Every finding on record at Franciscan Health Center

Based on observation, interview, and document review the facility failed to ensure they provided sufficient staffing per their facility assessment. In addition, the facility failed to provide sufficient staff to complete timely cares and assistance with checking and changing for 1 of 1 resident (R8) reviewed for activities of daily living and who were dependent on staff for assistance. This had the ability to affect all 36 residents residing in the facility. Findings include: The facility assessment, Franciscan Health Center Staffing Plan Staffing dated 10/23/25, identified the following staffing needs with an average daily census of 39: Licensed nurses providing direct care, every day of the week for AM and PM shift there were two eight-hour positions, and the overnight (NOC) shift had one eight-hour position. Unlicensed staff (NA), every day of the week for AM shift had five eight-hour positions, PM shift had four eight-hour positions, and NOC shift had two eight-hour shifts. During the survey, the following staffing shortages were noted: Monday 2/23/26, AM shift NA total was three from 6:30 a.m. until 12:30 p.m. when a fourth NA was added to the schedule. The resident census was 36. Tuesday 2/24/26, AM scheduled for four NAs. The resident census was 36. Wednesday 2/25/26, scheduled for three NAs. The resident census was 37. Thursday 2/26/26, AM scheduled for four NAs, there was a call-in for AM shift so there was a fourth aid who stayed until 10 a.m., from 10 a.m. to 2:30 p.m., there were three NAs. The resident census was 38. The PBJ Staffing Data Report for fiscal year 25, quarter 4 identified excessively low weekend staffing: 12/6/25, AM NA hours were actually 24, 32 were scheduled 12/7/25, AM NA hours were 16, 32 were scheduled. For PM, actual NA hours were 24 and 32 were scheduled. 12/8/25, PM NA hours were 24, 32 were scheduled 12/12/25, NOC NA hours were 16, 24 were scheduled 12/13/25, PM NA hours were 24 after 7 p.m., and 16 after 9 p.m., 40 were scheduled 12/14/25, AM NA hours 24, 32 were scheduled 12/15/25, PM NA hours were 24, 32 were scheduled 12/19/25, AM NA hours were 24, 32 were scheduled 12/20/25, PM NA hours were 24 after 9 p.m., and 16 after 9:30 p.m., 32 were scheduled 12/22/25, PM NA hours were 24 at 7 p.m., 32 were scheduled 12/27/25, PM NA hours were 16 at 10 p.m., 32 were scheduled 12/29/25, AM NA hours were 24, 32 were scheduled. PM NA hours were 24, 32 were scheduled 1/2/26, AM NA hours were actually 24, 32 were scheduled 1/4/26, NOC NA hours actually 8 after 4 a.m., 16 were scheduled 1/11/26, PM NA hours were actually 16 after 6 p.m., 32 were scheduled 1/16/26, PM licensed nurses were actually 8 after 8 p.m., 16 were scheduled 2/6/26, PM NA hours were actually 24 and 32 were scheduled 2/9/26, PM NA hours were actually 24 and 32 were scheduled 2/16/26, AM NA hours were actually 32, 40 were scheduled 2/21/26, AM NA hours were actually 24, 32 were scheduled 2/22/26, AM NA hours were actually 24, 32 were scheduled During the survey from 2/23/26 to 2/27/26, NA-E stated usually they have about 10 residents to care for during the day, but if they were short, it would be more. When they were short, NA-E described tactics like waiting to wash someone's face or brushing their teeth until later in the day or having to do a bed bath instead of a tub bath or shower. In an interview during the survey from 2/23/26 to 2/27/26, RN-E stated they were responsible for medications and treatments for 22 residents. RN-E also stated it was difficult to get it done; one medication pass ran into the next without time between. For example, today they were late with medications and treatments. In an interview during the survey from 2/23/26 to 2/27/26, stated today after 10 a.m., NA-D had 12 or 13 residents in their group, and that was typical as they were consistently short-staffed. They added the nurse managers were helpful on the weekdays, but on the weekends, there weren't any extra bodies here. NA-D stated they thought most of the important things got done, but they didn't get breaks. All core staff wrote a letter to management about 4 months ago and gave it to all of management and their union and they never heard anything back from anyone. In an interview during the survey from 2/23/26 to 2/27/26, NA-F stated they were responsible for about 14 people. They felt like they could get their work done but didn't have the extra time to do extras like visiting the residents or taking them outside anymore. During an interview on 2/27/26 at 11:52 a.m., facility scheduler (FS)-F stated she put out a two-week schedule a month in advance every month, and there had been times she had to put out a schedule with holes in it despite attempts to fill them with facility casual staff or staffing agency staff. FS-F stated when there was a call-in the NOC nurse starts calling through to fill it and then she would take over when she got to work. The struggle is with call-ins with weekends. They have recently had a large number of call-ins for the weekend and there isn't the support staff here to help out. FS-F considers the nurse managers and MDS coordinator are as staff that is hands-on caregiving because they do help out when they are here and they are always willing to help. During an interview on 2/27/26 at 12:14 p.m., the acting director of nursing (DON) confirmed there were times during the survey where they had call-ins they couldn't replace. Staff didn't really complain about the schedule, they might let the managers know and the managers would then help on the floor. The DON explained they have worked on making sure the care group sheets are fair and equal, have put out suggestion folders for staff to give feedback on the group sheets and shower schedule, and they just had a NA meeting the end of January so they talked about everyone's opinions and thoughts about where things are at currently. Nurse managers do help with things with med cart, help on the floor. There are days when a nurse calls in there are times when they may have to be just passing medications. The nurse managers are on call for the weekends, if there were an emergent staff issue, they would come in. An example would be if there were no RN in the building, or if they only had one or two aids. Self-Care and Activities of Daily Living:See also F677 R8: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 had diagnoses which included vascular dementia, depression, bipolar disorder, chronic pain, history of urinary tract infections, and post-traumatic stress disorder (PTSD). In addition, R8 was cognitively intact and required substantial to maximum assistance with activities of daily living and was always incontinent of bowel and bladder. A review of R8's current order summary report included the following orders: One half vinegar one half water solution soak two times a day, soak right abdominal groin folds and under both breasts for 10 minutes with solution, pat dry, apply zinc cream, dated 2/26/26. Skin charting one time a day every Saturday complete weekly per schedule, dated 11/22/25. Myrbetriq (medication used to treat overactive bladder) oral tablet extended release 24 hour 60 milligrams (mg) one time a day related to stress incontinence, dated 10/11/25. R8's history order summary report included the following orders: Nystatin external powder 100000 unit per gram (GM) apply to affected areas tropically as needed for two times a day apply to abdominal folds, groin, under breasts, dated 10/10/25. Monitor and document signs and symptoms of urinary tract infection and vitals every shift, document in progress notes, started on 1/26/25. R8's care plan dated 10/10/25, identified R8 had an activity of daily living deficit related to activity intolerance, impaired balance. Interventions included a toileting schedule every two to three hours and per their request. The care plan identified frequently incontinent of bowel and bladder. In addition, bowel incontinence related to immobility. Interventions included to check every two hours and assist with toileting as needed. R8's care plan dated 10/10/25, identified R8 was at risk for insomnia. Interventions included to maintain a consistent schedule with daily routine. R8's care plan dated 1/7/26, identified R8's personal care preferences. Interventions included, I prefer to be woken around and be out of bed after 9:00 a.m Do not wake me up before 9:00 a.m A review of R8's weekly skin assessments revealed the following: 2/21/26, moisture documented as normal, noted No, there are no skin concerns. 1/24/26, (about a month earlier) moisture documented as normal, noted No, there are no skin concerns. 1/21/26, moisture documented as normal, noted No, there are no skin concerns. 1/6/26, (about two weeks earlier) documented as other quarterly MDS. Skin group page 18 documented as No skin issues further pages identified perineum, right breast, left breast, rash all documented as resolved. 12/10/25, (about 4 weeks earlier) moisture documented as normal, noted No, there are no skin concerns. 12/2/25, moisture documented as normal, noted No, there are no skin concerns. 11/29/25, moisture documented as normal, noted No, there are no skin concerns. 10/14/25, (about 6 weeks earlier) moisture documented as normal 10/10/25, admission skin assessment, left and right breast, perineum rash, present on admission, chronic greater than 3 months. A review of R8's progress notes revealed the following: 2/24/26, 3:32 p.m., Writer asked to assess resident skin under breasts and abd (abdominal)/groin folds. Skin condition not improving with current treatment of Nystatin powder. Writer called Dr. XXXXX and received new order as follows: Soak right abdominal/groin folds and under both breasts for 10 minutes with 1/2 vinegar 1/2 water solution. Pat dry. Apply Zinc cream. Twice daily. Writer also discussed adding resident to list for wound care NP to see. 2/10/26, 10:47 a.m., New orders from MD Please keep pt (patient) dry r/t (related to) recurrent UTIs (urinary tract infections). A continuous observation started on 2/25/26 at 7:05 a.m. and ended at 11:01 a.m., four hours. At the beginning of the observation R8's door was closed and the lights in the hallway were dim. No staff were observed going into R8's room during the four-hour window. On 2/25/26 at 11:01 a.m., nursing assistant (NA)-B knocked and entered R8's room. R8 gave permission to observe cares. NA-B left the room to get the nurse for some skin issues. -at 11:15 a.m., registered nurse (RN)-E entered the room, performed hand hygiene, put on gloves and opened R8's brief. R8's skin was bright red in groin area (both sides), extending across her abdomen under pannus (hanging, apron-like layer of skin and fat that sags over the lower abdomen and pubic region). The bright red skin extended from one to four inches in groin and pannus areas. Under R8's breasts the skin was bright red with the redness extending two to three inches under breasts. RN-E told R8 the treatment with nystatin was not working and her provider changed the treatment order, RN-E told her it was a vinegar and water mixture and it might sting. -at 11:28 a.m., R8 was rolled to her left side, the brief was soaked yellow from urine and R8 had a moderate amount of formed brown stool, in her brief and stuck to her skin. R8's skin was intact on her buttocks. A new brief was positioned under R8. -at 11:35 a.m., RN-E returned to finish the treatment process. She removed the 4x4's, dried R8's skin, and put on the new skin treatment, she told R8 what she was doing and asked her if it was hurting. R8 periodically would answer yes or wince. -at 11:43 NA-B asked R8 if she had wanted to be woken up earlier, R8 responded with yes, wake me up. During an interview on 2/23/26 at 1:41 p.m., R8 stated she sometimes had to wait two hours to get the call light answered. R8 stated one night she was left wet all night until the next morning. During an interview on 2/24/26 at 10:25 a.m., R8 was dressed for the day and seated in her wheelchair in her room. R8 stated she liked to get up about 9:00 a.m. During an interview on 2/25/26 at 11:00 a.m., nursing assistant (NA)-B stated R8 had last been checked and changed at 6:30 a.m., by the night shift. NA-B stated she was aware R8 liked to be up around 9:00 a.m. and stated it had been too long to go without checking for incontinence. NA-B stated they were down one nursing assistant and were sometimes short. NA-B stated they were taking care of 14 residents by themselves. During an interview on 2/26/26 at 1:18 p.m., RN-A reviewed R8's care plan and stated R8's preference was to be up after 9:00 a.m RN-A verified four hours was too long to go without checking for incontinence and changing a resident's brief. RN-A stated R8 was having moisture related skin concerns, said it might be related to incontinence. RN-A reviewed the note from the provider to keep resident dry related to recurrent urinary tract infections. RN-A stated they had been treating the redness in her groin and under her breasts since October 2025. During an interview on 2/27/26 at 9:40 a.m., RN-A reviewed R8's skin assessments and verified they were being documented as moisture normal and no skin concerns. RN-A verified there were gaps sometimes as long as month with no skin assessment documented as completed. RN-A stated the expectation was skin checks would be completed weekly to monitor skin and keep track of any skin problems. During an interview on 2/27/26 at 10:59 a.m., the acting director of nursing (acting DON) stated it was the expectation the skin checks would be completed weekly on the shower day. The acting DON stated if the resident refused their shower, it was still the expectation the skin checks would be completed. If the resident refused the skin checks the acting DON stated, the expectation would be for the nurse to re-approach and notify the nurse manager of the refusal. The acting DON stated the weekly skin checks were important to look for skin breakdown. The acting DON stated checking and changing was also important to complete as identified in the care plan, again stated the purpose was to prevent skin breakdown. During an interview on 2/27/26 at 1:47 p.m. licensed practical nurse (LPN)-B stated they had finished R8's treatment and noted skin under breasts was pink, in the groin area bright red. LPN-B stated R8's skin looked improved from the previous week. LPN-B stated R8 said it burned a little during the treatment. Skin Integrity dated 5/21/25, identified nursing staff will monitor resident's skin integrity and address issues promptly while providing care and services consistent with professional standards of practice. In addition, the policy identified skin checks would be completed weekly by a licensed nurse and the provider would be notified of any significant changes or a delay in healing. The policy further identified skin issues would be tracked, trended and reported at the Quality Assurance Performance Improvement meetings to determine if corrective action needed to be taken.

Based on observation, interview and document review, the facility failed to ensure food safety practices were followed during meal preparation. This had the potential to affect all residents who ate food prepared in the kitchen. Findings include:On 2/23/26 at 12:00 p.m., raw chicken was observed in a covered plastic container resting in a sink. Dietary Manager (DM)-D stated the chicken was brining in a solution with lemon and garlic.On 2/23/26 at 12:04 p.m., [NAME] C-A stated the chicken had been thawed in the refrigerator and stated the solution was salt, sugar, thyme, lemons, and water. C-A stated it had been brining for about 30 minutes outside of the refrigerator and would be placed on pans and baked in about 10 minutes.On 2/23/26 at 12:09 p.m., C-A checked the temperature of the brine it was 36.5 degrees Fahrenheit. A chicken breast was checked and the temperature was 32.9 degrees Fahrenheit. C-A stated it would have been better to brine the chicken in the cooler or the refrigerator. A review of the recipe for Lemon-Thyme Brined Chicken from Dining Manager dated 2026, identified the following, Add the chicken to a resealable plastic bag or container with lid; then add in the liquid. Seal the bag and refrigerate for 4 hours (no more than 8hours).Perishable Food Management dated 8/29/22, identified the following, All perishable food will be appropriately managed (cooked, cooled and stored) to prevent bacteria from multiplying or forming toxins. In addition, the policy identified the following, Examples of foods that must be kept refrigerated for safety include meat, poultry, fish, dairy products, and all cooked leftovers.

