatives find local resources such as Medicare and Medicaid to support healthcare needs. Support for Lost Devices: In cases of lost medical devices, assistance will be provided to locate resources and schedule replacements. Non-Covered Services: For services not covered by Medicaid, the administrator and interdisciplinary team (IDT) will assess the need and attempt to arrange necessary services.

Based on interviews and record review, the facility failed to provide timely incontinence care for one of three sampled residents (Resident 3) when Certified Nursing Assistant (CNA) 1 did not clean or change the resident after being notified the resident was wet.This deficient practice had the potential to increase the risk of infection, including urinary tract infections (UTIs, a bacterial infection that affects any part of your urinary system, including the bladder, urethra, or kidneys), and negatively affect Resident 3's care.During a review of Resident 3's admission record dated 7/23/2026, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to lymphedema (a condition where part of the body-often an arm or a leg-gets swollen because fluid builds up under the skin. This happens when the body's lymphatic system, which is like a drainage system that removes extra fluid and helps fight infection, isn't working the way it should), muscle weakness, dementia (a condition that happens when a person's brain is damaged and can't work the way it used to) and obesity (a condition a person had too much body fat in a way that can harm that person's health). During a review of Resident 3's Minimum Data Set (MDS- resident assessment tool) dated 5/12/2026, the MDS indicated Resident 3 had mild cognition (ability to think, remember and reason for daily decision making) impairment; Resident 3 was dependent on staffs for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. In addition, MDS indicated Resident 3 is always incontinent. During a review of Resident 3's lab result report of urinalysis (UA, a test that checks your pee to see how healthy your body is, doctors use it to look for problems like infections, kidney issues, or diabetes) on 7/14/2026, the UA result indicated abnormal, with positive of bacteria present. During a review of Resident 3's lab result report of complete blood count (CBC, a blood test that tells doctors what's happening inside your body by measuring the different cells in your blood. It can be used to detect infection, anemia, and blood disorders) on 7/14/2025, the CBC result indicated white blood cell (WBC) count was high at 18.07 with a reference range 4.0 to 11.0, which indicated infection. During a review of Resident 3's nursing progress notes on 7/14/2026, the progress notes indicated Resident 3's UA, CBC result showing UTI infection, and Resident's attending physician was notified. During a review of Resident 3's care plan (CP) titled resident experience or is at risk for urinary incontinence . dated 5/22/2026, the CP indicated staffs should assist with perineal care as needed. During a phone interview with Resident 3's representative (RP) on 7/23/2026 at 9:10 am, Resident 3's RP started on 7/11/2026 around 3:00 pm, he pressed call light request CNA to check and change Resident 3 because he smelled odor of urine in the room. CNA 1 responded to call light around 3:30 pm, but only asked Resident 3 are you okay did not physically check if resident was wet or not. After resident response to her I am okay. CNA 1 turn around and walk out of the room. Resident 3's RP followed CNA 1 to the hallway and ask her again are you going to change her? CNA 1 responded she said she was okay and walk away. During an interview on 7/23/2026 at 1:57 pm with CNA 2, CNA 2 stated CNA should response to call light on time and check their resident often. CNA 2 continued stated, when resident or resident's RP request to be changed, CNA should physically check on the resident and help resident change if indicated. During an interview on 7/23/2026 at 2:08 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated CNA needed to response to call light on time and helped residents as their request. When resident's family requested CNA to help resident change because they smell odor of urine, it is a very reasonable request, CNA should have helped the resident, walking away was unacceptable. During an interview on 7/23/2026 at 3:57 pm with CNA 1, CNA 1 stated she remembered on 7/11/2026 responded to Resident 3 and Resident 3's RP. CNA 1 confirmed she did not physically check the resident and walk away. During an interview on 7/23/2025 at 4:50 pm with Director of Nursing (DON), DON stated, CNA 1's action was unacceptable, CNA should have provided good resident care and communicate well with resident and resident's RP. Failed to provide timely incontinence care and leave Resident 3 soiled will increase the risk for skin breakdown and could even lead to UTI. During a review of the facility's policy and procedure (P&P) titled activities of daily living, supporting, dated 11/20/2025, the P&P indicated resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure that medications were administered as ordered for three of three sampled residents (Residents 1, Resident 2 and Resident 3), whenfor Resident 1, the facility failed to administer multiple doses of prescribed seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse) medications, blood pressure medications and antibiotic (a medicine that kills bacteria), resulting in repeated missed doses.for Resident 2, the facility failed to administer multiple doses of prescribed seizure medications, resulting in repeated missed doses.for Resident 3, the facility failed to administer multiple doses of prescribed insulin (a medicine helps move sugar from your blood into your cells) injections, also resulting in repeated missed doses.These deficient practices had potential to cause serious adverse outcomes, including increased seizure activity, worsening infection, avoidable decline, compromised all sampled residents safety and could even result re-hospitalization.Findings:1.During a review of Resident 1's admission record dated 7/2/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included colon cancer (a disease that starts in the colon [a long tube in your belly that helps turn food into poop.] cells in colon start to grow in an uncontrolled way), muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypotension (low blood pressure).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was not intact, unable to make decisions.During a review of Resident 1's physician order dated 4/1/2026, the physician order indicated:Keppra (a medicine that helps prevent seizures) oral Tablet 750 mg (levetiracetam) give 1 tablet by month every 12 hours for seizure disorder.Lacosamide (a medicine that helps prevent seizures) oral tablet 100 mg (lacosamide) give 1 table by mouth every 12 hours for seizure disorder.Midodrine HCl (a medicine that helps raise low blood pressure) tablet 5mg give 2 table by mouth three times a day for hypotension (low blood pressure), hold if systolic blood pressure (the top number you see when someone gets their blood pressure checked) > 130During a review of Resident 1's physician order dated 4/16/2026, the physician order indicated:Depakote (a medicine that helps prevent seizure) oral tablet delayed release 250 mg (divalproex sodium) give 750 mg by mouth two times a day for anticonvulsant (a type of medicine that helps prevent seizure).During a review of Resident 1's physician order dated 5/5/2026, the physician order indicated:Metronidazole (an antibiotic that helps the body fight bacterial infections) oral tablet 600 mg (metronidazole) give 1 tablet orally every 8 hours for bacterial infection for 5 days.During a review of Resident 1's medication administration record (MAR) dated 5/2026, the MAR indicated the following:Keppra Oral Tablet 750 MG (Levetiracetam) Give 1 tablet by mouth every 12 hours forSeizure disorder, was not administered on the following dates and times:at 21:00 pm on 5/1, 5/2, 5/4, 5/5, 5/9, 5/17, 5/20Lacosamide Oral Tablet 100 MG (Lacosamide) Give 1 tablet by mouth every 12 hours for Seizure disorder, was not administered on the following dates and times:at 21:00 pm on 5/1, 5/2, 5/4, 5/5, 5/9, 5/17, 5/20Midodrine HCl tablet 5mg give 2 table by mouth three times a day for hypotension, hold if systolic blood pressure > 130, was not administered on the following dates and times:at 13:00 pm on 5/27at 1700 pm on 5/2, 5/4, 5/5, 5/9, 5/17, 5/20In addition to midodrine, Resident's blood pressure was also not monitored and recorded during midodrine missing dates and times.Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 750 mg by mouth two times a day for anticonvulsant, was not administered on the following dates and times:at 9:00 am, on 5/27.at 21:00 pm on 5/2, 5/4, 5/5, 5/9, 5/17, 5/20Metronidazole oral tablet 600 mg (metronidazole) give 1 tablet orally every 8 hours for bacterial infection for 5 days, was not administered on the following dates and times:22:00 pm on 5/5, 5/9 2. During a review of Resident 2's admission record dated 7/2/2026, the admission record indicated Resident 2 was admitted to the facility on [DATE] with the diagnoses that included muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypertension (high blood pressure), Diabetes (condition where the body has trouble using sugar the right way), and history of fall.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact.During a review of Resident 2's physician order dated 4/2/2026, the physician order indicated:Lamotrigine (a medicine that helps prevent seizures) oral tablet 100mg (Lamotrigine) give 1 table by month two times a day for anti-convulsantLevetiracetam (Keppra, a medicine that helps prevent seizures) ER oral tablet extended release 24-hour 1500 mg (Levetiracetam) give 1500 mg by mouth two times a day for anti-seizure.Pregabalin (a medicine that helps calm overactive nerves, can be used for nerve pain or seizure) oral capsule 200mg neuropathic pain hold if respiratory rate < 12 and/or excessive sedation.During a review of Resident 2's MAR dated 5/2026 and 6/2026, the MAR indicated the following:Lamotrigine oral tablet 100mg (Lamotrigine) give 1 table by month two times a day for anti-convulsant, was not administered on the following dates and times:at 17:00 pm: 5/1, 5/9, 6/13Levetiracetam ER oral tablet extended release 24-hour 1500 mg (Levetiracetam) give 1500 mg by mouth two times a day for anti-seizure. was not administered on the following dates and times:at 17:00 pm: 5/1, 5/9, 6/13Pregabalin oral capsule 200mg neuropathic pain hold if RR < 12 and/or excessive sedation. Was not administered on the following dates and times:at 9:00 am: 5/3, 5/4at 17:00 pm: 5/1, 5/2, 5/3, 5/4, 5/93. During a review of Resident 3's admission record dated 7/2/2026, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included cellulitis (an infection of the skin. It happens when germs (usually bacteria) get into the body through a cut, scratch, or any break in the skin) of right lower limb, cellulitis of left lower limb, diabetes (condition where the body has trouble using sugar the right way) and hypertension (high blood pressure).During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition (ability to think, remember and reason for daily decision making) was intact.During a review of Resident 3's physician order dated 5/13/2026, the order indicated:insulin aspart (a fast-acting insulin [a medicine helps move sugar from your blood into your cells]) injection solution 100 unit/ml per sliding scale (a way for nurses to decide how much insulin to give based on a person's blood sugar level).During a review of Resident 3's MAR dated 5/2026 and 6/2026, the MAR indicated the following:insulin aspart injection solution 100 unit/ml, inject as per sliding scale:if 0 - 150 = 0 unit,if 151 - 200 = 2 unitsif 201 - 250 = 3 unitsif 251 - 300 =5 unitsif 301 - 350 = 7 unitsif 351+ = 10 units call MD immediately for further instruction if blood glucose is greater than 400, subcutaneously before meals and at bedtime for diabetes. inject insulin 15 - 20 mins minutes before each meal, the blood sugar level was not monitor and medication order was not administered on the following dates and times:at 6:30 am: 6/6/at 4:30 pm: 6/13at 9:00 pm: 6/13 During an interview with Licensed Vocational Nurse (LVN) 1 on 6/30/2026 at 1:50 pm, LVN 1 stated resident's medications should be administered as physician's order.During an interview with Assistant Director of Nursing (ADON) on 7/1/2026 at 2:40 pm, ADON acknowledged that all Resident 1, Resident 2 and Resident 3 had multiple medications not administered as order. ADON further explained failed to administered medications as physician's ordered will affect resident' care, prolong their illness, and could even cause re-hospitalization.During a phone interview with Pharmacy Consultant (PC) on 7/2/2026 at 2:28 pm, the PC stated, antibiotics should be given as scheduled and completed, missing doses won't give the 100% effect of the medicine, and the infection could prolong. PC also stated missing seizure medications will increase the chance resident having seizure episodes. Facility should have follow physician's order for any medication administration.During a review of the facility's policy and procedures (P&P) titled administering medication, dated 11/20/2025, the P&P indicated Medication are administered in a safe and timely manner, and as prescribed.

Based on interviews and record review, facility failed to ensure three of three sampled residents (Resident 1, Resident 2 and Resident 3) were adequately monitored for changes in condition and adverse effects of medications, when:Resident 1 was not monitored for vital signs, pain level, seizure activity, hours of sleep and adverse effects of multiple medications,Resident 2 was not monitored for vital signs, pain level, seizure activity, opioid overdoes symptoms and adverse effects of multiple medications.Resident 3 was not monitored for vital signs, pain level, blood sugar level, oxygen level, opioid overdose, and anticoagulant (a medicine that helps prevent blood from clotting too easily) side effect.These deficient practices had potential to result in significant harm due to missed signs of deterioration or adverse medication consequences. 1.During a review of Resident 1's admission record dated 7/2/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included colon cancer (a disease that starts in the colon [a long tube in your belly that helps turn food into poop.] cells in colon start to grow in an uncontrolled way), muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypotension (low blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was not intact, unable to make decisions. During a review of Resident 1's physician order dated 4/1/2026, the order indicated the following: Pain monitor.During a review of Resident 1's physician order dated 4/2/2026, the order indicated the following: Monitor for seizure activity. Monitor for signs and symptoms of .During a review of Resident 1's physician order dated 4/6/2026, the order indicated the following: Anti-depressant Monitoring. Monitor hours of sleep.During a review of Resident 1's physician order dated 4/28/2026, the order indicated the following: Anti-Convulsant monitor.During a review Resident 1's MAR dated 5/2026 and 6/2026, the MAR indicated the following: Pain monitor. was not done on the following dates and times:Day shift:5/27Evening shift:5/2, 5/4, 5/5, 5/9, 5/17, 5/20 Monitor for seizure activity. was not done on the following dates and times:Evening shift:5/2, 5/4, 5/5, 5/9, 5/17, 5/20 Monitor for signs and symptoms of . vital signs were not done on the following dates and times:Day shift:5/27Evening shift:5/2, 5/4, 5/5, 5/9, 5/17, 5/20 Anti-depressant monitoring. was not done on the following dates and times:Day shift:5/27Evening shift:5/2, 5/4, 5/5, 5/9, 5/17, 5/20Monitor hours of sleep. was not done on the following dates and times:Evening shift:5/2, 5/4, 5/5, 5/9, 5/17, 5/20 Anti-Convulsant monitor. was not done on the following dates and times:Day shift:5/27Evening shift:5/2, 5/4, 5/5, 5/9, 5/17, 5/20 2. During a review of Resident 2's admission record dated 7/2/2026, the admission record indicated Resident 2 was admitted to the facility on [DATE] with the diagnoses that included muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypertension (high blood pressure), Diabetes (condition where the body has trouble using sugar the right way), and history of fall.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 4/8/2026, the MDS indicated Resident 2's cognition (ability to think, remember and reason for daily decision making) was intact.During a review of Resident 2's physician order dated 4/2/2026, the order indicated the following: Anti-anxiety medication (a medicine that helps a person feel less worried, nervous, or scared) monitor side effect. Anti-convulsant medication (a medicine that helps prevent seizures) monitor side effect. Anti-depressant (a medicine that helps a person feel less sad, hopeless, or tired all the time.) monitor side effect. Monitoring for opioid overdoes (when a person takes too much of an opioid [a type of drug used for pain]) symptoms. Observe for episode of seizure. Pain monitor .During a review of Resident 2's physician order dated 4/12/2026, the order indicated the following: Monitor abnormal signs/symptoms every shift.blood pressure, temperature, pulse, Respiratory rate.During a review Resident 2's MAR dated 5/2026 and 6/2026, the MAR indicated the following: Anti-anxiety monitor side effect . was not done on the following dates and times:Day shift: 5/27, 6/28Evening shift: 5/1, 5/4, 5/9, 6/13Night shift: 5/14 Anti-convulsant monitor side effect. was not done on the following dates and times:Day shift: 5/27, 6/28Evening shift: 5/1, 5/4, 5/9,6/13Night shift: 5/14 Anti-depressant monitor side effect. was not done on the following dates and times:Day shift: 5/27, 6/28Evening shift: 5/1, 5/4, 5/9,6/13Night shift: 5/14 Monitoring for opioid overdoes symptoms. was not done on the following dates and times:Day shift: 5/27, 6/28Evening shift: 5/1, 5/4, 5/9, 6/13Night shift: 5/14 Observe for episode of seizure. was not done on the following dates and times:Day shift: 5/27, 6/28Evening shift: 5/1, 5/4, 5/9, 6/13Night shift: 5/14 Pain Monitor. was not done on the following dates and times:Day shift: 5/27, 6/28Evening shift: 5/1, 5/4, 5/9, 6/13Night shift: 5/14Vital signs were not monitored on the following dates and times:Day shift: 5/12, 5/27, 6/28Evening shift: 5/1, 5/4, 5/9, 6/13Night shift: 5/14 3.During a review of Resident 3's admission record dated 7/2/2026, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included cellulitis (an infection of the skin. It happens when germs (usually bacteria) get into the body through a cut, scratch, or any break in the skin) of right lower limb, cellulitis of left lower limb, diabetes (condition where the body has trouble using sugar the right way) and hypertension (high blood pressure). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 6/15/2026, the MDS indicated Resident 3's cognition (ability to think, remember and reason for daily decision making) was intact. During a review of Resident 3's physician order dated 5/13/2026, the order indicated the following: Insulin aspart injection solution 100 unit/ml, inject as per sliding scale:if 0 - 150 = 0 unit,if 151 - 200 = 2 unitsif 201 - 250 = 3 unitsif 251 - 300 =5 unitsif 301 - 350 = 7 unitsif 351+ = 10 units call MD immediately for further instruction if blood glucose is greater than 400, subcutaneously before meals and at bedtime for diabetes, must take finger stick blood glucose prior to administration. inject insulin 15 - 20 mins minutes before each meal. Pulse oxygen (measured with a small device called a pulse oximeter, usually clipped onto a finger, tells you how much oxygen is in a person's blood) level every shift to keep oxygen saturation greater than or equal to 90% Pain monitor every shift.During a review of Resident 3's physician order dated 5/14/2026, the order indicated the following: Monitoring for opioid overdose symptoms: side effect: 1. Anticoagulant medication monitoring.During a review of Resident 3's physician order dated 5/24/2026, the order indicated the following: Monitor abnormal signs/symptoms every shift.Blood pressure, temperature, pulse, Respiratory rate.During a review Resident 3's MAR dated 5/2026 and 6/2026, the MAR indicated the following:Finger stick blood glucose was not monitored on the following dates and time:at 6:30 am: 6/6/at 4:30 pm: 6/13at 9:00 pm: 6/13Pulse oxygen was not monitored on the following dates and times:Day shift: 5/27Evening shift 5/14, 5/16, 6/13Night shift: 5/14Pain level was not monitored on the following dates and times:Day shift: 5/27Evening shift: 5/16, 6/13.Opioid overdose symptoms were not monitored on the following dates and times:Day shift: 5/27,Evening shift: 5/16, 6/13.Anticoagulant monitoring was not done on the following dates and times:Day shift: 5/27Evening shift: 5/16, 6/13.Vital signs were not monitored on the following dates and times:Day shift: 5/27Evening shift: 6/13. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/30/2026 at 1:51 pm, LVN 1 stated resident assessment and documentation should be specific, accurate and completed. If assessment and documentation were not accurate and completed, it could harm the residents and affect their care. During a phone interview with Director of Nursing (DON) on 7/2/2026 at 12:34 pm, the DON acknowledged that multiple assessments of multiple sampled residents were not completed. Residents were not monitored on vital signs, pain level, medication side effects. [NAME] stated no documentation or progress notes were done for those missing dates and times. It is not safe practice; it affected all the sampled residents' care. During a review of the facility's policy and procedures (P&P) titled charting and documentation, dated 11/20/2025, the P&P indicated documentation in the medical record will be objective, complete and accurate.

