Every finding on record at French Prairie Nursing & Rehabilitation Center

Based on observation, interview and record review it was determined the facility failed to utilize an available AED (Automated External Defibrillator- a portable device that checks heart rhythm and can send an electric shock to restart a normal heart rhythm) as part of Basic Life Support (BLS) for 1 of 1 sampled resident (#61), and failed to ensure licensed nurses were certified for BLS and familiar with use of the AED for 10 of 21 licensed nursing staff (#s 3, 8, 28, 31, 43, 44, 45, 46, 47, 48) reviewed for CPR. This failure was determined to be an Immediate Jeopardy situation (IJ) on [DATE] after it was determined that residents were at risk for not receiving full life-saving measures because licensed nurses who were actively working were not currently certified for BLS, not familiar with when to use the AED, and not familiar with the location and process for using the AED. Resident 61, who was to receive full life-saving measures, was pulseless, not breathing, and was unable to be revived after staff failed to utilize the available AED. Findings include:The 2025 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Adult Basic Life Support Algorithm indicated to send someone to get the AED after checking patient responsiveness and activating the emergency response system (call 911), and to use AED as soon as it is available. In addition, the 2025 AHA Guidelines stated early defibrillation is essential for survival and first-shock defibrillation success rates were 93% when the first shock occurred within 6 minutes and every minute of delay to first shock was associated with a 6% decreased probability of survival. The facility's 3/2026 CPR policy stated, When cardiac or respiratory arrest occurs, facility staff will initiate basic life support and CPR for residents who do not show obvious clinical signs of irreversible death and who have requested CPR in their advance directive. The facility's 3/2026 CPR Certification policy stated, All licensed nurses will have CPR certification for health care providers validated upon employment and will maintain current CPR certification during employment. Resident 61 was admitted to the facility in 2/2026 with diagnoses including chronic respiratory failure and esophageal cancer. On [DATE] Resident 61 signed a Portable Orders for Life Sustaining Treatment (POLST) form which indicated full treatment of life saving measures. A public complaint was received on [DATE] alleging facility staff did not attempt to utilize the facility's available AED when Resident 61 needed BLS. A [DATE] Progress Note written by Staff 3 (LPN) indicated Resident 61 had difficulty breathing even with the use of supplemental oxygen and a nebulizer treatment (liquid medicine inhaled to treat respiratory issues). The note documented facility staff called 911 and initiated CPR. The note documented Resident 61 passed away at 1:45 AM. From [DATE] through [DATE] an AED device was observed in the facility at the nurses station. The device was clearly marked and visible. On [DATE] at 11:01 AM and [DATE] at 2:00 PM Staff 3 (LPN) stated on [DATE] she performed CPR on Resident 61 with Staff 4 (LPN) and Staff 5 (CNA). Staff 3 stated 911 was called because the resident had trouble breathing, but after calling 911 the resident stopped breathing, had no pulse, and needed BLS. Staff 3 indicated chest compressions and breathing were completed, but the AED was not used. Staff 3 stated approximately four cycles of compressions and breathing were completed before paramedics arrived and took over. Staff 3 expressed belief that it was appropriate to provide at least five rounds of compressions and breaths before getting the AED, and the AED was not needed for Resident 61. (This information is contrary to AHA guidelines for BLS.)On [DATE] at 1:18 PM Staff 28 (LPN) indicated he did not know where the AED was located in the facility.On [DATE] at 6:45 PM Staff 4 (LPN) indicated it would have been appropriate to use an AED with Resident 61, but she did not know if the facility had an AED device. Staff 4 further stated neither of the other staff involved obtained or used an AED with Resident 61. On [DATE] at 7:02 PM and [DATE] at 9:53 AM Staff 5 (CNA) stated the AED was not obtained or used during CPR for Resident 61. Staff 5 stated her understanding of BLS was to obtain the AED as soon as possible. Staff 5 indicated the AED could have been obtained quickly since there were three staff members available. On [DATE] at 10:03 AM Staff 8 (LPN) was unable to articulate the process of using an AED as part of BLS, indicated she was not trained in BLS, did not know how to use the AED, or where the AED was located in the facility. On [DATE] at 8:18 AM Staff 53 (RN) stated she did not know where the AED was located in the facility. On [DATE] the facility provided a list of current residents and 36 of the 51 residents had a POLST or advance directive which indicated full life saving measures. On [DATE] the facility provided copies of Basic Life Support certifications for facility and agency staff. A review of these certifications revealed the following licensed nurses did not have current BLS certifications:Staff 28 (LPN): expired 1/2026Staff 31 (LPN): expired 2/2026Staff 43 (LPN): expired, unknown date. Staff 44 (LPN): expired 10/2023Staff 45 (LPN): expired 1/2024Staff 46 (LPN): expired 3/2026Staff 47 (RN): expired 2/2026Staff 48 (RN): expired 12/2024A review of staff schedules from [DATE] through [DATE] revealed the eight identified staff members without current BLS certification were assigned to work in the facility on various shifts during that time span. On [DATE] at 9:53 AM Witness 14 (EMT) stated facility staff called 911 and reported Resident 61 had a problem with breathing. Witness 14 stated she was dispatched to the facility at 1:05 AM and arrived at 1:11 AM. Upon arrival, Witness 14 observed staff performing CPR without use of the AED. Since the facility staff failed to notify emergency services that Resident 61 had a cardiac issue prior to her arrival at the facility, Witness 14 had to return to her vehicle to obtain the cardiac code equipment, including a defibrillator, which delayed use of the defibrillator. On [DATE] at 11:11 AM and [DATE] at 9:27 AM Staff 2 (DNS) stated licensed nurses were responsible for performing BLS and were required to have current BLS certification. Staff 2 stated the AED was to be obtained and used as soon as possible when CPR was administered. Staff 2 acknowledged licensed nurses did not properly perform the steps of BLS and did not use the available AED when they provided CPR to Resident 61. Staff 2 acknowledged the facility did not provide oversight to ensure all staff who worked in the facility had current BLS certification, and were proficient in providing BLS, including use of an AED. On [DATE] at 8:42 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified that the failure to ensure residents received appropriate BLS, including use of the AED, placed all Full Code Status residents at immediate risk and constituted an Immediate Jeopardy (IJ) situation. An IJ removal plan was requested related to the following findings:-Licensed nurses failed to properly complete the steps of BLS by not obtaining or using an AED during CPR for Resident 61 on [DATE]. -Licensed nurses actively working in the facility were unable to identify the AED location and demonstrated poor knowledge for the use of an AED during CPR. -The facility failed to provide oversight of staff training, proficiency, and certification of BLS.On [DATE] at 9:33 PM the facility provided an immediacy removal plan. The plan included the following:1. Immediate staff education- all licensed nurses working at the time of the IJ received immediate education related to the steps of BLS. All licensed nurses were to receive the same education prior to the start of subsequent shifts.2. AED verification- the facility identified the AED location and accessibility, battery status, electrode pad expiration dates, and functionality based on manufacturer recommendations.3. Competency validation- all licensed nurses on duty at the time of the IJ demonstrated proper AED retrieval, proper pad placement, safe AED operation, and initiation of CPR per the American Heart Association BLS guidelines.4. Certification review- the facility completed an audit to identify licensed nurses with expired BLS certifications, removed them from the schedule, and expedited BLS classes were scheduled. On [DATE] at 10:41 AM Staff 1 (Administrator) was notified the survey team verified completion of the IJ removal plan, and the immediacy was removed.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 3 of 7 sampled residents (#s 42, 51 and 62) reviewed for medications and hospitalizations. This failure resulted in Resident 51 experiencing a ten-minute seizure and being sent to the hospital for evaluation subsequent to not receiving antiseizure medication as ordered, and placed additional residents at risk for reduced efficacy of medication and adverse side effects of medication. Findings include: 1. Resident 51 admitted to the facility in 2025 with diagnoses including depression. On 5/18/26 the resident was diagnosed with epilepsy (a brain disorder that causes unprovoked seizures). The 6/23/26 physician order indicated Resident 51 was to receive Depakote (anticonvulsant medication) 250 mg once daily and Depakote 500 mg at bedtime for epilepsy. According to medlineplus.gov antiseizure medications must be taken on time and as directed, and missing a dose can cause seizures. The 7/2026 MAR report indicated Resident 51 received Depakote late on the following occasions: -7/1/26 8:00 AM Depakote was administered at 10:25 AM. -7/2/26 7:00 PM Depakote was administered at 8:52 PM. -7/6/26 8:00 AM Depakote was administered at 11:32 AM. -7/8/26 8:00 AM Depakote was administered at 4:17 PM. -7/9/26 8:00 AM Depakote was administered at 3:09 PM. -7/10/26 8:00 AM Depakote was administered at 9:48 AM. -7/12/26 8:00 AM Depakote was administered at 12:03 PM. -7/13/26 8:00 AM Depakote was administered at 11:19 AM. -7/14/26 8:00 AM Depakote was administered at 9:32 AM. -7/21/26 7:00 PM Depakote was administered at 8:15 AM. -7/23/26 7:00 PM Depakote was administered on 7/24/26 at 1:19 AM. -7/24/26 7:00 PM Depakote was administered at 11:38 PM. -7/25/26 8:00 AM Depakote was administered at 9:04 AM. -7/25/26 7:00 PM Depakote was administered at 8:05 PM. -7/27/26 8:00 AM Depakote was administered