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place for a resident who had chronic pressure ulcers (PU)s requiring ongoing wound care. This failure had the potential to increase the risk of transmission of multidrug-resistant organisms (MDROs) during high contact resident care activities for 1 of 1 resident (R3) reviewed for wound care. In addition, the facility failed to ensure appropriate infection control was completed during personal cares for 1 of 1 resident (R6) whose cares were observed. The facility also failed to provide appropriate hand hygiene, properly follow EBP precautions, and complete cleaning of shared equipment.Findings include: According to the Centers for Disease Control (CDC)'s web page, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, residents with wounds (including chronic wounds such as pressure injuries, diabetic foot ulcers, and venous stasis ulcers) are considered at increased risk for MDRO transmission and should be cared for using EBP during high-contact care activities. The CDC doesn't define chronic wounds by duration, but rather by presence and need for on-going wound care. R3's significant change in status assessment (SCSA) minimum data set (MDS) dated [DATE], identified a decline in cognition and diagnoses of hemiplegia and hemiparesis of the right side, cerebral vascular accident (CVA, a stroke), and severe protein-calorie malnutrition. The MDS identified R3 was at risk for and had actual pressure ulcers including a stage three and an unstageable deep tissue injury. R3 had a functional limit in range of motion of the upper and lower body on one side and was dependent with toilet hygiene, lower body dressing, transfers, and needed maximum assistance with bed mobility. R3's medication administration record (MAR) for the month of February 2026, identified wound care was provided daily to R3's foot and hip. R3's provider orders dated 2/27/26 didn't identify an order for EBP. R3's care plan contained an undated banner message on the first page titled Special Instructions which contained in part the following information, EBP related to wound, with no further details or instructions. The care plan didn't contain a focus statement for impaired skin integrity or wounds. A document, Integrated Wound Care (IWC) dated 12/3/25, identified R3 was evaluated and diagnosed with a stage three pressure ulcer of the right foot fifth interdigital space. The wound measured one centimeter (cm) by one centimeter, with heavy serous drainage, and a wound bed of 50% slough (dead or damaged tissue) and 50% granulation (new, healthy tissue). A second IWC document dated 1/5/26, identified R3 was evaluated and diagnosed with an unstageable deep tissue injury to the right lateral hip measuring two cm by two cm, with moderate serosanguineous drainage, and 100% slough tissue. During an observation on 2/26/26 at 10:47 a.m., registered nurse case manager (RNCM) with hospice and nursing assistant (NA)-D provided wound care to R3 without donning gowns. There wasn't a personal protective equipment (PPE) station in the room, nor was there a sign on R3's door indicating EBP was in place. During an interview on 2/26/26 at 1:32 p.m., the acting director of nursing (DON) stated they would use EBP for a chronic wound, and a chronic would be something present three months or longer or are not healable or resolved. They have discussed R3 and EBP, but they decided they weren't to that threshold yet. A policy, Enhanced Barrier Precautions dated 8/20/24, identified its purpose was to provide guidelines to staff in the application of EBP to safely care for residents colonized or infected with MDROs. EBPs shall be used when providing high contact care to residents who are colonized or are infected with an MDRO when contact or other precautions do not apply. EBP should also be used for residents with chronic wounds and/or indwelling medical devices (e.g., urinary catheters, feeding tubes, central line, tracheostomy). Chronic wounds are defined as pressure ulcer, diabetic foot ulcer, unhealed surgical wound, and venous stasis ulcer. Skin breaks or skin tears are not considered a chronic wound. High-contact resident care activities included wound care, dressing, bathing, showering, changing linen, hygiene care, toileting care. R6: Review of R6's quarterly MDS dated [DATE], identified R6 as moderately cognitively impaired. R6's facesheet included diagnoses of stage 4 pressure ulcer (PU4) left buttock, congestive heart failure (CHF), and venous insufficiency. R6's care plan revised 11/24/25, instructed: R6 required assistance of two when repositioned and when transferred with full sling mechanical lift use Enhanced Barrier Precautions (EBP) monitor dressing to ensure it is intact and adhering and report lose dressing to treatment nurse provide skin care per facility guidelines wound care per treatment order of specialized practitioner for wound management R6's provider orders dated 2/27/26 included: PU (pressure ulcer) to left buttock: as needed for If dressing soiled, came off during cares/shower etc Staff to use foot cradle in bed. Encourage Frequent offloading Q 2hrs (every 2 hours) and up in chair daily for 2 hrs. PU to left buttock: every evening shift related to pressure ulcer of left buttock, stage 4 WC (wound care) to wound bed, 1/4 strength Dakins packing (apply kerlex gauze and pack wound), cover with bordered foam to secure daily and prn (as needed), Encourage frequent offloading every 2 hours and up to chair daily for 2 hours. Pressure Ulcer L-heel every day shift every other day Wound cleaner, collagen sprinkles to wound bed, apply barrier swab to peri wound, and border foam to cover QOD (every other day) and PRN (as needed). Off load pressure. Pressure Ulcer L-heel as needed for as needed Wound cleaner, collagen sprinkles to wound bed, apply barrier swab to peri wound, and border foam to cover QOD (every other day) and PRN (as needed). Off load pressure. R6's Integrated Wound Care (IWC) progress notes dated 2/23/26 identified pressure wounds to left buttock, left heel, and right ankle. It also identified frequent incontinence of bowel and bladder results in difficulty with healing. R6's treatment administration record (TAR) dated 2/27/26, instructed staff to: provide wound care to left buttock PU4 every evening shift, packing the wound and covering with bordered foam to secure daily and as needed if soiled or change off in shower etc. monitor left buttock PU4 daily and create a progress note provide wound care to left heel PU every day shift every other day and as needed During an observation on 2/25/26 at 12:49 p.m., NA-A entered R6's room. R6's door had an EBP sign on the door. NA-A wearing gloves, but no gown, straightened R6's bedding and adjusted a lift sling around R6 as they sat in their wheelchair. Registered nurse (RN)-B with gloves but no gown arrived to assist NA-A with using a mechanical full sling lift to transfer R6 from wheelchair to bed. NA-A and RN-B put on gowns and changed R6's brief. NA-A removed PPE, (did not sanitize hands), adjusted blankets, elevated R6's ankles, moved bedside table, opened blinds, and exited R6's room without hand sanitizing. NA-A left mechanical lift outside R6's door and took the trash to dirty utility room. They unlocked dirty utility room, disposed of trash, and washed hands. NA-A did not return to sanitize the mechanical lift. During an interview on 2/25/26 at 2:28 p.m., NA-A confirmed they had not gowned for transferring R6 from wheelchair to bed, had not hand sanitized after removing gloves before touching R6's personal items, had not sanitized before exiting R6's room, and had not sanitized the mechanical lift after use. They confirmed the EBP sign on R6's door. They stated they should have done these steps for proper infection control. During an observation on 2/26/26 at 9:02 a.m., licensed practical nurse (LPN)-A was in R6's room, in gown and gloves, changing right ankle dressing and left heel dressing. They had completed the right ankle dressing change, changed gloves without hand sanitizing, removed left heel dressing and cleansed the wound, changed gloves without hand sanitizing, put wound cleanse spray in bin, and applied clean dressing to left heel. LPN-A removed PPE, hand sanitized, and left R6's room. LPN-A returned to R6's room with NA-A, both gloved but did not gown, and repositioned R6. During an interview on 2/26/26 at 10:02 a.m., LPN-A confirmed they should have sanitized hands with glove changes during dressing change. They stated hand sanitizing is important for infection control especially between removing the soiled dressing and applying a new dressing. They also confirmed R6 was on EBP and stated the sign on R6's door indicated gowning for transfers and dressing changes, but they were unsure about repositioning. During an interview on 2/26/26 at 2:57 p.m., acting DON stated they expected staff to perform proper hand sanitizing between residents, after cares, when moving from dirty dressing to clean dressing, and when hands were visibly soiled. They stated it was important to protect residents from further infection with EBP, and they expected staff to follow EBP door signs. Staff should wear PPE for transfers, position changes, and close cares. They also expected staff to sanitize shared equipment after each use. A facility provided Enhanced Barrier Protection sign, received 2/26/26, instructed staff to wear gloves and a gown for high-contact resident care activities, including dressing, transferring, changing briefs, and wound care. A facility policy Enhanced Barrier Protection dated 8/20/24, instructed staff to use EBP for high-contact cares including when briefs were changed, when wound care was performed, and when residents were dressed, bathed, and transferred. A facility policy Hand Hygiene revised 1/21/25, instructed staff to perform handwashing or hand sanitizing before and after direct contact with a resident, when moving from a contaminated body site to a clean body site during resident care, before and after contact with environmental surfaces or equipment in the immediate vicinity of the resident, and after removing gloves or gowns. A facility policy Cleaning Disinfecting Resident Care Equipment revised 1/25/22, instructed staff to disinfect mechanical lifts after each use. Staff were to use a disinfectant wipe to clean areas that came in contact with the resident and use a second disinfectant wipe to disinfect these areas.

Based on observation, interview, and record review the facility failed to ensure the proper labeling of medications and the removal of expired medications and supplies occurred in one of one medication rooms and one of two medication carts. In addition, the facility failed to ensure the proper storage of resident medications for 1 of 1 resident (R15) that self-administer medications. These deficient practices had the potential to impact all residents who received supplies and medications from reviewed medication rooms and carts.Findings include:During a review of Medication cart A on 2/24/26 at 3:20 p.m., with registered nurse (RN)-C. RN-C confirmed the following findings: Drawer one contained an undated insulin glargine pen for resident (R1). RN-C stated medications like insulin need to be dated when removed from the refrigerator because the expiration date of the medication changed when it moved to room air and most insulins expired after 30 days. RN-C stated R1's insulin pen was unused, but they were unsure when it was removed from the refrigerator because it was not dated. RN-C returned R1's undated insulin pen to the medication cart. Four inhalers in drawer one were reviewed. RN-C confirmed three inhalers were in use but had not been dated when opened and indicated inhalers should be dated when opened.During a review of the medication room on 2/26/26 at 12:12 p.m., with RN-A. RN-A confirmed the following findings: Lower cabinet one, below the sink, contained four boxes of Nestle arginine powder (nutritional protein supplement for human consumption), personal unlabeled electric shavers, four bottles of Clippercide, and cleaning supplies including bleach. RN-A confirmed 3 boxes of the arginine powder expired on 12/15/25 and stated they needed to dispose of the boxes. RN-A indicated they were not sure what the guideline was for storing food products and chemical products together. Lower cabinet two moving left to right contained an intravenous emergency kit (IV E-kit) labeled first drug expired 8/31/23. The IV E-kit included a normal saline IV bag which expired 9/20/23, a dextrose with half normal saline IV bag which expired 8/2023, three heparin syringes which expired 11/30/23, and a Continu-Flo solution set with regulator which expired 7/4/25. RN-A confirmed the expired items in the kit and stated the items needed to be discarded. During an observation and interview on 2/26/26 at 10:02 a.m., licensed practical nurse (LPN)-A unlocked and opened medication cart A and removed R1's insulin glargine pen. LPN-A confirmed R1's insulin pen was undated and indicated that the pen had been partially used. LPN-A removed the insulin pen from the drawer and stated they would get a new pen since they do not know when it was opened.During an interview on 2/26/26 at 1:38 p.m., the acting director of nursing (DON) stated insulin pens should be dated when removed from the refrigerator and if a nurse found a pen that was not dated, they expected the nurse would review the policy and do a calculation for administration. Dating the insulin pen was important because insulin was only good for so long. They stated they did not believe the Nestle Arginine drink mix was normally stored under the sink in the medication room and confirmed concerns about cleaning chemicals and consumables being stored together under the sink. The acting DON stated the facility checked for expired medication and supplies weekly on the night shift. They did not feel staff would use expired supplies but indicated the expired iv kit items and protein supplements would need to be disposed of.A facility conducted inventory of their intravenous emergency kit (IV E-kit) on 2/26/26 found the following items were expired: 4 normal saline (NS) 1-liter (L) intravenous (IV) bags expired 9/2023, 2 half NS L IV bags expired 8/2023, 2 dextrose with half NS L IV bags expired 8/2023, 2 dextrose with half NS and potassium IV bags expired 9/2023, 2 dextrose L IV bags expired 9/2023, 3 heparin pre-filled syringes expired 11/2023, 3 IV start kits expired 5/2024, 3 central line dressing change kits expired 1/2024, 4 22-gauge IV catheters expired 10/1/23, 4 24-gauge IV catheters expired 2/2024, and 3 adapter caps expired 9/2025.The facility provided manufacturer document Insulin Glargine - Insulin Glargine Injection Solution dated 3/3/25, the section Instructions for Use directed pens should be thrown away after 28 days if they are stored at room temperature.The facility provided Thrifty [NAME] Pharmacy Services document Insulin Administration - Pen dated 1/2018, directed to document the date open on the pen when it was obtained from the refrigerator.The facility policy Medication, Treatment, and Medical Supplies Storage dated 7/27/16, directed nursing staff to check expiration date prior to utilizing medications, treatment supplies, or medical supplies, and to conduct weekly audits of the medication storage room and medication carts for expired medications, treatment supplies, or medical supplies. Any found to be expired will be disposed of or destroyed, depending on the type of medication, treatment supply, or medical supply.A facility policy on insulin administration and insulin pens was requested but not received.R15:R15's annual Minimum Data Set (MDS) dated [DATE], indicated R15 was cognitively intact.R15's facesheet dated 2/27/26, included diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, congestive heart failure, and obstructive sleep apnea.R15's care plan last revised 11/24/25, in special instructions, identified self-administration of medication (SAM) of nebulizer treatments after set-up.R15 current provider orders dated 2/27/26, included:Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 3 ml inhale orally every 4 hours as needed for SOB- Spasm of Lung Air Passages Ok to self-administer after set upBudesonide Inhalation Suspension 0.5 MG/2ML (Budesonlde (Inhalation)) 2 ml inhale orally two times a day for Chronic Obstructive Lung Disease Rinse mouth after each use May self-administer after set upIpratroplum-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratroplum-Albuterol) 3 ml inhale orally four times a day for Chronic Obstructive Lung Disease May self-administer after set upNo evidence of orders for Magnesium Citrate 200 mg, Pure ZZZs Melatonin, or Centrum Men's Multivitamin.R15's medication administration record (MAR) dated 2/27/26, instructed that R15 may self-administer the following medications after set-up by the nurse:Budesonide Inhalation Suspension 2 ml inhaled orally two times a day.Albuterol Sulfate Inhalation Nebulization Solution 3 ml inhaled orally every 4 hours as needed.Ipratropium-Albuterol Inhalation Solution 3 ml inhaled orally four times a day.R15's SAM assessment dated [DATE], reported R15 was approved for self-administration of medications, including inhalants and oral medications, and was safe to leave medications at bedside after set-up, but was not capable of storing medications in a secure location and required assistance opening and closing medication containers. During an observation on 2/23/26 at 12:33 p.m., R15 was sitting in a wheelchair in their room completing a nebulizer treatment. There were three supplement bottles in a basket to the right of R15's recliner. Three unopened nebulizer ampules were on the bedside table in front of them. R15 stated they did their own nebulizer treatments.During an observation on 2/24/26 at 11:17 a.m., R15 was sitting in a wheelchair in their room. One unopened nebulizer ampule was on the bedside table in front of them. Three supplement bottles noted in a basket to the right on R15's recliner.During an observation on 2/25/26 at 1:24 p.m., R15 was sitting in a wheelchair in their room. One unopened nebulizer ampule was on the bedside table in front of them. Three supplement bottles noted in a basket to the right on R15's recliner.During an observation on 2/26/26 at 9:53 a.m., R15 was sitting in a wheelchair in their room. One unopened nebulizer ampule was on the bedside table in front of them. Three supplement bottles noted in a basket to the right on R15's recliner. R15 stated they no longer take these vitamins.During an interview on 2/25/26 at 1:55 p.m., RN-B stated medications and nebulizers can be kept at bedside if it is ordered. They stated R15 could self-administer nebulizer treatments after set-up by nurses.During an interview on 2/25/26 at 2:05 p.m., acting DON stated with SAM orders directing staff to set-up nebulizer treatments, staff would fill the nebulizer medication cup and return after treatment was completed to clean it. They stated for a resident to have medications at bedside, a SAM assessment needed to be completed. R15 had a SAM assessment previously which allowed them to set up their own nebulizer and have a small supply at bedside.During an interview on 2/26/26 at 2:44 p.m., RN-A stated for a resident to have medications in their room, a SAM assessment needed to be completed. They confirmed the importance of making sure the medications are secured so someone else cannot get them.During an interview on 2/26/26 at 2:57 p.m., the acting DON stated when a resident brought medications, nurses secured them until a SAM assessment was completed. They confirmed medications in a resident room required orders and needed to be secured. The acting DON stated they would not want vitamin bottles stored in R15's room and they were concerned that other residents could get an unsecured medication.During an interview on 2/26/26 at 4:22 p.m., the acting DON confirmed three bottles of gummy vitamins were in R15's room and R15 was not taking them. An inventory was completed with acting DON on the vitamins they removed from R15's room: Magnesium Citrate 200 mg gummies which expired 2/2025, Pure ZZZs Melatonin gummies which expired 6/2025, and Centrum Men's Multivitamin gummies which expired 7/2024.The facility policy Self-Administration of Medication by Residents dated 2/27/24, directed nursing staff to conduct a SAM assessment if a resident wanted to take their own medication. This assessment determined which medications were appropriate to self-administer, where to store the medications, and what assistance the resident needed to actively participate in the administration of their medications.