Based on interview and record review, the facility failed to ensure the development and implementation of person centered care plan for three of three sampled residents (Residents 1, 2, and 3) when:For Resident 1, the facility failed to create a person centered care plan that reflected the resident's assessed needs.For Residents 1, 2, and 3 the facility failed to implement care plan interventions by not administering medications as ordered, as required under professional standards and care plan directives.For Resident 3, the facility failed to implement the prescribed treatment as outlined in the resident's care plan.These deficient practices had result in unmet medical needs, increased risk of avoidable decline, and compromised quality of care for all affected Resident.1.During a review of Resident 1's admission record dated 7/2/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included colon cancer (a disease that starts in the colon [a long tube in your belly that helps turn food into poop.] cells in colon start to grow in an uncontrolled way), muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypotension (low blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was not intact, unable to make decisions. During a review of Resident 1's care plan titled The resident noted with lethargy, episodes of seizure. dated 2/21/2026, the care plan indicated intervention as following: administer medication as order, evaluate for side effects and effectiveness. During a review of Resident 1's care plan titled The Resident had an actual unwitnessed fall w. dated 3/29/2026, the care plan indicated intervention as following: check range of motion and continue interventions on the at risk-plan. During a review of Resident 1's care plan titled The Resident was observed with episode of 30 sec seizure, dated 4/14/2026, the care plan indicated intervention as following: vital signs taken with normal limits. During a review of Resident 1's care plan titled the Resident has significant of 5 lb (3.68%) loss. dated 6/4/2026, the care plan indicated intervention as monitor vital sign and reported to MD if indicated. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/30/2026 at 1:51 pm, LVN 1 stated, care plan lists current conditions, interventions and goals for the residents, care plan should be specific and individualized. During an interview with Assistant Director of Nursing (ADON) on 7/1/2026 at 2:40 pm, the ADON stated Resident 1's care plan was not specific enough. ADON further stated the following:Resident 1 experienced lethargy, it did not specify which medication to give and how often,Resident 1 had actual unwitnessed fall, it did not specify how often to check range of motion and what intervention to continue,Resident 1 observed with seizure, it did not specify on how often vital sign should be monitored.Resident 1 had significant 5 lb. loss, it did not specify what vital sign indicated to notify the physician. ADON continued stated that Resident's care plan should be specific, so facility know what intervention to follow. Failed to do so, making Resident 1's care plan was not specific and individualized, it affects the care and treatment for Resident 1. 2a.During a review of Resident 1's admission record dated 7/2/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included colon cancer (a disease that starts in the colon [a long tube in your belly that helps turn food into poop.] cells in colon start to grow in an uncontrolled way), muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypotension (low blood pressure).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was not intact, unable to make decisions.During a review of Resident 1's physician order dated 4/1/2026, the physician order indicated:Keppra (a medicine that helps prevent seizures) oral Tablet 750 mg (milligram, a very small unit that measures how much medicine is in a pill or dose) give 1 tablet by month every 12 hours for seizure disorder.Lacosamide (a medicine that helps prevent seizures) oral tablet 100 mg (Lacosamide) give 1 table by mouth every 12 hours for seizure disorder.During a review of Resident 1's physician order dated 4/16/2026, the physician order indicated:Depakote (a medicine that helps prevent seizure) oral tablet delayed release 250 mg (divalproex sodium) give 750 mg by mouth two times a day for anticonvulsant (a type of medicine that helps prevent seizure).During a review of Resident 1's care plan titled The Resident is at risk for seizure activity related to history of seizure disorder. Dated 4/19/2025, the care plan stated administer medication as ordered- Divalproex Sodium Oral Tablet Delayed Release- Lacosamide Oral Tablet- levetiracetam Oral TabletDuring a review of Resident 1's medication administration record (MAR) dated 5/2026, the MAR indicated the following:Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 750 mg by mouth two times a day for anticonvulsant, was not administered on the following dates and times:at 9:00 am, on 5/27.at 21:00 pm on 5/2, 5/4, 5/5, 5/9, 5/17, 5/20Lacosamide Oral Tablet 100 MG (Lacosamide) Give 1 tablet by mouth every 12 hours for Seizure disorder, was not administered on the following dates and times:at 21:00 pm on 5/1, 5/2, 5/4, 5/5, 5/9, 5/17, 5/20Keppra Oral Tablet 750 MG (Levetiracetam) Give 1 tablet by mouth every 12 hours forSeizure disorder, was not administered on the following dates and times:at 21:00 pm on 5/1, 5/2, 5/4, 5/5, 5/9, 5/17, 5/202b. During a review of Resident 2's admission record dated 7/2/2026, the admission record indicated Resident 2 was admitted to the facility on [DATE] with the diagnoses that included muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypertension (high blood pressure), Diabetes (condition where the body has trouble using sugar the right way), and history of fall.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 4/8/2026, the MDS indicated Resident 2's cognition (ability to think, remember and reason for daily decision making) was intact.During a review of Resident 2's physician order dated 4/2/2026, the physician order indicated:Lamotrigine (a medicine that helps prevent seizures) oral tablet 100 mg (milligram, a very small unit that measures how much medicine is in a pill or dose) give 1 table by month two times a day for anti-convulsantLevetiracetam (Keppra, a medicine that helps prevent seizures) ER oral tablet extended release 24-hour 1500 mg (Levetiracetam) give 1500 mg by mouth two times a day for anti-seizure.Pregabalin (a medicine that helps calm overactive nerves, can be used for nerve pain or seizure) oral capsule 200mg neuropathic pain hold if respiratory rate < 12 and/or excessive sedation.During a review of Resident 2's care plan titled The Resident is newly admitted to the facility, dated 4/2/2026, the care plan included interventions administer medication, treatments, and other services in accordance with physician orders.During a review of Resident 2's MAR dated 5/2026 and 6/2026, the MAR indicated the following:Lamotrigine oral tablet 100mg (Lamotrigine) give 1 table by month two times a day for anti-convulsant, was not administered on the following dates and times:at 17:00 pm: 5/1, 5/9, 6/13Levetiracetam ER oral tablet extended release 24-hour 1500 mg (Levetiracetam) give 1500 mg by mouth two times a day for anti-seizure. was not administered on the following dates and times:at 17:00 pm: 5/1, 5/9, 6/13Pregabalin oral capsule 200mg neuropathic pain hold if RR < 12 and/or excessive sedation. Was not administered on the following dates and times:at 9:00 am: 5/3, 5/4at 17:00 pm: 5/1, 5/2, 5/3, 5/4, 5/92c. During a review of Resident 3's admission record dated 7/2/2026, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included cellulitis (an infection of the skin. It happens when germs (usually bacteria) get into the body through a cut, scratch, or any break in the skin) of right lower limb, cellulitis of left lower limb, diabetes (condition where the body has trouble using sugar the right way) and hypertension (high blood pressure).During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 6/15/2026, the MDS indicated Resident 3's cognition (ability to think, remember and reason for daily decision making) was intact.During a review of Resident 3's physician order dated 5/13/2026, the order indicated:insulin aspart (a fast-acting insulin [a medicine helps move sugar from your blood into your cells]) injection solution 100 unit/ml per sliding scale (a way for nurses to decide how much insulin to give based on a person's blood sugar level).During a review of Resident 3's care plan titled Resident has type 2 diabetes. dated 5/26/2026, the care plan indicated to monitor Resident 2 blood glucose as ordered and administered antidiabetic medication as ordered.During a review of Resident 3's MAR dated 5/2026 and 6/2026, the MAR indicated the following:insulin aspart injection solution 100 unit/ml, inject as per sliding scale:if 0 - 150 = 0 unit,if 151 - 200 = 2 unitsif 201 - 250 = 3 unitsif 251 - 300 =5 unitsif 301 - 350 = 7 unitsif 351+ = 10 units call MD immediately for further instruction if blood glucose is greater than 400, subcutaneously before meals and at bedtime for diabetes. inject insulin 15 - 20 mins minutes before each meal, the blood sugar level was not monitor and medication order was not administered on the following dates and times:at 6:30 am: 6/6at 4:30 pm: 6/13at 9:00 pm: 6/13During an interview with Licensed Vocational Nurse (LVN) 1 on 6/30/2026 at 1:50 pm, LVN 1 stated resident's care plan should be followed and intervention should be implemented. LVN 1 also stated resident's medication should be administered as order.During an interview with Assistant Director of Nursing (ADON) on 7/1/2026 at 2:40 pm, the ADON stated resident's care plan should be followed and implemented. ADON continued stated, failed to implement the care plan by not administered seizure medications and insulin as order affected all residents care, increased the risk for injury, harm and re-hospitalization. 3.During a review of Resident 3's admission record dated 7/2/2026, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included cellulitis (an infection of the skin. It happens when germs (usually bacteria) get into the body through a cut, scratch, or any break in the skin) of right lower limb, cellulitis of left lower limb, diabetes (condition where the body has trouble using sugar the right way) and hypertension (high blood pressure).During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 6/15/2026, the MDS indicated Resident 3's cognition (ability to think, remember and reason for daily decision making) was intact.During a review of Resident's physician order on 5/14/2026, the physician order indicated the following:polysporin (a type of antibiotic ointment you put on the skin to help stop infections) external ointment [PHONE NUMBER]0 unit/gm (bacitracin-polymyxin B) Apply to BLE topically every shift for cellulitis for 14 days.During a review of Resident's physician order on 5/14/2026, the physician order indicated the following:left lower leg venous ulcer-clean with normal saline (NS), pat dry, apply polysporin, apply non-adherent dressing, apply abd pad (a thick, absorbent bandage used to cover big wounds or wounds that leak a lot of fluid), wrap with kerlix (a soft, stretchy bandage used to wrap wounds), secure with tape every day shift for 30 daysright lower leg front scattered fluid filled blister-clean with NS, pat dry, apply non-adhesive dressing, wrap with kerlix, secure with tape every day shift for 14 days.During a review of Resident 3's care plan titled Resident is newly admitted to facility dated 5/13/2026, the care plan included intervention as administered medication, treatment, and other services in accordance with physician's order.During a review of Resident 3's care plan titled Resident has actual skin breakdown. dated 5/13/2026, the care plan included intervention as provide wound treatment as ordered.During a review of Resident 3's treatment administration record (TAR) dated 5/2026, the TAR indicated the following:polysporin external ointment [PHONE NUMBER]0 unit/gm (bacitracin-polymyxin B) Apply to BLE topically every shift for cellulitis for 14 days, was not administered on the following date and time:day shift: 5/15, 5/16, 5/21, 5/28evening shift: 5/14, 5/15, 5/16, 5/17, 5/19, 5/20, 5/21night shift: 5/14, 5/15, 5/16, 5/22left lower leg venous ulcer-clean with NS, pat dry, apply polysporin, apply non-adherent dressing, apply abd pad, wrap with kerlix, secure with tape every day shift for 30 days, was not administered on the following date and time:Day shift: 5/15, 5/21, 5/26right lower leg front scattered fluid filled blister-clean with NS, pat dry, apply non-adhesive dressing, wrap with kerlix, secure with tape every day shift for 14 days, was not administered on the following date and time:Day shift: 5/15, 5/21, 5/26 During an interview with LVN 1 on 6/30/2026 at 1:51 pm, LVN 1 stated, resident's care plan and treatment orders should be followed and implemented. Failing to provide treatment as order would affect Resident 3's care and delay Resident 3's recovery. During an interview with ADON on 7/1/2026 at 2:40 pm, the ADON stated Resident 3's treatment did not administer as physician ordered, Resident 3's care plan was not implemented. Failing to follow the physician's order and implement resident's care plan would compromise resident 3's recovery and prolong her healing process. During a review of the facility's policy and procedures (P&P) titled administering medication, dated 11/20/2025, the P&P indicated Medication are administered in a safe and timely manner, and as prescribed.During a review of the facility's P&P titled, care plan comprehensive, dated 11/20/2025, the P&P indicated that facility must develop and implement a comprehensive person-centered care plan for each resident.

Based on interview and record review, the facility failed to ensure that accuracy of medical record documentation for one of three sampled residents (Resident 1) when Resident 1 was admitted to the hospital on [DATE] and not physically present at the facility on 6/18/2026, the Nurse Practitioner (NP) 1 documented in her 30 days follow up notes dated 6/18/2026 that resident was seen and evaluated at the facility.This deficient practice had potential to result in mislead clinical staff, and affect Resident 1 care planning, and compromise the integrity of Resident 1's medical record.During a review of Resident 1's admission record dated 7/2/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included colon cancer (a disease that starts in the colon [a long tube in your belly that helps turn food into poop.] cells in colon start to grow in an uncontrolled way), muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypotension (low blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was not intact, unable to make decisions. During a review of Resident 1's Change of Condition (COC) report dated 6/16/2026, the COC report indicated resident 1 was transferred to hospital on 6/16/2026. During a review of Resident 1's Progress notes dated from 6/17/2026 to 6/20/2026, the Progress notes indicated resident was still in the hospital and had not return to facility during any of those dates. During a review of Resident 1's 30-day follow-up progress notes dated 6/30/2026, Resident 1's 30-day follow-up progress notes indicated on 6/18/2026, Resident was seen and evaluated by the Nurse Practitioner (NP) 1 with the following statement: Pt seen for routine follow up, currently in bed, appears to be comfortable. Not in any distress with no nonverbal signs or symptoms of pain or discomfort. During an telephone interview with NP 1, on 7/1/2026 at 10:19 am, NP 1 stated the following, the 30-days follow up progress note was made by me. On 6/18/2026 Resident 1 was on the bed, non-verbal, I saw him. but I do not remind exact room number for this resident. Asked NP 1 if she aware Resident 1 was transferred to the hospital on 6/16/2026 and did not return to facility on 6/18/2026, NP then stated the following: Oh, No, I didn't see him on 6/18/2026, the last time I saw him was 5/26/2026, the 30-days follow up was an error documentation. NP 1 further explained she should not have documented she saw the resident, error documentation affect Resident 1's care. During an interview on 7/1/2026 at 2:40 pm with Assistant Director of Nursing (ADON), the ADON stated NP 1's action was not acceptable. If the physician or nurse practitioner did not see the resident, they should not document that they did. Facility administrations were responsible for making sure that all residents are seen by their physician or nurse practitioner. ADON further stated that NP 1's action should count as false documentation, and it would cause miscommunication between staff members, affect Resident 1's care planning and compromised the integrity of Resident 1's medical record.During a review of the facility's policy and procedures (P&P) titled, Charting and Documentation, dated the P&P indicated Documentation in the medical record will be objective, complete, and accurate.

Based on interview and record review, the facility failed to ensure safe medication management by not identifying and reporting multiple significant medication irregularities for one of three sampled residents (Resident 1) as required by accepted standards of practice, when:nurses failed to report medication dosages given outside of recommended guidelinesnurses failed to report repeated drug to drug interaction alerts,These deficient practices increase the risk of ineffective therapy, medication toxicity, uncontrolled symptoms, and preventable adverse drug events for Resident 1.During a review of Resident 1's admission record dated 7/2/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included colon cancer (a disease that starts in the colon [a long tube in your belly that helps turn food into poop.] cells in colon start to grow in an uncontrolled way), muscle weakness, seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), and hypotension (low blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was not intact, unable to make decisions. 1.During a review of Resident 1's nursing progress notes dated 5/27/2026, the progress notes indicated the following: Depakote (a medicine for seizure, that helps keep the brain calm and steady.) oral tablet delayed Release 250 mg (milligram, a tiny unit used to measure how much medicine is in a pill or liquid) give 250 mg by mouth in the afternoon for anticonvulsant (medicine that helps prevent seizures)-The dosing regimen of 250 mg daily is below the usual dosing regimen of 310 mg 2 times per day to 3 times per day-the frequency of daily is below the usual frequency of 2 to 3 times per day. 2.During a review of Resident 1's nursing progress notes dated 4/14/2026, the progress notes indicated, order of Ativan (seizure medication) tablet 1 mg, has triggered the drug to drug interaction with following medication:Depakote with severe severity.During a review of Resident 1's nursing progress notes dated 4/16/2026, the progress notes indicated, order of depakote (seizure medication) oral tablet delayed release 250mg, has triggered the drug to drug interaction with the following medication:Phenytoin sodium extened capsule 100mg with moderate severity.Ativan tablet 1mg with severe severity.During a review of Resident 1's nursing progress notes dated 6/13/2026, the progress notes indicated, order of lorazepam tablet 0.5mg, has triggered the drug to drug interaction with the following medication:Depakoe with severe severityDuring an interview with Licensed Vocational Nurse (LVN) 3 on 7/1/2026 at 1;28 pm, LVN 3 stated for any time drug to drug interactions triggered, nurses would notify the physician, get instruction from physician, and then acknowledge it and documented that they did it. For any medication dosing outside of recommendation, physicians should also be notified as well. LVN 3 continued stated, she cannot find any progress notes on 4/14/2026, 4/16/2026, 5/27/2026 and 6/13/2026, that physician was notified. LVN 3 further stated drug to drug interaction and order medication dosage out of recommendation are both considered as change of condition, physician need to be notified, otherwise it could harm the residents. During an interview with Assistant Director of Nursing (ADON) on 7/1/2026 at 2:50 pm, ADON stated, on 4/14/2026, 4/16/2026 and 6/13/2026, drug to drug interaction was triggered for Resident 1, the nurse only acknowledged but did not notify the physician, as well as 5/27/2026 medication was outside of recommendation. ADON continue stated failed to report those will affect Resident 1's care and could even cause harm to Resident 1. During a phone interview with Pharmacy Consultant, (PC) on 7/2/2026 at 2:28 pm, PC stated facility had not reported any drug to drug interaction or medication order outside of recommendation guideline to him. PC further explained that if there is a drug to drug interaction or medication dosing was outside of recommendation, the DON and Physician should be notified, if any facility needs guidance from pharmacist, they could also reach out to call any pharmacist or to PC. During a review of the facility's policy and procedures (P&P) titled change of condition: notification of, dated 11/20/2025, and P&P indicated facility should immediately inform Resident's physician a need to alter treatment significantly.

Based on observation, interview, and record review, the facility failed to ensure that the documentation was accurate and complete for three of seven sampled residents (Resident 7, Resident 85, and Resident 74) by failing to ensure:1. Licensed nurses (in general) documented the presence of new skin alterations (change to the skin's color, texture, or growth pattern) accurately on Resident 7's Medication Administration Record (MAR).2. Licensed nurses (in general) documented the Change in Condition Evaluation (a sudden clinically important deviation from a resident's baseline in physical, behavioral, or functional domains) form completely for Resident 85. 3. completed documentation in the MAR for Resident 74 as required. 4. Documenting a medication as administered when it was not given or delivered by the pharmacy for Resident 74.These failures had the potential for nurses (in general) to misinterpret (to understand or explain something incorrectly) the documented information and lead to a lack of care for Resident 7, Resident 85 and Resident 74's needs. Findings: 1.During a review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 11/19/2021 with diagnoses that included chronic respiratory failure (a long-term condition where the respiratory system cannot adequately supply oxygen to the blood or clear carbon dioxide from the body), cerebral infarction (a medical emergency that occurs when blood flow to a part of the brain is blocked), tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe (trachea) to insert a tube that allows air to reach the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dependence on respirator (ventilator, a mechanical device to help support or replace breathing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (weakness on one side of the body). During a review of Resident 7's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 2/27/2024 that indicated to apply hand mittens (a soft, padded covering that fits over a resident's hand, that resembles a small boxing glove) to the resident's left hand to prevent the resident from pulling out invasive tubing (any instrument, catheter, or implant that temporarily or permanently enters the body through an incision, a surgical puncture, or a natural body opening). The Order Summary Report indicated Resident 7's left - hand mitten was to be released every two hours. The Order Summary Report indicated Resident 7's left hand was to be checked for circulation (continuous flow of blood through the veins and arteries) and skin integrity (the overall health and completeness of the skin) every two hours. The Order Summary Report indicated to document + if Resident 7 had new skin alterations. The physician order indicated to document - if the resident had no new skin alterations. The physician order indicated to report any redness, swelling, and/or pain to Resident 7's physician. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated 11/13/2025, the MDS indicated the resident had severely impaired cognition (a profound decline in thinking, memory, and reasoning that makes a person unable to live independently). The MDS indicated Resident 7 was dependent on help for oral hygiene, toileting hygiene, showering/bathing himself, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 7 had a feeding tube (gastrostomy). The MDS indicated Resident 7 received tracheostomy care. The MDS indicated Resident 7 had a mechanical ventilator. The MDS indicated Resident 7 used a limb restraint (a device that inhibits an individual's movement in their arms or legs) daily. During a review of Resident 7's Medication Administration Record (MAR) dated 4/1/2026 to 4/30/2026, the MAR indicated to apply hand mittens to the resident's left hand to prevent the resident from pulling out invasive tubing. The MAR indicated to release Resident 7's left hand mitten every two hours. The MAR indicated to check Resident 7's left hand for circulation and skin integrity every two hours. The MAR indicated to document + if Resident 7 had new skin alterations. The MAR indicated to document - if the resident had no new skin alterations. The MAR indicated Registered Nurse 2 (RN 2) documented + on 4/21/2026 at 12 AM, 4/21/2026 at 2 AM, 4/21/2026 at 4 AM, 4/27/2026 at 8 PM, 4/27/2026 at 10 PM, 4/28/2026 at 12 AM, and on 4/28/2026 at 2 AM. During a review of Resident 7's MAR dated 5/1/2026 to 5/31/2026, the MAR indicated to apply hand mittens to the resident's left hand to prevent the resident from pulling out invasive tubing. The MAR indicated to release Resident 7's left hand mitten every two hours. The MAR indicated to check Resident 7's left hand for circulation and skin integrity every two hours. The MAR indicated to document + if Resident 7 had new skin alterations. The MAR indicated to document - if the resident had no new skin alterations. The MAR indicated RN 2 documented + on 5/4/2026 at 8 PM, 5/4/2026 at 10 PM, 5/18/2026 at 8 PM, 5/18/2026 at 10 PM, 5/19/2026 at 12 AM, 5/19/2026 at 2 AM, and 5/19/2026 at 6 AM. During a review of Resident 7's MAR dated 6/1/2026 to 6/11/2026, the MAR indicated to apply hand mittens to the resident's left hand to prevent the resident from pulling out invasive tubing. The MAR indicated to release Resident 7's left hand mitten every two hours. The MAR indicated to check Resident 7's left hand for circulation and skin integrity every two hours. The MAR indicated to document + if Resident 7 had new skin alterations. The MAR indicated to document - if the resident had no new skin alterations. The MAR indicated RN 2 documented + on 6/1/2026 at 8 PM, 6/1/2026 at 10 PM, 6/2/2026 at 12 AM, and 6/2/2026 at 2 AM During a concurrent telephone interview and record review on 6/9/2026 at 3:59 PM with RN 2, Resident 7's Order Summary Report dated 2/27/2024 and MAR dated 4/1/2026 to 4/30/2026, 5/1/2026 to 5/31/2026, and 6/1/2026 to 6/11/2026 were reviewed. RN 2 stated she (RN 2) was familiar with Resident 7. RN 2 stated Resident 7 had a left-hand mitten. RN 2 stated Resident 7 had a physician order to check the resident's skin on the left hand every two hours. RN 2 stated Resident 7 did not have any skin alterations to the left hand. RN 2 stated she (RN2) had mistakenly documented + on Resident 7's MARs dated 4/1/2026 to 4/30/2026, 5/1/2026 to 5/31/2026, and 6/1/2026 to 6/11/2026. RN 2 stated she (RN 2) should have documented - because Resident 7 did not have any new skin alterations to the left hand. RN 2 stated that documentation should be accurate. RN 2 stated that the documentation on the MAR should reflect Resident 7's status. RN 2 stated that there was potential for Resident 7's documentation to be misinterpreted which could in turn affect the resident's care if the documentation was not accurate. During a concurrent observation and interview on 6/11/2026 at 10:04 AM, in Resident 7's room, the resident's left hand was observed with Licensed Vocational Nurse 6 (LVN 6). Resident 7 was observed with a left-hand mitten. LVN 6 stated she (LVN 6) was assigned to care for Resident 7. LVN 6 stated Resident 7 had a left-hand mitten because the resident tried to pull his (Resident 7) gastrostomy and tracheostomy tubing. LVN 6 stated Resident 7's left hand circulation and skin was checked hourly. LVN 6 was observed removing Resident 7's left-hand mitten. Resident 7's left-hand skin and circulation was observed intact (undamaged, complete, and in its original state). During a concurrent interview and record review on 6/11/2026 at 11:16 PM with the Director of Nursing (DON), Resident 7's physician order dated 2/27/2024 and MAR dated 4/1/2026 to 4/30/2026, 5/1/2026 to 5/31/2026, and 6/1/2026 to 6/11/2026 were reviewed. The DON stated Resident 7 had a left-hand mitten because the resident attempted to pull his (Resident 7) gastrostomy and tracheostomy tubing. The DON stated the skin and circulation to Resident 7's left hand was checked regularly. The DON stated Resident 7's physician order and MAR indicated to document + if the resident had a new skin alteration and - if the resident did not have a new skin alteration. The DON stated RN 2 documented + on Resident 2's MAR dated 4/1/2026 to 4/30/2026, 5/1/2026 to 5/31/2026, and 6/1/2026 to 6/11/2026. The DON stated RN 2's documentation of + on Resident 7's MAR was a mistake. The DON stated documentation should always be accurate. The DON stated documentation should always reflect Resident 7's status. The DON stated Resident 7's physician order should be read properly to ensure that documentation was correct. The DON stated there was potential for Resident 7 to receive care that was not aligned with the resident's needs because staff (in general) may have misinterpreted the documentation on the resident's MAR. 2.During a review of Resident 85's admission Record, the admission Record indicated the facility admitted the resident on 10/13/2025 with diagnoses that included type 2 diabetes, sepsis (a life-threatening blood infection), end stage renal disease (irreversible kidney failure), dependence on renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), hemiplegia, and hemiparesis. During a review of Resident 85's MDS dated [DATE], the MDS indicated the resident was cognitively intact (had ability to think, understand, and reason). The MDS indicated Resident 85 required set up or clean up assistance (helper sets up or cleans up; resident completes activity) for eating. The MDS indicated Resident 85 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 85 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering/bathing himself, lower body dressing, and putting on/taking off footwear. During a review of Resident 85's Change in Condition Evaluation dated 3/21/2026 at 12:41 PM, the Change in Condition Evaluation indicated the resident had generalized weakness (a perceived decrease in physical or muscle strength that affects the entire body). The Change in Condition Evaluation indicated there was no documentation that Resident 85's physician was notified of the resident's generalized weakness. The Change in Condition Evaluation indicated there was no documentation that Resident 85's representative was notified of the resident's generalized weakness. The Change in Condition Evaluation indicated there was no documentation that the Change in Condition Evaluation was signed and dated. During a review of Resident 85's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 3/21/2026 to transfer the resident to General Acute Care Hospital 1 (GACH 1) due to generalized weakness. During a concurrent interview and record review on 6/10/2026 at 10:25 AM with RN 3, Resident 85's Change in Condition Evaluation dated 3/21/2026 at 12:41 PM was reviewed. RN 3 stated she (RN 3) was working as the RN supervisor on 3/21/2026. RN 3 stated Resident 85 was not feeling well and was feeling weak on 3/21/2026. RN 3 stated Resident 85's physician was notified and the resident was sent to the GACH (not specified). RN 3 stated Resident 85's change in condition documentation was started but not completed on 3/21/2026. RN 3 stated Resident 85's Change in Condition Evaluation should have been completed with all the details of what happened. RN 3 stated it was important to document a change in condition completely so that the documentation could be referenced by the physician or other nurses (in general) at a later time. RN 3 stated it was important that Resident 85's change in condition be documented completely so that nurses (in general) could have used the information to monitor the resident and provide the resident with the necessary interventions. RN 3 stated that if Resident 85's change in condition was not completely documented there was potential for the resident to not receive the necessary care needed after having a change in condition. During a concurrent interview and record review on 6/11/2026 at 11:22 AM with the DON, Resident 85's Change in Condition Evaluation dated 3/21/2026 at 12:41 PM was reviewed. The DON stated that Resident 85's Change in Condition Evaluation was started but not completed. The DON stated Resident 85's Change in Condition Evaluation should have been documented completely. The DON stated Resident 85's Change of Condition Evaluation should have contained information on what had occurred and information on the resident's assessment. The DON stated the information on the Change in Condition Evaluation would have contained information that was to be passed on to Resident 85's physician. The DON stated the Change in Condition Evaluation would have also indicated recommendations from Resident 85's physician. The DON stated that Resident 85's physician was notified of the resident's change in condition on 3/21/2026, but the Change in Condition Evaluation was not completed to indicate the physician was notified. The DON stated there was potential for the nursing staff (in general) to not have knowledge of Resident 85's change in condition if the change in condition was not documented. The DON stated there was a potential for the residents (in general) to not to be monitored after having a change in condition if the change of condition was not documented. During a review of the facility's Policy and Procedure (P&P) titled Charting and Documentation reviewed 11/20/2025, the P&P indicated Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 2.During a review of Resident 74's admission record, the admission record indicated that Resident 74 was originally admitted on [DATE], and readmitted on [DATE] with a diagnosis including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements); Alzheimer's disease (a disease characterized by a progressive decline in mental abilities); schizophrenia (a mental illness that is characterized by disturbances in thought); anxiety disorder (a mental health condition characterized by persistent, excessive fear or worry in everyday situations); and dementia (a progressive state of decline in mental abilities). During a review of Resident 74's Minimum Data Set (MDS- a resident assessment tool), dated 4/13/2026, the MDS indicated Resident 74 has some cognitive impairment (any condition that affects a person's mental functioning, and capacity.) The MDS indicated that Resident 74 uses a walker to ambulate (walk) and requires maximal assistance for toileting, showering, and lower body dressing; moderate assistance for oral & personal hygiene; and supervision for upper body dressing. During a review of the physician's orders dated 2/16/2026, the orders indicated the following: Atorvastatin tablet 40mg at bedtime (a medication used to treat high cholesterol) Buspirone tablet 5 mg two times a day (a medication used to treat anxiety) Quetiapine 25mg tablet two times a day (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]) Temazepam 7.5mg capsule at bedtime (a medication used to help with sleep) During a review of Resident 74's MAR for 4/2026, the MAR did not indicate medication was administered for quetiapine, or temazepam on 4/25/2026. The MAR indicated Resident 74 was administered temazepam on 4/11/2026, 4/13/2026, 4/18/2026, 4/20/2026, and 4/21/2026. During a review of Resident 74's MAR for 5/2026, the MAR did not document whether or not Resident 74 was administered atorvastatin, buspirone, temazepam, and quetiapine on 5/2/2026 and 5/9/2026. The MAR indicated that Resident 74 was administered temazepam on 5/6/2026, 5/7/2026, and 5/11/2026, when the medication was not delivered to the facility. During an interview on 6/11/2026 at 9:58 a.m. with Registered Nurse Supervisor (RN1), RN 1 stated that if the MAR has blank entries, that means the LVN did not indicate that the medication was administered to Resident 74. RN 1 stated it is important to administer medications as ordered and to document because Resident 74's medications treat her behavioral diagnoses. During a telephone interview on 6/11/2026 at 11:22 a.m. with the PharmD., the PharmD stated they have been delivering all the medications to the facility in a timely manner except for Temazepam, because they never received the order from the facility. During a concurrent observation and interview on 6/11/2026 at 11:58 a.m. with DON in the hallway, the DON could not find Resident 74's temazepam in two of the medication carts. DON stated there was no Temazepam found in any of the medication carts for Resident 74. During a telephone interview on 6/11/2026 at 12:10 p.m. with LVN 4, LVN 4 stated he accidentally marked the temazepam administration as completed, but he has never given temazepam to Resident 74. LVN 4 stated it is important to accurately document medication administration for safety, and to ensure the residents are receiving the therapeutic effects of the medication. During a phone interview on 6/11/2026 at 1:07 p.m. with LVN 5, LVN 5 stated that she documented medication administration of temazepam by accident. LVN 5 stated she made an error and thought she was giving temazepam, but she did not. LVN 5 stated it is important to document accurately because medications need to be given per the doctor's orders and residents need to receive the therapeutic effects of the prescribed medications. During a concurrent interview and record review on 6/11/2026 at 1:25 p.m. with the DON, the DON stated that the blank entries in the MAR indicated LVNs did not document the medication administration. The DON stated the documentation policy was not followed for Resident 74. DON stated LVNs did not follow up with the pharmacy to retrieve the temazepam, nor did they escalate it to the DON or RN Supervisor. During a review of the facility's policy and procedure (P&P), titled, Charting and Documentation last revised 8/2017, the P&P indicated that all documentation for medication administration must be objective, complete and accurate.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when:1. One large box of breaded chicken was thawing inside the Walk-in refrigerator with no thaw date.2. the ice machine was not maintained in a sanitary manner, the inner plastic board inside the ice storage bin had pink color stains and residue.3. One cook (Cook1) wearing layered gloves did not wash hands and replace gloves when moving between different tasks.4. Temperature of the potato salad held for cold holding during lunch service on 6/8/2026 was at 55.5 degrees Fahrenheit (F).These failures had the potential to result in harmful bacteria growth and cross contamination of food (transfer of harmful bacteria and chemicals form one place to another) that could lead to food borne illness in 66 out of 86 residents who received food and ice from the facility.Findings:1. During an observation in the walk-in refrigerator on 6/8/2026 at 9:15AM, there was one large box of breaded chicken that was stored on the bottom shelf with no date.During a concurrent observation and interview with the Dietary Supervisor (DS) on 6/8/2026 at 9:15AM, the DS stated the box of chicken was delivered on 6/4/2026. The DS stated the breaded chicken was delivered frozen, and it was stored in the freezer. The DS stated it was important to label with the thaw date or when it was removed from the freezer to know when to use or discard before it was expired. The DS stated food was thawed for three days in the refrigerator then cooked.During a review of facility's policy and procedure (P&P) titled Cold Foods (revised 2/2026) the P&P indicated, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.2.During an observation of the facility ice machine on 6/8/2026 at 10 AM, located in the kitchen, a clean paper towel swipe of the ice storage bin ceiling produced small amounts of pink residue. The residue was located under the plastic baffle (an ice machine baffle or [ice deflector] is an internal panel or partition that directs the flow of ice as it falls from the evaporator into the storage bin or dispenser. It prevents ice from jamming the machine, guides it evenly into the bin, and stops cubes from spilling out of the front panel)During a concurrent observation and interview with the DS on 6/8/2026 at 10 AM, the DS stated an outside vendor (unidentified) would clean the ice machine once a month. The DS stated there was pink residue produced on the paper towel when the under the plastic board was swiped. The DS stated it should be cleaned better. The DS stated the pink residue could contaminate the ice for the residents (in general).During an interview with the District Manager (DM) on 6/8/2026 at 10:10AM, the DM stated the facility should have the outside vendor (unidentified) go to the facility twice a month, to make sure the ice machine was clean.During a review of facility's policy and procedure (P&P) titled Ice (revised 10/2022) the P&P indicated, Ice will be prepared and distributed in a safe and sanitary manner. Ice bins will be cleaned monthly and as needed.During a review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Food-Contact Surfaces and Utensils code 4-602.11, the code indicated, (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.3.During an observation in the kitchen on 6/8/2026 at 11:45AM, [NAME] 1 was wearing disposable gloves, observed [NAME] 1 wearing two gloves on top of each other. Cook1 was transferring cooked food from the oven to the steam table (used to hold precooked food at safe temperatures >135 degrees F; it has multiple stainless-steel compartments (wells) that use heated water to produce steam and keep food warm), Cook1 left the area and grabbed serving utensils from the cabinets. Cook1 returned to the food preparation area, gathered ingredients in the blender to make minced chicken. When Cook1 finished making the minced chicken, observed Cook1 remove the top layer of the gloves and kept the gloves underneath and proceeded to remove the minced chicken from the blender into a pan. Cook1 then grabbed a thermometer and started checking the temperature of the food held on the steam table.During a concurrent observation and interview with Cook1 on 6/8/2026 at 12 PM, Cook1 stated that Cook1 removed the top layer gloves because they got dirty. Cook1 stated Cook1 had another layer of gloves under to work fast and quickly move from one task to another without stopping to wear another glove. Cook1 stated that the correct way was to wear one layer of gloves, wash hands and then replace gloves when they were dirty. Cook1 stated it was important to wash hands and change gloves because the gloves get dirty and it can contaminate food.During a review of the 2022 U.S. Food and Drug Administration Food Code, titled When to Wash Code 2-301.14, indicated, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and E) After handling soiled EQUIPMENT or UTENSILS. (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.(G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD.(H) Before donning gloves to initiate a task that involves working with FOOD.4.During an observation of the lunch service on 6/8/2026 at 12 PM, a temperature check of the potato salad a TCS food (Time/Temperature control for safety food, TCS foods are foods that can support bacterial growth that can result in food borne illness unless stored, prepared and served safely) using facility thermometer registered at 55.5 degrees F. During a concurrent observation and interview with DS on 6/8/2026 at 12 PM, the DS stated the potato salad was in the refrigerator. The DS stated it should be 41 degrees F or lower from the refrigerator and asked DA2 to return the salads to cool down. The DS said some residents may complain when salad is not very cold. DS stated if potato salad stays out of the refrigerator for long time it can go bad.During an interview with DA1 and Cook1 on 6/8/2026 at 12:05PM DA1 stated we finished scooping and portioning the potato salad in bowls around 11:30AM. Cook1 stated finished making the potato salad late and did not have enough time in the refrigerator to become cold.During an interview with RD1 and the DM on 6/8/2026 at 1:28PM, RD1 stated the holding temperature for cold food should be 41 degrees F and below and the potato salad was not. The DM stated the kitchen staff (in general) should prepare the potato salad the day before and store it in the refrigerator to get that cold temperature for lunch.During a review of facility policy and procedures (P&P) titled Food Storage: Cold Foods (revised 2/2026) the P&P indicated, All perishable foods will be maintained at a temperature of 41F or below, except during necessary periods of preparation and service.During a review of facility policy and procedures (P&P) titled Food: Preparation (revised 2/2026) the P&P indicated, All foods will be held at appropriate temperatures, greater than 135F for hot holding, and less than 41 degrees F for cold food holding.During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135 degrees F or above, and at 41 degrees F or below.

Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 6/8/2026 when:-Eleven residents (unidentified) on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received pureed carrots instead of pureed mixed vegetables (corn, carrots, peas, and green beans) per the menu.This failure had the potential to result in meal dissatisfaction and decreased nutritional intake for the residents (unidentified) on the pureed diet.Findings:During a review of the facility lunch menu on 6/8/2026, the following items were to be served for the pureed diet:Pureed fried chicken 1/2 cup; pureed potato salad 1/2 cup; pureed mixed vegetables 1/2 cup; pureed bread; pureed mandarin oranges, and beverage of choice.During an observation of the tray line service (tray line- a system of food preparation, in which trays move along an assembly line) for lunch on 6/8/2026 at 12:30PM, the residents (unidentified) on pureed diet received pureed carrots instead of pureed mixed vegetables per the menu.During a review of the facility spreadsheet (food portion and serving guide) and an interview with Cook1 on 6/8/2026 at 1 PM, Cook1 stated Cook1 made a mistake and forgot to prepare the pureed mixed vegetables. Cook1 stated Cook1 did not follow the menu and served the pureed carrots to all the residents (unidentified) who were on pureed diet instead of mixed vegetables. Cook1 stated it was important to follow the menu because the residents (unidentified) could be upset when they were expecting vegetables and receive something else. During an interview with Dietary Supervisor (DS) on 6/8/2026 at 1 PM, the DS stated cooks (in general) needed to follow the menu, and it was important to serve what was on the menu and inform the DS when any ingredient needed to be replaced. During a review of the facility cooks spreadsheet titled New Gen Fountain View Spring 2026 for week 1 Tuesday (dated 6/8/26), the spreadsheet indicated to serve Pureed/Level4 diets: pureed fried chicken, pureed potato salad; pureed mixed vegetables; pureed bread; pureed mandarin oranges and beverage.During a review of facility's policy and procedure (P&P) titled Menus (revised 2/2026) the P&P indicated, Menus will be planned in advance to meet the nutritional needs of the resident in accordance with established national guidelines. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.

Based on interview and record review, the facility failed to ensure to complete the Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) Acknowledgement Form (a written documentation of request or refused formulation of advanced directives) for one of eight sampled residents (Resident 73). This failure violated Resident 73's rights to be fully informed of the option to request or refuse medical care and treatment.Findings:During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident originally on 3/2/2024 and readmitted the resident on 4/24/2026 with diagnoses that included muscle weakness, abnormalities of gait (a person's specific manner or pattern of walking or moving on foot), end stage renal disease (irreversible kidney failure), and essential hypertension (high blood pressure). During a review of Resident 73's untitled history and physical document dated 8/3/2025, the untitled history and physical document indicated Resident 73 had the capacity to understand and make decisions. During a review of Resident 73's Advance Directive Acknowledgement Form dated 4/24/2026, the Advanced Directive Acknowledgement form indicated Resident 73 had not executed an Advance Directive and was not offered options to execute or decline Advanced Directive. During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool) dated 4/28/2026, the MDS indicated Resident 73 made herself understood and understood others. The MDS indicated Resident 73's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS indicated Resident 43 required maximal assistance with mobility. During a concurrent interview and record review on 6/9/2026 at 11:05 AM with the Social Service Director (SSD), Resident 73's Advance Directive Acknowledgement Form was reviewed. The SSD stated that an advanced directive allowed a resident to designate an agent or family member to participate in medical decision making. The SSD stated that the Advanced Directive Acknowledgement Form was initiated upon admission and completed for all residents (in general). The SSD stated that Resident 73's Advanced Directive Acknowledgement Form indicated none of the available option boxes were checked. The SSD stated that the form should have contained a checked box response indicating the Resident 73's choices and options regarding advance directive information. The SSD stated that the incomplete form did not reflect whether Resident 73 was provided information regarding advanced directives or whether resident 73 had elected any available options. The SSD stated that the facility failed to document and communicate Resident 73's choices regarding advance directive options. During a concurrent interview and record review on 6/9/2026 at 11:52 AM with the Administrator (ADM), Resident 73's Advance Directive Acknowledgement Form was reviewed. The ADM stated that the Advance Directive Acknowledged Form was used to communicate how residents (in general) wanted their care to be provided. The ADM stated that Resident 73's Advance Directive Acknowledgement Form contained option boxes that were not checked. The ADM stated that without the boxes being checked there was no indication that advance directive information was offered to Resident 73. The ADM stated that the Advance Directive Acknowledged Form was incomplete. During a concurrent interview and record review on 6/9/2026 at 12:03 PM with the Director of Nursing (DON) Resident 73's Advance Directive Acknowledgement Form reviewed. The DON stated that an advanced directive was a legal document that outlined a resident's in general) preferences for medical care. The DON stated that an advance healthcare directive was important to ensure that a resident's (in general) personal wishes were expected and conflicts avoided regarding care and medical treatment decisions. The DON stated the Advance Healthcare Directive Acknowledgement Form was completed upon admission by the resident or responsible party. The DON stated that resident 73's Advanced Directive Acknowledgement Form was incomplete because of the option boxes. The DON stated that the boxes should have been checked to indicate Resident 73 responded to choices on advance directive and ensured the form was complete. During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated 11/20/2025, the P&P indicated to provide residents with the opportunity to make decisions regarding their health care. The P&P indicated the admission staff or designee will inform the resident of their right to execute an Advance Directive Form, if one does not already exist. The P&P indicated each resident is informed that it is their choice to complete the Advance Directive. The P&P indicated the choice not to complete the Advance Directive Form is recorded in the resident's medical record.

Based on interview and record review, the facility failed to ensure adequate monitoring for the symptoms of anxiety (nervousness) and manifestations of verbalizing feeling anxious and/or nervous for one of five sampled residents (Resident 101) who had physician orders for Alprazolam (a medication used to treat anxiety) 0.25 milligrams (mg, a unit of weight and mass). This failure had the potential for Resident 101 to experience anxiety that was not treated, affecting the resident's quality of life. Findings:During a review of Resident 101's admission Record, the admission Record indicated the facility admitted the resident on 6/7/2026 with diagnoses that included intervertebral disc degeneration (a condition in which the cushioning in the spine begins to wear away), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), need for assistance with personal care, difficulty in walking, and hypertension (high blood pressure).During a review of Resident 101's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 6/9/2026 for Alprazolam 0.25 mg by mouth every 6 hours as needed for anxiety manifested by verbalization of feeling nervous/anxious for 14 days.During a concurrent interview and record review on 6/11/2026 at 11:34 AM with Registered Nurse 1 (RN 1), Resident 101's Order Summary Report was reviewed. RN 1 stated Resident 101 had physician orders for Alprazolam 0.25 mg by mouth every 6 hours as needed for anxiety manifested by the verbalization of feeling nervous/anxious for 14 days. RN 1 stated there was no physician order to monitor Resident 101 for symptoms of anxiety. RN 1 stated there should be physician orders to monitor Resident 101 for symptoms of anxiety. RN 1 stated that if there was no physician order to monitor Resident 101 for symptoms of anxiety the nurses (in general) would not be prompted to monitor the resident for symptoms of anxiety. RN 1 stated there was potential for Resident 101 to have symptoms of anxiety that would not be treated. RN 1 stated there a was potential for Resident 101's physician to not know if the order for Alprazolam needed to be continued or updated if the resident was not monitored for symptoms of anxiety.During a concurrent interview and record review on 6/11/2026 at 12:24 PM with the Director of Nursing (DON), Resident 101's Order Summary Report was reviewed. The DON stated Resident 101 had physician orders for Alprazolam 0.25 mg every 6 hours as needed for anxiety manifested by the verbalization of nervous/anxious feelings for 14 days. The DON stated there was no physician order to monitor Resident 101 for the verbalization of nervous/anxious feelings. The DON stated Resident 101 needed to be monitored for the verbalization of feeling nervous/anxious. The DON stated there was potential for Resident 101 to experience symptoms of anxiety that were not addressed. The DON stated there was potential for Resident 101's physician to not know if Alprazolam was effective at treating the resident's symptoms of anxiety if the symptoms were not monitored. During an interview on 6/11/2026 at 3:09 PM with Resident 101, Resident 101 stated he (Resident 101) had feelings of anxiousness, especially when people (unidentified) would bother him (Resident 101) at night.During a review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use reviewed 11/20/2025, the P&P indicated Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring and review requirements specific to psychotropic medication.anti-anxiety medications.Proper psychotropic medication selection and prescribing (including dose, duration, and type of medication(s) may help stabilize or improve a resident's outcome, quality of life, and functional capacity. Residents receiving psychotropic medication are monitored and the response to treatment is documented. Monitoring may include lab results, vital signs, progress notes, behavior flow sheets, medication administration records, and the drug regimen review from the consultant pharmacist

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs by not having the call light within reach for one out of one sampled resident (Resident 12). This failure had the potential for Resident 12 to not be able to receive assistance in a timely manner.Findings:During a review of Resident 12's admission Record, the record indicated that Resident 12 was originally admitted on [DATE] and readmitted on [DATE] with a diagnoses of metabolic encephalopathy (an altered mental state usually caused by organ failure or chemical imbalances); Alzheimer's disease (a disease characterized by a progressive decline in mental abilities); history of falling; generalized muscle weakness, and difficulty in walking. During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool), dated 5/28/2026, the MDS indicated that Resident 12 has significant cognitive impairment (any condition that affects a person's mental functioning, and capacity). The MDS indicated that Resident 12 uses a walker to ambulate (walk) and requires supervision for oral hygiene, moderate assistance for toileting and upper body dressing, and maximal assistance for showering and lower body dressing. During an observation on 6/8/2026 at 12:14 p.m. in Resident 12's room, Resident 12 was sitting in bed, and her call light was not visible. Resident 12 stated she was unable to find her call light. Licensed Vocational Nurse 1 (LVN 1) came to the bedside and located the call light hanging along the left side of Resident 12's bed, out of reach from Resident 12. During an interview on 6/8/2026 at 12:27 p.m. with LVN 1, LVN 1 stated Resident 12's call light was not in reach but should have been. LVN 1 stated Resident 12 can use the call light when needed and had used it earlier in the day. LVN 1 stated it is important for the residents to have their call bell in reach, because the resident could require emergency services, and/or need assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During an interview on 6/9/2026 at 11:54 a.m. with the Registered Nurse Supervisor (RN 1), RN 1 stated that part of her job duties includes rounding (a proactive process in which a licensed staff member visits the resident to promote safety and evaluate care) on all the residents to ensure the call light is in reach. RN 1 stated the call light is used for resident needs and should always be within easy reach of the resident to prevent potential falls, or unknown patient distress. RN 1 stated that CNAs, nurses, charge nurses, supervisors, and the Director of Staff Development are all responsible for making sure the call light is in reach. During an interview on 6/11/2026 at 1:42 p.m. with the Director of Nursing (DON), the DON stated the facility's call light policy includes making sure the call light is within the resident's reach. The DON stated if the call light is not in reach there could be a delay in care, an accident, or accidental falls for the residents. The DON stated everyone in the facility is responsible for making sure the call light is in reach of the resident and that the staff did not follow the call light policy for Resident 12 but should have. During a review of the facility's policy and procedure (P&P), titled Answering the Call Light, last revised 10/24/2024, the P&P indicated that the call light should be accessible to the resident at all times.

Based on interview and record review, the facility failed to obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with sertraline (a medication used to treat mental illness) for one of five sampled residents (Resident 62) reviewed for unnecessary medications. This failure had the potential to prevent Resident 62 from exercising his right to decline treatment for the use of sertraline, increasing the risk of Resident 62 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to sertraline, leading to impairment or decline in his mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 62's admission Record, the admission Record indicated the facility admitted on [DATE], and readmitted the resident on 9/25/2025 with diagnoses including but not limited to depression (a mood disorder that causes persistent feelings of sadness and loss of interest) and dementia (a progressive state of decline in mental abilities). The face sheet also indicated Resident 62 has a designated responsible party. During a review of Resident 62's History and Physical (H&P) dated 4/3/2026, the H&P indicated Resident 62 had fluctuating capacity to understand and make decisions. During a review of Resident 62's Order Summary Report dated 4/6/2026, the Order Summary Report indicated an order for Resident 62 to take sertraline 25 milligrams (mg, a unit of measurement for mass) by mouth one time a day for depression manifested by difficulty falling asleep. During a review of Resident 62's Care Plan Report dated 4/7/2026, the Care Plan Report indicated Resident 62 was currently using sertraline for depression. The Care Plan Report indicated to provide informed consent to resident or healthcare decision maker. During a review of Resident 62's Minimum Data Set (MDS - a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 62 had severe problems with thinking or memory. During an interview on 6/10/2026 at 11:08 AM with the Medical Records Director (MRD), the MRD stated there was no documentation of an informed consent for Resident 62 use of sertraline. During an interview on 6/10/2026 at 11:16 AM with the Director of Nursing (DON), the DON stated there was no documentation of an informed consent for Resident 62's sertraline. The DON stated an informed consent for psychotropic medications (medications that affect the mind, emotions, or behavior) was important to ensure the resident had the opportunity to make an informed decision about whether to receive treatment with psychotropic medications or not. The DON stated psychotropic medications, like sertraline, could cause adverse effects that could cause a decrease in quality of life. The DON stated that there was no documentation of Resident 62's informed consent for sertraline. The DON stated Resident 62 was at additional risk of an adverse effects related to the use of sertraline. During a review of the facility's policy and procedure (P&P) titled, Informed Consent for Psychotropic Drugs, undated, the P&P indicated the prescriber must obtain consent for the medication before administration. The prescriber must discuss and document material information such as the risks and benefits of the medication.

Based on interview and record review, the facility failed to update and revise the care plan for one of eight sampled residents (Resident 73) for hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney) by failing to: -Ensure the licensed nurses (in general) updated Residents 73's Care Plan Report to include hemodialysis orders on 4/25/2026 and change of hemodialysis days. This failure had the potential to result in a delay in nursing care for Resident 73.Findings: During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident originally on 3/2/2024 and readmitted on [DATE] with diagnoses that included but not limited to muscle weakness, abnormalities of gait (a person's specific manner or pattern of walking or moving on foot), end stage renal disease (irreversible kidney failure), and essential hypertension (high blood pressure). During a review of Resident 73's Care Plan Report dated 7/31/2025, the Care Plan Report indicated Resident 73's hemodialysis treatment was two to four hours bedside dialysis treatment days Monday, Tuesday, Wednesday, Thursday and Friday. During a review of Resident 73's Order Summary dated 7/31/2025, the Order Summary indicated physician's order to provide two to four hours bedside dialysis treatment days: Monday, Tuesday, Wednesday, Thursday and Friday. During a review of Resident 73's untitled history and physical document dated 8/3/2025, the untitled history and physical document indicated Resident 73 had the capacity to understand and make decisions. During a review of Resident 73's Order Summary dated 4/25/2026, the Order Summary indicated the following physician's orders: emergency care instructions after dialysis treatment day, hemodialysis access monitoring every shift, do not take blood pressure in the right arm, dialysis emergency kits at bedside as needed, and monitor AV (arteriovenous, connection refers to a direct link between an artery and a vein) fistula (an abnormal connection between an artery and a vein site ) for signs and symptoms of infection, edema (swelling), and bleeding. During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool)) dated 4/28/2026, the MDS indicated Resident 73 made herself understood and understood others. The MDS indicated Resident 73's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) is intact. The MDS indicated Resident 43 required maximal assistance with mobility. During a concurrent interview and record review on 6/10/2026, at 12:12 PM with Licensed Vocational Nurse 1 (LVN1) Resident 73's Order Summary and Care Plan Report on hemodialysis were reviewed. LVN 1 stated the order dated 7/31/2025 indicated hemodialysis treatment days were Monday to Friday and no weekends. LVN 1 stated that resident 73's Care Plan Report dated 7/31/2025 indicated hemodialysis treatment days Monday to Friday without weekends treatment. During a concurrent interview and record review on 6/10/202 at6 12:20 PM with LVN 1, Resident 73's Home Hemodialysis Order dated 5/12/2026 was reviewed. LVN 1 stated that Resident 73's Home Hemodialysis Order indicated four (Monday, Tuesday, Wednesday and Friday) treatments per week with treatment notes to be off on Thursday. LVN 1 stated that the Care Plan Report on hemodialysis should have been updated with changed treatment dates. During a concurrent interview and record review on 6/10/2026, at 12:20 PM with LVN 1, Resident 73's Order Summary Report dated 4/25/2026 was reviewed. LVN 1 stated that Resident 763's hemodialysis care related order summary indicated emergency care instructions after dialysis treatment day, hemodialysis access monitoring every shift, do not take blood pressure in the right arm, dialysis emergency kits at bedside as needed, and monitor AV fistula for signs and symptoms of infection, edema, and bleeding. The LVN 1 stated that Resident 73's Care Plan Report on hemodialysis should have been updated including Resident 73's hemodialysis care orders dated 4/25/2026. During a concurrent interview and record review on 6/10/2026, at 1:34 PM with the Director of Nursing (DON), Resident 73's Care Plan Report for hemodialysis dated 7/31/2025 and Resident 73's Order Summary dated 4/25/2026 were reviewed. The DON stated that Resident 73's Care Plan Report for hemodialysis indicated that it was initiated on 7/31/2025 and was not updated with Resident 73's hemodialysis care ordered on 4/25/2026. The DON stated that Resident 73's Care Plan Report for hemodialysis dated 7/31/2025 should have been updated with Resident 73's hemodialysis care ordered on 4/25/2026. During a concurrent interview and record review on 6/11/2026, at 11:31 AM with Hemodialysis Nurse1 (HDN 1), Resident 73's Home Hemodialysis Order dated 5/12/2026 was reviewed. HDN 1stated that Resident 73's Home Hemodialysis Order dated 5/12/2026 indicated new dialysis treatment schedule. HDN 1 stated Resident 73'S dialysis procedure was scheduled five times a week (Monday to Friday) except weekends. HD 1 stated that Resident 73's Home Hemodialysis Order was changed on 5/12/2026 and indicated four (Monday, Tuesday, Wednesday and Friday) treatment per week and off on Thursday. HDN 1 stated Resident 73's Home Hemodialysis Order dated 5/12/2026 should have been updated at Resident 73's Care Plan Report. During review of the facility's policy and procedure titled, Care Plan Comprehensive, dated 11/20/2025, it indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, physical, mental and psychosocial needs shall be developed for each resident. The P&P indicated assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident 's condition change.