at 9:51 AM. -7/29/26 7:00 PM Depakote was administered at 10:04 PM. -7/30/26 7:00 PM Depakote was administered on 7/31/26 at 12:04 AM. -7/31/26 8:00 AM Depakote was administered at 10:08 AM. The 7/10/26 progress note indicated Resident 51 had a seizure on 7/10/26 that lasted 10 minutes. The resident was sent to the hospital and returned to the facility on the same day. On 8/3/26 at 9:49 AM Witness 12 (Family Member) stated Resident 51's Depakote was not given on time and the resident was observed to receive Depakote up to three hours late. Witness 12 further stated Resident 51 had a seizure in July 2026. On 8/10/26 at 8:36 AM Staff 2 (DNS) acknowledged Resident 51 had a seizure on 7/10/26 and was sent to the hospital for further evaluation. Staff 2 acknowledged the late Depakote administrations and provided no additional information. b. The 6/10/26 pharmacy recommendation indicated Resident 51 had an order for lorazepam 1 mg/0.5 ml every six hours PRN for seizures. A rationale and duration was requested for the extended use of lorazepam. On 6/12/26 the physician signed the recommendation and ordered to continue lorazepam 1 mg/0.5 ml oral concentration PRN for active seizure treatment for 180 days. The 7/2026 MARs indicated lorazepam was discontinued on 7/9/26. A review of the clinical record was completed, and no physician order or a rationale was found to indicate why the lorazepam was discontinued. The 7/10/26 progress note indicated Resident 51 had a seizure on 7/10/26 that lasted 10 minutes, the resident was sent to the hospital and returned to the facility on the same day. The 7/2026 MAR indicated Resident 51 did not receive a lorazepam when needed for the seizure on 7/10/26. On 8/3/26 at 9:49 AM Witness 12 (Family Member) stated Resident 51 had a seizure in July 2026 and she had to fight and fight to get Resident 51's lorazepam order. On 8/10/26 at 10:30 AM Staff 2 (DNS) acknowledged Resident 51's 6/12/26 order for lorazepam was discontinued without an order or rationale. 2. Resident 62 admitted to the facility on [DATE] with diagnoses including aortic valve stenosis (narrowing of a heart valve). The 7/10/26 physician order indicated Resident 62 was to receive warfarin (anticoagulant medication) 6 mg once daily on 7/10/26 and 7/11/26. The 7/2026 MAR did not include a 7/10/26 or 7/11/16 warfarin order. The 7/12/26 progress note indicated Resident 62's 7/10/26 warfarin order was not inputted into the electronic health record (EHR), and Resident 62 missed her/his warfarin dose on 7/10/26 or 7/11/26. Resident 62 went to the hospital for evaluation and not return to the facility. A 7/12/26 Emergency Department note indicates Resident 62 was not admitted to the hospital and chose to not return to the nursing facility. On 8/5/26 at 1:49 PM Staff 43 (LPN) stated he did not input the 7/10/26 warfarin order on 7/10/26. Staff 43 noticed on 7/12/26 the resident missed two doses of warfarin and contacted the on-call physician. The on-call physician advised to send Resident 62 to the hospital. On 8/7/26 at 3:22 PM Staff 2 (DNS) stated staff were to enter new orders into the EHR immediately upon receiving them from the physician. Staff 2 acknowledged Resident 62 missed two doses of warfarin and was sent out to the hospital. 3. Resident 42 admitted to the facility in 2/2025 with diagnoses including hemiplegia (weakness to one side of the body). a. The 5/28/26 physician order indicated Resident 42 was to receive Lantus (insulin medication) 30 units in the morning and Lantus 14 units at bedtime. From 6/3/26 to 8/8/26 the MAR indicated 23 times when the Lantus was administered between 2 and 12 hours late. On 8/3/26 at 11:33 AM Witness 13 (Family Member) stated Resident 42's Lantus was not given on time, and she expressed awareness of the Lantus being administered up to four hours late. On 8/5/26 at 2:10 PM Staff 43 (LPN) stated he administered Resident 42's Lantus late on several occasions due to lack of nursing staff, but could not recall specific dates. On 8/7/26 at 3:23 PM Staff 2 (DNS) stated medications were to be administered within one hour before or after the scheduled administration time. Staff 2 acknowledged the late administration of Resident 42's Lantus on the identified dates. b. The 6/4/26 physician order indicated Resident 42 was to receive carbamazepine (seizure medication) 50 mg two times a day. The 6/2026 and 8/2026 MARs report indicated Resident 42 received carbamazepine late on the following occasions: -6/3/26 8:00 AM carbamazepine was administered at 10:49 AM. -6/17/26 8:00 AM carbamazepine was administered at 11:39 AM. -6/28/26 8:00 AM carbamazepine was administered at 9:10 AM. -8/3/26 8:00 AM carbamazepine was administered at 10:10 AM. On 8/3/26 at 11:33 AM Witness 13 (Family Member) stated Resident 42's morning medications were not given on time on 6/3/26, 6/17/26, 6/28/26 and 8/3/26. On 8/5/26 at 2:10 PM Staff 43 (LPN) stated he administered Resident 42's carbamazepine late on several occasions due to lack of nursing staff, but could not recall specific dates. On 8/7/26 at 3:23 PM Staff 2 (DNS) stated medications were to be administered within one hour before or after the scheduled administration time. Staff 2 acknowledged the late administration of Resident 42's carbamazepine.