Based on observation, interview, and record review, the facility failed to ensure ongoing skin inspections, wound assessments, and timely repositioning were performed for a resident with pressure ulcers for 1 of 2 residents (R3) reviewed for pressure ulcer care. These failures resulted in the development of facility-acquired pressure ulcers and placed the resident at risk for worsening skin breakdown and infection.Findings include:R3's significant change in status assessment (SCSA) minimum data set (MDS) dated [DATE], identified a decline in cognition and diagnoses of hemiplegia and hemiparesis of the right side related to a cerebral vascular accident (CVA, a stroke), severe protein-calorie malnutrition, a stage three pressure ulcer, and an unstageable deep tissue wound. R3 had functional limit in range of motion of the upper and lower body on one side and was dependent for toilet hygiene, lower body dressing, and transfers. R3 needed maximal assist with bed mobility. R3 was admitted to hospice on 1/30/26.Review of R3's care plan revealed a focus statement for activities of daily living (ADL)s dated 2/20/26, which instructed staff to turn and reposition R3 every two hours and as needed. R3 preferred not to be woken at night. The care plan included a focus statement for limited mobility related to CVA dated 2/20/26, which instructed staff to report skin breakdown. However, the care plan didn't have a focus statement for being at risk for or having actual skin breakdown or interventions to monitor and assess the wounds. Review of R3's electronic medical record (EMR) identified the following timeline:9/15/25, admission to facility9/18/25, a Skin and Wound Assessment identified no skin concerns.From 9/19/25 to 11/7/25, R3's EMR didn't contain evidence of skin checks or assessments.11/8/25, a Skin and Wound Assessment identified no skin concerns.11/12/25, a Skin and Wound Assessment identified a new wound with no detail provided.From 11/13 to 11/25/25, R3's EMR didn't contain evidence of skin checks or assessments.11/14/25, a provider order for clotrimazole (a topical antifungal medication used to treat fungal infections) cream to right foot fourth and fifth digit three times per day for two weeks. Ensure you wash and dry area completely before applying clotrimazole.11/26/25 at 5:39 a.m., a progress note: skin warm and dry, skin color within normal limits, and turgor is normal.11/26/25 at 3 p.m., a provider order for skin charting one time a day every Wednesday using assessment, N Adv Skin Check.11/26/25, a N Adv Skin Check identified a wound issue with no detail provided.11/26/25 at 3:53 p.m., a progress note: resident has been refusing clotrimazole (a topical antifungal medication used to treat fungal infections) to right foot according to staff. During cares today, resident had redness, swelling, and foul smell. On-call provider updated and sent a request for oral antibiotics. Will await response.11/26/25 at 5:23 p.m., a progress note: provider responded no oral antibiotic at this time. Provider to see him on next rounds and provided an order to soak foot and dry well once daily and will send a new order for spray clotrimazole to foot for seven days.11/26/25, a provider order to soak right foot in warm soapy water daily. Ensure that foot is dried thoroughly before redressing. Apply clotrimazole aerosol spray between toes on both feet topically two times a day for infection.11/27/25 3:03 a.m., a progress note: athlete's foot to bilateral feet in between toes being treated with clotrimazole aerosol spray two times per day. Foot soaks with Epsom salts at bedtime prior to clotrimazole application.11/27/25 at 9:41 p.m., a progress note: writer inspected resident's toe today and it appeared infected. It had an open area approximately three-quarters of a centimeter (cm) long by one cm wide. The area appeared red and had a yellowish pus coming out of it. Writer cleaned and dressed it per house standing orders. SBAR (a type of communication) placed in rounding book to update provider.12/1/25, a provider visit summary identified resident complained of pain over the right fifth toe due to the ulcer.12/1/25, a provider order for doxycycline 100 mg give one tablet two times a day for infection of the toe for 7 days until finished for 14 doses.12/2/25, a visit summary from Integrated Wound Care (IWC) identified R3 was evaluated and diagnosed with a stage three pressure ulcer of the right foot fifth interdigital space. The wound measured 1 centimeter (cm) by 1 centimeter, with heavy serous drainage, and a wound bed of 50% slough (dead or damaged tissue) and 50% granulation (new, healthy tissue).From 11/28/25 to 12/9/25, R3's EMR didn't contain evidence of skin checks or wound assessments performed by facility.12/10/25, EMR wound portal entry: new, in-house acquired stage three pressure ulcer at the right fourth interdigital toe space, full-thickness tissue loss measuring 1 cm by 1 cm.12/16/26, N Adv Skin Check with issue noted, didn't provide detail and directed reader to see wound portal.From 12/17/25 to 12/29/25, R3's EMR didn't contain evidence of skin checks or assessments by facility or by IWC.12/29/25, a visit summary from IWC for toe wound.1/5/26, a visit summary from IWC identified R3 was evaluated and diagnosed with a pressure ulcer of the right hip, unstageable, and measured two cm by two cm, with moderate serosanguineous drainage, and 100% slough tissue.1/7/26, EMR wound portal entry: new, in-house acquired unstageable pressure ulcer on the right lateral hip measuring 1.93 cm by 2.32 cm.1/12/26, a visit summary from IWC identified right hip wound was 100% slough and too painful to debride. IWC provided education regarding the need for repositioning.1/12/26, EMR wound portal, a facility assessment for the hip and toe.From 1/13 to 1/23/26, R3's EMR didn't contain evidence of a wound assessment.1/13/26, provider orders for right foot fifth digit: every evening shift for wound, cleanse with wound cleanser. Apply stock antibiotic ointment, cut a piece of calcium alginate with silver to fit wound bed, cover with bordered gauze daily and as needed.1/14/26, provider orders for skin charting every evening shift on Tuesdays for shower day. Go to assessments and start form N ADV Skin Check.1/23/26, EMR wound portal, a facility assessment for the hip and toe.1/26/26 a visit summary from IWC identified sharp debridement was performed on the right hip to remove slough.From 1/27 to 2/9/26, R3's EMR didn't contain evidence of a wound assessment.2/6/26, a provider order for lying and sitting tissue tolerance to be discontinued when completed. Evidence of tissue tolerance testing wasn't located in R3's EMR.2/9/26, IWC visit2/17/26, a provider order for pressure injury right lateral hip, wash with normal saline, apply Vaseline and bordered foam, change daily and as needed. 2/17/26, a provider order for pressure injury right lateral hip, clean with wound cleanser, apply Vaseline and bordered foam, change daily and as needed.During a continuous observation on 2/25/26 from 10:02 a.m. to 12:12 p.m., R3 was observed in the main dining room. At 10:02 a.m., R3 was asleep, leaning to the right in a Broda chair, with his right shoulder and knee lower than the left. There was a tray table in front and slightly to the right of R3, with three bowls and two cups with straws in them. At 10:42 a.m., RN-A straightened up R3's blankets and adjusted his baseball cap. At 10:48 a.m., the dietary manager (DM)-D came to his table and removed the bowls and left the cups. At 11:25 a.m., R3 has gotten a new tray of food placed on his table at his right side, he is using his left hand to feed himself. At 11:31 a.m., DM-D came by and straightened the table closer to his center and then arranged the bowls of food. At 11:45 a.m., NA in blue pants and green top came by and asked R3 if he was struggling and proceeded to hold the ice cream cup for him to take a couple bites. NA then walked away and set the ice cream cup on R3's tray on the opposite side he was eating from. At 12:12 p.m., nursing assistant (NA)-A wheels R3 from the dining room to his room. R3 was heard telling NA-A he wasn't ready to lay down yet, to which NA-A responded for him just to let her know when he was ready. R3 remained in the Broda chair leaning to his right, with his left foot off the footrest. During an interview on 2/25/26 at 2:02 p.m., NA-A stated R3 was in her group today and she thought he needed to be repositioned every two hours she knew he should've been repositioned sooner than this, but when she did bring R3 to his room, he didn't want to lay down but she said she should have repositioned him a little bit in his chair if he wanted to stay in the chair. NA-A stated it was important to reposition R3 so he didn't get any sores on his bottom, and he already had one on his side. During an interview on 2/27/26 at 10:37 a.m., the acting director of nursing (DON) stated her expectation was for skin and wounds to be checked at a minimum of weekly with documentation about how a wound looked, its characteristics, dressing appearance, odor or signs of infection. For R3, hospice did wound care on their visits and documented in their own charting system. The DON explained R3 had wound rounds with a contracted wound nurse practitioner along with a facility nurse manager. The wound nurse documented the wound measurements. The DON stated the risk of not doing so would be something didn't get noticed or treated in time and could get worse. At 12:46 p.m., the DON stated her expectation would be for R3 to be repositioned every two hours. During an interview on 2/27/26 at 11:18 a.m., primary care provider (PCP)-C stated he saw R3 on 12/1/25, and R3 had complained of pain in his toes on the right. The PCP stated he was concerned for infection in the toes and started doxycycline. The PCP would expect skin to be looked at every week, and stated the facility had a wound nurse who came to see the patients and she was very good, he was more comfortable with this. A policy, Skin Integrity dated 5/21/25, identified its purpose was to provide guidance to nursing staff on identifying, evaluating, monitoring, and preventing resident skin integrity issues. The care center will assess each resident's risk for skin integrity issues at move in, quarterly, with any significant change in condition, and with a new or potential pressure ulcer and will identify interventions to help prevent skin integrity issues.A licensed nurse will:a. Assess the area and identify the cause, if possible.b. Remove any source of pressure or trauma to the area.c. Clean the area and provide treatment per care center House Standing Orders.d. Determine if the skin integrity issue is reportable to the State Agency (SA). If yes,notify the Administrator and Director of Nursing and proceed with the SA reportingprocess. (CCEP.MP.SNF.005 Maltreatment Investigation & Reporting)e. Complete a Skin Incident report in the resident EHR.f. Notify resident and/or responsible party.g. Notify Provider and request treatment orders, if applicable.h. Notify the Nurse Manager, Wound Nurse, or designee.i. Initiate a new tissue tolerance for any newly opened area or redness.j. Initiate appropriate preventive measures based on the immediate root cause.C. Images of wound(s) will be taken utilizing approved equipment for medicaldocumentation, treatment planning, and monitoring progress.EvaluationA. Nurse Manager, Wound Nurse, or designee will assess and complete a root causeanalysis.B. Interdisciplinary Team (IDT) will review the skin incident report and evaluation of rootcause for further recommendations.C. The provider will review, to diagnosis, if root cause was not related to an injury (i.e., skintear, bruise), make recommendations, and/or initiate order(s). MonitoringA. A licensed nurse will complete the skin check weekly and document it in the EHR.B. Nurse Manager, Wound Nurse, or designee will assess all applicable wounds weeklyincluding pressure ulcers, venous ulcers, arterial ulcers, diabetic ulcers, MASD, and otherwounds of concern.a. Documentation will be completed in the resident electronic health record and willinclude describing the following characteristics:i. Locationii. Stage if pressure ulceriii. Measurements, including depth, undermining or tunneling/sinus tract.iv. Exudatev. Painvi. Wound bedvii. Wound edges and surrounding tissueviii. Signs and symptoms of infectionix. Progress towards healingx. Current interventions, including treatment, and any changes made to plan ofcare.b. The provider will be notified of any significant changes and/or a delay in healing.

Based on interview and record review, the facility failed to ensure accuracy of the minimum data set (MDS) was coded accurately for 3 of 14 residents (R3, R12, R15) reviewed for MDS accuracy. Findings include: R3: R3's significant change in status assessment (SCSA) minimum data set (MDS) dated [DATE], identified a decline in cognition and diagnoses of hemiplegia and hemiparesis of the right side, cerebral vascular accident (CVA, a stroke), severe protein-calorie malnutrition. The MDS identified R3 was at risk for and had actual PUs including a stage three and an unstageable deep tissue injury, both were identified as present on admission. R3's quarterly MDS dated [DATE], identified R3 was at risk for and had an actual stage three pressure ulcer (PU) that was not present on admission. R3's admission MDS dated [DATE], identified R3 was not at risk for and didn't have any actual PUs. Further, the MDS identified a formal assessment tool (i.e., Braden Scale) was not performed. R3's care area assessment (CAA) dated 9/22/25, identified the pressure ulcer care area and care planning decision were triggered. R3's care plan didn't contain a focus statement for at-risk or actual skin impairment. On 9/19/25, R3's care plan had a focus statement for activities of daily living (ADL) self-care performance deficit related to CVA with an intervention for staff assist of one to turn and reposition every two hours and as needed and preferred not to be woken at night. A Braden Scale for Predicting Pressure Sore Risk performed on 9/19/25, identified R3's score was 17, which correlated to an at-risk category. The wound portal in R3's electronic medical record (EMR) identified a new in-house acquired stage three pressure ulcer at the right dorsum, fourth interdigital space on 12/10/25. A new in-house acquired unstageable pressure injury to the front right trochanter (hip) on 1/7/26. During an interview on 2/26/26 at 3:57 p.m., registered nurse (RN)-D stated they were the MDS nurse, and she would say the information in section M of the 2/6/26 MDS was an error. RN-D stated the error would affect reimbursement. R12: R12's significant change MDS dated [DATE], identified R12 had diagnoses which included malignant neoplasm of right renal pelvis, hypothyroidism, dementia, and hypertension. In addition, R12's MDS identified they were severely cognitively impaired. Section N Medications: High-Risk Drug Classes: Use and Indication Antipsychotic: is taking, this was marked as yes. The section Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? This was marked as not necessary, marked as not on an antipsychotic. R12's current order summary identified the following: Observe closely for side effects of antipsychotic medication dated 10/27/25. Olanzapine (an atypical antipsychotic medication) 15 milligrams (mg) dated 1/13/26 R12's care area assessment dated [DATE], identified the following: Section N-Medications N0415, identified R12 was taking an antipsychotic Section N- Medications N0450, identified R12 was receiving antipsychotics on a routine basis only. It was marked as no a gradual dose reduction had not been attempted. During an interview on 2/25/26 at 1:31 p.m., registered nurse (RN)-D reviewed the MDS dated [DATE], and verified it contained contradictory information. RN-D stated it was a glitch and the MDS would need to be modified. RN-D verified it was important to ensure accuracy for pharmacy review to ensure the need for the medication and to monitor if it was working. R15: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2025, identified Section O0110G3: Non-invasive Mechanical Ventilator – CPAP, code any type of CPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously throughout the breathing cycle. R15's annual Minimum Data Set (MDS) dated [DATE], indicated R15 was cognitively intact. Section O: Special Treatments, Procedures, and Programs, question O0110G3 identified R15 had not received CPAP in the last 14 days. R15's facesheet included diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, congestive heart failure, and obstructive sleep apnea. R15's care plan revised 11/24/25, included CPAP settings. R15's current provider orders dated 2/27/26, included: CPAP: staff to set up at HS (bedtime) and when in bed for naps. every shift Startup CPAP as machine is preprogrammed and will adjust to inhalation pressure needs R15's treatment administration record (TAR) for the months of 12/2025, 1/2026, and 2/2026 instructed staff to set up the CPAP nightly and as needed for naps. Staff documented daily use of CPAP for the 3 months reviewed. During an interview on 2/23/26 at 12:33 p.m., R15 stated they used their CPAP every night. During an interview on 2/27/26 at 11:03 a.m., RN-D reviewed the MDS dated [DATE], and confirmed it did not contain coding for R15's use of CPAP. They stated it should be coded if the resident is using it. After reviewing R15's record, RN-D confirmed that the CPAP should have been coded on the MDS. A facility policy MDS 3.0 Completion dated 8/20/24, instructed that all MDS item sections were to be reviewed to develop an interdisciplinary care plan. The MDS Coordinator was responsible for conducting audits to identify errors to ensure accuracy of information, and they needed to sign and date the assessment upon completion.

Based on interview and document review, the facility failed to ensure an OBRA Level II evaluation was completed as identified on the pre-admission screening to ensure mental health needs were appropriately addressed or provided for 1 of 1 resident (R8) reviewed for preadmission screening and resident review (PASRR).Findings include:R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 had diagnoses which included vascular dementia, depression, bipolar disorder, and post-traumatic stress disorder (PTSD). In addition, R8 was cognitively intact and required substantial to maximum assistance with activities of daily living.R8's corrected preadmission screening dated 10/14/25, identified they required an OBRA Level II screening for mental illness. The question, Is an OBRA Level II referral needed and is the person currently seeking admission to a nursing facility? The question was answered as yes.During an interview on 2/24/26 at 10:44 a.m., social service designee (SSD)-A stated R8 came from a different facility. SSD-A stated she was not sure if an OBRA Level II was completed and would check. The facility was not able to provide evidence this was completed prior to admission, nor was there evidence this was completed after admission to the facility.During an interview on 2/27/26 at 11:01 a.m., the acting director of nursing (ADON) stated they were not familiar with the OBRA Level II process and would defer this to the SSD.Pre-admission Screening & Resident Review (PASRR) dated 6/25/24, identified the following, If a mental illness or development disability is identified, an additional screening, referred to as a PASRR Level II screening is required.