Based on interview and record review, the facility failed to ensure one of three randomly selected residents (Resident 32) and/or resident representative received mandatory information on Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN: a Skilled Nursing Facility [SNF] must issue this notice to a resident when it believes that Medicare (Federal health insurance) may not cover their care or stay. The SNF must provide the notice to the resident before providing the non-covered care) appeal process. This failure resulted in the facility denying Resident 32's right to accept or declined non-covered specific skilled services or ability to file an appeal placing Resident 32 at risk for unexpected financial burden/crisis.Findings:During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted Resident 32 on 11/10/2021 and readmitted Resident 32 on 3/23/2026 with diagnoses that included heart failure (a chronic condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, hemiplegia and hemiparesis following cerebral infarction of left non-dominant side (the person experienced a stroke that damaged the right side of the brain, resulting in weakness or inability to move the left side of the body if they are right handed or right side if they are left handed), dementia (a progressive state of decline in mental abilities), aphasia (a disorder that makes it difficult to speak), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of multiple sites (unspecified), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool) dated 11/5/2025, the MDS indicated Resident 32 had severe cognitive [ability to think, read, learn, remember, reason, express thoughts, and make decisions] impairment). The MDS indicated Resident 32 was dependent (helper does all of the effort) for eating, oral hygiene (ability to clean mouth/teeth), toileting, showering/bathing, and for upper/lower body dressing. During a review of Resident 32's SNF Beneficiary (someone receiving benefits) Protection Notification Review (a quality-control audit that checks whether a SNF properly followed Medicare rules that ensures the SNF gives patients written warnings before stopping or changing their Medicare-covered care, thereby protecting them from unexpected bills and preserving their right to appeal) indicated the facility did not give Resident 32's or Resident 32's representative, the Notice of Medicare Non-Coverage (NOMNC) because the resident was on custodial care (care provided by a SNF that is not covered by Medicare for non-medical help with everyday life like eating, bathing, or dressing). During an interview on 6/11/2026 at 10:28 AM with the Business Office Manager (BOM), the BOM stated Resident 32 did not receive a NOMNC and Resident 32's last Medicare Part A coverage was on 11/5/2025. The BOM stated the facility discontinued Resident 32's therapy and Resident 32 became custodial on 11/6/2025. The BOM stated she (BOM) was not sure if Resident 32 or Resident 32's representative should have received a NOMNC. The BOM called the facility's Accounts Receivable Consultant (ARC) and placed the ARC on speakerphone. The ARC stated Resident 32 did not exhaust (use up all) of her (Resident 32) Medicare Part A benefits. The ARC stated the BOM should have given Resident 32 a NOMNC. During an interview on 6/11/2026 with the BOM and Director of Nursing (DON), the BOM stated the facility should have given Resident 32 a NOMNC in the event Resident 32 or Resident 32's representative wanted to appeal. The DON stated the NOMNC should have been given to protect Resident 32 from potential surprise or hidden charges. The DON stated Resident 32 should have been given the NOMNC two days before the last covered day. During a review of the of the facility's policy and procedure (P&P) titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised on 9/2024, the P&P indicated the following: A resident (who is a Medicare beneficiary) is informed in advance and in writing when Medicare payment denial or change in coverage is likely.1. Written notices of the likelihood of Medicare payment denial are provided to the resident/beneficiary:a. as soon as the facility makes the assessment that Medicare payment certainly or probably will not be made and before the item or service is furnished;b. far enough in advance of an event (e.g., receiving a medical service) so that the beneficiary can make a rational, informed decision (choice you make based on facts, research, and understanding) without undue (excessive or unreasonable) pressure; andc. before a procedure is initiated and before physical preparation of the resident (e.g., disrobing, placement in or attachment of diagnostic or treatment equipment [tool or machine used to discover what is wrong with a person]) begins. 4. Written notices are provided in person to the beneficiary when possible. A copy of the notice is provided to the beneficiary (or authorized representative) immediately after the notice is signed. During a review of the facility's NOMNC form, last approved on 12/31/2011, the NOMNC form indicated the resident (in general) would possibly need to pay for services after a date (in general) indicated by the facility when Medicare probably would no longer pay for services. The NOMNC form indicated the resident (in general) had a right to appeal the decision and provided instructions on how the resident (in general) could appeal through an reviewer independent of the facility (not associated with the facility). The NOMNC form indicated a Quality Improvement Organization (QIO - a group of health experts hired by the government to protect Medicare patients, ensure proper care, and advocate for patients) could be contacted for immediate appeal.

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 2) received the necessary treatment and services to promote healing of a pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to:-Ensure the licensed nurses (in general) promptly identified Resident 2's Stage 2 pressure ulcer/injury (partial-thickness loss of skin, presenting as a shallow open sore or wound) to the right heel.-Ensure Treatment Nurse 1 (TN 1) was competent (having the necessary skill, knowledge, or ability to do something well enough to meet a specific standard or requirement) in identifying pressure ulcers/injuries.-Notify the wound specialist (a medical professional-such as a specialized physician or a nurse practitioner-with advanced training in managing and treating complex, non-healing wounds) of Resident 2's stage 2 pressure ulcer to the right heel.-Ensure the licensed nurses (in general) did not have no more than a bedsheet on Resident 2's Low Air Loss Mattress (LALM, a specialized medical support surface designed to prevent and treat skin breakdown and pressure ulcers). These failures had the potential for Resident 2's Stage 2 pressure ulcer/injury to the right heel to worsen, develop an infection, and had the potential for Resident 2 to develop new pressure ulcers/injuries.Cross reference F726FindingsDuring a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/24/2025 with diagnoses that included chronic respiratory failure (a long-term condition where the respiratory system cannot adequately supply oxygen to the blood or clear carbon dioxide from the body), chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing), dependence on the respirator (ventilator, a mechanical device to help support or replace breathing), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), severe protein-calorie malnutrition (a life-threatening condition caused by a severe, prolonged deficiency of all macronutrients, particularly calories and protein), dysphagia (difficulty swallowing), stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (tailbone area), dementia (a progressive state of decline in mental abilities), tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe (trachea) to insert a tube that allows air to reach the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right hand. During a review of TN 1's Competency Skills: Skin Evaluation with Documentation dated 1/10/2026, the Competency Skills: Skin Evaluation with Documentation indicated TN 1 was competent in the identification of skin problems and/or facility acquired pressure ulcers. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 3/31/2026, the MDS indicated the resident had severely impaired cognitive skills for daily decision making (never/rarely made decisions). The MDS indicated Resident 2 was dependent on help for oral hygiene, toileting hygiene, showering/bathing himself, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 2 was at risk of developing pressure ulcers. The MDS indicated Resident 2 had three stage 4 pressure ulcers, two of which were present on admission/entry or reentry to the facility. The MDS indicated Resident 2 utilized a pressure reducing device for bed and was receiving pressure ulcer care. During a review of Resident 2's Treatment Administration Record (TAR) dated 4/1/2026 to 4/30/2026, the TAR indicated the resident received treatment to his (Resident 2) right heel skin tear daily from 4/12/2026 to 4/17/2026 and 4/20/2026 to 4/26/2026. The TAR indicated TN 1 provided treatment to Resident 2's right heel skin tear on 4/12/2026, 4/14/2026, 4/15/20256, 4/16/2026, 4/17/2026, 4/20/2026, 4/21/2026, 4/22/2026, 4/23/2026, and 4/26/2026. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 4/8/2026 for a LALM for skin management. The physician order indicated Resident 2's LALM was to be at a setting between 100 -150. The physician order indicated Resident 2's LALM was to be monitored for proper functioning and placement every shift for wound management. During a review of Resident 2's Change in Condition Evaluation dated 4/10/2026, the Change in Condition Evaluation indicated a skin tear had occurred to the resident's right heel during wound care. The Change in Condition Evaluation indicated that the abdominal pad (an extra-thick, highly absorbent medical dressing used to manage wounds and surgical incisions with heavy fluid drainage) on Resident 2's right heel was soaked with normal saline to prevent the abdominal pad from sticking. The Change in Condition Evaluation indicated that skin on Resident 2's right heel had accidentally peeled after the abdominal pad on the resident's right heel had slowly been removed. The Change in Condition Evaluation indicated Resident 2's physician was notified and provided new orders to cleanse the resident's right heel with Normal Saline (NS, a saltwater solution), pat dry the right heel, apply a xeroform (a sterile, non-adhering wound dressing) dressing to the right heel, and then cover the right heel with a dry dressing. During a review of Resident 2's physician order dated 4/10/2026 at 2:45 PM, the physician order indicated the resident was to receive treatment to the resident's right heel skin tear. The physician order indicated Resident 2's right heel skin tear was to be cleansed with NS, and pat dried. The physician order indicated to have a xeroform dressing applied to Resident 2's right heel skin tear. The physician order indicated to then cover Resident 2's right heel skin tear with a dry dressing every day shift for seven days. The physician order indicated it was confirmed by TN 1. During a review of Resident 2's physician order dated 4/19/2026 at 2:45 PM, the physician order indicated the resident was to have treatment for his right heel skin tear. The physician order indicated Resident 2's right heel skin tear was to be cleansed with NS, and pat dried. The physician order indicated to have a xeroform dressing applied to Resident 2's right heel skin tear. The physician order indicated to then cover Resident 2's right heel skin tear with a dry dressing every day shift for 7 days. The physician order indicated it was confirmed by TN 1. During a review of Resident 2's physician order dated 4/27/2026 at 1:50 PM, the physician order indicated the resident was to have treatment for his right heel skin tear. The physician order indicated Resident 2's right heel skin tear was to be cleansed with NS, and pat dried. The physician order indicated to have a xeroform dressing applied to Resident 2's right heel skin tear. The physician order indicated to then cover Resident 2's right heel skin tear with a dry dressing every day shift for seven days. The physician order indicated it was confirmed by TN 1. During a review of Resident 2's physician order dated 5/5/2026 at 12:15 PM, the physician order indicated the resident was to have treatment for his right heel skin tear. The physician order indicated Resident 2's right heel skin tear was to be cleansed with NS, and pat dried. The physician order indicated to have a xeroform dressing applied to Resident 2's right heel skin tear. The physician order indicated to then cover Resident 2's right heel skin tear with a dry dressing every day shift for seven days. The physician order indicated it was confirmed by TN 1. During a review of Resident 2's physician order dated 5/17/2026 at 3:47 PM, the physician order indicated the resident was to have treatment for his (Resident 2) right heel skin tear. The physician order indicated Resident 2's right heel skin tear was to be cleansed with NS, and pat dried. The physician order indicated to have a xeroform dressing applied to Resident 2's right heel skin tear. The physician order indicated to then cover Resident 2's right heel skin tear with a dry dressing every day shift for 14 days. The physician order indicated it was confirmed by TN 1. During a review of Resident 2's TAR dated 5/1/2026 to 5/31/2026, the TAR indicated the resident received treatment to his right heel skin tear daily from 5/1/2026 to 5/4/2026, 5/6/2026 to 5/12/2026, and 5/18/2026 to 5/31/2026. The TAR indicated TN 1 provided treatment to Resident 2's right heel skin tear on 5/3/2026, 5/4/2026, 5/8/2026, 5/10/2026, 5/20/2026, 5/21/2026, 5/22/2026, 5/26/2026, 5/27/2026, and 5/29/2026. During a review of Resident 2's physician order dated 6/1/2026 at 3:19 PM, the physician order indicated the resident was to have treatment for his right heel skin tear. The physician order indicated Resident 2's right heel skin tear was to be cleansed with NS, and pat dried. The physician order indicated to have a xeroform dressing applied to Resident 2's right heel skin tear. The physician order indicated to then cover Resident 2's right heel skin tear with a dry dressing every day shift for 14 days. The physician order indicated it was confirmed by TN 1. During a review of Resident 2's TAR dated 6/1/2026 to 6/10/2026, the TAR indicated resident 2 received treatment to his right heel skin tear daily from 6/2/2026 to 6/9/2026. The TAR indicated TN 1 provided treatment to Resident 2's right heel skin tear on 6/2/2026, 6/3/2026, 6/4/2026, 6/7/2026, 6/8/2026, and 6/9/2026. During a review of Resident 2's Surgical Consult dated 6/9/2026, the Surgical Consult indicated that Medical Doctor 1 (MD 1) was consulted for the resident's wounds found at the sacrococcyx (tailbone area), left ischium (the left lower posterior bone of the pelvis), and right ischium (right lower posterior bone of the pelvis). The Surgical Consult indicated a comprehensive skin examination was performed of Resident 2's head, face, scalp, neck, back, buttocks, sacrum (tailbone area), coccyx (tailbone), left ischium, right ischium, left trochanter (left hipbone area), right trochanter (right hipbone area), left upper extremity, right upper extremity, left lower extremity, and right lower extremity to examine for any new or current lesions (any damaged, abnormal, or diseased area on the skin) on the resident's body. The Surgical Consult indicated Resident 2 had wounds located on the sacrococcyx, left ischium, and right ischium. During a review of Resident 2's physician order dated 6/10/2026 at 1:31 PM, the physician order indicated the resident was to have treatment for his right heel skin tear. The physician order indicated Resident 2's right heel skin tear was to be cleansed with NS, and pat dried. The physician order indicated to have a xeroform dressing applied to Resident 2's right heel skin tear. The physician order indicated to then cover Resident 2's right heel skin tear with a dry dressing every day shift for 14 days. The physician order indicated it was discontinued on 6/10/2026 due to a clarification of wound classification. The physician order indicated it was confirmed by TN 1. During a concurrent observation and interview on 6/10/2026 at 11:56 AM, in Resident 2's room, TN 1 was observed performing treatment to Resident 2's right foot. The back of Resident 2's right foot was observed to have dry peeling and scaly skin above the heel and around the top of the right foot. Thickened dark brown skin with an open wound in the shape of a butterfly was observed directly below the heel of Resident 2's right foot. The open wound was observed with a red fleshy base approximately 2 inches (a unit of length) wide by 1.5 inches tall. Below the wound towards the base of the foot a moist lifting skin flap was observed covering the width of the heel and extending approximately 1 to 1.5 inches into the center of Resident 2's right foot. The corners of the lifting skin were noted with thickened darkened skin. TN 1 stated that the wound on Resident 2's right heel was a skin tear. TN 1 stated he (TN 1) was the one who noticed that a part of the skin to Resident 2's right heel had fallen off. TN 1 stated Resident 2's wound on the right heel had been observed there for a while. TN 1 stated he (TN 1) did not know or remember the date of when Resident 2's right heel wound opened. TN 1 stated Resident 2 used to have a pressure ulcer to the right heel. TN 1 stated he was not sure if the wound specialist was aware of the wound to Resident 2's right heel. During an interview on 6/10/2026 at 1:43 PM with TN 1, TN 1 stated Resident 2 was at risk for developing pressure ulcers. TN 1 stated Resident 2 previously had a pressure ulcer to the right heel. TN 1 stated Resident 2's right heel was dry but one day the resident's skin on the right heel had come off. TN 1 stated he (TN 1) thought the wound to Resident 2's right heel was a skin tear. TN 1 stated he (TN 1) had Nurse Practitioner 1 (NP 1) come and see the wound to Resident 2's right heel after he (TN 1) performed treatment on 6/10/2026 at 11:56 AM. TN 1 stated NP 1 assessed Resident 2's wound on the right heel to be a stage 2 pressure ulcer and not a skin tear. TN 1 stated Resident 2 was seen by the wound specialist on a weekly basis. TN 1 stated that when Resident 2's skin on the right heel had come off he (TN 1) notified the resident's attending physician but not the wound specialist. TN 1 stated that in hindsight he (TN 1) should have also notified the wound specialist that the skin on Resident 2's right heel had come off. TN 1 stated he (TN 1) was with Resident 2 when the wound specialist saw the resident on 6/9/2026. TN 1 stated the wound specialist did not assess Resident 2's right foot. TN 1 stated he (TN 1) performed treatment to Resident 2's right heel almost daily. TN 1 stated he (TN 1) did not know when Resident 2's right heel wound became a stage 2 pressure ulcer. TN 1 stated a pressure ulcer was a wound that appeared in areas where there was pressure. TN 1 stated he (TN 1) did not really know how to describe the different stages of pressure ulcers. TN 1 stated it was important to be able to promptly identify changes to Resident 2's skin condition to ensure the resident received the appropriate treatment. TN 1 stated there was potential for Resident 2's pressure ulcer to worsen and for the resident to develop new pressure ulcers if he (TN 1) did not know the different stages of pressure ulcers or could not identify changes in the resident's skin. During an interview on 6/10/2026 at 2:05 PM with Nurse Practitioner 1 (NP 1), NP 1 stated she (NP1) was assigned to the care of Resident 2. NP 1 stated Resident 2 was at risk for developing pressure ulcers. NP 1 stated she evaluated Resident 2's right heel on 6/10/2026 after she was asked by TN 1 to examine the resident's right foot. NP 1 stated Resident 2 had been receiving treatment for a skin tear to the right heel. NP 1 stated the wound on Resident 2's right heel was not a skin tear. NP 1 stated she identified the wound to Resident 2's right heel as a stage 2 pressure ulcer. NP 1 stated this was the first time she (NP 1) was made aware of Resident 2's stage 2 pressure ulcer to the right heel. NP 1 stated she (NP1) informed TN 1 to have the wound specialist come and see Resident 2's right heel for treatment. NP 1 stated that it was important to ensure that any changes to Resident 2's skin were promptly identified to ensure treatment would be provided to the resident. NP 1 stated that if changes to Resident 2's skin condition were not identified promptly there was potential for the resident's wounds to worsen or for the resident to develop new pressure ulcers. During a review of Resident 2's Change in Condition Evaluation dated 6/10/2026 at 3:09 PM, the Change in Condition Evaluation indicated the resident had a change in skin color or condition that started the afternoon of 6/10/2026. The Change in Condition Evaluation indicated the wound classification of Resident 2's right heel skin tear was clarified. The Change in Condition Evaluation indicated Resident 2's wound was seen and examined by NP 1 for a reassessment. The Change in Condition Evaluation indicated Resident 2's wound to the right heel was reclassified to a 6 x 5.5 centimeters (cm) stage 2 pressure ulcer. The Change in Condition Evaluation indicated Resident 2's stage 2 pressure ulcer to the right heel had partial thickness tissue loss with no signs or symptoms of infection, drainage, or odor. The Change in Condition Evaluation indicated current treatment to Resident 2's right heel was continued as ordered to cleanse with NS, pat dry, apply xeroform and cover with a dry dressing. The Change in Condition Evaluation indicated it was signed by TN 1. During a concurrent observation and interview on 6/10/2026 at 2:45 PM with the Director of Nursing (DON), in Resident 2's room, the resident's right heel was observed. The DON stated that he (DON) would identify the wound on Resident 2's right heel as a stage 2 pressure ulcer. The DON stated the wound on Resident 2's right heel was not a skin tear. The DON stated he (DON) did not know when Resident 2 developed the stage 2 pressure ulcer to the right heel. The DON stated there was no documentation of when Resident 2's right heel stage 2 pressure ulcer was identified. The DON stated Resident 2 was being seen by the wound specialist. The DON stated Resident 2's most recent wound specialist note did not indicate the wound specialist was aware of the resident's right heel pressure ulcer. The DON stated the wound specialist did not see Resident 2's right heel wound because the documentation indicated the wound was a skin tear and not a pressure ulcer. Resident 2 was observed on a Med Aire LALM. The DON stated Resident 2 was on a LALM for skin management. The DON stated that Resident 2 was wearing an incontinent brief. The DON stated Resident 2 was also laying on a cloth pad and a bed sheet that was on top of the LALM. The DON stated that having more than one bedsheet on the LALM defeated the purpose of the LALM. The DON stated there should only be one bedsheet on the LALM to ensure the LALM was efficient as treatment for pressure ulcers. The DON stated that it was important that TN 1 be able to identify any changes in Resident 2's skin so the resident could be treated promptly. The DON stated that without prompt identification of changes in Resident 2's skin there was potential for the resident's pressure ulcers to worsen, potential for the resident to develop new pressure ulcers, or potential for the resident to develop an infection to the wound. During a concurrent interview and record review on 6/11/2026 at 12:30 PM with the DON, TN 1's Competency Skills: Skin Evaluation with Documentation dated 1/10/2026 was reviewed. The DON stated he (DON) performed the Competency Skills: Skin Evaluation with Documentation dated 1/10/2026 with TN 1. The DON stated TN 1 did not identify when Resident 2's developed the stage 2 pressure ulcer to the right heel. The DON stated TN 1 did not inform the DON of the change in Resident 2's skin. The DON stated he (DON) was made aware of Resident 2's pressure ulcer to right heel on 6/10/2026. The DON stated TN 1 was supposed to be competent at identifying changes to Resident 2's skin. The DON stated TN 1 should have been able to identify when Resident 2 developed the stage 2 pressure ulcer to the right heel. The DON stated TN 1 should have notified the DON and wound specialist about Resident 2's right heel. The DON stated TN 1 needed to be competent in all aspects of wound care or there would be potential for the residents (in general) to develop changes in skin that were not identified and promptly treated. During a review of the Operator's Manual titled Med Aire Plus Alternating Pressure and Low Air Loss Mattress Replacement Manual dated 3/15/16, the Operator's Manual indicated Cover the mattress with a cotton sheet.Patient Use: When the normal pressure indicator lights up (green), the pressure in the mattress had reached the pre-defined level, and the patient can then be placed on the mattress. Cover the mattress with a cotton sheet to avoid direct skin contact and improve the patient's comfort level. During a review of the facility's Job Description (JD) titled Licensed Practical (Vocational) Nurse (LPN)/(LVN) dated 5/2022, the JD indicated Monitor the skin health of the resident; provide preventative skin care; administer wound treatments as ordered. During a review of the facility's JD titled Wound Care/Treatment Nurse dated 7/2022, the JD indicated The Primary Purpose of this position is to provide wound care and treatments to residents as ordered and/or within the scope of nursing practice for the state.Duties and Responsibilities: . Identify management, and treat primary and secondary wound, including pressure ulcers/injuries, ostomies, surgical wounds, traumatic wounds and burns.Help identify and mitigate specific resident risk factors for pressure ulcers/injuries.Complete regular skin assessments on residents and document the findings.Provide skin and wound care and treatments, as ordered.Experience: Must have, as a minimum, two (2) year(s) experience as a registered nurse.Must possess a current unencumbered active license to practice as a registered nurse in the state of practice. During a review of the facility's Policy and Procedure (P&P) titled Skin Integrity Management reviewed 11/20/2025, the P&P indicated To provide safe and effective care to prevent the occurrence of pressure ulcers, management treatment, and promote healing of all wounds. The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revision to the plan of care as needed.Perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. Perform daily monitoring of wounds or dressing for presence of complications or declines and document if needed.Nursing staff will observe for any sign of potential or active pressure injury daily while providing nursing care. During a review of the facility's P&P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 4/2026, the P&P indicated In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, and presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments and preventive strategies; and all active diagnoses. During a review of the P&P titled Support Surface Guidelines dated 4/2026, the P&P indicated Following manufacturer's recommendation for use, ensure the support surface accommodates the weight, heights, size, and body mass index (BMI) of the resident. Ensure bed linens and other resident-care devices do not interfere with the function of the support surface. Check linens are free of wrinkles.