Based on observation, interview and record review it was determined the facility failed to follow physician orders related to wound care for 3 of 3 sampled residents (#s 13, 28 and 60) reviewed for wounds and 6 of 8 sampled residents (#s 2, 11, 13, 24, 51, and 58) reviewed for bowel care and medications. This deficient practice resulted in an actual wound infection for Resident 60 requiring antibiotics and placed residents at risk for worsening wounds, increased risk for infection, pain, constipation and unmet care needs. Findings include: 1. Resident 60 was admitted to the facility on [DATE] with a diagnosis including diverticulitis of the large intestine with perforation and abscess. The care plan initiated on 6/25/26 revealed Resident 60 had an impairment to her/his skin integrity due to a surgical site to the abdomen. The 6/29/26 admission MDS revealed Resident 60 had a BIMS score of 15, indicating she/he was cognitively intact. It also revealed Resident 60 had surgical wound(s) and received surgical wound care. The 6/25/26 Nursing admission Evaluation revealed the resident had a surgical incision with a dressing present to the abdomen. A 6/26/26 at 12:45 AM Physician Order revealed an order indicating to change the abdominal dressing as needed for soilage until further orders from the surgical team or facility provider were received. Review of the TAR from 6/2026-7/2026 lacked evidence that facility staff completed Resident 60's surgical wound care as ordered from 6/26/26 (one day after Resident 60's admission) to 7/2/26, a period of seven days. On 7/6/26 a public complaint was received by the State Agency alleging the facility failed to provide Resident 60 with wound care and on 7/2/26 the resident was sent to the emergency room. A 7/2/26 at 3:18 AM Progress Note by Staff 57 (LPN) revealed Resident 60 was concerned about no output in her/his colostomy and Staff 57 called the on-call physician via video. Staff 57 removed the packing in the abdominal incision, and the abdominal incision was viewed by the on-call physician via video. The physician directed staff to send Resident 60 to the emergency room for concerns of an infection. The 7/2/26 Hospital Provider Note revealed Resident 60 reported sharp abdominal pain, nausea and the resident stated she/he was concerned of infection due to delayed dressing change at the facility. The note stated Resident 60 had an incision to the right of her/his belly button with pus like drainage. A CT (computed tomography) scan of the abdomen was completed and revealed a small fluid collection at the abdominal wound. Resident 60 was diagnosed with a wound infection. The wound was repacked and dressed; an antibiotic was ordered along with the following wound care order: -Remove wound packing and irrigate the wound with saline once a day and PRN. Clean the area around the wound with Vashe or skin cleanser and pat dry. Repack the wound with the silver packing or packing strips once a day and PRN if packing becomes dirty. Cover with a clean dressing and change dressing daily with wound packing and PRN if dressing becomes soiled or saturated. A 7/2/26 at 5:56 PM Progress Note by Staff 58 (LPN) revealed Resident 60 returned to the facility from the hospital with a new order for amoxicillin-potassium clauvate (an antibiotic) 875-125 MG BID. A review of the 7/2026 TAR revealed the physician wound care order for the abdominal wound was not implemented upon Resident 60's return from the hospital on 7/2/26. Resident 60 did not receive any wound care from 7/3/26 to 7/5/26 (three days). A 7/6/26 at 6:00 AM Physician Order revealed staff were to complete wound care to Resident 60's lower abdomen once a day by cleansing the area with wound cleanser and applying a dry dressing. On 8/7/26 at 4:29 PM Staff 57 stated she admitted Resident 60 to the facility in the evening on 6/25/26 and after completion of the Nursing admission Evaluation realized the resident had an abdominal wound with a dressing and no wound care orders. Staff 57 stated she called the on-call provider to obtain wound care orders and was provided with a PRN order and was told to have the facility house doctor follow up the next day to provide further orders. Staff 57 stated she placed that information in Staff 59's (Former LPN Unit Manager) box. Staff 57 stated during her next shift she followed up with Staff 59 and Staff 27 (Former DNS) to ask where Resident 60's scheduled wound care orders were. Staff 57 stated Staff 27 asked Staff 59 to assess Resident 60's abdominal wound and Staff 59 stated she already had. Staff 57 stated later in her shift Resident 60 was complaining of no output in her/his colostomy and possible blood in the colostomy bag. Staff 57 stated she called the on-call provider via video, and the provider assessed the abdominal wound after she took out the packing, and she was directed to send Resident 60 to the emergency room. On 8/10/26 at 12:16 PM attempts to reach Staff 59 via phone and text message were unsuccessful. On 8/10/26 at 12:25 PM Staff 27 stated she recalled asking Staff 59 about Resident 60's abdominal wound care and what currently was ordered for the resident. Staff 27 stated Staff 59 said the wound was being packed and she saw it that day. Staff 27 stated she trusted Staff 59, as Staff 59 was also the wound nurse at the time. On 8/10/26 at 1:17 PM Staff 2 (DNS) confirmed Resident 60 had PRN abdominal wound care orders effective on 6/26/26 with no dressing changes completed. Staff 2 confirmed Resident 60 did not have any scheduled wound care orders and no wound care completed from 6/25/26 to 7/2/26 (seven days). Staff 2 confirmed Resident 60 did not have scheduled wound care orders implemented when the resident returned from the hospital emergency room from 7/2/26 to 7/6/26 (four days) and did not receive any PRN wound care treatments during that time. 2. Resident 2 was admitted