Based on interview and record review, the facility failed to update the plan of care to reflect changes in resident's needs related to the risk of, and actual, skin impairment, to reflect interventions after a fall, to reflect current elopement risk and interventions, to individualize pain management, and to accurately reflect the resident's current mobility status for 1 of 13 residents (R3) reviewed for care planning timing and revision.Findings include:R3's significant change in status assessment (SCSA) minimum data set (MDS) dated [DATE], was performed following a hospice admission on [DATE], and identified a decline in cognition and diagnoses of hemiplegia and hemiparesis of the right side, cerebral vascular accident (CVA, a stroke), severe protein-calorie malnutrition, a stage three pressure ulcer, and an unstageable deep tissue wound. R3 had a functional limit in range of motion upper and lower body on one side and was dependent with toilet hygiene, lower body dressing, and transfers. R3 needed maximal assistance with bed mobility and set-up assistance to wheel themselves in a wheelchair for 50 and 150 feet. The MDS also reflected R3 had a wander or elopement alarm used daily.R3's care plan identified:-a revision on 2/20/26, identified a focus statement for risk for falls with interventions dated 9/19/25 to assist resident with ambulation and transfers utilizing therapy recommendations, to determine resident's ability to transfer, and if resident is a fall risk, initiate fall precautions.-a revision on 2/20/26, a focus statement for limited physical mobility related to stroke with interventions dated 9/18 and 9/19/25, to utilize foot pedals on the right side of the wheelchair only to and from destinations; resident able to propel the wheelchair with his left foot, to work on ambulation with therapy only at this time, assist with propelling wheelchair as needed, and to monitor, document, and report any signs or symptoms of immobility, contractures, thrombus formation, skin breakdown or fall-related injury.-a revision on 2/20/26, a focus statement for at risk for falls related to gait and balance problems with interventions dated 9/15/25 to ensure call light in reach and encouragement to use the call light, to educate resident, family and caregivers about safety reminders and what to do if a fall occurs, to encourage resident to participate in activities that promote exercise, physical activity for strengthening and mobility improvement, to ass fall risk quarterly and with changes in condition, to provide resident with easy access to a urinal, provide verbal cues and reminders as needed, and for physical therapy as ordered or as needed. On 11/14/25, the interventions were updated to include ensuring resident had a large, covered mug with fresh water in room in the morning, bedtime, and as needed. On 1/14/26, an intervention to offer to get R3 up for the day at around 7:30 a.m. The care plan didn't contain an intervention for the fall of 2/22/26.-a revision on 2/20/26, a focus statement for acute and chronic pain with interventions dated 11/8/25 to determine resident's satisfactory pain level, to evaluate mood and behavior, and to monitor for factors or activities that precipitate or aggravate pain.-R3's care plan didn't contain a focus statement, goals or interventions for wandering, elopement and the use of an elopement alarm.-R3's care plan didn't contain a focus statement, goals or interventions for actual skin impairment.An elopement assessment dated [DATE], identified R3 wasn't physically immobile, did display wandering and hovering around exits, and made statements of wanting to go home. A wander guard was placed on 9/15/25.An elopement assessment dated [DATE], identified R3 didn't have a wander guard in place as resident was unable to propel himself in his wheelchair and was not at risk for elopement at this time.R3's electronic medical record (EMR) identified post-fall evaluations on 11/8/25, 1/3/26, and 2/22/26.During an observation on 2/23/26 at 2:20 p.m., R3 had a non-removable white bracelet on the left wrist.During an observation on 2/26/26 at 10:47 a.m., nursing assistant (NA)-B confirmed the device on R3's left wrist was a wander guard.During an interview on 2/27/26 at 12:46 p.m., the director of nursing (DON) stated her expectation would be for the care plan to reflect R3's needs.A policy, Person Centered Care Planning dated 4/20/23, identified the facility will develop a comprehensive person-centered care plan with the resident and/or family representative for each resident in our care center, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment. The plan of care will describe the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment, and any alternative means to address the need.c. Management of risk factors and prevent avoidable declines in functioning.The resident's care plan is reviewed every 90 days or more frequently if necessary, with a significant change. Care plans are updated on an ongoing basis as needed based on changes that occur between care conferences.

Based observation, interview and document review the facility failed to provide timely assistance with checking and changing for 1 of 1 resident (R8) reviewed for activities of daily living and who were dependent on staff for assistance.Finding include:R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 had diagnoses which included vascular dementia, depression, bipolar disorder, chronic pain, history of urinary tract infections, and post-traumatic stress disorder (PTSD). In addition, R8 was cognitively intact and required substantial to maximum assistance with activities of daily living and was always incontinent of bowel and bladder.A review of R8's current order summary report included the following orders:One half vinegar one half water solution soak two times a day, soak right abdominal groin folds and under both breasts for 10 minutes with solution, pat dry, apply zinc cream, dated 2/26/26.Skin charting one time a day every Saturday complete weekly per schedule, dated 11/22/25.Myrbetriq (medication used to treat overactive bladder) oral tablet extended release 24 hour 60 milligrams (mg) one time a day related to stress incontinence, dated 10/11/25.R8's history order summary report included the following orders:Nystatin external powder 100000 unit per gram (GM) apply to affected areas tropically as needed for two times a day apply to abdominal folds, groin, under breasts, dated 10/10/25.Monitor and document signs and symptoms of urinary tract infection and vitals every shift, document in progress notes, started on 1/26/25.R8's care plan dated 10/10/25, identified R8 had an activity of daily living deficit related to activity intolerance, impaired balance. Interventions included a toileting schedule every two to three hours and per their request. The care plan identified frequently incontinent of bowel and bladder. In addition, bowel incontinence related to immobility. Interventions included to check every two hours and assist with toileting as needed.R8's care plan dated 10/10/25, identified R8 was at risk for insomnia. Interventions included to maintain a consistent schedule with daily routine.R8's care plan dated 1/7/26, identified R8's personal care preferences. Interventions included, I prefer to be woken around and be out of bed after 9:00 a.m. Do not wake me up before 9:00 a.m.A review of R8's weekly skin assessments revealed the following:2/21/26, moisture documented as normal, noted No, there are no skin concerns.1/24/26, (about a month earlier) moisture documented as normal, noted No, there are no skin concerns.1/21/26, moisture documented as normal, noted No, there are no skin concerns.1/6/26, (about two weeks earlier) documented as other quarterly MDS.Skin group page 18 documented as No skin issues further pages identified perineum, right breast, left breast, rash all documented as resolved.12/10/25, (about 4 weeks earlier) moisture documented as normal, noted No, there are no skin concerns.12/2/25, moisture documented as normal, noted No, there are no skin concerns.11/29/25, moisture documented as normal, noted No, there are no skin concerns.10/14/25, (about 6 weeks earlier) moisture documented as normal10/10/25, admission skin assessment, left and right breast, perineum rash, present on admission, chronic greater than 3 months.A review of R8's progress notes revealed the following:2/24/26, 3:32 p.m., Writer asked to assess resident skin under breasts and abd (abdominal)/groin folds. Skin condition not improving with current treatment of Nystatin powder. Writer called Dr. XXXXX and received new order as follows: Soak right abdominal/groin folds and under both breasts for 10 minutes with 1/2 vinegar 1/2 water solution. Pat dry. Apply Zinc cream. Twice daily. Writer also discussed adding resident to list for wound care NP to see.2/10/26, 10:47 a.m., New orders from MD Please keep pt (patient) dry r/t (related to) recurrent UTIs (urinary tract infections).A continuous observation started on 2/25/26 at 7:05 a.m. and ended at 11:01 a.m., four hours. At the beginning of the observation R8's door was closed and the lights in the hallway were dim. No staff were observed going into R8's room during the four-hour window.On 2/25/26 at 11:01 a.m., nursing assistant (NA)-B knocked and entered R8's room. R8 gave permission to observe cares. NA-B left the room to get the nurse for some skin issues.-at 11:15 a.m., registered nurse (RN)-E entered the room, performed hand hygiene, put on gloves and opened R8's brief. R8's skin was bright red in groin area (both sides), extending across her abdomen under pannus (hanging, apron-like layer of skin and fat that sags over the lower abdomen and pubic region). The bright red skin extended from one to four inches in groin and pannus areas. Under R8's breasts the skin was bright red with the redness extending two to three inches under breasts. RN-E told R8 the treatment with nystatin was not working and her provider changed the treatment order, RN-E told her it was a vinegar and water mixture and it might sting.-at 11:28 a.m., R8 was rolled to her left side, the brief was soaked yellow from urine and R8 had a moderate amount of formed brown stool in her brief and stuck to her skin. R8's skin was intact on her buttocks. A new brief was positioned under R8.-at 11:35 a.m., RN-E returned to finish the treatment process. She removed the 4x4's, dried R8's skin, and put on the new skin treatment, she told R8 what she was doing and asked her if it was hurting. R8 periodically would answer yes or wince.-at 11:43 NA-B asked R8 if she had wanted to be woken up earlier, R8 responded with yes, wake me up.During an interview on 2/23/26 at 1:41 p.m., R8 stated she sometimes had to wait two hours to get the call light answered. R8 stated one night she was left wet all night until the next morning.During an interview on 2/24/26 at 10:25 a.m., R8 was dressed for the day and seated in her wheelchair in her room. R8 stated she liked to get up about 9:00 a.m.During an interview on 2/25/26 at 11:00 a.m., nursing assistant (NA)-B stated R8 had last been checked and changed at 6:30 a.m., by the night shift. NA-B stated she was aware R8 liked to be up around 9:00 a.m. and stated it had been too long to go without checking for incontinence. NA-B stated they were down one nursing assistant and were sometimes short. NA-B stated they were taking care of 14 residents by themselves.During an interview on 2/26/26 at 1:18 p.m., RN-A reviewed R8's care plan and stated R8's preference was to be up after 9:00 a.m. RN-A verified four hours was too long to go without checking for incontinence and changing a resident's brief. RN-A stated R8 was having moisture related skin concerns, said it might be related to incontinence. RN-A reviewed the note from the provider to keep resident dry related to recurrent urinary tract infections. RN-A stated they had been treating the redness in her groin and under her breasts since October 2025.During an interview on 2/27/26 at 9:40 a.m., RN-A reviewed R8's skin assessments and verified they were being documented as moisture normal and no skin concerns. RN-A verified there were gaps sometimes as long as month with no skin assessment documented as completed. RN-A stated the expectation was skin checks would be completed weekly to monitor skin and keep track of any skin problems.During an interview on 2/27/26 at 10:59 a.m., the acting director of nursing (acting DON) stated it was the expectation the skin checks would be completed weekly on the shower day. The acting DON stated if the resident refused their shower, it was still the expectation the skin checks would be completed. If the resident refused the skin checks, the expectation would be for the nurse to re-approach and notify the nurse manager of the refusal. Weekly skin checks were important to look for skin breakdown. The acting DON stated checking and changing was also important to complete as identified in the care plan, again stated the purpose was to prevent skin breakdown.During an interview on 2/27/26 at 1:47 p.m. licensed practical nurse (LPN)-B stated they had finished R8's treatment and noted skin under breasts was pink, in the groin area bright red. LPN-B stated R8's skin looked improved from the previous week. LPN-B stated R8 said it burned a little during the treatment.Skin Integrity dated 5/21/25, identified nursing staff will monitor resident's skin integrity and address issues promptly while providing care and services consistent with professional standards of practice. In addition, the policy identified skin checks would be completed weekly by a licensed nurse and the provider would be notified of any significant changes or a delay in healing. The policy further identified skin issues would be tracked, trended and reported at the Quality Assurance Performance Improvement meetings to determine if corrective action needed to be taken.

Based on observation, interview and document review, the facility failed to ensure a wound bed was protected in a resident at risk for cross contamination due to incontinence for 1 of 1 resident (R6) whose cares were observed.Findings include:Review of R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 as moderately cognitively impaired.R6's face sheet, undated, included diagnoses of stage 4 pressure ulcer left buttock, congestive heart failure (CHF), and venous insufficiency.R6's care plan revised 11/24/25, instructed the following:R6 required assistance of two when repositioned and when transferred with full sling mechanical liftuse Enhanced Barrier Precautionsmonitor dressing to ensure it is intact and adhering and report lose dressing to treatment nurseprovide skin care per facility guidelineswound care per treatment order of specialized practitioner for wound managementR6's current provider orders dated 2/27/26 included:PU (pressure ulcer) to left buttock: as needed for if dressing soiled, came off during cares/shower, etc. Staff to use foot cradle in bed. Encourage Frequent offloading Q 2hrs (every 2 hours) and up in chair daily for 2 hrs.PU to left buttock: every evening shift related to pressure ulcer of left buttock, stage 4 WC (wound care) to wound bed, 1/4 strength Dakins packing (apply kerlex gauze and pack wound), cover with bordered foam to secure daily and prn (as needed), Encourage frequent offloading every 2 hours and up to chair daily for 2 hours.R6's Integrated Wound Care (IWC) progress notes dated 2/23/26, identified pressure wounds to left buttock, left heel, and right ankle. It also identified frequent incontinence of bowel and bladder results in difficulty with healing.R6's treatment administration record (TAR) dated 2/27/26, instructed staff to provide wound care to left buttock wound every evening shift, packing the wound and covering with bordered foam to secure daily and as needed if soiled or change off in shower etc.During an observation on 2/25/26 at 12:49 p.m., nursing assistant (NA)-A and registered nurse (RN)-B changed R6's brief. NA-A told RN-B that R6 had no dressing on their left buttock wound. RN-B motioned to continue with brief change. The wound had packing and the brief was saturated, no stool, and there was a baseball-sized amount of light yellow-brown drainage where brief aligned wound. NA-A cleansed R6's skin and replaced their brief. No dressing was applied to the left buttock wound.During an interview on 2/25/26 at 1:55 p.m., RN-B confirmed that R6's left buttocks wound dressing was not in place when they changed R6's brief. They stated they would need to check the order as orders may have changed, and they thought a previous order was to keep the wound open to air. They stated they would review the orders and either do the dressing before the end of their shift or pass it on to the next nurse as a priority.During an interview on 2/25/26 at 3:28 p.m., licensed practical nurse (LPN)-A stated R6's uncovered left buttock wound was passed off to them during shift report from RN-B. They stated they planned to replace the dressing in a few hours but had other priorities first. LPN-A reported that R6 often had multiple stool incontinence episodes per shift. They confirmed concern for infection prevention with the wound being open to the brief.During an interview on 2/26/26 at 2:57 p.m., acting director of nursing (DON) stated they expected staff to notify the nurse if there was no dressing on a wound, and they expected nurses changed dressings as needed for soiled or excessive drainage. Acting DON confirmed their concern for infection control because R6's incontinence of bowel and bladder put them at risk for contamination of the wound bed.The facility policy Skin Integrity revised 5/21/25, directed staff to evaluate the status of the wound dressing and notify the nurse manager if the dressing was not intact or drainage was present.

Based on interview and document review, the facility failed to ensure residents were educated on COVID-19 vaccinations when administered to 1 of 5 residents (R8).Findings include:R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 had diagnoses which included vascular dementia, depression, bipolar disorder, chronic pain, and post-traumatic stress disorder (PTSD).A review of R8's immunization record identified they received the Covid-19 vaccination on 11/4/25, education given was documented as no.During an interview on 2/26/26 at 12:18 p.m., the acting director of nursing acting (DON) stated when residents were admitted they received the Vaccine Information Statement (VIS) in their admission packet.During an interview on 2/26/26 at 3:36 p.m., the nurse consultant (NC)-B stated when vaccines were given new consents were obtained and new education was given along with a VIS.Resident Immunizations dated 1/21/25, identified the facility would offer vaccinations based on the Centers for Disease Control recommendations and physician orders. The policy further identified Vaccine Information Statements would be provided to the resident and/or representative prior to administration of the vaccination. Education would be provided and any questions answered prior to administration of the vaccine and documented in the electronic medical record.