Based on observation, interview, and record review, the facility failed to ensure an individualized care plan was in place for two of two sampled residents (Resident 12 and Resident 70): to monitor for side effects and effectiveness of mirtazapine (a tetracyclic antidepressant (TeCA) primarily prescribed to treat Major Depressive Disorder (MDD) for Resident 12.to monitor episodes of restlessness for Resident 70 every shift.These failures had the potential for Resident 12 and Resident 70's delaying of care and treatment to be unidentified. Findings: 1.During a review of Resident 12's admission Record, the record indicated that Resident 12 was originally admitted on [DATE] and readmitted on [DATE] with a diagnoses of metabolic encephalopathy (an altered mental state usually caused by organ failure or chemical imbalances); Alzheimer's disease (a disease characterized by a progressive decline in mental abilities); generalized muscle weakness, and depression (a mood disorder that causes persistent sadness, a loss of interest in activities, and affects how one thinks, feels, and behaves.)During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool), dated 5/28/2026, the MDS indicated that Resident 12 has significant cognitive impairment (any condition that affects a person's mental functioning, and capacity). The MDS indicated that Resident 12 uses a walker to ambulate (walk) and requires supervision for oral hygiene, moderate assistance for toileting and upper body dressing, and maximal assistance for showering and lower body dressing.During a review of Resident 12's physician's orders, dated 6/11/2026, the orders indicated the following:a. The resident is to receive mirtazapine tablet 7.5 milligrams (mg) for depression manifested by verbalization of feeling sad and crying.b. Staff to monitor the resident every shift for the following side effects related to mirtazapine use (Sedation, Drowsiness, Dry Mouth, Blurred Vision, Urinary Retention, Tachycardia, Muscle Tremor, Agitation, Headache, Skin Rash, Photosensitivity (skin), Excess Weight Gain).c. Staff to monitor the effectiveness of mirtazapine every shift for episodes of verbalization of feeling sad. 2. During a review of Resident 70's admission Record, the record indicated that Resident 70 was originally admitted on [DATE], and readmitted on [DATE] with a diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), vascular dementia (a progressive state of decline in mental abilities), and altered mental status.During a review of Resident 70's MDS dated [DATE], the MDS indicated that Resident 70 has significant cognitive impairment. The MDS indicated that Resident 70 required maximal assistance for showering, and supervision for oral hygiene, toileting, lower body dressing, and upper body dressing.During a review of Resident 70's physician's orders, dated 1/27/2026, the orders indicated to monitor the resident for episodes of restlessness and document effectiveness of interventions every shift.During an interview on 6/10/2026 at 9:59 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the purpose of a care plan is to highlight the process in how the facility addresses situations, identifies problems with residents, and manages them. LVN 2 stated if there is no care plan, there can be a communication breakdown between the nurses and residents can experience inconsistency of care.During an interview on 6/10/2026 at 10:15 a.m. with Registered Nurse Supervisor 1 (RN 1), RN 1 stated the purpose of the care plan is to ensure that any concerns or needs of the residents are addressed adequately. RN 1 stated the Director of Nursing (DON), MDS Nurse (MDSN), and licensed nurses are responsible for creating the care plan, and everyone is responsible for implementing it. RN 1 stated if the care plan is not created and not implemented, the issues the residents have will not be addressed effectively.During a concurrent interview and record review on 6/11/2026 at 2:14 p.m. with the DON, the DON stated that the purpose of the care plan is to guide the nurses on the interventions necessary for the residents. The DON stated licensed nurses are responsible for ensuring the care plan is in place and should be implemented by the nurses and certified nursing assistants. The DON stated if there is no care plan in place, it could cause a delay in care and possible harm if issues are not addressed timely. The DON stated there was no care plan in place for Resident 12 and Resident 70 but should have been and staff did not follow the care plan policy and procedure.During a review of the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, dated 8/25/2021, the P&P indicated that a care plan should be developed for all residents within 7 days of completion of the resident's comprehensive assessment (MDS).

Based on observation interview and record review, the facility failed to ensure there was effective coordination and communication of hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care for one of nine sampled residents (Resident 73) reviewed for dialysis by failing to ensure to:-Obtain and maintain Resident 73's current hemodialysis orders in Resident 73's medical record following readmission on [DATE] and after changes to Resident 73's dialysis treatment schedule on 5/12/2026.-Place an identifiable dialysis emergency kit (a sudden, unexpected, and dangerous situation that poses an immediate threat to life and health) readily available.These failures had the potential to delay recognition of changes to Resident 73's hemodialysis treatment orders and emergency interventions. Findings:During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident originally on 3/2/2024 and readmitted on the resident on 4/24/2026 with diagnoses that included but not limited to muscle weakness, abnormalities of gait (a person's specific manner or pattern of walking or moving on foot) , end stage renal disease (irreversible kidney failure), and essential hypertension (high blood pressure).During a review of Resident 73's Order Summary dated 4/25/2026, the Order Summary indicated dialysis emergency kits at bedside as needed.During a review of Resident 73's Order Summary dated 7/31/2025, the Order Summary indicated physician's order to provide two to four hours bedside dialysis treatment days: Monday, Tuesday, Wednesday, Thursday and Friday.During a review of Resident 73's untitled history and physical document dated 8/3/2025, the untitled history and physical document indicated Resident 73 had the capacity to understand and make decisions.During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool) dated 4/28/2026, the MDS indicated Resident 73 made herself understood and understood others. The MDS indicated Resident 73's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) is intact. The MDS indicated Resident 43 required maximal assistance with mobility.During a concurrent observation and interview on 6/10/2026, at 12:12 PM with Licensed Vocational Nurse 1 (LVN 1), in Resident 73's room, a clear plastic bag was observed. LVN 1 was observed grabbing a clear plastic bag on top of Resident 73's bedside table with other Resident 73's personal belongings. LVN 1 stated the clear bag did not have a label but was the dialysis emergency kit. LVN 1 stated it should have been clearly labeled with Resident's name and should have been identifiable as dialysis emergency kit. LVN 1 stated that the dialysis emergency kit should have been located with easy access and not mixed with Resident 73's belongings.During a concurrent interview and record review on 6/10/2026 at 12:20 PM with LVN 1, Resident 73's Home Hemodialysis Order dated 5/12/2026 was reviewed. LVN 1 stated that Resident 73's Home Hemodialysis Order indicated four (Monday, Tuesday, Wednesday and Friday) treatments per week with treatment notes off on Thursday. LVN 1 stated that the Home Hemodialysis Order dated 5/12/2026 from the dialysis provider was not on Resident 73's medical records.During a concurrent interview and record review on 6/10/2026, at 1:20 PM with the Medical Records Director Resident 73's hemodialysis orders were reviewed. The MRD stated that there was hemodialysis ordered on 7/31/2025 and 6/10/2025. The MRD stated there was no hemodialysis treatment ordered dated 4/25/206 readmission of Resident 73 and no hemodialysis treatment ordered 5/12/2026. The MRD stated the nurses (in general) were responsible for placing all orders on admission.During a concurrent interview and record review on 6/10/2026, at 1:34 PM with the Director of Nursing (DON) Resident 73's hemodialysis orders were reviewed. The DON stated hemodialysis services were done in the facility with a contracted provider (unidentified). The DON stated that the contracted hemodialysis provider nurse (unidentified) received the hemodialysis order from the doctor (unidentified) and communicated residents (general) on hemodialysis care to the facility's nurse (unidentified) to place the order. The DON stated that there was no hemodialysis ordered on Resident 73's readmission. The DON stated that nurses (in general) should have placed the hemodialysis orders when Resident 73 was readmitted on [DATE] and on 5/12/2026 when the hemodialysis treatment order was changed to four days treatment. The DON stated that there was a failure to communicate Resident 73's hemodialysis orders from both the contracted hemodialysis provider nurse (unidentified)and facility nurse (unidentified).During an interview on 6/10/2026, at 1:43PM with the DON, the DON Stated that that dialysis emerging sick was important to be located at the bedside for dialysis access emergencies. The DON stated it was prepared, put together, and labeled with resident's room number(general) and identified as dialysis emergency kit. Stated Resident 73's dialysis emergency kit should have been labeled.During a concurrent interview and record review on 6/11/2026, at 11:31 AM with the Hemodialysis Nurse (HDN) the Home Health Dialysis order dated 5/12/2026 reviewed. The HDN stated that the process was to communicate to the nurse supervisor (general). The HDN stated provider dialysis did not document verbal communication on Resident 73's admission hemodialysis orders on 4/24/2026 to the admitting nurse (unidentified). The HDN stated it was important to document the communication from provider dialysis nurse to the facility nurse to ensure hemodialysis orders were in Resident 73's medical record.During review of the facility's policy and procedure (P&P) titled, Dialysis Care, dated 11/20/2025, the P&P indicated the facility will arrange for dialysis care as ordered by the attending physician. The P&P indicated that the facility maintains a contract with the dialysis service provider which addresses communications between the facility and provider. The P&P indicated communication and collaboration with nursing staff, dialysis provider staff and the physician will be on a regular basis concerning the residents care as follows: nursing staff will communicate the information in writing to the dialysis staff the residents' changes of conditions specific to the resident with each treatment.

Based on interview and record review, the facility failed to provide and accurate Minimum Data Set (MDS - a resident assessment tool) for one of five sampled residents (Resident 6) by failing to: -Document Resident 6's diagnosis of deep vein thrombosis (a serious condition that occurs when a blood clot forms in a deep vein usually in the leg or thigh). This failure had the potential to result in a delay in the necessary care and treatment for Resident 6.Findings:During a review of Resident 6's admission Record, the admission Record indicated the facility originally admitted Resident 6 on 2/10/2024, and readmitted Resident 6 on 5/9/2026 with diagnoses that included encephalopathy (damage or disease that affects the brain), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), reduced mobility, functional quadriplegia (a person is completely unable to move their arms and legs due to severe frailty or a non-spinal medical condition, not an injury), dementia (a progressive state of decline in mental abilities), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), ESRD (End Stage Renal Disease-irreversible kidney failure), and acute embolism and thrombosis of unspecified deep veins (a sudden blood clot in a deep vein that either blocks blood flow or has broken off to travel elsewhere in the body) of left lower extremity (leg). During a review of Resident 6's left lower extremity ultrasound (a safe, painless test that allows doctors to see inside your body using sound waves) dated 4/28/2026, the ultrasound indicated Resident 6 had a DVT of the left posterior tibial vein (a major vein that pumps used, oxygen-depleted blood from your left foot, ankle, and calf back up your leg and toward your heart). During a review of Resident 6's Change of Condition Evaluation dated 5/5/2026, the Change of Condition Evaluation indicated Resident 6 complained about pain in the left lower extremity and an ultrasound showed a new DVT and PAD (Peripheral Artery Disease - a slow progressive narrowing of the blood flow to the arms or legs). During a review of Resident 6's acute hospital record dated 5/6/2026, the acute hospital record indicated Resident 6 had a partially occlusive (partially blocked) DVT of the right leg. During a review of Resident 6's History and Physical (H&P) dated 5/11/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 usually could make himself (Resident 6) understood and usually had the ability to understand others. During a review of Resident 6's Attending Progress note dated 5/18/2026, the Attending Progress note indicated Resident 6 should continue Xarelto (blood thinner) for right lower extremity (RLE) DVT. During a review of Resident 6's Order Recap Report dated 6/10/2026, the Order Recap Report indicated Resident 6's physician prescribed Resident 6 Xarelto Oral Tablet (20 milligrams [mg- metric unit of measurement] used for medication dosage and/or amount) by mouth one time a day for DVT. During a concurrent interview and record review on 6/10/2026 at 10:28 AM with the MDS Nurse (MDSN), Resident 6's History and Physical (H&P) dated 5/11/2026 was reviewed. The H&P indicated Resident 6 had a right lower extremity (RLE/right leg) DVT. The MDSN verified the H&P indicated Resident 6 had a RLE DVT. During a concurrent interview and record review on 6/10/2026 at 10:28 AM with the MDS Nurse (MDSN), Resident 6's MDS dated [DATE] was reviewed. The MDS indicated Section I - Active Diagnoses in the last seven days indicated the box was not checked for question I0500 for deep Venous Thrombosis (DVT), Pulmonary Embolus (PE - a sudden blockage in a lung artery, usually caused by a blood clot that travels from elsewhere in the body), or Pulmonary Thrombo-Embolism (PTE - a life-threatening medical emergency where a blood clot gets stuck in an artery in your lungs, blocking blood flow). The MDSN stated she (MSDN) missed the diagnosis of DVT. The MDSN stated an inaccurate MDS assessment could affect Resident 6's care planning. During a concurrent interview and record review on 6/10/2026 at 10:38 AM with Registered Nurse 1 (RN 1) and the Director of Nursing (DON), Resident 6's History and Physical (H&P) dated 5/11/2026 was reviewed. The H&P indicated Resident 6 had a right lower extremity (RLE/right leg) DVT. RN 1 and the DON stated the H&P Resident 6 had a RLE DVT. During a concurrent interview and record review on 6/10/2026 at 10:38 AM with the DON, Resident 6's MDS dated [DATE] was reviewed. The MDS indicated Section I - Active Diagnoses in the last seven days indicated the box was not checked for question I0500 for DVT, PE, or PTE. The DON stated Resident 6's MDS was not accurate because the MDS nurse did not indicate on the MDS that Resident 6 had a DVT. During a review of the facility's policy and procedure (P&P), titled Certifying Accuracy of the Resident Assessment, reviewed 11/20/2025, the P&P indicated the following: 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment.