to the facility in 5/2022 with diagnoses including dementia and constipation. The 7/13/26 physician orders indicated Resident 2 was to receive the following PRN bowel care medication for constipation: -milk of magnesia 400 MG/ 5 ML, give 30 ML PRN. -lactulose solution 30 ML every 12 hours PRN. -bisacodyl suppository PRN. -Dulcolax Suppository 10 MG once every 24 hours if not relieved by bisacodyl tablet. Notify physician if more than four days since last bowel movement. Resident 2's 7/2026 bowel records indicated the following days with no bowel movement: -7/6/26 through 7/12/26 (Seven days without a bowel movement) -7/15/26 through 7/18/26 (Four days without a bowel movement) -7/25/26 through 7/30/26 (Six days without a bowel movement) A review of Resident 2's 7/2026 MAR revealed the following: -7/6/26 through 7/12/26, Resident 2 received PRN milk of magnesium and PRN lactulose on 7/12/26 (day seven of no bowel movement). -7/15/26 through 7/18/26 there was no indication any PRN bowel care medications were offered or administered. -7/25/26 through 7/30/26 there was no indication any PRN bowel care medications were offered or administered. A review of Resident 2's progress notes revealed the resident's physician was not notified of not having a bowel movement for more than four days for the dates identified. On 8/10/26 at 11:39 AM Staff 17 (LPN Unit Manager) acknowledged Resident 2 did not have a bowel movement on the identified dates; the physician orders were not followed, and the bowel protocol was not implemented. On 8/10/26 at 1:06 PM Staff 2 (DNS) stated if a resident did not have a bowel movement for three days she expected staff to implement the PRN bowel care medications and on day four the physician was to be notified. Staff 2 acknowledged Resident 2's physician orders for bowel care were not followed. 3. Resident 28 was admitted to the facility in 2023 with diagnoses including stroke, DMII, PVD, Venous insufficiency, non-pressure chronic ulcer. The facility policy for Clean Dressing Change dated 3/2026 states: Physician's orders will specify type of dressing and frequency of changes. Resident 28's physician orders on 7/27/26 and 7/29/26 included the following: Wound care to left leg: cleanse with Vashe (wound cleanser), cover wound bed with collagen dressing followed by Optilock (absorbent dressing), then wrap the leg with two-layer Unna boot (compression dressing). Wound care to front of right leg: cleanse with Vashe, cover wound bed with collagen dressing followed by Optilock, then wrap the leg with two-layer Unna boot. According to Wound Care Advisor Journal, https://woundcareadvisor.com/unna-boot/, an Unna boot consists of a pre-moistened gauze covered with zinc, calamine, or glycerin and wrapped from the base of the toes to an inch below the knee using a spiral technique overlapping prior layers by 75% and secured with a stretch, cohesive wrap. Progress notes dated 8/4/26 at 11:11 PM and 8/3/26 at 2:36 PM Staff 31 (LPN) documented the use of two-layer Unna boots for wound care to the left and right leg. On 8/5/26 at 3:06 PM Staff 28 (LPN) was observed to remove two-layer compression dressings (not Unna boots) from Resident 28's bilateral lower legs. Staff 28 (LPN) applied collagen with Ag+ (silver) to the resident's bilateral leg wound beds. Staff 28 wrapped the Unna gauze around Resident 28's left lower leg and mid-calf several times then descended to cover the heel, but not the foot, then back up in large loops around the calf with the gauze twisted. Staff 28 did not have scissors and proceeded to wrap extra Unna gauze around the calf. Staff 28 wrapped Resident 28's right leg with the Unna gauze beginning at the ankle and stopping just above the mid-calf. On 8/5/26 at 4:04 PM Staff 28 (LPN) agreed the prior dressing removed from Resident 28 was not an Unna boot. Staff 28 reported he was not aware of having applied a silver (Ag+) dressing to the wound beds and was not familiar with what Ag+ meant when present on a wound product label. Staff 28 confirmed the order for wound care did not include silver collagen. Staff 28 stated he applied an Unna boot once before and did not receive any additional wound care instruction from the facility. On 8/5/26 at 4:15 PM Staff 17 (LPN Unit Manager) reported knowing facility staff had applied a two-layer compression wrap, not an Unna boot. Staff 17 referred to Staff 20 (LPN) regarding the order discrepancy as Staff 20 was present at the time of the physician visit. On 8/5/26 at 4:18 PM Staff 20 (LPN) stated she assisted the physician with wound care for Resident 28 on 8/3/26. Staff 20 reported the physician applied a two-layer compression dressing but ordered an Unna boot. Staff 20 stated managers would clarify order discrepancies with the physician. On 8/6/26 at 2:08 PM Staff 17 (LPN Unit Manager) confirmed staff were to perform wound care as ordered and all discrepancies were to be immediately reported to the physician. Staff 17 confirmed understanding the difference between an Unna dressing and a two-layer compression wrap system, confirmed the current order for Resident 28 specified the use of an Unna dressing, and confirmed staff applied a two-layer compression wrap. 4. Resident 51 admitted to the facility in 2025 with diagnoses including muscle weakness. The 6/23/26 physician order indicated Resident 51 was to receive: -senna 17.2 mg PRN for constipation. -bisacodyl 10 mg PRN for constipation daily. -sodium phosphate rectal enema PRN constipation. There was no indication on the 7/2026 MAR that it was administered. The 7/2026 bowel records indicated Resident 51 did not have a bowel movement from 7/15/26 through 7/24/26. There was no indication the resident was offered or received PRN bowel medications from 7/15/26 through 7/25/26. On 8/3/26 at 9:59 AM Witness 12 (Family Member) stated Resident 51 often went a long time without having a bowel movement. On 8/10/26 at 8:32 AM Staff 2 (DNS) acknowledged Resident 51 did not have a bowel movement from 7/15/26 through 7/25/26 and the 7/2026 MARs indicated PRN bowel medications were not administered to the resident. 