Based on observation, interview and document review, the facility failed to ensure the continuous positive airway pressure machine (CPAP) was properly cleaned and maintained for 1 of 1 resident (R15) reviewed for respiratory care.Findings include:R15's annual Minimum Data Set (MDS) dated [DATE], indicated R15 was cognitively intact. Section O: Special Treatments, Procedures, and Programs was not coded for CPAP.R15's face sheet dated 2/27/26, included diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, congestive heart failure, and obstructive sleep apnea.R15's care plan revised 11/24/25, included CPAP settings but did not address standard cleaning and maintenance of CPAP for infection prevention.R15's provider orders dated 2/27/26, included:CPAP: staff to set up at HS and when in bed for naps. every shift Startup CPAP as machine is preprogrammed and will adjust to inhalation pressure needsNo evidence of orders for cleaning and maintenance of R15's CPAP machine.R15's treatment administration record (TAR) instructed staff to set-up the CPAP nightly and as needed for naps, but there were no instructions for cleaning and maintaining the CPAP. TARs dated 12/025, 1/2026, and 2/2026, had no instructions for cleaning and maintenance of R15's CPAP machine.During an observation on 2/23/26 at 12:33 p.m., R15's CPAP machine had visible water in the chamber.During an observation on 2/24/26 at 11:17 a.m., R15's CPAP machine had visible water in the chamber.During an observation on 2/25/26 at 1:24 p.m., R15's CPAP machine had visible water in the chamber.During an observation on 2/26/26 at 9:53 a.m., R15's CPAP machine had a dry water chamber.During an interview on 2/26/26 at 2:30 p.m., nursing assistant (NA)-B and NA-C stated the nurses started the CPAP, monitored, and cleaned it.During an interview on 2/26/26 at 2:44 p.m., registered nurse (RN)-A stated, nurses were responsible for placing the CPAP on the resident, monitoring it, and washing it per guidelines: daily empty and clean the humidifier and weekly clean the head gear, tubing, mask, and chin strap. RN-A stated CPAP orders, including cleaning, were on the TAR or MAR. They stated CPAP orders are expected on admission. They confirmed the importance of monitored use and cleaning for infection prevention.During an interview on 2/26/26 at 2:57 p.m., acting director of nursing (DON) stated residents with CPAPs should have had orders in place for CPAP application, water chamber filling, and for cleaning the CPAP machine and tubing/mask. They stated they would be concerned if a resident didn't have CPAP orders because the orders on the TAR were what let nursing know they needed to perform these tasks.During an observation on 2/27/26 at 11:30 a.m., R15's CPAP machine again had visible water in the chamber.The facility provided undated document Cleaning Your CPAP/Bi-level Equipment instructed daily wiping of mask, daily washing and air drying of humidifier, and weekly washing of the mask and head gear.A CPAP policy was requested but not received.

Based on interview and document review the facility failed to offer influenza and pneumococcal vaccinations and or provide education according to Centers for Disease Control (CDC) guidelines for 3 of 5 residents (R12, R13, R8) reviewed for vaccinations.Findings include:R12's significant change Minimum Data Set (MDS) dated [DATE], identified R12 had diagnoses which included malignant neoplasm of right renal pelvis, hypothyroidism, dementia, and hypertension. A review of R12's immunization record identified they received the influenza vaccine on 11/4/25, education given was documented as no.R13's comprehensive MDS dated [DATE], identified R13 had diagnoses which included atrial fibrillation (fast, irregular heart rate), gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH [noncancerous enlargement of the prostate gland]), hyperlipidemia, arthritis, and depression.A review of R13's Vaccination Consent form dated 9/17/25, identified they wanted to receive the influenza vaccine during the influenza season. There was no evidence R13 was offered the vaccine during the immunization season.R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 had diagnoses which included vascular dementia, depression, bipolar disorder, chronic pain, and post-traumatic stress disorder (PTSD).A review of R8's immunization record identified they received the influenza vaccine on 11/4/25, education given was documented as no.During an interview on 2/26/26 at 12:18 p.m., the acting director of nursing acting (DON) stated when residents were admitted they received the Vaccine Information Statement (VIS) in their admission packet. The acting DON stated during the flu and cold season they have a vaccine clinic and re-do consents and VIS.During an interview on 2/26/26 at 3:36 p.m., the nurse consultant (NC)-B stated when flu season comes around new consents were obtained and new education was given along with a VIS.Resident Immunizations dated 1/21/25, identified the facility would offer vaccinations based on the Centers for Disease Control recommendations and physician orders. The policy further identified Vaccine Information Statements would be provided to the resident and/or representative prior to administration of the vaccination. Education would be provided and any questions answered prior to administration of the vaccine and documented in the electronic medical record.

Based on interviews and record review the facility failed to report an allegation of sexual assault within 2 hours to the State Agency (SA) for 2 of 3 clients (R1, R2) when reviewed for abuse. Findings include:Facility incident report dated 1/20/26 indicated on the morning of 1/20/26 at approximately 9:15 a.m., registered nurse (RN)-A reported R1 came to the dining room to greet his wife (R3) when an aide asked R1 to move to passed him. R1 moved and continued around the table to his wife (R3) and came behind R2 and groped her breasts without R2's consent. R1 was redirected to his room and was educated on the matter. R1 had little to no remorse for the action he had made towards R2. RN-A stated R2 was aware the incident happened, but shortly after R1 groped her she closed her eyes and showed no visual negative reaction or distress. R2 was later interviewed by staff and had slight to no recall on the incident. Police were called and R1 and R2's responsible parties were notified. RN-A who reported the incident had not worked at the facility for a length of time and was not aware of the plans in place for R1 and R2, however the plan of care was followed. Facility reported incident to SA on 1/20/26 at 4:25 p.m.When interviewed on 1/29/26 at 2:14 p.m., social worker (SW) stated it was decided to make the report to SA after the investigation was mostly done and she was not aware to make the report first. SW agreed the incident was reported late and not within the two hours according to regulations and facility policy.Facility policy titled Maltreatment Reporting Guidelines reviewed date 11/26/24, indicated if alleged maltreatment occurs, report immediately, but not later than 2 hours after the allegation is made if the incident involved abuse, neglect, or financial exploitation, including injurie of unknown sources and misappropriation of VA property.

Based on observation, interview and document review, the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares were completed timely for 4 of 7 residents (R8, R23, R15, R22) who received their morning medications late, in addition for a resident with pressure ulcers needing assistance turning and repositioning for 1 of 3 residents (R25). This deficient practice had the potential to affect all 39 residents who resided in the facility. Findings include: Free of Medication errors of 5 percent or more see also F759 R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 was moderately cognitively intact and had diagnoses which included, gastro-intestinal appliance, anxiety, depression, surgical aftercare following a surgery on the digestive system, dysphagia (difficulty swallowing foods or liquids arising from the throat or esophagus, ranging from mild to difficult to complete and painful blockage), nutritional deficiency, and history of malignant neoplasm of other organ system. R8's Physician Order Review as of 12/12/24, identified identified R8 had orders which included the following: fluoxetine 10 milligrams (mg) one tablet into gastric tube one time per day every day at morning 7:00 a.m.-10:00 a.m acetaminophen extra strength oral liquid 500 mg/5 milliliters (ml) 1000 mg every six hours every day and 12:00 a.m., 6:00 a.m., 12:00 p.m., 6:00 p.m midodrine 5 mg one tablet into gastric tube two times per day every day at 7:00 a.m., 5:00 p.m Pepcid 20 mg one tablet into feeding tube two times per day every day at morning 7:00 a.m.-10:00 a.m., 7:00 p.m.-10:00 p.m ProStat 1 ounce two time per day every day at 7:00 a.m.-11:00 a.m., 4:30 p.m.-8:30 p.m. Jevity 1.5 240 ml bolus three times per day every day at 10:00 a.m., 2:00 p.m., 6:00 p.m On 12/11/24 at 12:21 p.m., registered nurse (RN)-E prepared medications for R8, crushing each medication and placing the medication in labeled plastic medication cups. RN-E donned an isolation gown and gloves prior to entering R8's room, RN-E placed paper towels down on R8's table prior to placing medications, graduate, and 60 ml syringe. RN-E checked the patency of R8's gastric tube by pulling back and getting tube feeding returns, RN-E flushed R8's gastric tube with 30 ml of water. RN-E proceed to give each medication after adding water to dissolve the medication: fluoxetine 10 mg, 30 ml water flush acetaminophen 1000 mg, 30 ml water flush midodrine 5 mg, 30 ml water flush Pepcid 20 mg, 30 ml water flush ProStat 1 ounce, 30 ml water flush Jevity 1.5 240 ml bolus, followed by 300 ml of water R8's Time Variance Report for 12/11/24, identified the following: fluoxetine 10 mg due at 7:00 a.m.-10:00 a.m., given at 1:15 p.m. acetaminophen 1000 mg due at 12:00 p.m., given at 1:15 p.m. midodrine 5 mg due at 7:00 a.m., given at 1:15 p.m. Pepcid 20 mg due at 7:00 a.m.-10:00 a.m., given at 1:15 p.m. Jevity 1.5 240 ml due at 10:00 a.m., given at 1:15 p.m. R23's quarterly MDS dated [DATE], identified R23 was severely cognitively impaired and had diagnoses which included dementia, anemia, neurogenic bladder, and depression. R23's Physician Order Review as of 12/12/24, identified R23 had orders which included the following: divalproex sodium delayed release 125 mg two times per day every day at 7:00 a.m. -11:00 a.m. and 7:00 p.m. -10:00 p.m Miralax oral powder 17 grams (GM) per scoop by mouth one time per day in the a.m. every day at 7:00 a.m. - 11:00 a.m senna-s 8.6-50 mg two tablets by mouth two times per day every day at 7:00 a.m. - 10:00 a.m. and 7:00 p.m. - 10:00 p.m sertraline 25 mg one tablet one time per day every day at 7:00 a.m. - 10:00 a.m Tylenol 325 mg two tablets by mouth three times per day every day at 8:00 a.m., 2:00 p.m., 8:00 p.m R23's Time Variance Report for 12/11/24, identified the following: divalproex 125 mg due at 7:00 a.m. -11:00 a.m., given at 11:14 a.m. Miralax 17 GM due at 7:00 a.m. - 11:00 a.m., given at 11:14 a.m. senna-s 8.6-50 mg due at 7:00 a.m. - 10:00 a.m., given at 11:14 a.m. sertraline 25 mg due at 7:00 a.m. - 10:00 a.m., given at 11:14 a.m. Tylenol 650 mg due at 8:00 a.m., given at 11:14 a.m. R15's, quarterly MDS dated [DATE], identified R15 was severely cognitively impaired and had diagnoses which included Alzheimer's disease and dysphasia (a communication disorder that affects a person's ability to understand and produce language). R15's Physician Order Review as of 12/12/24, identified R15 had orders which included the following: acetaminophen 500 mg two tablets by mouth two times per day every day at 10:00 a.m., 6:00 p.m senna 8.6 mg two tablets by mouth two times per day every day at 7:00 a.m. - 10:00 a.m and 7:00 p.m. - 10:00 p.m R15's Time Variance Report for 12/11/24, identified the following: acetaminophen 1000 mg due at 10:00 a.m., given at 10:59 a.m. senna 8.6 mg due at 7:00 a.m. - 10:00 a.m., given at 10:59 a.m. R22's significant change MDS dated [DATE], identified R22 was cognitively intact and had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), anemia, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety, and depression. R22's Physician Order Review as of 12/12/24, identified R22 had orders which included the following: cholecalciferol 25 micrograms (mcg) per 0.04 ml 25 mcg by mouth one time per day every at 7:00 a.m. - 10:00 a.m flomax 0.4 mg one capsule by mouth one time per day every day at 7:00 a.m. - 10:00 a.m furosemide 20 mg 0.5 tablet by mouth one time per day every day at 7:00 a.m. - 10:00 a.m levothyroxine 125 mcg one tablet by mouth one time per day every day at 7:00 a.m. - 10:00 a.m pantoprazole 20 mg one tablet by mouth one time per day every day at 7:00 a.m. - 10:00 a.m sertraline 100 mg one tablet by mouth one time per day every day at 7:00 a.m. - 10:00 a.m Trelegy Ellipta inhalation aerosol powder breath activated 200-62.5 mcg/ACT one puff into the lungs one time per day every day at 7:00 a.m. - 10:00 a.m Tylenol 500 mg two tablets by mouth three times per day every day at 8:00 a.m., 2:00 p.m., 8:00 p.m R22's Time Variance Report for 12/11/24, identified the following: cholecalciferol 25 mcg due at 7:00 a.m. - 10:00 a.m., given at 12:14 p.m. flomax 0.4 mg due at 7:00 a.m. - 10:00 a.m., given at 12:14 p.m. furosemide 20 mg due at 7:00 a.m. - 10:00 a.m., given at 12:14 p.m. levothyroxine 125 mcg due at 7:00 a.m. - 10:00 a.m., given at 12:14 p.m. pantoprazole 20 mg due at 7:00 a.m. - 10:00 a.m., given at 12:14 p.m. sertraline 100 mg due at 7:00 a.m. - 10:00 a.m., given at 12:14 p.m. Trelegy Ellipta inhaler due at 7:00 a.m. - 10:00 a.m., given at 12:14 p.m. Tylenol 1000 mg due at 8:00 a.m., given at 12:14 p.m. During an interview on 12/11/24 at 3:45 p.m., RN-E verified she was passing medications for 23-24 residents, crushing medications for seven residents (stated those medication passes could sometimes take 15 minutes or more), and about eight residents in enhanced barrier precaution rooms (requiring donning and doffing of personal protective equipment). RN-E verified medications for R8 were late despite not taking a morning break or lunch break and stated several other residents received their morning medications late as well (R23, R15, and R22). During an interview on 12/12/24 at 1:48 p.m., the director of nursing (DON) stated the nurses on the medication carts were passing medications for half of the residents in the building (census of 39 would be about 20 each) and they try to adjust the medication pass to keep it even. The DON verified it was important for residents to receive their medications timely to keep medication delivery on schedule. During an interview on 12/12/24 at 4:15 p.m., nursing assistant (NA)-C stated the nurse on the cart is really busy, if they would go to the nurse managers to get assistance on a new wound or pain they would be told the needed to go to the nurse on the cart first. NA-C stated the cart nurses were trying hard just to get the morning medications passed. Franciscan Health Center Order Pass Times undated, identified the following times for medication delivery: Daily- 7:00 a.m. - 10:00 a.m. Two times daily - 7:00 a.m. -11:00 a.m. and 7:00 p.m. - 10:00 p.m. Three times daily - 7:00 a.m. - 10:00 a.m. and 12:30 p.m. - 2:30 p.m. and 7:00 p.m. - 10:00 p.m. Daily every six hours - midnight and 6:00 a.m. and noon and 6:00 p.m. 48109 Treatment or services to prevent or heal pressure ulcers (PU)s See also F686 R25's significant change in status assessment (SCSA) MDS dated [DATE], identified intact cognition and diagnoses of Parkinson's with dyskinesia, diabetes mellitus, stage two PU of sacral region, stage two PU of left buttock, dermatitis due to friction or contact with body fluids, non-pressure chronic ulcer of skin limited to breakdown of skin. R25 was dependent on staff for bed mobility. R25's care plan dated 1/5/23, identified dependence on staff to reposition in bed every two to three hours. R25 was incontinent of bowels and needed assistance after each episode with staff to check every two hours. During a continuous observation starting 12/12/24 at 8:14 a.m., R25 was observed in bed with the head of bed at about 20 degrees, with the bend in the bed partway up his back. R25 didn't appear to be propped to one side or the other and stayed in that position until NA-D came in at 10:02 a.m. During an interview at 10:05 a.m., NA-D stated the last time they were able to reposition R25 was shortly after 7 a.m. when the nurse had to give R25 some medications. NA-D also stated R25 should be repositioned every two hours, but the morning had been very busy, and they weren't able to get back to him until now. When NA-D rolled R25 onto his right side they noted the wound was not covered with a dressing and was actively bleeding bright red blood. NA-D called for help and RN-D came in with supplies to clean and dress the wound. RN-D took measurements and commented it looked worse than it did the day before and she would be updating the provider again. During an interview on 12/12/24 at 3:30 p.m., RN-D stated she had been doing weekly measurements and wound assessment since the rounding wound provider stopped coming the end of November. Review of these measurements indicated the wound was worsening, however R25's provider was aware and rounding in the facility at least once a week. R25 has had a SCSA after hospitalization for sepsis, and then contracting COVID-19. RN-D shared R25 had an appointment with a wound provider on 12/16/24, and a new rounding wound provider would be starting at the facility next week. RN-D stated she would expect residents were turned and repositioned as care planned, and it would especially be important for a resident with a wound so they can help the wound as much as possible. A policy, Franciscan Health Center Repositioning Policy dated 10/23/16, identified its purpose was to establish a system to ensure every resident is repositioned as determined by individual assessment. All residents will be repositioned based on their individualized assessments, their preference or their request. Staffing Interviews During an interview on 12/11/24 at 1:07 p.m., RN-C stated they were responsible for medications and treatments for 20 residents, which left 27 residents for the RN on the other side. RN-C provided it was difficult to get their work done on their shift and ran over to the next shift almost every time they worked. RN-C also stated it was nearly impossible to pass medications for 20 residents and be available to answer questions the NAs may have, or if they needed help, or if a resident wanted to talk. RN-C stated they don't always take their lunch when they are just working eight hours, but if they did a double, they would for sure take their half hour break. During an interview on 12/12/24 at 7:45 a.m., NA-D and NA-H stated they were short on Monday 12/9/24 and again today. NAs -D and -H shared they were often short on this shift, and it was frequent that the restorative NA would be pulled from their restorative duties to work the missing staff person's shift. NA-H added they used to have three NAs on the overnight shift and now there are only two, and for the afternoons they had 5 NAs and now have four. NAs -D and -H also stated they have talked with management and were told the staffing fits with their census. NA-H added the residents they care for were heavier care, needing two-person lifts and lots of redirection for behavior. During an interview on 12/12/24 at 3:29 p.m., the facility scheduler (FS)-A stated she posted open shifts in the upcoming schedule four weeks in advance so facility staff and then agency staff could pick up the open spots, however the schedule still went out with open shifts. FS-A confirmed staff would complain to her and vented about being short-staffed. The nurse managers would help by trying to even out the care groups. FS-A stated when they had a call in, they would try to replace the shift and if they weren't able then they would have to mandate but only the facility-employed NAs could be mandated, not the supplemental nursing agency NAs. FS-A explained there was one restorative aide (RA) scheduled, but they were always an aid first and would be pulled to fill a NA call-in, which was difficult for one of the two weekends because there wasn't a scheduled RA that weekend. During an interview on 12/12/24 at 3:56 p.m., NA-G stated concerns with the staffing levels for overnight as there were only two NAs on and it was hard to get their work done and they didn't take breaks. NA-G provided it was difficult to get through one whole round done on the residents before it was time to start the next round. NA-G had talked with management but was told this was the way it was. During an interview on 12/12/24 at 4:14 p.m., NA-F stated even on days things went smoothly, there still wasn't enough time to get their work done and they had trouble getting their breaks in. NA-F stated the biggest problem was when a resident needed to be checked on for things only a nurse could do, like a new wound or pain, they were told to tell the cart nurse first. But the cart nurses were trying so hard to just get the medications out, it took them most of their shifts just doing that. Facility Assessment and Payroll-Based Journal Report Review of the facility assessment dated [DATE], identified a plan for licensed staff providing direct care on the weekdays and weekends to be two per day and evening shift and one per overnight shift; and NAs at five per day shift, four per afternoon shift and two per overnight shift. The Centers for Medicare and Medicaid Services (CMS) quarterly reporting of the facility's payroll-based journal for the fourth quarter (July 1 to September 30) of the fiscal year 2024 identified excessively low weekend staffing levels. Review of facility-submitted daily staffing worksheets from 11/10/24 to 12/12/24 identified the following days to have lower than planned staffing: 11/10 afternoon shift short 1.5 NA hours 11/11 day shift short 8 NA hours, no RA scheduled 11/12 day shift short 8 NA hours, RA pulled to cover 8 additional NA hours 11/16 day shift short 1.5 NA hours, afternoon shift short 1.5 RN hours 11/18 day shift RA pulled to cover 8 NA hours 11/20 no RA scheduled 11/23 afternoon shift short 2 NA hours 11/24 day shift short 8 NA hours, no RA; afternoon shift short 2 NA hours 11/25 day shift short 12.5 NA hours, no RA scheduled; afternoon shift short 2.5 NA hours 11/26 day shift no restorative scheduled; afternoon shift short 2 NA hours 11/27 day shift no RA scheduled 11/28 day shift RA pulled to cover 8 NA hours; afternoon shift short 2 NA hours 11/29 day shift short 8 NA hours, no RA scheduled 11/30 day shift short 8 NA hours, no RA scheduled 12/1 day shift short 8 NA hours, no RA scheduled 12/4 day shift RA pulled to cover 8 NA hours 12/5 day shift RA pulled to cover 8 NA hours 12/6 overnight shift short 1.5 NA hours 12/7 afternoons short 1.5 NA hours 12/8 day shift RA pulled to cover 8 NA hours; afternoon shift short 1.5 NA hours 12/9 day shift short 12.5 NA hours, no RA scheduled: afternoons short 2 NA hours 12/10 afternoon shift short 3 NA hours 12/12 day shift RA pulled to cover 8 NA hours; afternoon shift short 2 hours