This is a repeat deficiency from the Recertification Survey conducted on 4/18/2024. Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control scabies (a highly contagious skin condition caused by the itch mite that infests and irritates your skin), per the facility policy and procedure (P&P) tiled, Scabies Identification, Treatment and Environmental Cleaning, for four of four sampled residents (Residents 1, 2, 3 and 4), by failing to: -Identify and detect symptoms of scabies and provide treatment for Resident 1 when the resident had a skin rash on 6/7 and 6/8/2024. -Control the spread of scabies by placing Resident 1 on contact precautions (isolation precautions, actions taken to prevent the or control infections) when Resident 1 was being treated with Elimite and Ivermectin on 6/11/2024 and diagnosed with scabies on 6/13/2024. -Maintain contact precautions, per the Physician's Order on 6/13/3024 -Implement control measures to prevent the transmission of scabies among residents in the facility, staff, and visitors. These deficient practices resulted in the facility not adhering to its Scabies P&P and had a potential of transmitting scabies to 86 inhouse residents, the staff, and community. On 6/26/2024 at 5:39 PM, an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and the Director of Nursing (DON) for the facility's failure to implement measures to prevent the transmission of scabies which threatened the health and safety of the 86 residents, staff, and family. On 6/28/2024 at 4:17 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and the DON, after the facility submitted an acceptable IJ Removal Plan (interventions and implementation to correct the deficient practices). The survey team verified and confirmed through observation, interview, and record review the implementation of the of the IJ removal plan. The accepted IJ removal plan included the following actions: -On 6/27/2024 Licensed Nurses completed skin assessments for Residents 1, 2, 3, and 4. -Resident 1: Noted to have a generalized body rash secondary to diagnosis of eczematous dermatitis (a common condition that causes swelling and irritation of the skin. It has many causes and forms and often involves itchy, dry skin or a rash) from 5/25/2024 and 6/7/2024 upon re-admission from hospital, in addition to the recently treated scabies diagnosed on [DATE] and will be re assessed by a dermatologist after 14 days (about 2 weeks) after final treatment. -Resident 2: Noted to have body rash on chest, abdomen, arms, back and thighs secondary to dermatitis. -Resident 3: Noted to have a body rash on bilateral arm secondary to dermatitis. -Resident 4: Noted to have body rash extending from back to abdomen secondary to dermatitis -Treatment Plan for Residents 1, 2, 3 and 4 included: -Resident 1: Clobetasol Propionate External Cream (a medication used to reduce swelling, redness, itching or rashes) 0.05% to generalize body topically daily x 2, Permethrin External Cream (Elamite, a skin cream that treats scabies, infestations of small parasites [an organism that lives off a host]), 5% to neck and toes topically at bedtime every Thursday until 7/11/24 and Ivermectin 9 mg via GT every Wednesday until 7/12/24. -Resident 2: Refused treatment and was educated regarding risks of refusing treatment and the importance of receiving treatment. Resident 2 was subsequently placed in contact isolation pending test results. -Resident 3: Clobetasol Propionate External Cream 0.05% to arms twice daily. -Resident 4: Hydrocortisone Cream 0.1% and Clindamycin Phosphate External Gel I% to abdomen and back. -On 6/27/2024, Residents 2, 3, and 4 had skin scraping (the collection of the superficial skin cells and further evaluation of the cells) completed, pending results. -On 6/27/2024, Environmental Service completed a deep cleaning of the room for Residents 1, 2, 3, and housekeeping department will continue with deep clean schedule for all resident care areas. Work areas were also deep cleaned 6/27/2024. Deep cleaning consisted of cleaning all contact surface areas and room furniture bedframe and nightstand, T.V/ remote, ceiling, vents, light fixtures, garbage cans, wipe down walls and base boards, privacy curtains, closets, restroom sink & toilet grab bars, windows, call light, floor, resident multiple use items, wheelchairs. All personal clothing and linen are washed. -On 6/26/2024 the Infection Control committee, including the Medical Director held an ad hoc QAA meeting to review the IJ Removal Plan for further review and recommendations. -The Infection Control Nurse and/or designee connected with the Public Health Nurse for further recommendations and validation to confirm that the facility took all necessary steps for Residents 1, 2, 3, and 4. Findings: a. A review of Resident 1's admission record indicated the facility readmitted the resident on 6/7/2024 with diagnoses including chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), pneumonia and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). The admission record also indicated the facility was Resident 1's responsible party. A review of Resident 1's General Body care plan initiated 3/22/2024, indicated the resident was diagnosed with dermatitis unspecified and had a positive skin scraping for scabies on 6/13/2024 (one week after admission). The care plan interventions indicated for staff to check resident's skin to determine affected areas, dermatologist consult, follow up treatment as needed, and the facility staff was to perform a skin scraping and to place Resident 1 on contact precautions (initiated on 6/13/2024). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 4/10/2024, indicated Resident 1's cognition was severely impaired (never/rarely made decisions) and was totally dependent upon staff for all activities of daily living (ADLs - essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). The MDS also indicated Resident 1 had one Stage IV pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle). A review of Resident 1's Body Check form for readmission to the facility, dated 6/7/2024, indicated Resident 1 had a generalized body rash, but did not indicate the areas on the body where the rash was located. The Body Check form, dated 6/8/2024, indicated the resident was reassessed and a general rash. The body check form did not include a measurement for the rash. A review of Resident 1's History and Physical (H&P), dated 6/8/2024 indicated the resident did not have the capacity to understand and make decisions. The H&P did not address Resident 1's body rash in accordance with the Body Check form on 6/7/2024. According to a review of Resident 1's Body Check form, dated 6/11/2024, the resident's rash was diagnosed as dermatitis (a common condition that causes swelling and irritation of the skin. It has many causes and forms and often involves itchy, dry skin or a rash). A review Resident 1's Dermatology Progress Notes, dated 6/11/2024, indicated Resident 1 was diagnosed with generalized body dermatitis and the treatment included Elimite (generic name permethrin), topical steroids (anti-inflammatory preparation used to treat skin conditions), Ivermectin (medication used to treat diseases caused by parasites) and oral steroids. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR - a documentation of a complete assessment in response to a change in condition [COC]), dated 6/11/2024 at 1 PM, indicated Resident 1 was seen by the dermatologist and was observed with a generalized rash. The resident received a shower and creams were applied to relieve the skin from further damage. The SBAR form indicated the Certified Nursing Assistants (CNAs) and family members were educated to be gentle with skin and not rub or scrub the skin. A review of the Physician's Order, dated 6/11/2024, indicated Resident 1 was to receive: -One tube of Elimite 5% cream applied from neck to toes, leave on for 12 hours then rinse and to repeat once a week for four weeks. - Three Ivermectin (an anti-parasitic medication used to treat worms, head lice and skin conditions) 3 milligram (mg) oral tablets for a total of 9 mg once a week for four weeks. - Clobetasol 0.05% cream applied to general body rash twice a day for four weeks. - Prednisone (a steroid medication) 20 mg tablet twice a day for five days. A review of Resident 1's Medication Administration Record (MAR) for June 2024 indicated the resident received three Ivermectin three mg tablets for a total of a nine mg dose via g-tube once a week every Wednesday for three doses on 6/12 and 6/19/2024. According to a review of Resident 1's Treatment Administration Record (TAR) for June 2024, the resident received two of four total doses ordered of Elimite treatment on 6/13 and 6/20/2024. A review of the Physician's Order, dated 6/12/2024, indicated Resident 1 was to have a skin scraping to rule out scabies. A review of Resident 1's SBAR a form, dated 6/12/2024 at 12 AM, indicated, There were no situational facts given for the SBAR. A further review of the SBAR indicated the primary physician ordered the medications Ivermectin and Elimite and ordered Resident 1 to receive a skin scraping. A review of the Physician's Order, dated 6/13/2024, indicated the facility was to place Resident 1 on contact precautions due to the resident being positive for scabies. A review of Resident 1's Laboratory Result, dated 6/13/2024, indicated the resident was examined for scabies and the results indicated Resident 1 was positive for scabies adults and eggs. A review of the At Risk for further Skin Breakdown Care Plan, initiated 6/26/2024, indicated the goal was for Resident 1's skin condition to resolve with no further damage. The care plan interventions included for Resident 1 to avoid scratching and keep hands and body parts from excessive moisture and to keep fingernails short. The treatment order included to cleanse with normal saline, pat dry, paint with betadine, apply xeroform and cover with a dry dressing. b. A review of Resident 2's admission record (roommate of Resident 1) indicated the facility readmitted the resident on 6/9/2022, with diagnoses including presence of a tracheostomy (a surgical opening created through the neck into the windpipe to allow air to fill the lungs), hepatomegaly (enlargement of the liver beyond its normal size) and diabetes (high blood sugar). A review of Resident 2's H&P dated 6/5/2024, indicated the resident had the capacity to understand and make decisions. The H&P also indicated the resident had the current skin conditions of eczema (skin dryness) and moisture associated skin damage (MASD, inflammation of the skin caused by sources of moisture such as urine, perspiration, stool or mucus). A review of the Physician's Orders, dated 6/11/2024, indicated Resident 3 was to receive application of Permethrin External cream (Elimite) 5% from neck to toes, leave on for 12 hours, then rinse and to repeat once a week for four weeks. A review Resident 2's Dermatology Progress Notes, dated 6/11/2024 indicated Resident 2 was diagnosed with generalized body dermatitis and the treatment included Elimite, topical steroids (anti-inflammatory preparation used to treat skin conditions), Ivermectin and oral steroids. According to a review of Resident 2's Treatment Administration Record (TAR) for June 2024, the resident received two of four total doses ordered of Elimite treatment on 6/13/2024 and 6/20/2024. c. A review of Resident 3's admission record (roommate of Resident 1) indicated the facility readmitted the resident on 12/14/2022 with diagnoses including cellulitis (skin infection), quadriplegia, epilepsy, and dementia. A review of Resident 3's MDS, dated [DATE], indicated the resident's cognition was severely impaired (never/rarely made decisions) and the resident was completely dependent upon staff for all ADLs. The MDS further indicated Resident 3 did not have an open lesion or laceration. A review of the Resident 3's Body Check form, dated 6/8/2024, indicated the resident had skin issues and a generalized rash, but there was no measurement for the rash or location of the rash specified. A review of Resident 3's Dermatology Progress Notes, dated 6/11/204, indicated Resident 3 had folliculitis on her abdomen and back. A review of the Physician's Orders, dated 6/13/2024, indicated the following: - Resident 3 was to have skin scraped to rule out scabies and - Resident 3 was to be placed on contact precautions due to exposure to scabies positive roommate. - The facility was to apply Elimite 5% topical cream apply from neck to toes then to rinse after 12 hours for one administration due to exposure. According to a review of Resident 3's Treatment Administration Record (TAR) for June 2024, the resident was treated with Elimite treatment on 6/14/2024. d. A review of Resident 4's admission record (roommate of Resident 1) indicated the facility readmitted the resident on 10/11/2023 with diagnoses including chronic respiratory failure, atrial fibrillation, and ventilator dependent. A review of Resident 4's MDS, dated [DATE], indicated Resident 1's cognition was severely impaired, was totally dependent upon staff for all ADLs and the resident had a Stage IV pressure injury. The MDS further indicated Resident 4 did not have an open lesion or laceration. A review of Resident 4's Dermatology Progress Report, dated 6/11/2024, indicated Resident 4 was diagnosed with eczema on her arms. A review of the Physician's Orders, dated 6/13/2024, indicated the following: - Resident 4 was to have her skin scraped to rule out scabies - Resident 4 was to be placed on contact precautions due to exposure to scabies positive roommate. - The facility was to apply Permethrin 5% topical cream apply from neck to toes then to rinse after 12 hours for one administration due to exposure. A review of Resident 4's Treatment Administration Record (TAR) for June 2024 indicated the resident was treated with Elimite treatment on 6/13/2024. During an interview on 6/26/2024 at 8:40 AM, the Infection Preventionist (IP) stated Resident 1 was recently readmitted to the facility. Resident 1 was evaluated by the dermatologist (DERM), who also evaluated Residents 2, 3, and 4, who were all roommates. The IP stated Resident 1's test for scabies was positive. The IP further stated Resident 1 was never isolated from the other roommates and Resident 1 never had a room change. The IP stated, We began to test the whole unit for scabies on 6/12/2024. During an initial tour of the facility on 6/26/2024 at 8:51 AM, Residents 1, 2, 3 and 4's room was observed. Resident 1, 2, 3, 4 were present in their respective beds. During observation, there was signage outside of the room which indicated Resident 1, 2, 3 and 4 were on enhanced barrier precautions which required everyone to clean their hands, including before entering and when leaving the room. The signage did not indicate staff or visitors were required to wear gown and gloves at all times when in the room. During an interview on 6/26/2024 at 8:56 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 1 returned to the facility after hospitalization with a rash. Resident 1 returned to the same room with the same roommates and had never changed rooms. LVN 1 stated Resident 1 was tested for scabies a week after returning to the facility and was positive. During an observation on 6/26/2024 at 9:07 AM with Treatment Nurse (TN) 1, Resident 1's skin assessment was observed. During a concurrent interview, TN 1 stated Resident 1 had new body scratches. TN 1 stated Resident 1's medial thigh had multiple scratches that removed the top layer of skin, and the surrounding area was very red. TN 1 also stated Resident 1 had open scratches to her mid back, right and left buttocks and left hip. On 6/27/2024 at 10:10 AM, during a concurrent interview and record review with LVN 1, Resident 1's electronic chart was reviewed. For the SBAR form dated 6/11/2024, LVN 1 stated that on 6/11/2024 there was a change in Resident 1's skin condition and the doctor diagnosed Resident 1 with unspecified dermatitis due to a general body rash. After review of Resident 1's physician's orders, LVN 1 stated the physician ordered a skin scraping for Resident 1 on 6/12/2024 and on 6/13/2024 the physician ordered contact isolation precautions for Resident 1. LVN 1 stated the contact isolation order was discontinued on 6/26/2024 at 8:28 PM. LVN 1 stated, Yesterday (6/26/2024), Resident 1 should have still had contact isolation in place during our conversation on 6/26/2024 at 8:56 AM. LVN 1 stated not following contact precautions could place Resident 1's roommates at risk of scabies. During an interview on 6/27/2024 at 12:26 PM, the IP stated contact isolation precautions was initiated late, and the contact isolation should have been initiated when Resident 1 was suspected of having scabies. The IP stated contact isolation should have been initiated on 6/12/2024 when the resident was suspected of having scabies. The IP stated the rule was contact isolation should be in place until 24 hours post treatment with the Elimite cream and the contact precautions were initiated for scabies to protect the spread to other residents. During a phone interview on 6/27/2024 at 2:58 PM, Resident 3's attending physician (PHY 1) stated he was not involved in ordering Elimite for Resident 2. PHY 1 stated he was told that the facility dermatologist would address that. During an observation on 6/27/2024 at 3:05 PM, Resident 2 was observed sitting in a wheelchair and Resident 2 had a diffuse rash on both her arms. During a concurrent interview, Resident 2 stated that the rash itches badly. During an interview on 6/27/2024 at 3:15 PM, TN 1 stated scabies was transferred through contact and required contact precautions which included the use personal protective equipment, with gown and gloves whenever entering the resident's room. TN 1 stated enhanced precautions did not demand putting on a gown or gloves every time when one entered the resident's room. TN 1 stated enhanced precautions were not as strict and with contact precautions, You really have to wear it - gown, gloves, everything should be covered. On 6/28/2024 at 12:22 PM, during a phone interview, the Medical Director (MD) stated he was first notified about Resident 1's scabies diagnosis around 5 PM on 6/26/2024. The MD stated he believed it was nursing protocol to initiate contact isolation when suspicion for scabies was high and it was the IP role to guide the facility in which measures to take. During an interview on 6/28/2024 at 2:34 PM, the Director of Nursing (DON) stated staff should have initiated contact precautions for Residents 1, 2, 3 and 4 on 6/11/2024 when the dermatologist ordered skin scrapings for Residents 1 and 2. The DON stated contact isolation was used to prevent the spread of scabies in the facility. During a concurrent review of the facility's P&P, Scabies Identification, Treatment and Environmental Cleaning, the DON stated, per the policy residents with scabies were placed on contact precautions during the treatment period, 24 hours after application of 5% Elimite cream or 24 hours after last application of scabicides (a medication used to treat scabies) requiring more than one application. During a phone interview on 6/28/2024 at 4:07 PM, the Dermatologist stated he was suspicious that Resident 1 had scabies on 6/11/2024 and so the prophylactic treatment for scabies was started. The Dermatologist stated he told TN 1 to complete a skin scraping to rule out scabies and residents with scabies was placed on contact precautions and isolated until 24 hours after treatment has started to prevent the spread of the infection. A review of the Center for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions (EBP) in Nursing Homes, dated 6/28/2024, EBP was a less restrictive approach to Multiple Drug Resistant Organisms (MDRO) prevention that places fewer limitations on resident activities than Contact Precautions (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro /faqs.html#:~:text=Contact%20Precautions%20has%20created%20challenges,resident%20activities%20than%20Contact%20Precautions). A review of the facility's P&P titled, Scabies Identification, Treatment and Environmental Cleaning, reviewed 3/21/2024, indicated the purpose of this procedure was to treat residents infected with and sensitized to Sarcoptesscabiei and to prevent the spread of scabies to other residents and staff. This P&P indicated Scabies was spread by skin-to-skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. Place residents with typical scabies on contact precautions during the treatment period; 24 hours after application of 5% permethrin cream or 24 hours after last application of scabicides requiring more than one application. A review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions (TBP), 9/2022, indicated transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The P&P also indicated When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Signs and notifications comply with the resident's right to confidentiality or privacy. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The individual on contact precautions is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low-risk roommate). Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control scabies (a highly contagious skin condition caused by the itch mite that infests and irritates your skin), per the facility policy and procedure (P&P) tiled, Scabies Identification, Treatment and Environmental Cleaning, for four of four sampled residents (Residents 1, 2, 3 and 4), by failing to: -Identify and detect symptoms of scabies and provide treatment for Resident 1 when the resident had a skin rash on 6/7 and 6/8/2024. -Control the spread of scabies by placing Resident 1 on contact precautions (isolation precautions, actions taken to prevent the or control infections) when Resident 1 was being treated with Elimite and Ivermectin on 6/11/2024 and diagnosed with scabies on 6/13/2024. -Maintain contact precautions, per the Physician's Order on 6/13/3024 -Implement control measures to prevent the transmission of scabies among residents in the facility, staff, and visitors. These deficient practices resulted in the facility not adhering to its Scabies P&P and had a potential of transmitting scabies to 86 inhouse residents, the staff, and community. On 6/26/2024 at 5:39 PM, an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and the Director of Nursing (DON) for the facility's failure to implement measures to prevent the transmission of scabies which threatened the health and safety of the 86 residents, staff, and family. On 6/28/2024 at 4:17 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and the DON, after the facility submitted an acceptable IJ Removal Plan (interventions and implementation to correct the deficient practices). The survey team verified and confirmed through observation, interview, and record review the implementation of the of the IJ removal plan. The accepted IJ removal plan included the following actions: -On 6/27/2024 Licensed Nurses completed skin assessments for Residents 1, 2, 3, and 4. -Resident 1: Noted to have a generalized body rash secondary to diagnosis of eczematous dermatitis (a common condition that causes swelling and irritation of the skin. It has many causes and forms and often involves itchy, dry skin or a rash) from 5/25/2024 and 6/7/2024 upon re-admission from hospital, in addition to the recently treated scabies diagnosed on [DATE] and will be re assessed by a dermatologist after 14 days (about 2 weeks) after final treatment. -Resident 2: Noted to have body rash on chest, abdomen, arms, back and thighs secondary to dermatitis. -Resident 3: Noted to have a body rash on bilateral arm secondary to dermatitis. -Resident 4: Noted to have body rash extending from back to abdomen secondary to dermatitis -Treatment Plan for Residents 1, 2, 3 and 4 included: -Resident 1: Clobetasol Propionate External Cream (a medication used to reduce swelling, redness, itching or rashes) 0.05% to generalize body topically daily x 2, Permethrin External Cream (Elamite, a skin cream that treats scabies, infestations of small parasites [an organism that lives off a host]), 5% to neck and toes topically at bedtime every Thursday until 7/11/24 and Ivermectin 9 mg via GT every Wednesday until 7/12/24. -Resident 2: Refused treatment and was educated regarding risks of refusing treatment and the importance of receiving treatment. Resident 2 was subsequently placed in contact isolation pending test results. -Resident 3: Clobetasol Propionate External Cream 0.05% to arms twice daily. -Resident 4: Hydrocortisone Cream 0.1% and Clindamycin Phosphate External Gel I% to abdomen and back. -On 6/27/2024, Residents 2, 3, and 4 had skin scraping (the collection of the superficial skin cells and further evaluation of the cells) completed, pending results. -On 6/27/2024, Environmental Service completed a deep cleaning of the room for Residents 1, 2, 3, and housekeeping department will continue with deep clean schedule for all resident care areas. Work areas were also deep cleaned 6/27/2024. Deep cleaning consisted of cleaning all contact surface areas and room furniture bedframe and nightstand, T.V/ remote, ceiling, vents, light fixtures, garbage cans, wipe down walls and base boards, privacy curtains, closets, restroom sink & toilet grab bars, windows, call light, floor, resident multiple use items, wheelchairs. All personal clothing and linen are washed. -On 6/26/2024 the Infection Control committee, including the Medical Director held an ad hoc QAA meeting to review the IJ Removal Plan for further review and recommendations. -The Infection Control Nurse and/or designee connected with the Public Health Nurse for further recommendations and validation to confirm that the facility took all necessary steps for Residents 1, 2, 3, and 4. Findings: a. A review of Resident 1's admission record indicated the facility readmitted the resident on 6/7/2024 with diagnoses including chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), pneumonia and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). The admission record also indicated the facility was Resident 1's responsible party. A review of Resident 1's General Body care plan initiated 3/22/2024, indicated the resident was diagnosed with dermatitis unspecified and had a positive skin scraping for scabies on 6/13/2024 (one week after admission). The care plan interventions indicated for staff to check resident's skin to determine affected areas, dermatologist consult, follow up treatment as needed, and the facility staff was to perform a skin scraping and to place Resident 1 on contact precautions (initiated on 6/13/2024). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 4/10/2024, indicated Resident 1's cognition was severely impaired (never/rarely made decisions) and was totally dependent upon staff for all activities of daily living (ADLs - essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). The MDS also indicated Resident 1 had one Stage IV pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle). A review of Resident 1's Body Check form for readmission to the facility, dated 6/7/2024, indicated Resident 1 had a generalized body rash, but did not indicate the areas on the body where the rash was located. The Body Check form, dated 6/8/2024, indicated the resident was reassessed and a general rash. The body check form did not include a measurement for the rash. A review of Resident 1's History and Physical (H&P), dated 6/8/2024 indicated the resident did not have the capacity to understand and make decisions. The H&P did not address Resident 1's body rash in accordance with the Body Check form on 6/7/2024. According to a review of Resident 1's Body Check form, dated 6/11/2024, the resident's rash was diagnosed as dermatitis (a common condition that causes swelling and irritation of the skin. It has many causes and forms and often involves itchy, dry skin or a rash). A review Resident 1's Dermatology Progress Notes, dated 6/11/2024, indicated Resident 1 was diagnosed with generalized body dermatitis and the treatment included Elimite (generic name permethrin), topical steroids (anti-inflammatory preparation used to treat skin conditions), Ivermectin (medication used to treat diseases caused by parasites) and oral steroids. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR - a documentation of a complete assessment in response to a change in condition [COC]), dated 6/11/2024 at 1 PM, indicated Resident 1 was seen by the dermatologist and was observed with a generalized rash. The resident received a shower and creams were applied to relieve the skin from further damage. The SBAR form indicated the Certified Nursing Assistants (CNAs) and family members were educated to be gentle with skin and not rub or scrub the skin. A review of the Physician's Order, dated 6/11/2024, indicated Resident 1 was to receive: -One tube of Elimite 5% cream applied from neck to toes, leave on for 12 hours then rinse and to repeat once a week for four weeks. - Three Ivermectin (an anti-parasitic medication used to treat worms, head lice and skin conditions) 3 milligram (mg) oral tablets for a total of 9 mg once a week for four weeks. - Clobetasol 0.05% cream applied to [NAME][TRUNCATED]