5. Resident 13 readmitted to the facility in 2026 with diagnoses including amputation between left hip and knee. The 7/27/26 physician order indicated Resident 13 was to receive wound care to the right lower extremity and to apply silvercel (antimicrobial wound dressing). On 8/4/26 at 3:13 PM Staff 36 (RN) was observed to complete a dressing change to the right lower extremity. The silvercel dressing was not applied. On 8/4/26 at 3:34 PM Staff 36 stated silvercel was not available and the wound care orders were not followed. The 8/4/26 at 4:49 PM progress note indicated Resident 13's wound care orders included to apply silvercel to the open areas and it was not available. On 8/10/26 at 8:42 AM Staff 2 (DNS) acknowledged Resident 13's silvercel was not available on 8/4/26 and physician orders were not followed. 6. Resident 58 admitted to the facility on [DATE] and discharged on 5/1/26 with diagnoses including Parkinson's disease. On 4/22/26 a provider progress note indicated Resident 58 was seen for a follow up due to concerns for right arm weakness. The provider indicated therapy records were reviewed, and the resident was noted with a diagnosis of Parkinson's. The note indicated a referral to neurology would be made for an evaluation. Review of Resident 58's medical record revealed a 4/22/26 physician order for a neurology consult referral. On 5/1/26 a provider Discharge Evaluation progress note indicated a referral was requested by the physician on 4/22/26 and it was unclear if the referral was completed. Review of the resident's medical record indicated no evidence a referral for a neurology consult was made. On 8/7/26 at 11:27 AM Staff 17 (Unit Manager) stated referrals for residents was something the facility identified as an issue that needed some work. Staff 17 stated the process was once the provider requested a referral the appointment was made. Staff 17 stated she followed up on any referrals as soon as it was requested from the provider. Staff 17 stated the order for Resident 58's referral for a neurology consult was received on 4/22/26. Staff 17 stated no follow-up was completed because the resident discharged on 5/1/26 (eight days after the referral was made) and she was unaware of the resident's situation. On 8/7/26 at 1:25 PM Staff 2 (DNS) stated nursing staff were to follow up on referrals requested by the provider right away, regardless of the resident's situation. Staff 2 stated eight days was sufficient time for staff to follow up on Resident 58's 4/22/26 referral for a neurology consult. 7. Resident 11 was admitted to the facility on [DATE] with diagnoses including heart failure. The 6/18/26 Comprehensive MDS indicated Resident 11 had a BIMS score of 15 indicating Resident 11 was cognitively intact. An 8/4/26 physician order indicated Resident 11 was to receive metoprolol (medication used to lower heart rate and blood pressure) daily. The medication order indicated staff were to check Resident 11's heart rate prior to administration. On 8/5/26 at 8:04 AM, Staff 64 (RN) indicated Resident 11 did not have orders to check the resident's heart rate prior to administering metoprolol. Staff 64 proceeded to administer the medication without checking the resident's heart rate. On 8/5/26 at 8:13 AM, Staff 64 reviewed Resident 11's MAR and acknowledged Resident 11 had orders to check her/his heart rate prior to administering metoprolol. On 8/7/26 at 10:30 AM, Staff 2 (DNS) stated staff were expected to follow physician orders related to heart medications. 8. A 7/2026 facility Medication Administration Policy indicated staff administered medications within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. Resident 24 was admitted to the facility in 12/2025 with diagnoses including multiple sclerosis. An 8/4/26 Quarterly MDS indicated Resident 24 had a BIMS score of 15 indicating the resident was cognitively intact. On 8/5/26 at 9:00 AM, Resident 24 was observed requesting her/his morning medications after breakfast was over. Resident 24 stated she/he preferred to take morning medications before breakfast, and often reminded staff of that preference. On 8/5/26 at 9:01 AM, Staff 29 (Agency RN) stated Resident 24's morning medications were late. An 8/5/26 MAR indicated Resident 24's 7:00 AM and 8:00 AM medications were administered at 10:25 AM. On 8/7/26 at 10:30 AM, Staff 2 (DNS) stated staff were expected to follow physician orders related to medication administration. 9. A 6/2019 Diabetes Mellitus Management Policy indicated blood glucose results which fell outside of the physician established parameters would be reported to the physician and any new orders would be implemented. Resident 13 was admitted to the facility on [DATE] with diagnoses including diabetes. The 7/21/26 Quarterly MDS indicated Resident 13 had a BIMS score of 12 indicating Resident 13 was cognitively intact. A 7/25/26 physician order indicated to notify the provider for a CBG number less than 70 before meals. On 8/4/26 at 12:06 PM, Staff 65 (Agency RN) was observed obtaining Resident 13's CBG, which indicated 64. Staff 65 instructed Resident 13 to drink orange juice. Staff 65 stated she was to recheck Resident 13's CBG in one hour. On 8/4/26 at 1:28 PM, Staff 65 stated she did not recheck Resident 13's CBG. Staff 65 was observed to enter Resident 13's room and the resident indicated she/he drank five 12-ounce orange juices. The order was reviewed with Staff 65, and Staff 65 acknowledged she did not notify the provider or follow the order related to Resident 13's blood sugar. On 8/7/26 at 10:30 AM, Staff 2 (DNS) stated staff were expected to follow physician orders related to hypoglycemic management.