Based on observation, interview, and document review the facility failed to ensure medications and supplies available for use in a the medication storage room were not expired. This had the potential to affect all 39 residents residing in the facility. Findings include: On 12/11/24 at 1:35 p.m., during an inspection of the locked medication room with the director of nursing (DON) the following observations were made: -lab cart for blood draws had nine yellow top blood tubes with an expiration date of 10/31/24 -all four respiratory viral panel swabs were expired -two bottles of hibiclens had expiration dates of 8/2024 and 11/2024 -two tubes of Bacitracin ointment with expiration dates of 11/2023 During an interview on 12/11/24 at 2:09 p.m., the DON stated would not want to use expired medications as could not be sure of their potency and efficacy. The DON stated it was the responsibility of the night shift to check for out dated supplies but they did not have any check off sheet to ensure it was completed. Night Nurse Weekly Duties undated, identified each Tuesday the night nurse would check for dates on opened medications and expired medication on both medication carts, treatment carts, and the medication room. Highlight any dates that expire within the current month.

Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 13.79% with 4 errors out of 29 opportunities for error involving 1 of 7 residents (R8) who were observed during the medication passes. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 was moderately cognitively intact and had diagnoses which included, gastro-intestinal appliance, anxiety, depression, surgical aftercare following a surgery on the digestive system, dysphagia (difficulty swallowing foods or liquids arising from the throat or esophagus, ranging from mild to difficult to complete and painful blockage), nutritional deficiency, and history of malignant neoplasm of other organ system. R8's Physician Order Review as of 12/12/24, identified the following orders: fluoxetine 10 milligrams (mg) one tablet into gastric tube one time per day every day at morning 7:00 a.m.-10:00 a.m acetaminophen extra strength oral liquid 500 mg/5 milliliters (ml) 1000 mg every six hours every day and 12:00 a.m., 6:00 a.m., 12:00 p.m., 6:00 p.m midodrine 5 mg one tablet into gastric tube two times per day every day at 7:00 a.m., 5:00 p.m Pepcid 20 mg one tablet into feeding tube two times per day every day at morning 7:00 a.m.-10:00 a.m., 7:00 p.m.-10:00 p.m ProStat 1 ounce two time per day every day at 7:00 a.m.-11:00 a.m., 4:30 p.m.-8:30 p.m. Jevity 1.5 240 ml bolus three times per day every day at 10:00 a.m., 2:00 p.m., 6:00 p.m On 12/11/24 at 12:21 p.m., registered nurse (RN)-E prepared medications for R8, crushing each medication and placing the medication in labeled plastic medication cups. RN-E donned an isolation gown and gloves prior to entering R8's room, RN-E placed paper towels down on R8's table prior to placing medications, graduate, and 60 ml syringe. RN-E checked the patency of R8's gastric tube by pulling back and getting tube feeding returns, RN-E flushed R8's gastric tube with 30 ml of water. RN-E proceed to give each medication after adding water to dissolve the medication: fluoxetine 10 mg, 30 ml water flush acetaminophen 1000 mg, 30 ml water flush midodrine 5 mg, 30 ml water flush Pepcid 20 mg, 30 ml water flush ProStat 1 ounce, 30 ml water flush Jevity 1.5 240 ml bolus, followed by 300 ml of water R8's Time Variance Report for 12/11/24, identified the following: fluoxetine 10 mg due at 7:00 a.m.-10:00 a.m., given at 1:15 p.m. acetaminophen 1000 mg due at 12:00 p.m., given at 1:15 p.m. midodrine 5 mg due at 7:00 a.m., given at 1:15 p.m. Pepcid 20 mg due at 7:00 a.m.-10:00 a.m., given at 1:15 p.m. Jevity 1.5 240 ml due at 10:00 a.m., given at 1:15 p.m. During an interview on 12/11/24 at 3:45 p.m., RN-E verified she was passing medications for 23-24 residents, crushing medications for seven residents (stated those medication passes could sometimes take 15 minutes or more), and about eight residents in enhanced barrier precaution rooms (requiring donning and doffing of personal protective equipment). RN-E verified medications for R8 were late despite not taking a morning or lunch break and stated several other residents received their morning medications late as well (R23, R4, and R22). During an interview on 12/12/24 at 1:48 p.m., the director of nursing (DON) stated the nurses on the medication carts were passing medications for half of the residents in the building (census of 39 would be about 20 each) and they try to adjust the medication pass to keep it even. The DON verified it was important for residents to receive their medications timely to keep medication delivery on schedule. Franciscan Health Center Order Pass Times undated, identified the following times for medication delivery: Daily- 7:00 a.m. - 10:00 a.m. Two times daily - 7:00 a.m. -11:00 a.m. and 7:00 p.m. - 10:00 p.m. Three times daily - 7:00 a.m. - 10:00 a.m. and 12:30 p.m. - 2:30 p.m. and 7:00 p.m. - 10:00 p.m. Daily every six hours - midnight and 6:00 a.m. and noon and 6:00 p.m.

Based on observation, interview, and document review the facility failed to ensure resident call lights were within reach from the bathroom floor in multi -resident bathrooms for 5 of 5 residents (R3, R15, R23, R40, R22) reviewed for call light accessibility. Findings include: On 12/12/24 at 8:22 a.m., the following bathroom call lights were observed: room [ROOM NUMBER] call light did not reach the floor, there were several knots in the cord. room [ROOM NUMBER] call light was short approximately 12 inches in length and did not reach the floor. room [ROOM NUMBER] call light was short approximately 15 inches from the floor. room [ROOM NUMBER] call light would not turn on when the cord was pulled. room [ROOM NUMBER] call light was approximately 12 inches in length and did not reach the floor. During an interview on 12/12/24 at 9:43 a.m., nursing assistant (NA)-D stated he thought call light cords in the bathroom had to reach below the toilet. NA-D could not recall any education on the length of the call light cord in bathrooms. During an interview on 12/12/24 at 10:48 a.m., with registered nurses (RN)-A and RN-B neither was aware of any regulations about the length of call lights in resident bathrooms. On 12/12/24 at 12:04 p.m., maintenance director (M)-A went to each room and measured the call light cords: room [ROOM NUMBER] bottom of call light cord was 23 inches from the floor - cord had several knots in it room [ROOM NUMBER] bottom of call light cord was 15 inches from floor - cord had several knots in it room [ROOM NUMBER] call light was not working and M-A had not been made aware of this and had not received any repair requests room [ROOM NUMBER] bottom of call light cord was 20.5 inches from the floor room [ROOM NUMBER] bottom of call light cord was 9 inches from the floor - cord had several knots in it During an interview on 12/12/24 at 1:36 p.m., the director of nursing (DON) stated it was important to have call lights that reached to the floor in resident bathrooms in case of a fall so they could reach the call light. Call light dated 10/23/17, did not address the length of call lights in resident bathrooms.

Based on interview, and document review, the facility failed to ensure current contact information of all pertinent State Agency and advocacy groups were posted at a level accessible to all residents. This had the potential to affect all residents who chose to view this information. Findings include: On 12/9/24 at 6:51 p.m., the resident council president gave permission to review the resident council meetings. The resident council meetings revealed rights were not reviewed at the 12/4/24, and 11/4/24, resident council meeting but were reviewed at the 10/7/24, and the 9/3/24, meeting. On 12/10/24 at 1:26 p.m., a resident council meeting was held with four residents in attendance (R2, R17, R12, and R26) all of whom required the use of a wheelchair. The four residents in attendance did not know where the state inspections were posted and volunteered some of the postings were too high to read for residents in a wheelchair and with poor eyesight. On 12/10/24 at 2:05 p.m., the large bulletin board in the main dining room was reviewed. The poster for information regarding the ombudsman was viewed at the top right hand corner of the bulletin board approximately six inches from the ceiling. There were not any pamphlets or cards for the ombudsman in the area near the bulletin board. On 12/12/24 at 1:56 p.m., the director of nursing (DON) reviewed the bulletin board and verified the information related to the ombudsman was approximately six inches from the ceiling and too high for residents in wheelchairs to read. The Combined Federal and State [NAME] of Rights dated 2/1/17, provided to all residents identified the facility must post, in a form and manner accessible and understandable to residents, and resident representatives this included information related to the Office of the State Long-Term Care Ombudsman program.