Based on interview and record review, the facility failed to supervise one of three sampled residents (Resident 1) who had a history of significant alcohol dependence (addiction that causes excessive drinking of alcohol) by failing to: 1. Ensure Resident 1 did not leave the facility unsupervised. 2. Conduct Quarterly Elopement Risk Assessments (assessment for resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected). As a result, Resident 1 eloped (leaving a safe area unsupervised without notice and permission) from the facility to the liquor store is a retail shop that predominantly sells prepackaged drinks- typically in bottles). Resident 1 consumed alcohol and suffered from an altered level of consciousness (ALOC-not awake, alert, or able to understand or react as one normally would) and was transferred to General Acute Care Hospital (GACH) 1. While at GACH 1, he was diagnosed with alcohol intoxication (occurs when a person drinks an excess of alcohol in a short period of time, can cause alcohol poisoning when severe and can lead to death). Resident 1 had a blood alcohol level (measurement of alcohol in your blood that develops from drinking alcohol, normal value 0-10 milligrams [mg]/deciliter [dL]) of 358 mg/dL. Findings: A review of Resident 1's Admission Record (face sheet) indicated the facility admitted Resident 1 to the facility on [DATE], with diagnoses that included cognitive communication deficit (difficulty communicating because of an injury to the brain), opioid abuse (use of prescription pain medication illegally), alcohol dependence, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily functioning). The Admission Record further indicated Resident 1 was homeless and had no responsible party listed. A review of Resident 1's Elopement Risk assessment dated [DATE], indicated Resident 1 was at risk for elopement because he was able to ambulate or self-propel the wheelchair independently. Further review of Resident 1's medical record indicated no further documented Elopement Risk Assessments after 11/29/2021. A review of Resident 1's History and Physical (H&P) dated 11/30/2021, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Risk for Substance Use of Alcohol and Drugs Care Plan, dated 12/10/2021, indicated a goal that Resident 1 would have decreased episodes of alcohol and drug seeking behaviors. The listed interventions included to monitor Resident 1 for conditions that may contribute to substance abuse. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 6/6/2022, indicated Resident 1 had moderately impaired cognition (decisions poor, cues/supervision required) and required limited assistance and one-person physical assistance for bed mobility, transferring, walking, dressing, toilet use, and personal hygiene. A review of Resident 1's Social Services Assessment and Documentation dated 6/10/2022, indicated Resident 1 had no family support or involvement, relied on his peers and staff for support, and had a significant history of Alcohol Abuse. A review of Resident 1's Risk for Cardiovascular Symptoms and Respiratory Symptoms Care Plan dated 6/13/2022, indicated Resident 1 had an episode of [CONDITION(S)] (low blood pressure) related to alcohol abuse on 6/13/2022. A goal for Resident 1 was to not have [CONDITION(S)] related to alcohol abuse. A review of Resident 1's Care Plan for exhibiting behaviors related to non-compliance with rules and policies of the company dated 6/14/2022, indicated the facility staff had found a bottle of alcohol beverages in the resident's room. A goal for Resident 1 was to comply with the rules and policy of the company, and interventions included the monitoring of medical conditions that may contribute to behaviors. A review of Resident 1's Physician Orders dated 6/29/2022, indicated the resident may go out on pass for four - six hours with a responsible party. A review of Resident 1's Incident Note dated 7/28/2022 at 7:35 p.m., indicated Resident 1 was last seen wheeling around the facility for his usual activity of either smoking on the patio or in front of the facility. Around 5:30 p.m., it was noticed that Resident 1 was not in his room and had not eaten his dinner. The incident note indicated all nursing staff searched for Resident 1 throughout the facility and the surrounding neighborhood. The Incident Note further indicated a nurse from GACH 1 called the facility around 8 p.m. and informed them Resident 1 was being admitted to GACH 1. A review of Resident 1's GACH 1 Emergency Department (ED) Summary Report dated 7/28/2022 and timed at 5:45 p.m., indicated the resident was brought in from a public area and was found ALOC (altered level of consciousness) in front of a liquor store. The Summary Report indicated the owner of the liquor store called 911 and stated Resident 1 drank 2 pints of [NAME] Beam (alcoholic drink). The ED Summary Report indicated Resident 1's blood pressure was 82/50 millimeters of mercury (mm Hg, unit of measurement for blood pressure, low blood pressure is considered less than 90/60 mm Hg), pulse 112 (normal pulse is 60 - 100 beats per minute), and alcohol blood level was 358 mg/dL (0-10 mg/dL) on arrival. A review of Resident 1's GACH 1 History and Physical (H&P) dated 7/28/2022 at 7:34 p.m., indicated Resident 1 looked homeless and was brought in by the paramedics for altered level of consciousness and diagnosis of alcohol intoxication. The H&P indicated Resident 1 was prone to alcohol withdrawal and had a blood alcohol level of 358 mg/dL. The H&P further indicated Resident 1 was admitted to a monitored bed (an area of the hospital used to monitor patients at risk for life-threatening heart rhythms and sudden death), started on intravenous (IV) fluids, [MEDICATION(S)] (a vitamin supplement given to alcohol users to prevent brain damage), [MEDICATION(S)] (a vitamin supplement given to alcohol users to prevent brain damage) , [MEDICATION(S)] (a medication used to manage anxiety levels in alcohol users), and magnesium (a medication used to decrease the intensity of symptoms from alcohol intoxication). A review of Resident 1's Incident Note dated 7/30/2022 at 2:25 p.m., indicated Resident 1 called the facility asking to speak with the activities coordinator to see if she would pick him up from the hospital. Licensed vocational nurse (LVN) 1 then informed the resident they were looking for him all over. The Incident Note indicated Resident 1 stated he didn't have intentions of leaving the facility for good he just wanted to go to the barber shop down the street to get a haircut but didn't have any cash, so he went to the store next door to get some cash from the automated teller machine (ATM, a machine, usually in a wall outside a bank, store, etc. from which you can take money out of your bank account using a special card) when he began to experience chest pain. The note indicated Resident 1 informed the cashier at the store he was having chest pain and they called the ambulance from the store. During an interview on 8/1/2022 at 3:33 p.m., Licensed Vocational Nurse (LVN) 1 stated on 7/28/2022 at around 4:30 p.m. to 5:00 p.m. Resident 1 was not in his bed and noticed his meal tray was still at bedside. LVN 1 stated, We called the code missing resident, and we all went looking for the resident. LVN 1 stated Resident 1 frequently went in and out of the facility in his wheelchair. LVN 1 stated Resident 1 did not sign out that day (7/28/2022) and did not say he was going anywhere so they did not know he was gone until they noticed he did not eat dinner. During a telephone interview on 8/1/2022 at 4:03 p.m., LVN 2 stated she was working on 7/28/2022 when Resident 1 was missing. LVN 2 stated staff looked around the facility and around the neighborhood but could not find Resident 1. LVN 2 stated the director of nursing (DON) was notified, and afterward the facility received a call from GACH 1 indicating Resident 1 was being admitted to GACH 1. During an interview on 8/1/2022 at 4:10 p.m., Resident 2 stated Resident 1 was his roommate in the bed next to him. Resident 2 stated on 7/28/2022 Resident 1 left the room around 3 p.m. and that was the last time he saw Resident 1. Resident 2 stated Resident 1 usually goes in and out of the room on his wheelchair and stated that night around 5 p.m. there was a lot of staff who were coming in and out of the room, looking in the bathroom, and asking him when he had last seen Resident 1. Resident 2 stated he didn't talk to Resident 1 much but knew Resident 1 would come in the room and would sometimes be drunk. Resident 2 stated once a Certified Nursing Assistant (CNA) found an empty alcohol bottle in Resident 1's closet. Resident 2 stated he didn't remember who the CNA was and can't remember much about how the CNA looked. During an interview on 8/1/2022 at 4:45 p.m., CNA 1 stated Resident 1 has a history of alcohol use. CNA 1 stated when Resident 1 could not be located on the night of 7/28/2022, the facility staff were looking for him around the facility. CNA 1 stated eventually someone from GACH 1 called and told the facility that Resident 1 was at the GACH 1. During an interview on 8/2/2022 at 1 p.m., with the Liquor store owner 1 stated on 7/28/2022 a resident was at his liquor store buying [NAME] Beam and asked to call a cab. Owner 1 stated he doesn't remember where the resident wanted the cab to take him but stated that the resident was asked to wait for the cab outside of the store. Owner 1 stated he saw the resident slump down in his wheelchair outside, so he called the police. Owner 1 stated the ambulance came to pick up the resident at the front of the store, and when they left, he found an empty bottle of alcohol. Owner 1 stated this resident comes into the liquor store about once or twice a month by himself and buys about half a pint of [NAME] Beam. During a concurrent interview and record review on 8/9/2022 at 4:25 p.m., with Receptionist 1, the document Release of Responsibility for Leave of Absence for Resident 1 was reviewed. Receptionist 1 verified Resident 1 did not have an out on pass log for 7/28/2022. Receptionist 1 stated Resident 1 is not allowed to go outside unaccompanied because he is not fully alert and oriented. Receptionist 1 stated residents are allowed to go outside with supervision or an out on pass order from their physician only if they are fully alert and oriented. Receptionist 1 stated residents must sign out on the out on pass log indicating when they are leaving, the anticipated time gone, and must sign the log when coming back. During a telephone interview on 8/25/22 at 3:55 p.m., the Director of Nursing (DON) stated when she was informed Resident 1 could not be found and his dinner tray was not touched, she told staff to look around the facility. The DON stated the staff informed her they checked the patio, checked the vicinity, and they could not find Resident 1. DON stated the last time staff had seen Resident 1 was on the patio. DON stated Resident 1 usually smoked outside the facility, so maybe he would come back. DON stated she was informed Resident 1 is alert, knows what he wants, knows what to do, is a smoker, has a routine of smoking in front or outside of the facility, and has a history of leaving the hospital against medical advice (AMA). During a concurrent telephone interview and record review on 8/25/2022 at 4:05 p.m., with the DON, the facility's policy and procedure titled Elopement of Patient revised 5/1/2022 was reviewed. The DON stated Resident 1 was not supervised when leaving the facility. DON stated residents who leave the facility must have an out on pass physician order and should be supervised by a responsible party; Resident 1 did not have a responsible party so staff should have supervised the resident when leaving the facility. The DON further stated it is not an acceptable practice for Resident 1 to drink alcohol in the facility. On the same interview and review of Resident 1's Elopement Risk assessment dated [DATE] on 8/25/2022 at 4:05 p.m., the DON stated the risks of drinking alcohol should be explained in the Resident and Elopement Risks Assessments. Don stated the Resident and Elopement Risks Assessments should be done on admission, quarterly, or as needed. The DON further stated there was no Elopement Risk Assessments evidence documented after 11/29/2021 indicated in Resident 1's medical record. During a concurrent interview and record review on 8/25/2022 at 4:34 p.m., with the Administrator (ADM), the facility's policy and procedure Elopement of Resident revised 5/1/2022 was reviewed. The ADM stated when residents leave the facility, they must sign out on the out on pass log with the Receptionist and must have physician orders for out on pass. The ADM stated he was informed by the DON that Resident 1 had left the facility. The ADM further stated Resident 1 had a history of alcohol and drug use and stated Resident 1 loved staying at the facility and verbalized he didn't want to leave the facility, so it's possible the resident eloped. A review of the facility's policy and procedure titled Alcoholic Beverages revised 11/01/19 indicated a physician's order will be obtained for a patient to receive alcoholic beverages at the Center. Alcohol is supplied by the patient/responsible party; however, a Center may offer alcoholic beverages at special events if permitted by state regulation. The policy further indicated its process is to verify the physician's order. Alcohol supplied by the patient/responsible party is labeled with patient name, room number, and date opened and stored in a secure location. A licensed nurse, trained recreation or guest services staff per physician order will dispense alcoholic beverages for each patient. The policy also indicated, if the chart of Medication Administration Record (MAR) / Treatment Administration Record (TAR) if ordered for specific time, etc. If alcohol consumption precipitates unsafe behavior, the Center will contact the physician for recommendations. A review of Lexicomp's (an online database that is a collection of content sets and clinical tools that provides users with clinical drug information) titled [MEDICATION(S)] Level dated 6/16/2021, indicated Ethyl (alcohol is a central nervous system depressant and one of the most common drugs of abuse. [MEDICATION(S)] level is used to diagnose alcohol intoxication and to screen for alcoholism. Normal value is less than 10 mg/dl which indicates a negative test. A critical value is greater than 30 mg/dL which indicates alcohol consumption. A panic value is greater than or equal to 300 mg/dL. A review of Lexicomp's document titled Alcohol Intoxication ED dated 2/23/2022, indicated alcohol intoxication occurs when someone drinks too much in a short amount of time. Alcohol intoxication is the same as being drunk. Severe alcohol intoxication is known as alcohol poisoning. It can make you pass out and can be life threatening if you stop breathing or choke on your own vomit. Alcohol poisoning can also cause [CONDITION(S)] or an irregular heartbeat. A review of the facility's policy and procedure titled Elopement of Patient revised 5/1/2022, indicated elopement occurs when a patient leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence (LOA) and/or any necessary supervision to do so. Identify patient's elopement risk by reviewing the following upon admission, re-admission, quarterly, or with a significant change in conditions as defined by Resident Assessment Instrument (RAI) - Minimum Data Set (MDS) Manual criteria utilizing the nursing assessment, social services assessment, and other disciplinary assessments.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity and prevent an unstageable (full thickness tissue loss in which the base of the sore is covered by yellow/white material and/or brown/black material [dead tissue] in the wound bed) pressure sore (also known as pressure ulcers or bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) for one of two sampled residents (Resident 39). Resident 39, who had a moisture associated skin disorder (MASD - inflammation of the skin caused by sources of moisture such as urine, stool, perspiration or mucous), required extensive assistance with bed mobility, and was at risk for developing pressure sores, was not monitored to prevent deterioration of the sacro-coccyx area (lower back, base of the spine and tail bone area). This deficient practice resulted in Resident 39's intact sacro-coccyx area to progress to an unstageable pressure sore (pressure sores covered with slough or eschar [the yellow/white dead skin material shedding from the wound bed, dead tissue] are by definition unstageable), requiring tissue debridement (removal of dead skin tissue to help the wound heal) performed by surgical excision (removal of tissue using a sharp knife) of the sacrum area. Resident 39 required weekly debridement of the pressure sore and new wound treatment. Findings: A review of Resident 39's Face Sheet (Admission Record) indicated the facility admitted the resident on 6/3/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 39's Braden Scale Risk Assessment (For Predicting Pressure Sore Risk) dated 6/4/2021 indicated Resident 39 had a score of 16, indicating mild risk (mild risk = 15-18) in developing pressure sores. A review of the Care Plan dated 6/5/2021 indicated Resident 39 was at risk for skin breakdown, related to limited mobility and incontinence. The care plan goal indicated Resident 39 would not show signs of skin breakdown for 90 days. The care plan interventions included applying barrier cream with each cleansing, observing skin for signs and symptoms of skin break down (redness, cracking, blistering, or decreased sensation), observing verbal and non-verbal signs of pain related to wound, and weekly wound assessment. A review of Resident 39's Minimum Data Set (MDS, standardized assessment and care-planning tool) dated 6/7/2021, indicated the resident required extensive assistance with one-person physical assist for bed mobility and was at risk for developing pressure sores. The same MDS indicated Resident 39 did not have any pressure sores at the time of the assessment but had a MASD and the current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 39's Skin Check dated 6/10/2021, indicated the resident had no signs of skin breakdown in the sacro-coccyx. According to a review of Resident 39's Braden Scale Risk Assessment form dated 6/10, 6/17 and 6/24/2021, Resident 39 had a score of 15 indicating a mild risk of developing pressure sores. A review of Resident 39's Nursing Progress Note, dated 7/5/2021, indicated resident had a MASD to bilateral (both sides) breast fold, abdominal fold, and perineal area. There was no mention of the saccro-coccyx area. A review of Resident 39's Skin Check form dated 7/20/2021 indicated Resident 39 had a deep tissue pressure injury (DTPI, a serious type of pressure injury that begins in the muscle closest to the bone. In the early stages of the injury, damage may not be visible on the skin's surface) located at the sacro-coccyx, measuring 4.0 centimeters (cm) in length by 3.0 cm in width. The report indicated Resident 39's DTPI appeared purple/maroon in color and was warm to touch. According to a review of the American Journal of Nursing, May 2017, volume 117, page 50 - 57, a deep tissue pressure injury resulted from intense and/or prolonged pressure and shear forces at the bone-muscle interface. If necrotic tissue, subcutaneous tissue, granulation tissue, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage III or Stage IV). A review of Resident 39's Change in Condition (COC) form, dated 7/20/2021, indicated Treatment Nurse 2 notified Resident 39's physician of the DTPI on the sacro-coccyx area. The physician ordered a wound consult. A review of Resident 39's Surgical Consult Notes dated 7/21/2021, indicated Resident 39 was evaluated for a wound in the sacrum (triangular bone at the base of the spine) area. Resident 39 underwent tissue debridement (removal of dead skin tissue to help a wound heal) performed by surgical excision (removal of tissue using a sharp knife) of the sacrum area. The Surgical Consult Notes indicated Resident 39 would require debridement on a weekly basis. A review of Resident 39's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It is called normal because the salt concentration is similar to tears, blood and other body fluids), pat dry, apply Santyl ointment (prescription ointment [chemical debridant] that removes dead tissue from wounds so they can start to heal) with Z-guard cream (cream used to treat and prevent skin conditions such as minor skin irritation, scratches, and diaper rash) around the wound, then cover with dry dressing daily for 30 days. During an interview on 8/3/2021 at 10:55 AM Resident 39 stated, Someone comes in a couple times a day to remind me to turn and see if I need help. They prop me up on a pillow sometimes, but I don't always feel comfortable, so I move away from it. During an observation with Treatment Nurse 1, on 8/3/2021 at 12:48 PM, Resident 39 was in bed and noted with an open pressure sore on the sacro-coccyx area, with slough and redness that extended to the left buttock. During an interview on 8/4/2021, at 3:34 PM the Director of Nursing (DON) stated the facility staff did not document when a resident was turned or repositioned. On 8/5/2021 at 11:35 AM, during an interview, the Wound Specialist Doctor stated Resident 39's wound was unstageable on initial assessment on 7/21/2021 and was not a deep tissue pressure injury, as classified by the facility. The Wound Specialist doctor stated a wound debridement was done on the unstageable pressure sore to Resident 39's sacrum area and that, Wound debridement will be done weekly until the wound can maintain healthy granulating tissue (tissue that fills in a wound that is healing) along the wound bed. During an observation and concurrent interview on 8/5/2021 at 2:24 PM, Resident 39 was observed supine (laying on the back) and stated, They don't come to move me. I don't like to be a bother and ask for help all the time. I move on my own two to three times a day. During an interview on 8/18/2021 at 4:09 PM, the DON stated the skin check documentation was used for the documentation of observing for signs and symptoms of skin breakdown for Resident 39. The DON stated the 7/8 and 7/15/2021 weekly wound assessments did not have any documentation regarding Resident 39's sacrum or saccro-coccyx area. The DON stated the skin check on 7/15/2021 did not mention anything about Resident 39's sacrum or saccro-coccyx area. A review of the facility's policy titled, Skin Integrity Management, dated 5/26/2021, indicated a procedure to identify skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information; perform skin inspection on admission/re-admission and weekly; perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound; perform daily monitoring of wounds or dressings for presence of complications or declines and document if indicated; nursing staff will observe for any sign of potential or active pressure injury daily while providing nursing care. This same facility policy indicated to develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated: Implement pressure ulcer prevention for identified risk factors; and turning and repositioning based on resident care needs.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity and prevent a recurrent avoidable pressure sore (also known as pressure ulcers or bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin, especially where the bones are close to the skin such as in the hip, back, heels, and elbows) for one of three sampled residents (Resident 1). Resident 1, who was totally dependent on staff for bed mobility, was on diuretics (medications designed to increase the amount of water and salt expelled from the body as urine), was a high risk for developing pressure sores, and was not monitored or maintained clean and dry, to prevent deterioration of the sacro-coccyx (lower back and tail bone) area. These deficient practices resulted in Resident 1's sacrococcyx area to progress from moisture associated [CONDITION(S)] (MASD, inflammation of the skin caused by sources of moisture such as urine, perspiration, stool or mucus) to a Stage III pressure sore (involves the full thickness of the skin and may extend into the subcutaneous (under the skin) tissue layer; subcutaneous fat may be visible but bone, tendon, or muscle are not exposed, partial thickness loss of skin exposing the dermis [inner layer of skin] presenting as a shallow open ulcer with a red/pink wound bed). Resident 1 required a new wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the facility readmitted the resident on 2/11/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Skin Check form dated 2/11/2018, indicated the resident had a sacrococcyx Stage II pressure sore (skin breaks open, tender and painful) that appeared as a Stage I (redness to the skin with no skin break). A review of Resident 1's Care Plan developed on 11/27/2020 for the resident skin breakdown, indicated Resident 1's Stage II sacrococcyx pressure sore was healed. According to a review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-planning tool) dated 1/11/2021, the resident was unable to communicate needs and could not make decisions. Resident 1 required total care, was dependent on staff for bed mobility and repositioning. The same MDS indicated Resident 1 was at risk for developing pressure sores and did not have any skin problems present. A review of Resident 1's Braden Scale (pressure sore risk predictor tool) dated 4/1/2021, indicated Resident 1 had a Braden score of 11 which placed the resident in the high-risk category to develop a pressure injury. A review of Resident 1's Skin Integrity Report dated 2/25/2021, 3/4/2021, 3/11/2021, 3/18/ , 3/25/2021, 4/1/ , 4/8/2021, and 4/15/2021 indicated Resident 1 had MASD to the left buttocks. The report did not include measurement of the MASD to determine the size. The report indicated Resident 1's MASD appeared with redness and the surrounding tissue was healthy. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It is called normal because its salt concentration is similar to tears, blood and other body fluids), pat dry, apply [MEDICATION(S)] cream (cream used to treat and prevent skin conditions such as minor skin irritation, scratches, and diaper rash) with [MEDICATION(S)] powder (powder used to prevent fungal infections of the skin), then cover with dry dressing as needed if soiled or dislodged for 14 days. According to a review of Resident 1's Care Plan developed on 4/21/2021 for the resident's MASD on the sacrococcyx extending to buttocks, the approaches included monitoring for any unusual changes in condition. A review of Resident 1's Skin Integrity Report dated 5/3/2021, indicated Resident 1 had MASD to the right and left buttocks and a resolved pressure sore to the sacrococcyx extending to right and left buttocks. During an observation with Licensed Vocational Nurse 1 (LVN 1), on 5/4/2021 at 9:48 a.m., Resident 1 was in bed on a low air loss mattress, noted wearing an incontinent brief (no control of urination). The certified nursing assistant was preparing to clean the resident with soap and water. During the observation Resident 1 was noted with a saccrococcyx pressure sore that was opened with depth, and redness that extended to the left and right buttocks. On 5/4/2021 at 10:10 a.m., during an interview, LVN 1 was asked due to Resident 1's open wound, how was this documented and she stated, It was documented as a MASD wound because Resident 1 was taking [MEDICATION(S)] (water pill - medication that reduces extra fluid in the body causing frequent urination) and she goes all the time. On 5/4/2021 at 11:30 a.m., during an interview with Registered Nurse 1 (RN 1) and a review of the weekly Skin Integrity Reports, RN 1 could not explain why there was no Skin Integrity Report completed for Resident 1 on 4/22/2021 and 4/29/2021. RN 1 stated the Skin Integrity Report was supposed to be done weekly to monitor the progress of the wound. During an observation of Resident 1's pressure sore to the sacarococcyx with RN 1 and LVN 2, on 5/4/2021 at 1:41 p.m., RN 1 stated and confirmed there was skin breakdown and Resident 1 had a Stage II pressure sore. LVN 2 measured the Stage II pressure sore at 2.0 centimeters (cm) in length by 0.5 cm in width by 0.2 cm in depth. The pressure sore having depth indicated Resident 1 had a Stage III pressure sore. Stage II pressure sores indicate a skin break, superficial or at the surface. On 5/4/2021 at 2:10 p.m., during an interview, RN 1 stated the skin should be assessed thoroughly and it was important to measure the pressure sore to monitor for worsening of the wound. RN 1 stated if the skin assessment was not done properly or if the pressure injury was not measured, the pressure sore can get worse and cause more harm and pain to the resident. On 5/4/2021 at 2:35 p.m., during an interview, the Director of Nursing (DON) stated LVNs should document any changes to Resident 1's skin weekly, and if changes were noted, the physician should be notified. A review of Resident 1's Change in Condition (COC) form, dated 5/4/2021, indicated LVN 1 notified Resident 1's physician of the pressure sore on the sacrococcyx area. The physician ordered wound consult and treatment to cleanse the sacrococcyx pressure sore with normal saline apply [MEDICATION(S)] twice a day and cover with dry dressing for 14 days. A review of Resident 1's Surgical Consult Notes dated 5/5/2021, indicated Resident 1 was evaluated for a wound reopening at the sacrococcyx area caused by pressure sore. Resident 1 received muscle tissue debridement (removal of dead skin tissue to help a wound heal) performed by surgical excision (removal of tissue using a sharp knife) of the sacrococcyx area. The Surgical Consult Notes further indicated Resident 1 would require debridement on a weekly basis. On 6/15/2021 at 2:08 PM, during an interview, physician's assistant (PA) stated a wound debridement was done on the Stage III pressure ulcer to Resident 1's sacrococcyx area. The PA further stated, A debridement would need to be done weekly until the wound improves and as needed to maintain healthy granulating tissue (tissue that fills in a wound that is healing) along the wound bed. The PA stated a wound debridement is done anytime there is devitalized tissue (slough, necrotic). A review of the National Pressure Ulcer Advisory Panel Pressure Injury Staging System indicated a Stage III pressure involves full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar (necrotic tissue) may be visible, and the depth of tissue damage varies by anatomical location. A review of Woundsource.com, 2020 indicated the goal of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of the facility's policy titled, Skin Integrity Management, revised 1/31/2020, nursing staff were to perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly and with anticipated decline of wound. The policy further indicated to perform daily monitoring of wounds or dressings for presence of complications or declines and document. For wounds requiring daily dressing change or wounds without a dressing, monitor for signs of decline in wound status. If unanticipated decline in wound, surrounding tissue, or new or increased wound pain, complete the Skin Integrity Report and notify physician.

Based on interview and record review, the facility failed to ensure residents were free from sexual abuse for one of three sampled residents (Resident 1). Resident 1 informed three different facility staff that Certified Nuse Assistant 1 kissed Resident 1. In addition, CNA 1 was not removed form duty after this incident. As a result, Resident 1 became anxious, afraid, and felt unsafe in the facility. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS-an assessment and care screening tool), dated 2/5/2021, indicated Resident 1`s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. During an interview with Resident 1, on 2/12/2021, at 3 PM, Resident 1 stated On 2/10/2021 the Certified Nurse Assistant, this big Asian guy pulled down his mask, puts his arms around me and leaned to kiss me on the lips. I told him to stop and he kept trying to kiss me. You are not supposed to be doing this, look at the condition I am in, this happened three times in the same day. The third time he came back, he bends over to kiss my lips, I turned my head and he kissed my cheek, also he was very sweaty. I told him to stop and please go away. He said to me that I was nice before, I told him that is a stupid thing to say and I do not have to live this long to know that his behavior is inappropriate. Resident 1 stated, I do not feel safe here, I guess I look like a victim because I am a nice person. I told another nurse and they said they were going to tell the charge nurse. Yesterday morning 2/11/21, he was outside my room just staring at me. I am worried that he might have given me Coronavirus disease 2019 (COVID-19 an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death). I thought they did something about it. During an interview with Certified Nurse Assistant (CNA 3), on 2/12/2021, at 3:20 PM, CNA 3 stated, Resident 1 told me yesterday morning at 7:30 AM that CNA 1 had been trying to kiss her and hug her, and that she did not feel safe and was very uncomfortable. Resident 1 requested for another nurse to take care of care. This was reported to the Administrator and Director of Staff Development (DSD). During an interview with Licensed Vocational Nurse (LVN 1), on 2/18/2021, at 7:45 AM, LVN 1 stated Resident 1 reported she felt uncomfortable with CNA 1 because he was hugging her and kissing her. Resident 1 told LVN 1 she was afraid because she was vulnerable, totally dependent and expressed concerns about contracting COVID-19. LVN 1 texted the Administrator and Director of Staff Development (DSD) on 2/11/2021 at 7:45 AM. They replied they already knew about it. LVN 1 thought they did something about it, but CNA 1 came back to work for the 3-11 shift on 2/11/2021. During an interview with Certified Nurse Assistant (CNA 2), on 2/18/2021, at 9:30 AM, CNA 2 stated she went to say hello to Resident 1 on 2/10/2021 at 1:30 PM. Resident 1 reported she did not want CNA1 assigned to her and she wanted someone else to care for her. Resident 1 informed CNA 1 he was hugging her and kissing her, she was very scared about contracting COVID-19. CNA 1 immediately went to get a charge nurse and the DSD, as Resident 1 was very nervous and uncomfortable. During an interview with Resident 2, on 2/18/2021, at 9:50 AM, Resident 2 stated, I saw CNA 1 kissing Resident 1 and I heard her saying please stop and go away. During an interview with the DSD, on 2/18/2021, at 10 AM, the DSD stated she called to come to Resident 1's room on 2/10/2021. Resident 1 stated CNA 1 hugged and kissed her. The DSD reported the allegation to the Administrator. CNA 1 was not suspended, and the allegation was not reported within two hours. The allegation was reported on 2/12/2020. During an interview with the Administrator, on 2/18/2021, at 10:25 AM, the Administrator stated, he was made aware of Resident 1's allegation on 2/10/2021. The Administrator instructed the DSD to change CNA 1's assignment and CNA 1 was assigned to other residents. This should have been reported as a sexual abuse allegation within two hours. The Administrator stated CNA 1 was not suspended, and this had the potential for further sexual abuse to continue to Resident 1 or other residents. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/10/2021, at 9:20 PM, Resident 1 requested an additional dose of [MEDICATION(S)] for anxiety, was was administered. A review of the SOC 341 (a report template for reporting suspected dependent adult/elder abuse) dated 2/12/2021, indicated the sexual abuse allegation occurred on 2/10/2021. The Los Angeles Police Department and local ombudsman were notified on 2/12/2021 at 6 PM. A review of the facility's police and procedure, titled, Abuse Prohibition, dated, 7/1/2019, indicated, upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the designee will perform the following; report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation was made.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) with gastrostomy tube ([DEVICE], a medical device inserted through the abdomen that delivers nutrition directly to the stomach for residents who are unable to obtain adequate nutrition by mouth) received the necessary treatment and services to prevent negative consequences of [DEVICE] use and complications. For Resident 1, who was totally dependent on staff for eating and was at risk for complications of infection related to the presence of a [DEVICE], daily evaluation of the [DEVICE] site and timely reporting to physician was not provided, per the care plan and facility policy. This deficient practice resulted in Resident 1 experiencing leaking from the [DEVICE] site, being transferred to the General Acute Care Hospital (GACH) for infected gastrostomy tube site, removal of current [DEVICE], requiring a new [DEVICE] site access, and a wound care referral. Findings: A review of the Admission Record indicated Resident 1 was originally admitted , on 7/17/15, with [DIAGNOSES REDACTED]. A review of the care plan, dated 7/20/15, indicated Resident 1 was at risk for [DEVICE] site redness. The care plan goals indicated for the site to remain free from signs and symptoms of infection and for Resident 1's wound to heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] (redness) and drainage and presence of granulation (healing tissue). The care plan interventions included to evaluate the [DEVICE] site area daily, including surrounding tissue and presence or absence of drainage/infection, and/or new wound pain, and report to MD as indicated. A review of the care plan, dated 2/2/16, indicated Resident 1 was at risk for complications of infection related to the presence of a [DEVICE]. The care plan goal indicated Resident 1 was to remain free of complications or infections and the care plan interventions included monitoring for signs and symptoms of infections and report to physician, and also included to monitor for skin breakdown and report to physician. According to a review of the Physician order [REDACTED]. A review of the treatment order, dated 12/19/18, indicated to cleanse the [DEVICE] site with normal saline solution, apply steri-strips and Stomadhesive paste, and cover with a dry dressing every day for 14 days. This order was renewed for another 14 days on 1/2/19 and again for another 14 days on 1/16/19. A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/19/18, indicated Resident 1 had severely impaired cognitive skills for daily decision making and was totally dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene and bathing. The MDS indicated the proportion of total calories Resident 1 received through [MEDICATION NAME] or tube feeding was 51% or more. A review of the Skin Integrity Report for Resident 1's [DEVICE] site indicated, on 11/30/18, there was no presence of drainage, and the surrounding tissue and wound edges were healthy. On 12/7/18, the skin integrity report indicated Resident 1's [DEVICE] site had a minimum amount of serosanguineous (contains both blood and the liquid part of blood - serum) drainage and macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) wound edges. A review of the Physician order [REDACTED]. The Physician order [REDACTED]. According to a review of the nursing notes for Skin Check from the electronic medical chart for (MONTH) 2019, Resident 1's [DEVICE] site had redness on the following dates: 1/4, 1/11, 1/18, and 1/25/19. A review of the Nursing Summary notes from the electronic medical chart for (MONTH) 2019 indicated Resident 1's [DEVICE] site had redness on the following dates: 1/4, 1/11, 1/18, and 1/25/19. A review of Resident 1's Skilled MD Progress Notes, dated 1/4, 1/18, and 1/24/18, had no indication of Resident 1's [DEVICE] site redness, drainage, or macerated edges. A review of the Transfer Form, dated 1/29/19, indicated Resident 1 was transferred to the GACH for a huge stoma with leakage (the result of an operation that is meant to remove disease and relieve symptoms, an artificial opening that allows feces or urine either from the intestine or from the urinary tract to pass) and infected gastrostomy tube site. According to a review of the GACH emergency room Procedure Notes, dated 1/29/19, Resident 1 had an attempted [DEVICE] exchange on 1/29/19. The procedure notes indicated the [DEVICE] site was found to have dried, had sticky tube feedings, macerated skin (softening and breaking down of skin resulting from prolonged exposure to moisture), and [MEDICATION NAME] exudate (pus consistent with more severe infections, indicating a more severe injury where larger holes develop, allowing [MEDICATION NAME] (a protein that stops excessive bleeding) to get out into the tissue), concerning for chronic gastrostomy tube leakage with [MEDICAL CONDITION]. According to the notes, the procedure was aborted since a new [DEVICE] site access would be needed. The recommendation was for nasogastric (NG Tube - a special tube that carries food and medicine to the stomach through the nose) for feeds, removal of current [DEVICE], and a wound care referral. During an interview with the Treatment Nurse, Licensed Vocational Nurse 1 (LVN 1), on 2/11/19, at 11:30 a.m., LVN 1 stated there was always an issue with Resident 1's GT leaking. LVN 1 stated the [DEVICE] would leak during turning and repositioning, the physician (MD) was aware of the leaking and would place silver [MEDICATION NAME] on the site and close it up with steri-strips and ordered for the staff to use steri-strips for treatment as well. LVN 1 stated the skin around Resident 1's [DEVICE] was red and macerated because the steri-strips were not working. LVN 1 stated when the steri-strips treatment was not working, the physician was made aware and Resident 1 was transferred out to the GACH. When asked if there were any signs and symptoms of infection, LVN 1 stated Resident 1 had no fevers and no complaints of pain. When asked if redness was a sign of infection, LVN 1 stated Yes, it could be. During an interview and concurrent record review of Resident 1's nursing progress notes with Registered Nurse 2 (RN 2), on 3/29/19, at 9 a.m., when asked if there were any documentation regarding Resident 1's leaking [DEVICE], RN 2 stated no. RN 2 stated she looked as far back as (MONTH) (YEAR) and could only find documentation regarding Resident 1's [DEVICE] site redness. During an interview and concurrent record review of Resident 1's Skin Integrity Report for the [DEVICE] site and electronic medical chart with the Director of Nursing (DON), on 3/29/19, at 10 a.m., when asked if there was a documented Change of Condition (C[NAME]) record for the change in [DEVICE] site condition on 12/7/18, the DON stated no. When asked if a C[NAME] should have been completed, the DON stated yes. During an interview and concurrent record review of Resident 1's paper and electronic medical charts with the Director of Nursing (DON) on 3/29/19, at 10 a.m., when asked if there were any consults regarding the [DEVICE], the DON stated no. During an interview and concurrent record review of Resident 1's Skin Integrity Report for the [DEVICE] site with the treatment nurse, Licensed Vocational Nurse 1 (LVN 1), on 3/29/19, at 12:45 p.m., when asked if a Change of Condition was done regarding the change in [DEVICE] site on 12/7/18, LVN 1 stated no because it was a recurrent condition. A review of the policy and procedure, dated 11/28/16, titled, Skin Integrity Management, indicated the facility would provide safe and effective care to manage treatment and promote healing of all wounds. A review of the policy and procedure, revised 10/1/18, titled, Enteral Management, indicated the facility would assure that the patient being fed by a feeding tube maintains the highest degree of quality of life possible. Cross-Reference F656