Based on interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 3 of 3 halls (100, 200 and 300 Halls) reviewed for staffing. This placed residents at risk for delayed care and unmet care needs. Findings include:On 8/10/26 the facility provided lists of residents who:-Required assistance with eating: 5-Required assistance with transfers: 25-Required a mechanical lift with transfers: 10- Required one or two-person assistance with bathing: 27-Required one or two-person assistance with toileting: 14-Required assistance with personal hygiene and dressing: 25-Had behavioral healthcare needs: 11These residents resided on all three facility halls. a. A review of the facility Direct Care Staff Daily Reports from 7/1/26 through 7/31/26 revealed the facility did not meet state minimum ratios for CNA staff on one or more shifts on the following dates:-7/3/26-7/4/26-7/5/26-7/12/26 b. On 8/10/26 at 10:15 AM grievances were provided for the past 30 days and indicated the following concerns:-7/25/26: staff did not respond timely to the call light.-7/29/26: medications were administered late and staff did not offer to make the bed during care.c. Interviews with residents and witnesses revealed the following concerns:-On 8/3/26 at 9:34 AM Resident 38 stated it was difficult to get a brief change on evening and night shift and she/he had to wait and wait for anyone to come and help me.-On 8/3/26 at 10:48 AM Resident 21 stated it took up to an hour for call lights to be answered.-On 8/3/26 at 11:00 AM Resident 34 stated on night shift it took a while to get help because one staff covered two halls.-On 8/3/26 at 11:04 AM Resident 13 stated the facility was often short staffed and it took staff a long time to answer call lights.-On 8/3/26 at 11:27 AM Resident 24 stated call lights took up to an hour or longer to be answered and often evening agency staff did not answer the call lights.On 8/3/26 at 12:04 PM Resident 11 stated she/he preferred female staff and on 8/2/26 during the evening shift the hall was not staffed with female staff, so she/he went 11 hours without a brief change.-On 8/3/26 at 12:56 PM Witness 10 (Family Member) stated there was low staffing on the weekends.-On 8/3/26 at 1:23 PM Resident 26 stated evening and weekend staffing was horrible with long call light times and agency staff did not respond to call lights.-On 8/4/26 at 8:36 AM Witness 11 (Family Member) stated the facility did not staff to resident acuity.d. Interviews with staff revealed the following concerns:-On 8/3/26 at 12:11 PM Staff 49 (CNA) stated staffing was never good, especially on evening shift. Staff 49 stated call lights did not get answered for hours, staff often worked double shifts, and several residents were higher acuity residents.-On 8/3/26 at 12:15 PM Staff 15 (CNA) stated staffing issues were worse in the evening due to a lot of two person cares, staff were not able to complete showers and call lights took a long time to answer especially around dinner time.-On 8/5/26 at 11:44 AM Staff 11 (CNA) stated the facility struggled to get CNA coverage and they were short a CNA that day so the restorative aide had to help out on the floor instead of completing restorative duties.-On 8/5/26 at 4:15 PM Staff 34 (CNA) stated nurses were always in a rush, especially agency nurses. Staff 34 stated recently one nurse was behind in passing medications, she stated medications were due at 2:00 PM and the nurse was passing those medications after 5:00 PM. Staff 34 further stated the nurses were too busy to assist with things like diabetic nail care.-On 8/7/26 at 11:31 AM Staff 50 (CNA) stated the restorative aide sometimes got pulled to be a CNA on the floor instead of completing restorative therapy for residents due to short staffing. -On 8/10/26 at 10:07 AM Staff 51 (LPN) stated nurses administered all medications and treatments which were late all of the time. Staff 51 further stated several residents' medications were so late on 8/7/26, the doctor was notified and the doctor ordered to hold the remaining medications because it was too late to administer morning medications.On 8/10/26 at 12:24 PM and 2:18 PM Staff 1 (Administrator) stated the facility followed state minimums for CNA staffing and nurses were staffed according to acuity and the budget. Staff 1 was asked about staffing to acuity and stated we have identified that as an issue, we now have a benefits coordinator that will keep track of that. Staff 1 provided no additional information.Refer to F677, F684 and F760.

Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment to care for its residents competently during day to day operations. This placed residents at risk for unidentified and unmet needs. Findings include:The 10/17/25 Facility Assessment was reviewed. The assessment was not comprehensive and failed to accurately include information on the following:- How the facility assessment was used to address staffing needs and competencies.- Necessary staffing and equipment needed to provide bariatric services.- The ethnic, cultural and religious makeup of the facility resident population.On 8/10/26 at 2:28 PM Staff 1 (Administrator) reviewed the Facility Assessment and acknowledged the assessment was not comprehensive and did not have accurate information. No further information was provided.