Based on interview and document review the facility failed to ensure a copy of the baseline care plan was provided to the resident and/or representative for 1 of 3 residents (R40) reviewed who was a new admission. Findings include: R40's Resident Face Sheet dated 12/12/24, identified R40 was admitted on [DATE], with spastic hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting right dominant side and nontraumatic intercerebral hemorrhage. R40's 48 hour baseline care plan dated 11/19/24, identified R40's short term goals, health maintenance needs, pain intervention, safety concerns, medication concerns, and designated representative. R40's 48 hour baseline care plan identified needs and interventions for the following: eating, toileting, bathing, grooming, dressing, bed mobility, and transfers. However, the 48 hour baseline care plan lacked any indication that R40 or R40's representative had been offered or received a copy of the 48 hour baseline care plan. During an interview on 12/9/24 at 2:55 p.m., neither R40 nor his family member (FM)-A thought there had been any meetings regarding care plans. During an interview on 12/12/24 at 1:20 p.m., the director of nursing (DON) stated she would expect the 48 hour baseline care plan to be reviewed and a copy offered to the resident and or the resident representative. The DON stated the baseline care plan is important so staff know how to safely care for the resident. During an interview on 12/12/24 at 2:32 p.m., registered nurse (RN)-D provided a copy of the baseline care plan. RN-D stated the care plan was developed with the resident but that they did not offer a copy to the resident or the resident's representative. RN-B also verified the care plan was not ever offered to the resident or to the resident's representative. During an interview on 12/12/24 at 3:18 p.m., the corporate RN verified it was important to offer a copy of the baseline care plan so the resident and their family would be aware of the plan of care. Person Centered Care Planning dated 4/20/23, identified the facility would develop and implement a baseline care plan for each resident within 48 hours of admission. In addition, a summary or a copy of the baseline 48 hour care plan would be given to the resident and/or representative.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R1, R2, R3) reviewed for drug diversion were free from exploitation when a staff member took resident's narcotic pain medications for personal use. This resulted in an immediate jeopardy (IJ) when licensed practical nurse (LPN)-B diverted 134 [MEDICATION(S)] tablets, and 18 [MEDICATION(S)] tablets. The immediate jeopardy (IJ) began on [DATE], when registered nurse (RN)-B notified the administrator and the director of nursing (DON) via email with her concerns LPN-B was giving narcotics to residents when she was able to control their pain with Tylenol, thus diverting narcotics. The administrator and the DON failed to conduct a thorough investigation, failed to remove LPN-B from working while they conducted an investigation, and failed to notify law enforcement. The administrator and DON were notified of the IJ on [DATE], at 4:30 p.m. The IJ was removed on [DATE], at 3:30 p.m. but non-compliance remained at the lower scope and severity of D, potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Face Sheet printed on [DATE], indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Active and Inactive Orders sheet indicated on [DATE], R1's [MEDICATION(S)] 2.5 mg by mouth every eight hours as needed for pain, was discontinued due to R1 not utilizing. R2's Face Sheet printed on [DATE], indicated R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The documents provided did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Face Sheet printed on [DATE], indicated R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the Face Sheet indicated R3 had expired [DATE]. R3's Active and Inactive Orders sheet indicated R3 had an order on [DATE], for [MEDICATION(S)]-acetaminophen ([MEDICATION(S)], an opioid pain medication consisting of a combination of [MEDICATION(S)] and acetaminophen [Tylenol] used to moderate to severe pain) ,d+[DATE] mg by mouth every four hours as needed for pain. The order included a finish date of [DATE]. Review of R1, R2, and R3's medical records indicated none of the residents had negative outcomes from not recieving their narcotic medications. Review of the facility's narcotic books on the Lakeside unit and Bayside unit medication carts indicated the following: The Lakeside unit narcotic Book One, page 13, indicated on [DATE], 30 [MEDICATION(S)] tablets (Rx number 88) were received for R1. On [DATE], at 7:00 p.m. The book indicated 14 tablets remained. The page was crossed off with an X with a date of discontinuance of [DATE]. There was no signature on the page. The Lakeside unit narcotic Book Two pages 105, 106, 107, and 108, indicated on [DATE], 120 [MEDICATION(S)] tablets (Rx number 97) in four cards of 30 tablets each were received for R2. Each page indicated 30 tablets remained. Each page was crossed off with an X with a notation at the bottom of each page of D/C'd (discontinued) without a signature or date. The Bayside unit narcotic book page 22 indicated on [DATE], 30 [MEDICATION(S)] ,d+[DATE] tablets (Rx number 82) were received for R3. On [DATE], at 6:35 p.m. The book indicated 18 tablets remained. The page was crossed off with an X, and lacked a date, signature or notation of why the page had an X over it. Review of the facility's Destruction of Controlled Substances book indicated the following: R3's [MEDICATION(S)]/acetaminophen ,d+[DATE] (Rx number 82) 18 tablets was destroyed on [DATE], with two signatures. One signature was that of LPN-B and the other signature was illegible. On a separate page of the book, with no other controlled medications listed, were R2's [MEDICATION(S)] 5 mg (Rx number 97), 120 tablets destroyed on [DATE], with two signatures and R1's [MEDICATION(S)] 2.5 mg (Rx number 88) 14 tablets destroyed on [DATE], with two signatures. One signature was that of LPN-B and the other signature was illegible. On [DATE], LPN-A submitted a report to the State Agency (SA) which indicated on the evening of [DATE], at 10:30 p.m. LPN-A was doing the shift narcotic count with the off-going unnamed registered nurse (RN), and there were no notable discrepancies. After count was done and the RN had left, LPN-A noticed a page in the narcotic book was crossed out (Lakeside unit narcotic book two, page 13). The page indicated R1 had 14 [MEDICATION(S)] 5 mg half tablets remaining on the page, but the medication card (number 13) was not in the locked narcotic drawer. There was no proof the [MEDICATION(S)] was destroyed in the narcotic book, and there was no proof of the destruction being done in the narcotic destruction book. The narcotic book only indicated R1's [MEDICATION(S)] was discontinued per MD order. The same page also included R1's scheduled dose of [MEDICATION(S)] 5 mg half tablets was still an active order. The medication card containing R1's [MEDICATION(S)] should have remained in the narcotic drawer and should have been used for her scheduled [MEDICATION(S)]. Also in the narcotic book, pages 105, 106, 107, 108 were R2's [MEDICATION(S)] 5 mg tablets, and all pages were crossed out, indicating it was discontinued. However, these medications were signed destroyed by LPN-B, and co-signed with an illegible signature. R1 had a total of 14 missing [MEDICATION(S)] tablets and R2 had a total of 120 missing [MEDICATION(S)] tablets. R3 had a total of 18 missing [MEDICATION(S)] tablets. On [DATE], at 12:04 p.m. LPN-C was interviewed and stated R3's [MEDICATION(S)] ,d+[DATE] mg of which the narcotic book indicated there were 18 tablets, was not in the medication cart. LPN-D stated she then checked the narcotic destruction book. The narcotic destruction book indicated on [DATE], R3's [MEDICATION(S)] was destroyed by LPN-B and LPN-A. LPN-C further stated the signature did not look like LPN-A's signature, it did not match. LPN-C left the interview to alert the director of nursing (DON). On [DATE], at 12:15 p.m. LPN-D was interviewed and stated he had reordered R1's [MEDICATION(S)] on [DATE], and indicated on the reorder sheet the [MEDICATION(S)] was out with a question mark next to the RX number. LPN-D stated he was looking for R1's [MEDICATION(S)], and it was not in the medication cart. LPN-D stated he did not know where R1's [MEDICATION(S)] may have gone. On [DATE], at 2:13 p.m. the DON reviewed the signatures on R3's narcotic log. The DON stated the signatures were of LPN-B and registered nurse (RN)-A. The DON stated he compared RN-A's signature to the signature on file, and stated it was questionable that the narcotic log had the same signature. The DON further stated no one had informed him of any missing narcotics last week or this week. The DON stated at the end of January, he did an audit of narcotics because RN-B was questioning why LPN-B (who worked opposite days of RN-B) was giving the residents narcotics, when she was giving them Tylenol which relieved their pain. The DON stated at that time, he did not believe there was any drug diversion. The DON was unsure what happened to R3's [MEDICATION(S)], and stated he would investigate. On [DATE], at 2:16 p.m. the DON and administrator were interviewed. The DON stated the nurse practitioner came late Friday, [DATE], and discontinued R1's as needed (PRN) [MEDICATION(S)]. The orders were processed on Saturday [DATE]. The DON stated LPN-D worked a 12 hour day to evening shift, and LPN-B worked a 12 hour evening to night shift on Saturday [DATE]. LPN-D gave R1 her scheduled 8:00 a.m. and 8:00 p.m. [MEDICATION(S)] on Saturday [DATE]. When LPN-D returned to work on Sunday [DATE], R1's [MEDICATION(S)] was not in the medication cart. LPN-D then attempted to order the [MEDICATION(S)] from the pharmacy. LPN-D did not report the missing [MEDICATION(S)] because he got busy, and the medication came in on Sunday. The DON stated it seemed weird that LPN-B would take R1's [MEDICATION(S)] knowing the next nurse to follow him was LPN-D. The DON verified R2 was missing 120 [MEDICATION(S)] tablets. On [DATE], at 2:46 p.m. RN-B was interviewed and stated she emailed the administrator and the DON on [DATE], primarily questioning why narcotics were being signed out by LPN-B for residents who do not ask for narcotics at night. RN-B stated she talked to the DON on the previous Friday and was told he was looking into it. RN-B further stated it seemed suspicious because narcotics were being signed out for residents who slept through the night when she worked. RN-B stated she worked the opposite night shift of LPN-B. RN-B provided a copy of the email she had sent to the administrator and the DON. On [DATE], at 3:00 p.m. LPN-A was interviewed. LPN-A stated she and trained medication aide (TMA)-A found major discrepancies between the narcotic books for both the Bayside unit nursing cart and Lakeside unit nursing cart. LPN-A stated R2 had over 120 missing narcotic medications in the Lakeside unit narcotic book. The narcotic destruction book indicated LPN-B destroyed the narcotics. LPN-A stated this appeared suspicious to her because the signatures in the narcotic destruction book were of LPN-B, and the other signature was not readable. LPN-A did not report it to the DON or administrator, and stated it was because in the past, she had felt her concerns had been brushed off. On [DATE], at 3:18 p.m. the DON stated he found an entry for R2's [MEDICATION(S)] in the narcotic destruction book on a separate page in the back of the book. The DON was able to identify LPN-B's signature but was unable to identify the second signature. On [DATE], at 9:00 a.m. the administrator and the DON were interviewed again. The DON stated they had interviewed LPN-B, and he was evasive and defensive. LPN-B had told them he was unable to remember who co-signed with him when destroying the narcotics. LPN-B was unable to explain what happened with R1's medications and became defensive towards them. On [DATE], at 11:19 a.m. the consultant pharmacist (CP)-A was interviewed. CP-A stated he was unaware of the narcotic diversion until last night when the facility called and informed him. CP-A stated when destroying narcotics, there needs to be two licensed staff, and one of those should be the DON, or ADON. On [DATE], at 1:52 p.m. LPN-B was interviewed. LPN-B stated he was innocent and would not say anything further. The facility's Drug Diversion policy dated [DATE], directed the facility would identify, thoroughly investigate and report suspected or known incidents of drug diversion. The facility's Controlled Substances policy dated [DATE], directed controlled substances cannot be returned to the pharmacy for credit. If a controlled substance is discontinued, the dose changed or resident is no longer in the facility, the discontinued substance is to be removed as soon as workable from the substance cart using the following procedure: 1. On the count sheet, make an entry indicating the substance was transferred to the nursing director or designee for destruction. 2. Mark the count as 0 (zero). This act requires two signatures, the nurse that is initiating and the nursing director or designee that is taking the controlled substance for destruction. The IJ was removed on [DATE], when it was verified through staff interview and document review the facility implemented corrective action to prevent recurrence. LPN-B was suspended pending the facility investigation, the policies and procedures on controlled substances and drug diversion were reviewed by the IDT team, all narcotics were reviewed and counted, residents were interviewed and staff was educated. \

Based on interview and document review, the facility failed to ensure residents were free from abuse by staff during rough, unsafe transfers for 2 of 4 residents (R1, R2) reviewed for an allegation of abuse. The facility's failure to protect residents resulted in an immediate jeopardy situation. This had the potential to affect all 27 residents residing in the facility who required assistance from staff for transfers. The IJ began on 3/26/21, when nursing assistant (NA)-F stated she had witnessed NA-A transfer residents in a rough and unsafe manner, she reported this to the DON and administrator, and the facility failed to ensure all residents residing in the facility who required assistance from staff for transfers were protected from NA-A, who was allowed to continue working at the facility and continued to perform rough unsafe transfers for those residents who required assistance with transfers. The facility administrator, the director of nursing (DON), and the nurse consultant (NC)-A were notified of the IJ on 5/28/21, at 10:04 a.m. The IJ was removed on 5/28/21, at 2:29 p.m. but non-compliance remained at the lower scope and severity of D, potential for more than minimal harm that is not immediate jeopardy. Findings Include: R1's Admission Record printed 5/28/21, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had significant cognitive impairment, and required total assistance with transfers using a mechanical lift. R1's care plan initiated 12/17/18, indicated R1 required assistance with transfers. R1's care group sheet (nursing assistant care guide) printed 5/27/21, directed R1's transfers were to be completed with the assist of two staff and mechanical (Hoyer) lift. R2's Admission Record printed 5/28/21, indicated R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly MDS dated [DATE], indicated R2 had significant cognitive impairment, and required total assistance with transfers using a with mechanical lift. R2's care plan initiated 7/16/20, indicated R2 required assistance with transfers. R2's care plan further directed transfers were to be completed with the assistance of two staff and mechanical (Hoyer) lift. R2's care group sheet printed 5/27/21, directed R2's transfers were to be completed with the assistance of two staff and Hoyer lift. On 5/20/21, at 3:08 p.m. Minnesota Department of Health (MDH) received a video showing NA-A transferring R1 in his arms from her wheelchair. NA-A turned and roughly dropped R1 onto her bed. R1 was stating, Ow, ow during the transfer. A facility document by NA-F titled Mentor Evaluation Input dated 3/26/21, indicated NA-F had observed NA-A completing unsafe transfers. NA-F also included in her comments that during her training with NA-A it was hard to learn from him, and questioned if NA-A should be training new staff. NA-A was identified in the facility as a trainer and mentor for new staff. On 5/27/21, at 9:43 a.m. NA-B was interviewed and stated she had witnessed the rough, unsafe transfers by NA-A. NA-B stated she had reported this multiple times to nurse supervisors and the DON, and nothing had been done about it. NA-B stated herself, along with NA-C, NA-D, NA-E, had a meeting with human resources (HR)-A, the scheduling coordinator, the DON, and the administrator in March, 2021. NA-B stated they shared their concerns regarding NA-A which included rough, unsafe transfers and physically lifting residents into bed. NA-B stated during the meeting, the DON told them they were handling it. The DON stated, That's your beef? and stopped the meeting. On 5/27/21, at 10:22 a.m. NA-F was interviewed and stated she had witnessed NA-A perform rough, unsafe transfers many times. NA-F stated she had witnessed NA-A transferring R2 by picking her up in his arms and placing her in her bed. NA-F stated R2 had yelled out in pain during the transfer, and she immediately reported this to one of the nurses in charge. NA-F stated the nurse instructed her to put it in writing. NA-F stated she reported this to the DON in writing and put in in his mailbox. NA-F stated she later turned in her resignation partially due to her observations of NA-A's rough, unsafe transfers and training. NA-A stated she had also completed a Mentor Evaluation form where she documented her concerns with NA-A's rough, unsafe transfers. NA-F further stated NA-A told her he would deny everything if she reported him for rough, unsafe transfers of residents and that the facility would believe him over her. On 5/27/21, at 1:31 p.m. NA-D was interviewed and stated she had been at the meeting with administrative staff. NA-D stated she had brought her concerns regarding NA-A's rough, unsafe transfers verbally to the nurses and the DON and felt nothing had been done about it. On 5/27/21, at 1:33 p.m. NA-E was interviewed and stated she had attended the meeting with the administrative staff where NA-A's rough, unsafe transfers were discussed. NA-E stated she had not witnessed NA-A transfer residents unsafely, but had been told those concerns by other staff. On 5/27/21, at 2:46 p.m. NA-G stated she had observed NA-A transfer residents. NA-G stated she had reported this verbally to the nurses and the DON numerous times, however, nothing had been done to stop NA-A from performing the rough, unsafe transfers. On 5/27/21, at 2:52 p.m. NA-C stated she had observed NA-A transfer R1 many times by picking her up and putting her into bed. NA-C stated she was part of the meeting in March with administrative staff where they let them all know about NA-A's rough, unsafe transfers with R1. NA-C also stated she verbally had reported these concerns to the DON and was dismissed. On 5/27/21, at 3:37 p.m. the DON and administrator were interviewed together. The DON stated he expected all staff were providing cares for the residents per the individual care plan, and that staff were following the residents care guide sheet. The DON stated it would be unacceptable for a NA to physically lift and transfer the resident from their wheelchair to their bed rather than using the Hoyer lift. The DON and administrator both stated they had not been notified of any concerns with NA-A. The DON and administrator were informed a video was received which showed NA-A transferring R1 in his arms from her wheelchair, and he then turned and roughly dropped her onto her bed. The administrator stated the facility has a policy which prohibits staff from taking video/pictures /recordings of residents during cares or at any time. On 5/28/21, at 8:13 a.m. the DON and administrator both stated again they had not been informed of any concerns with NA-A and unsafe transfers. Both the DON and the administrator stated they did not recall being in a meeting with the HR assistant, the staffing coordinator, and the four NAs on 3/19/21. On 5/28/21, at 9:44 a.m. the DON and administrator both stated they went and reviewed their calendars and discovered there had been a meeting back in March, 2021. The DON stated the HR, the scheduling coordinator, the administrator, four NA staff and himself were all at the meeting. The DON stated his recollection was the meeting was about the facility being overstaffed, and staff was concerned about not getting overtime. The DON stated he felt the meeting was very inappropriate. The DON was asked again if concerns were brought up about NA-A's rough, unsafe transfer of residents. The DON stated during the meeting, there were multiple conversations going on at one time, but he did not recall information being discussed about one specific staff. On 5/28/21, at 10:01 a.m. with facility scheduling coordinator (SC)-A stated he collected the Mentor Evaluation Forms filled out by staff being trained. SC-A stated he reviewed them, and shared any relevant information with the DON and administrator. SC-A stated he remembered sharing the information NA-F documented on her Mentor Evaluation Form dated 3/26/2, indicating NA-F had observed NA-A completing unsafe transfers. The facility policy Maltreatment Prohibition Policy Plan revised 2/19/18, defined St. [NAME] Health Services of [NAME] (SFHS) has established the safeguards to prohibit Maltreatment (Abuse, Neglect, and Financial Exploitation) of any Vulnerable Adult in SFHS care centers. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. This also includes deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, spiritual and psychosocial well-being that causes physical harm, pain, or mental anguish. The policy directed it is the facility's responsibility to ensure the safety and wellbeing of the residents which included ensuring that all staff are trained and knowledgeable in how to react and respond appropriately. The policy further defined Neglect as the failure or refusal of a caregiver to provide for the elder's basic physical, emotional, or social needs, or failure to protect them from harm. This may include the facility's failure to provide necessary staff, supplies, services, policies, training, or staff supervision and oversight to meet the resident's needs. The IJ was removed on 5/28/21, when it was verified through staff interview and document review the facility implemented corrective action to prevent recurrence. Staff were educated on using mechanical lifts, when to report allegations of abuse, and residents were assessed and none had concerns of abuse.