Based on interview and record review, the facility failed to permit Resident 1 to remain in the facility and discharged Resident 1 to a shelter without after-discharge support or a coordinated discharge / transfer plan from the facility for one of three sampled residents (Resident 1). This resulted in Resident 1's admission to a General Acute Care Hospital (GACH) for low back pain, after the resident fell in the bathroom, the same day of arrival, to the shelter. Resident 1 was treated for [REDACTED]. Findings: On 6/13/17, an unannounced visit was made to the facility to investigate a complaint regarding Admission, Transfer and Discharge Rights. A review of the Admission Record indicated Resident 1 was admitted to the facility, on 4/30/15, with [DIAGNOSES REDACTED]. The clinical record also indicated Resident 1 was at risk for falls relating to impaired mobility, and sustained a fall outside the facility on 5/28/16, resulting in an acute right ankle fracture. A review of the Minimum Data Set (MDS - a care planning and assessment tool), dated 3/12/17, indicated Resident 1 was alert and oriented, and required extensive assistance one person assist with dressing, toilet use, and bathing. The resident was assessed with [REDACTED]. The MDS indicated Resident 1 was incontinent with bowel and bladder (the inability to control bowel movements and urinating), and was on a pain management regimen. A review of the History and Physical, dated 5/22/17, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's care plan, initiated on 6/1/17, for potential of discharge indicated the goal to provide a safe and effective discharge. The care plan interventions indicated to discuss with the resident potential barriers to discharge transition planning, evaluating discharge planning needs taking into consideration care plans, goals, cognitive skills, functional mobility, and need for assistive devices. Additional care plan interventions included making referrals to community-based agencies, providers, and services and communicating the resident's needs and barriers of care. According to the Certified Nursing Assistant Activity of Daily Living (ADLs) form, dated 6/1/17 through 6/8/17, Resident 1 required extensive assistance with one person assist for bed mobility, extensive assistance with one to two persons assist for transfers, extensive assistance with one person assist for toilet use during the day and evening. The resident was totally dependent with one person assist at night. A review of the final Licensed Nurses Progress Notes, dated 6/8/17, at 5 p.m. indicated there was no documented evidence of physician notification or that an order was obtained to discharge Resident 1. There was no documented evidence for the reason for discharge, no documentation of Resident 1's condition at the time of discharge, or an assessment of the resident's pain prior to discharge. According the Resident 1's final Licensed Nurses Progress Notes, the section for disposition of belongings and residents medication were left blank without a licensed nurses' signature. A review of Resident 1's Social Service notes, dated 6/8/17, indicated Resident 1 was non-compliant with her plan of care and treatment. According to the Post Discharge Plan of Care, undated, Resident 1's appointments and discharge services were not provided and remained blank. Follow up appointments, transportation, medical equipment, and community resources were indicated as, Not Applicable, or the section remained blank, unsigned and undated. A record review of Resident 1's Medication List for discharged Patients, dated 6/8/17, indicated the resident was discharged with Trazadone 25 mg, 10 1/2 tablets (antidepressant but ordered for [MEDICAL CONDITION]). Trazadone side effects include drowsiness, increased sedation, fatigue, and ataxia (lack of muscle control). There was no signature of the releasing nurse on the discharged medication list. In addition, a review of Resident 1's Discharge Summary form, dated 6/8/17, was not completed. The final diagnosis, discharge diagnosis, and prognosis section all remained blank. A review of the GACH emergency room (ER) record indicated Resident 1 was admitted , on 6/9/17, for increased low back pain after the resident fell in the bathroom at a shelter. Resident 1 was treated for [REDACTED]. On 6/13/17, at 9:05 a.m., an interview was conducted with the Administrator who stated the Nurse Consultant denied Resident 1's return to the facility because the resident no longer needed skilled nursing services. The Administrator stated he contacted Uber, scheduled a pick up time, and paid for the ride to transport the resident to the shelter. On 6/13/17, at 11:05 a.m., an interview was conducted with the Director of Nursing (DON) and Director of Staff Development (DSD) who both stated and confirmed no documentid evidence of nursing notes reflecting the discharge for Resident 1. The DON stated it was the responsibility of the Registered Nurse to coordinate and ensure safe discharge and transfer plan in place for the resident. The DON also stated there was no documented evidence of the Interdisciplinary Team (IDT) notes addressing Resident 1's plan for discharge. During an interview, on 6/13/17, at 12:49 p.m., an interview was conducted with the Registered Nurse 1 (RN 1) unit manager who stated licensed vocational nurses (LVN's) were supposed to complete discharge documents and summary prior to being discharged . RN 1 stated this was not in accordance with facility policy. A review of the facility policy and procedure titled, Discharge and Transfer, dated 11/28/16, indicated the Registered Nurse is ultimately responsible to ensure there is a safe and coordinated discharge and transfer plan in place for the resident. All resident will receive a Notice of Transfer of Discharge and/or Discharge Transition plan whenever discharge occurs to meet resident's needs, federal and state regulations and facilitate a safe transition to another setting; the Interdisciplinary Care Team (IDT) will provide sufficient preparation prior to discharge; and a copy of the Discharge Transition Plan will be place in the resident's medical record. On 7/7/17, at 1:34 p.m., an interview was conducted with Social Worker / Case Manager 1 at the shelter, who stated Resident 1 arrived with no equipment to ambulate and could barely walk. The resident fell overnight at the shelter and cried because she was in a lot of pain. Case Manager 1 stated the shelter was not equipped to handle this type of resident, was not an appropriate placement, and she contacted the Administrator at the skilled nursing facility who refused to take Resident 1 back. Case Manager 1 stated the shelter called 911 to transfer Resident 1 to the emergency room because the resident required help the shelter could not provide. A review of the Facility's Discharge Planning Process Roles and Responsibilities, dated 3/2017 indicated Post Discharge (within 72 hours of Discharge) Social Services or designee contacts patient or family to ensure successful transition to discharge setting and satisfaction with services. During an interview with the Administrator, on 7/10/17, at 1:45 p.m., he stated Resident 1 called the facility and informed the staff she was happy, but a review of the clinical record indicated this was not documented. When the Administrator was asked where was Resident 1 currently located, he stated he did not know. A review of the Facility's Policies and Procedures titled Discharge Planning Process, dated 2/13/17, indicated the facility must develop and implement an effective discharge planning process that focused on the resident's discharge goals and effectively transition them to the post discharge care and reduce factors leading to preventable re-admissions, weekly review by the Interdisciplinary Utilization Management and discharge planning meeting for evaluation of potential discharge. Social Services staff initiates the Discharge Transition Plan, communicates the discharge date s and prepares the patient and family for transition. The policy indicated the IDT would use discharge planning process to document that patient had been asked about his/her interest in receiving community based services. Documentation would include nurse progress notes indicating Discharge Transition Plan and reviews.

Based on interview, and record review, the facility failed to ensure one sampled resident (Resident 1) who required extensive assistance for bed mobility, toilet use, and personal hygiene, was provided necessary treatments and services (observe skin condition with care daily and report abnormalities) for prevention of pressure sore (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and to promote healing of pressure sore by failing to: 1. Promote the prevention of pressure sore development. 2. Identify a newly developed pressure sore. 3. Develop a care plan to implement interventions to promote the prevention / healing of pressure sore on the right buttocks. 4. Evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection, and report to physician as indicated. This deficient practice caused the resident to be transferred to a general acute care hospital (GACH) with [DIAGNOSES REDACTED]. Resident 1 also developed an abscess (a localized collection of pus in the tissues of the body, accompanied by swelling and inflammation, frequently caused by bacteria) to the left buttock and subsequently died two days after admission to the GACH, due to cardio [MEDICAL CONDITION] arrest ([MEDICAL CONDITION], a sudden stop in effective blood flow due to the failure of the heart to contract effectively). Findings: a. A review of the clinical record indicated Resident 1 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the nursing progress note, dated [DATE], indicated a Braden Scale (tool used to assess a resident's risk of developing a pressure sore) was completed for Resident 1 with a score of 13, which indicated a moderate risk for developing pressure sores. A review of the Minimum Data Sheet (MDS - an assessment and care planning tool), dated [DATE], indicated Resident 1 was at risk for developing pressure sores and did not have any pressure sores at Stage I (intact skin with non-blanchable redness of a localized area, usually over a boney prominence) or higher. A review of the Skin Assessment code sheets, dated [DATE], and [DATE], indicated there was no identification of a right buttocks pressure sore. The skin integrity reports, dated [DATE], [DATE], [DATE], and [DATE], did not identify a right buttocks pressure sore. A review of the Treatment Administration Record dated, from [DATE], through [DATE], indicated there was no identification of a right buttocks pressure sore. A review of the clinical record indicated there was no care plan developed regarding Resident 1's skin integrity to promote the prevention / healing of pressure sore prior to [DATE]. A review of the nursing progress note, dated [DATE], indicated Resident 1 had a low blood pressure ,[DATE] mmHg (normal blood pressure ,[DATE]), heart rate 91 (normal range 60 - 80), the physician was notified, and ordered to transfer Resident 1 to the GACH. A review of Resident 1's Nursing Home to Hospital transfer form, dated [DATE], indicated the skin/wound care area remained blank. There was no documentation to indicate Resident 1 had a skin / wound issue upon transfer to the general acute care hospital (GACH). According to the general acute care hospital (GACH) Consultation form, dated [DATE], Resident 1 had an infected Stage IV pressure sore on his right buttocks with malodor (bad odor) and [MEDICAL CONDITION] secondary to the pressure sore. The GACH consultation form indicated Resident 1 also had a second superficial pressure sore present on the posterior (back) right leg. During a telephone interview, on [DATE], at 9:30 a.m., the GACH general surgeon (Surgeon 1) stated he debrided (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) Resident 1's infected Stage IV pressure sore on [DATE] (two days after the resident was transferred to the GACH). A review of the clinical record indicated Resident 1 was readmitted to the skilled facility, on [DATE], and the Skin Integrity report with same date indicated the resident had a Stage IV pressure sore on the right buttock. A review of Resident 1's nursing care plan, dated [DATE], indicated a focus area of nutritional risk, the goal indicated the resident would have improved skin integrity for 90 days. The care plan interventions indicated to observe skin condition with care daily and report abnormalities. A review of the Braden Scale for Predicting Pressure Sore form, dated [DATE], indicated Resident 1 had a score of 15, which indicated a mild risk for pressure sore. A review of the Minimum Data Sheet (MDS - an assessment and care planning tool), dated [DATE], indicated Resident 1 had clear speech, able to express ideas and wants, and needed extensive assistance for bed mobility, toilet use, and personal hygiene. The MDS Care Area Assessment summary indicated pressure sore was triggered as a care area with care planning to address the problem. A review of the nursing care plan, dated [DATE], indicated Resident 1 had actual skin breakdown related to shear/fiction risks, and limited mobility. The interventions indicated to assist resident in turning every two hours and as needed, evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to medical doctor as indicated. A review of the physician's orders [REDACTED]. A review of the GACH's history and physical, dated [DATE], indicated Resident 1 was admitted to the GACH for altered level of consciousness, [MEDICAL CONDITION] (bacteria in the blood) with leukocytosis (elevated white blood cells which indicate infection). b. A review of the skilled nursing facility skin integrity reports, dated [DATE], [DATE], and [DATE], did not identify a left buttock wound for Resident 1. A review of the Nursing Home to Hospital transfer form, dated [DATE], indicated there was no documentation regarding Resident 1's left buttock abscess in the skin/wound care section. A review of the GACH general surgery consultation note, dated [DATE], indicated Resident 1 had a new left buttock abscess (a localized collection of pus in the tissues of the body, accompanied by swelling and inflammation, frequently caused by bacteria). Surgeon 1 documented on the consultation note that he knew Resident 1 from the previous debridement surgery of the right buttock pressure sore, performed on [DATE]. During a telephone interview, on [DATE], at 9:30 a.m., Surgeon 1 stated Resident 1's left buttock abscess was new and it happened after the right buttock debridement. Surgeon 1 described the left buttock abscess as 4 inches in diameter with reddish/brown, very foul smelling drainage, and stated, The drainage smelled like a dead dog. A review of the skilled nursing facility's May and [DATE] treatment records indicated there was no identification of treatment for [REDACTED]. During the interview with LVN 1, on [DATE], at 1 p.m., she stated she was the treatment nurse full time since the beginning of [DATE] and she performed Resident 1's dressing change on the right buttock. When asked about Resident 1's left buttock wound she stated, What about it, there was no treatment done to the left buttocks. LVN 1 stated she did not see a left buttock abscess/wound for Resident 1 and denied smelling a foul odor. A review of the death certificate indicated Resident 1 died on [DATE] (two days after admission) at the GACH from cardio [MEDICAL CONDITION] arrest. A review of the facility's policy titled, NSG 236 Skin Integrity Management, dated [DATE], indicated the staff continually observed and monitor patients for changes and implement revisions to the plan of care as needed. Staff performs daily monitoring of wounds or dressings for presence of complications, or declines and document. A review of the facility's policy and procedure titled, Skin Integrity Management, dated [DATE], indicated the staff would continually observe and monitor the residents for changes and implement revisions to the plan of care as needed. Staff will perform daily monitoring of wounds or dressings for presence of complications or declines and document.

Based on observation, interview, and record review the facility failed to ensure Resident 1 who had a history of [REDACTED]. 1. Develop a plan of care with interventions useful and effective in the prevention of the resident's second fall that resulted in severe brain injury. 2. Closely monitor the resident to anticipate the needs for assistance. 3. Provide supervision and/or frequent scheduled nursing rounds to monitor the resident's safety. 4. Apply a monitoring device such as a bed alarm (a devise used to alerts care givers with audio alarm when patient has moved or tries to get out of a chair or bed) and/or to detect the alarm if applied, in order to assist the resident before an incident of fall occurred. On [DATE], the Department received a complaint that alleged Resident 1 who was at a high risk for falls was found on the floor and no one in the facility knew how long he had been on the floor. On [DATE], at 8:15 a.m. the resident was transferred to an acute care hospital, and placed on life support for three days until he was pronounced dead due to blunt head trauma. On [DATE], an investigation of the above allegation revealed that the resident was transferred to the acute care hospital emergency room (ER) after he was found on the floor on [DATE], at 1 a.m. According to the emergency room (ER) report dated [DATE], the resident was unresponsive on arrival to the ER and was admitted to an intensive care unit (ICU) for higher level of care after he was intubated (insertion of a tube into the trachea for assisted or mechanical breathing). The resident was diagnosed as having a large left subdural hematoma (a collection of blood on the surface of the brain usually caused by a serious head injury and often requires surgical intervention) and expired on [DATE], at 11.20 a.m. The death certificate indicated the cause of death was, "Blunt Head Trauma." Findings: A review of the Skilled Nursing Facility's admission record dated [DATE], at 11 p.m. indicated Resident 1 was an [AGE] year-old admitted from the acute care hospital after being hospitalized for [REDACTED]. The resident had the first fall at an Assisting Living Facility and had sustained a laceration to his left forehead that was repaired with sutures at the hospital. The cranial computerized tomography (CT) scan dated [DATE], done after the first fall indicated there was no evidence of acute hemorrhage (profuse bleeding) from the first fall. However, the resident did not return to the Assisting Living Facility because he required Skilled Nursing Care. The resident's admission [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE], and 6, 2010, indicated the resident scored 15 and 18 respectively. According to the fall assessment tool, a score of 10 and above represents a high risk for falls. The fall risk assessment also indicated the resident was disoriented at all times, ambulatory, incontinent, had poor vision, and had a balance problem while standing and walking. The admission physician's orders [REDACTED]. The Physical Restraint/Device assessment dated [DATE], indicated the resident's cognitive status, memory, and hearing were impaired and he required assistance for transfers. There was a care plan initiated on [DATE], that indicated the resident had a fall in the last 30 days and was a fall risk. The approach was to keep the bed in the lowest position with both upper side rails up for turning and repositioning, and to include the resident in the "Restraint Alternative Program." The care plan also indicated the resident required extensive assistance in bed mobility, transfers, walking in his room, and eating, and was totally dependent on staff for dressing, personal hygiene and bathing. The plan of care however, did not specify how the nursing staff members would be able to remind a resident assessed as disoriented, not to get up unassisted. In addition, the care plan did not include interventions useful and effective to prevent an injury from a fall for a resident assessed as "disoriented at all times" and who had a history of [REDACTED]., including to get out of bed if he needed, or to perform specific tasks at set intervals and/or monitor the resident for safety. The plan of care also did not include effective interventions in the prevention of accidents from falls such as the use of a bed alarm adequately audible to the nursing staff to alert them to provide immediate assistance when the resident moved or attempted to rise to get out of bed. During an interview with Registered Nurse (RN 1) after review of the care plan, she stated the Restraint Alternative Program means the use of a low bed, remind the resident not to get up unassisted, and side rails up for positioning. A review of the literature indicates that falls frequently occur when residents get out of bed and go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent "structured" nursing rounds in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the resident needed anything and assisting with toileting at set intervals was associated with statistically significant reductions in residents' use of call lights and the incidence of falls, and with an increase in resident satisfaction (Stefancyk, Amanda, "Safe and Reliable Care," American Journal of Nursing, [DATE], Volume 109 No. 7, Pages ,[DATE]). According to the Daily and Q (every) Shift Charting form dated [DATE], 1 a.m., (two hours after the resident was admitted to the facility), Certified Nurses Assistant 1(CNA 1) found the resident on the floor trying to crawl, saying he had to go to his "office." According to the licensed nurse's note, the resident had a bump on his left upper forehead that measured 2 centimeters (cm) by 2 cm. The sutures on the forehead from the previous fall were opened and there was a small amount of bleeding. The resident was put back to bed. There was no documentation to show how long the resident had been on the floor. And there was no documentation whether the bed was in a low position. There was a two hour interval between the time the resident was observed alert, and the time he was observed on the floor. A review of the Post Fall assessment dated [DATE], 1 a.m. indicated the resident was found on the floor next to his bed, alert and confused, kneeling and crawling. According to the assessment, the side rails were in an upward position. However, the post fall assessment did not indicate how the resident managed to fall out of bed with both siderails in an upward position. In addition, the implementation of the care plan to keep the bed in the lowest position was unknown. The notes indicated that the physician was notified and orders for a skull x-ray and neuro checks every 2 hours for 72 hours were obtained. The Neurological Observation Form dated [DATE], from 1:30 a.m. to 6 a.m. indicated, with the exception of the resident's vital signs (blood pressure, temperature, pulse and respiration), the resident's neurological status was not monitored as ordered by the physician. For example, according to the Neurological Observation Form the resident's pupil sizes and reactions, responsiveness, and neurological conditions of the extremities, were blank and not assessed. The skull x-ray report dated [DATE], done at 4:24 a.m. indicated the multiple views of the skull demonstrated a normal [DIAGNOSES REDACTED] pattern. There was no linear or depressed fracture. The orbits were grossly intact. A review of the Daily and Q (every) Shift Charting dated [DATE], at 7:55 a.m. indicated the resident was not responding to touch, verbal stimuli, and his eyes were closed. The resident's vital signs were: blood pressure was ,[DATE], pulse was 100, respirations were 20, temperature was 97.8 degrees Fahrenheit, and his oxygen saturation was 96 percent (%) on room air. The physician was notified and the paramedics transferred the resident to the acute care hospital emergency room . According to the emergency room (ER) report dated [DATE], the resident was unresponsive on arrival to the ER and was admitted to an intensive care unit (ICU) for a higher level of care after he was intubated. While the resident was having a (CT) scan the resident had [DIAGNOSES REDACTED] (abnormally rapid and ineffective heart beats), a "code blue" was called and the resident had cardioversion (a medical procedure performed to restore a normal heart rhythm for people who have certain types of abnormal heartbeats (arrhythmias)) performed and normal sinus rhythm was established. The CT scan revealed a large subdural hematoma (SDH) that measured 3 centimeters with midline shift and radiographic evidence of brainstem herniation. The resident was diagnosed as having a large left subdural hematoma. There was no surgical procedure performed. The resident's neurological status worsened and he was pronounced dead on [DATE], at 11.20 a.m. A review of the Certificate of Death dated [DATE], obtained from the acute care hospital revealed the cause of death was "Blunt Head Trauma" from a ground level fall at the nursing home. A review of the literature indicates that in the older adult, traumatic injuries are typically more severe than a younger resident's and prospects for survival less certain. Recovery takes longer and the threat of complications looms larger (Stamatos, Christine A. RN, MS, CCRN and Co. American Journal of Nursing: [DATE]- Volume 96-Issue 5-Pages ,[DATE]). During an interview on [DATE], at 10:45 a.m., Family Member 1 (FM 1) stated she called the facility at 9 a.m. on [DATE], to check on Resident 1 and heard commotion in the background. Someone asked her to call back, but went on to tell her that Resident 1 was unresponsive and was transferred to the acute care hospital emergency room . According to FM 1 she rushed to the acute care hospital and observed the resident with a knot about the size of a goose egg, on the left side of his head behind the laceration sustained on the first fall at the Board and Care. When she asked, the doctor at the hospital informed her that the resident was unconscious an unknown period of time. On [DATE] at 1:45 p.m., during an interview, Administrative Staff 1 (AS 1) stated the facility uses low beds and alarms (to alert staff when the resident attempts to rise). He stated he thought the facility had 24 hours after admission to obtain equipment, including Resident 1's low bed. According to AS 1, the facility's regular bed can be lowered to a height of two feet above the floor and the high/low bed can be lowered to 12 inches above the floor (from the bottom of the frame, not the top of the mattress). A review of the facility's Physical Restraint Review document revealed that in addition to providing a low bed or an alarm to alert staff when the resident attempted to get out of bed unassisted, the mattress could have been placed on the floor until a "low" bed was received. On [DATE], at 3:48 p.m. during an interview, CNA 1 stated that Registered Nurse 2 (RN 2) found the resident on the floor and called her to the resident's room to help put the resident back to bed. The resident was too big, so she with the assistance of RN 2 and RN 3 put the resident back to bed. According to CNA 1, she asked the resident why he did not call for help, and he replied he had to get something from his home. CNA 1 further stated the resident was bleeding from his eyebrow, but she did not remember which one. CNA 1 stated the resident had an alarm on his bed, but she could not hear it because she was in Room 4 at the time of the resident's fall, who was in Room 33. However, the plan of care did not indicate a bed alarm had been applied, and if one was applied as indicated by CNA 1, it should have been audible to alert the nursing staff members. On [DATE], at 10:05 a.m. during an interview, RN 2 stated on the day of the incident he saw the resident sitting on the floor while he was on his way to the supply room. According to RN 2, when he asked the resident if he was ok, the resident responded he was fine. RN 2 stated he called for CNA 1 and RN 3. RN 3 checked for injuries while the resident was still on the floor. After a few minutes all three employees put the resident back to bed. RN 2 stated he saw a bruise on the resident's forehead but he could not remember which side. He also stated he could not remember if the bed was in a low position. When asked about the bed alarm, RN 2 stated he did not hear the sound of a bed alarm. According to RN 2 the bed alarm, when activated, will continue to sound until it is reset. A review of the literature indicates to reduce the patient's risk of falling from bed, use a bed that can be lowered nearer to the floor and place padded mats on the floor at the side of the bed. Remove side rails, unless the patient uses them to reposition himself in bed, in which case a half rail should be used. High-risk patients require close observation and surveillance. Move the person at risk for falls closer to the nurses' station, use of bed alarms may be useful. Meade and colleagues found that hourly rounds that are focused on anticipating and meeting patients' needs may help prevent injuries from falls, and nursing assistants are especially critical to its success. (AJN, American Journal of Nursing: [DATE] - Volume 108 - Issue 3 - p ,[DATE]).