Based on observation, interview, and document review, the facility failed to ensure the care plan was followed to prevent falls with injuries for 1 of 5 residents (R27) reviewed for accidents. This resulted in actual harm for R27. The facility had implemented corrective action prior to the survey, so the deficiency was issued as past non-compliance for R27. Findings include: R27's Face Sheet printed 2/27/20, indicated R27's [DIAGNOSES REDACTED]. R27's annual Minimum Data Set ((MDS) dated [DATE], indicated R27 was cognitively intact, did not display symptoms of [MEDICAL CONDITIONS], or behaviors, required assistance of two staff with transfers, extensive assistance of two staff with toilet use, was always incontinent of bladder, frequently incontinent of bowel, and was nonambulatory. R27's MDS further indicated R27 had a balance impairment, and required staff assistance to stabilize, and had one fall with injury since the previous MDS assessment. R27's General Nurse's Observation (GNO) notes dated 10/10/19, for quarterly MDS with an assessment date of 10/9/10, indicated R27 was alert, oriented, and was able to make needs known. R27's notes further indicated R27's fall risk assessment identified R27 as being at risk for falls, and had one fall since the previous assessment. R27's risk factors for falls included urinary incontinence, AKA, recurrent urinary tract infections, history of falls, hypertension, and history of self transfers. R27's notes identified potential side effects of [MEDICAL CONDITION] medications received by R27, including dizziness, sedation, and agitation. R27's notes further indicated R27 required extensive assistance with toileting tasks, and transfers to and from the toilet. R27 was identified as being nonambulatory, and used a stand assist lift with two staff for transfers. R27 experienced urge incontinence and had difficulty getting to the bathroom in time, which had been exacerbated by the need for staff assistance with transfers. R27's note indicated R27 was previously able to transfer self to the toilet, and required assistance to get off the toilet. R27 was able to notify staff of urge to void or defecate. R27 chose not to have a lower extremity prosthesis. R27's care plan initiated 5/2/17, indicated R27 was nonambulatory, and required two staff assist with hoyer (mechanical lift) transfers, with a goal of using the stand assist lift following healing of the calcaneous (heel bone) fracture. R27's care plan further identified R27 as at risk for falls or injury related to an expected decline in physical condition. Interventions related to fall risk included assist with mobility and transfers, encourage R27 to ask for assistance with transfers and to use call light, keep call light in easy reach, and pendant necklace/call light. R27's Physicians Order Sheet printed 2/27/20, included orders for medications with potential side effects of dizziness or low blood pressure, including [MEDICATION NAME] (for anxiety), [MEDICATION NAME] (for high blood pressure), [MEDICATION NAME] (for high blood pressure), losartan potassium (for high blood pressure)and, [MEDICATION NAME] (for [MEDICAL CONDITION]). R27's Incident Details report for a fall dated 6/14/19, at 3:45 p.m. indicated R27 was reaching to water plants, and rolled out of her wheelchair, due to lack of support on that side related to amputation of lower leg. In addition, R27's wheelchair cushion was on the floor, under R27 in front of the wheelchair. R27 was reminded to call for help when necessary and not to reach out. R27's blood pressure was 115/68 at the time of the incident. R27's Incident Details report dated 6/14/19, indicated corrective measures taken included frequent safety checks, requested order for occupational therapy (OT) to look at wheelchair cushion and potentially find a more appropriate cushion that may fasten in wheelchair. R27's incident report note dated 7/3/19, indicated interdisciplinary team (IDT) had met, and concluded R27 had leaned too far forward, and this conclusion was accurate, and intervention of educating R27 had been effective. R27 had continued to use the call light appropriately. R27's Incident Details report for a fall dated 7/23/19, at 9:10 p.m. indicated R27 had fallen near the dresser while reaching for a piece of clothing. R27's care plan had been determined to have been followed, and there were no environmental concerns that contributed to R27's fall. R27's incident report note dated 7/24/19, indicated IDT determined R27's dresser was too far back, and R27 had difficulty reaching her items. R27's incident report follow up note dated 7/29/19, indicated the interventions implemented of adjusting the dresser and rearranging clothes was appropriate. R27 was able to reach her clothes. R27's Incident Details report for a fall on 8/10/19, at 11:20 a.m. indicated R27 fell in the bathroom during a staff-assisted transfer. R27 had needed to use the bathroom and did not want to wait for the mechanical lift, so the nursing assistant (NA) used a pivot disc (circular disc that the resident stands on, and the disc is turned to pivot the resident to another direction), and did not ask for assistance in transferring R27. R27 fell to the ground, complained of right ankle pain, winced when trying to move her right ankle, and stated she had felt her ankle snap when she hit the floor. R27's incident report IDT note dated 8/12/19, indicated R27 fell due to inappropriate transfer and not following the care plan. R27's IDT intervention was staff education to follow group sheets as they were an extension of the care plan. R27's incident report IDT follow-up note indicated education of staff was appropriate as it was the key factor in R27's fall. The facility email to all staff dated 8/12/19, directed R27's care staff to use a hoyer lift for transfers, and R27 was non-weight bearing on the left foot. The email also directed staff to read group sheets before transferring all residents, as the group sheets were an extension of the care plan. The facility email to all staff dated 8/13/19, directed staff to follow the care plan and group sheets in detail at all times. In addition, staff were to fill out care sheets completely, get them signed and handed in at the end of each shift. Not following the care plan/sheet is not an optional matter and if not followed may lead to a disciplinary event for the employee. R27's Physical Therapy (PT) Evaluation and Plan of Treatment dated 10/4/19, indicated R27 had been referred to PT for transfers following a left calcaneal (heel) fracture on 8/10/19. R27 had received full-weight-bearing orders on 10/3/19. On 2/26/20, at 10:37 a.m. R27 was observed to be transferred into bed using the hoyer with the assistance of NA-C and NA-E. No concerns were noted. On 2/27/20, at 10:52 a.m. NA-F stated R27 was always to have two to transfer, and they were always to use two to transfer when using mechanical lifts. NA-F stated she was aware of R27's fall with the fracture due to the care plan not being followed. NA-F stated they were to transfer residents according to the care guide sheets. On 2/27/20, at 2:00 p.m. registered nurse (RN)-A verified R27 had fallen due to the staff not following the care plan, and staff were to follow the care plan. RN-A stated the responsible staff member was no longer employed at the facility. RN-A stated all staff were educated, and other residents at risk were identified for incidents such as R27's when the care plan was not followed. On 2/27/20, at 2:24 p.m. the director of nursing (DON) stated they investigated R27's fall on 8/10/19, and the NA had made a decision not to follow the care plan, and transferred R27 inappropriately. The DON stated R27 was having bowel urgency, was persuasive, and the NA felt R27 was going to self-transfer, so the NA used the pivot disc, which should not have been in R27's room. The DON stated the other staff knew what to do when questioned. The DON stated they had provided education following the incident, and sent out a communication to all staff using their internal communication system. The DON stated it was the expectation all staff read the updates. The DON stated he also met with staff often times on days and afternoons at shift change. On 2/27/20, at 4:15 p.m. the DON stated the RN managers continued to be out on the floor frequently, and were auditing/observing transfers. The DON stated NAs tell the RN managers if the resident were having difficulty or changes in transfers. The DON stated NA care sheets were signed and turned in at the end of the shift, signed by the supervisor or nurse, reviewed by the RN managers and signed, and then went to the DON. The facility had implemented corrective action to prevent recurrence by 8/15/19, when it was verified education had been provided to all staff members regarding transfers and following the care plan/care sheets, and the facility began observing/auditing transfers. The implemented corrective actions were verified by interview with staff and audit/ policy review. The facility policy Fall Prevention and Management dated 4/17, directed nursing staff to complete a post-fall assessment to include a determination of whether any neglect had occurred, such as if the care plan was not followed and resulted in a fall. If neglect occurred, the administrative staff would be notified and a report would be made to the state agency. The policy further directed the completion of a root cause analysis of the fall and initiation of interventions according to the determined cause of the fall to assist in preventing further falls.

Based on interview and document review, the facility failed to ensure a system to identity a resident's Physician order [REDACTED]. This resulted in an immediate jeopardy (IJ) situation placing the resident at risk for death in the event their heart stopped beating, and their breathing ceased. The immediate jeopardy began on [DATE], when it was identified that R7's wishes for CPR would not be honored when the facility failed to properly identify R7's accurate code status by not having her name on the Full Code Status clipboard kept at both nursing stations. The Full Code Status clipboard was available at the nursing stations for quick staff reference in the event of a cardiac event. However, R7's orders in the Electronic Medical Record (EMR), and signed POLST all indicated R7's wishes were to be full code resuscitation status. The administrator and director of nursing (DON) were informed of the IJ on [DATE], at 4:38 p.m. The IJ was removed on [DATE], at 3:32 p.m. but non-compliance remained at the lower scope and severity of a D, no actual harm with potential for more than minimal harm. Findings include: The facility policy Advance Care Planning reviewed [DATE], directed a POLST would be filled out and signed by the resident and/or their legal representative upon admission. The policy directed staff to initiate CPR on resident with a CPR status unless the [MEDICAL CONDITION] was unwitnessed and obvious signs of clinical death e.g. rigor mortis, decapitation or decomposition were present. The policy lacked direction on where staff would obtain code status information in the event of a resident having a cardiac emergency. The facility policy Procedure for CPR undated, directed residents who have elected Full Code status would be identified by their POLST located in their hard chart, or by the Full Code clipboard at the nursing stations. R7's Face Sheet printed [DATE], indicated R7's [DIAGNOSES REDACTED]. The Face Sheet also indicated R7 had CPR status on file. R7's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R7 had intact cognition, and required staff assistance with activities of daily living (ADLs). R7's POLST dated [DATE], signed by R7 and R7's physician identified R7 wished were to be a full code resuscitation status in the event R7 had no pulse and was not breathing. However, R7 was not listed on the undated Full Code Status clipboard at the nursing station. On [DATE], at 9:38 a.m. the Full Code Status clipboard was observed to not have R7's name listed, indicating she was a do not resuscitate/do not intubate (DNR/DNI) resuscitation status. On [DATE], at 9:59 a.m. licensed practical nurse (LPN)-A stated she would look in the paper chart for code status, but stated she has used the Full Code Status clipboard in the past. On [DATE], at 10:09 a.m. registered nurse (RN)-B stated she would reference the Full Code Status clipboard for code status. On [DATE], at 10:15 a.m. nursing assistant (NA)-A stated she would check the Full Code Status clipboard, and said it was updated monthly. On [DATE], at 10:55 a.m. the DON stated he expected staff to reference the Full Code Status clipboards for code status. The DON further stated that if a resident's name was not on the Full Code Status clipboard, they would not do CPR on that resident. The DON stated the social services director updated the list when there were new admissions. It was not able to be determined when the clipboard had last been updated. On [DATE], at 11:41 a.m. R7 was interviewed and stated she didn't remember if they asked her about CPR status upon admission, but if her heart were to stop, she would want them to restart it. On [DATE], at 3:43 p.m. R7's physician (MD)-A was interviewed and stated R7 was to receive CPR. The immediate jeopardy that began on [DATE], was removed on [DATE], at 3:32 p.m. when the facility took the following actions and was verified as implemented. However, the noncompliance remained at the lower scope and severity level of a D (no actual harm, with potential for more than minimal harm). -development of a new policy that eliminated the Full Code Status clipboard, and eliminated a colored sticker system on the front of the paper charts. -all staff were re-educated before their next shift to look for code status on the POLST or on the resident's electronic record for code status. -reviewed all resident's code status, and ensured the POLST and the EMR matched for each resident.

Based on interviews and record review the facility failed to ensure that one of six residents (R1) was free of significant medications errors when staff failed to administer R1's acetazolimde/[MEDICATION NAME] medication for six days. R1 suffered harm when staff failed to administer [MEDICATION NAME]. As a result, the hospital admitted R1 with low oxygen levels along with high carbon [MEDICATION NAME] levels in his blood, shortness of breath, and an irregular heartbeat. Findings include: R1's medical record was reviewed and indicated R1's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Medication Administration Record [REDACTED]. Nurse's notes dated 12/17/17, and 12/20/17, indicated LPN-J accidently marked the [MEDICATION NAME] given on the MAR. A nurse's note dated 12/21/17, indicated R1's [MEDICATION NAME] medication was not present on the medication cart since 12/15/17, staff pharmacy contacted, staff previously requested medication from pharmacy earlier in the week and no was medication delivered. Staff contacted the physician. R1was asymptomatic with no signs of fluid overload. A nurse's note dated 12/22/17, 3:35 p.m. indicated R1's oxygen saturation level in his blood was 84 percent in the morning. R1 received oxygen 2 liters per minute per nasal cannula to and his oxygen saturation level went up to 97 percent. R1's lungs sounds had expiratory wheezes and where diminished in the bases bi-laterally. R1 had no shortness of breath. R1 left the facility at at 12:00 p.m. to a clinic appointment and refused to wear his oxygen at that time. R1's son called the facility at approximately 1:00 p.m. to inform the facility that the clinic sent R1 to the hospital. Hospital records dated 12/2217 , indicated the hospital admitted R1 with low oxygen levels along with high carbon [MEDICATION NAME] levels in his/her blood, shortness of breath, and an irregular heartbeat. During an interview on 01/03/18, at 10:29 a.m., the resident stated he was not aware that he did not receive his/her [MEDICATION NAME] for five days. The resident stated there was a mix up with the pharmacy and the mistake was not the fault of the facility nurses. The resident stated he needed to go the hospital to get his oxygen level back to normal although he was not upset and experienced no pain. During an interview on 01/03/18, at 2:02 p.m. registered nurse supervisor (RN)-C stated she was was caring for R1 on 12/21/17, and got report that R1's [MEDICATION NAME] medication was missing. RN-C immediately called the pharmacy. RN-C stated the pharmacy delivered the medication in the evening at approximately 9:30 p.m. RN-C stated R1 did not receive a dose that day because R1 was clinically stable and sleeping. During an interview on 01/03/18, at 2:42 p.m. , registered nurse supervisor (RN)-D stated she did not know that R1's [MEDICATION NAME] medication was missing. RN-D stated she did not administer medication to R1 during the week of 12/16/18, not until 12/22/17. RN-D stated R1 had a low oxygen level and she administered oxygen on 12/22/18, prior to a clinic appointment. RN-D stated on 12/22/17, the clinic nurse called a critical carbon [MEDICATION NAME] level to the facility just before R1 went to the hospital. During an interview on 01/23/18, at 1:23 p.m., the pharmacist (P)-H stated that the facility called the pharmacy to report that R1 was missing his [MEDICATION NAME] medication on 12/21/17. The pharmacy sent 4 tablets of [MEDICATION NAME] 250 mg tablets to the facility on [DATE]. During an interview on 01/23/18, at 1:59 p.m. licensed practical nurse (LPN)-J stated R1's [MEDICATION NAME] medication was missing on two separate occasions. She did not recall the exact dates. LPN-J stated she notified the pharmacy both times and the pharmacy did not deliver the medication. During an interview on 02/05/18, at 2:08 p.m., licensed practical nurse (LPN)-N stated she cared for R1 for several days during the week of 12/16/18. LPN-N stated that on 12/16/18, R1's [MEDICATION NAME] was missing. LPN-N reported the missing medication to the nursing supervisor. LPN-N could not recall the name of the nursing supervisor. The nursing supervisor told LPN-N that the nursing supervisor would call the pharmacy. LPN-N stated the next day R1's [MEDICATION NAME] was missing, and LPN-N assumed that the pharmacy was checking R1's insurance and would send the medication. LPN-N stated she could not recall if the medication was missing on other days that week. LPN-N stated she is new and learning. A policy titled, Medication Errors undated, indicated all medications prescribed do need to be administered as prescribed. A policy titled, Missing/Unavailable Medications dated 11/10/15, indicated if a resident's medication is missing that staff notify the physician if the pharmacy is unable to deliver the medication.