Based on interview and record review it was determined the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program implemented action plans to correct identified quality deficiencies. This placed all residents at risk for not receiving the care and services for optimal resident outcomes. Findings include: The facility's 4/25/26 QAPI policy indicated the facility was to develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.A review of the 6/26/26 Facility QAPI plan failed to recognize or address the following:-Lack of sufficient staffing based on acuity.-Lack of CNA annual performance reviews.-Lack of appropriate infection control practices during wound care.-Not following Physician Orders related to referrals, bowel care, wound care/not receiving wound care orders.-Residents with significant medication errors.-Dependent residents not receiving ADL care.-Lack of licensed nurses certified in and proficient with basic life support. On 8/10/26 at 2:29 PM Staff 1 (Administrator) acknowledged the QAPI program did not recognize or address the identified concerns. Refer to F677, F678, F684, F725, F726, F730, F760 and F880.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received ADL care for 3 of 5 sampled residents (#s 5, 9 and 22) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: 1. Resident 22 admitted to the facility in 2025 with diagnoses including dementia. The 3/6/26 care plan indicated Resident 22 had cognitive impairment and required assistance with bathing. On 8/3/26 at 11:47 AM Resident 22 stated staff did not offer to cut her/his fingernails. On 8/3/26 at 11:47 AM and 8/4/26 at 9:05 AM Resident 22's fingernails were observed to be long with brown and yellow substance under the fingernails. On 8/6/26 at 4:25 PM Staff 35 (CNA) stated nail care was not always provided due to short staffing. On 8/6/26 at 4:41 PM Staff 2 (DNS) observed Resident 22 and acknowledged the resident had long fingernails that were dirty. Staff 2 stated the expectation was for staff to clean and cut residents' fingernails. 2. Resident 5 admitted to the facility in 2025 with diagnoses including dementia. The 6/24/26 Annual MDS Functional Abilities CAA indicated Resident 5 had cognitive impairment and required assistance with bathing. The shower records indicated Resident 5 had a shower on 8/3/26 at 9:08 AM that was completed by Staff 34 (CNA). Resident 5 was observed on the following dates: -8/3/26 at 11:32 AM wearing faded black jeans and a gray shirt, she/he was not shaved. The resident's sheets had an orange substance smeared on them and her/his drink cup was caked with an orange substance. The resident stated the orange substance was Cheetos. -8/4/26 at 8:53 AM the resident was wearing the same clothes as the previous day, was not shaved, and the orange substance was still on the sheets and the drink cup. -8/5/26 at 1:25 PM the resident was wearing the same clothes as the previous two days, was not shaved, the orange substance was still on the sheets and the drink cup. Resident 5 was not wearing socks and her/his toenails extended past the end of her/his toes. On 8/5/26 at 4:15 PM Staff 34 (CNA) observed Resident 5 and stated she gave the resident a shower on 8/3/26 and the resident requested to wear the same dirty jeans after the shower. Staff 34 acknowledged the resident was still wearing the same jeans from 8/3/26 and her/his sheets and drink cup had an orange substance on them. Staff 34 acknowledged the resident was not shaved and stated she did not offer to shave her/him on the shower day. Staff 34 further acknowledged she/he had long toenails and stated she reported it to the nurse and the nurse was too busy to follow up on nail care. On 8/5/26 at 4:28 PM Staff 2 (DNS) observed Resident 5 and acknowledged the resident had long toenails, was not shaved, was wearing dirty jeans, and the sheets and drink cup had an orange substance on them. Staff 2 further stated the expectation was for staff to assist with ADL care. 3. Resident 9 was admitted to the facility on [DATE] with diagnoses including stroke. Resident 9 had a BIMS score of 9 indicating she/he was moderately cognitively intact. Resident 9 was dependent for all ADLs including nail care. Resident 9's 8/2026 shower record indicated Resident 9 was showered on 8/2/26 by Staff 62 (CNA). The document indicated fingernail and toenail care was not completed. On 8/4/26 at 10:48 AM, Resident 9 was to have a right hand contracture; her/his fingernails were long and touching her/his palm. Resident 9's right and left fingernails had a yellow and brown substance under the nail bed. Resident 9's toenails were long and had a yellow substance under the nail bed. On 8/5/26 at 10:24 AM, Resident 9 stated she allowed staff to trim her/his fingernails and toenails if offered. Resident 9 stated staff did not offer to trim her/his fingernails and toenails after her/his scheduled shower. On 8/5/26 at 12:58 PM, Staff 63 (CNA) stated she did not perform nail care during her shift because Resident 9 did not shower. Staff 63 acknowledged Resident 9 had a yellow and brown substance on her/his left and right hand. Staff 63 stated Resident 9's contracted right hand had long fingernails touching her/his palm. Staff 63 stated nail care was difficult to complete due to short staffing. On 8/5/26 at 5:09 PM, Staff 62 (CNA) stated she did not complete nail care after Resident 9's scheduled shower on 8/2/26 because she was not trained. Staff 62 stated she feared to trim Resident 9's fingernails especially on her/his right hand because of the contracture. Staff 62 stated she notified staff that she did not complete nail care after the shower. On 8/5/26 at 7:30 PM, Witness 15 (Family Member) stated staff refused to trim Resident 9's fingernails and toenails because staff were not trained. Witness 15 stated staff were aware nail care was not completed. On 8/6/26 at 4:49 PM, Staff 2 (DNS) acknowledged Resident 9's fingernail and toenails were not trimmed or cleaned. Staff 2 stated she expected staff to complete nail care during scheduled showers.

Based on interview and record review it was determined the facility failed to ensure performance reviews were completed at least once every 12 months for 4 of 4 CNAs (#s 38, 39, 40 and 41) reviewed for staffing. This placed residents at risk for a lack of care by competent staff. Findings include:Annual performance reviews and hire dates were requested on 8/10/26 from Staff 1 (Administrator) for the following staff and the following information was provided:-Staff 41 (CNA) was hired on 7/12/21. The last annual performance review was completed on 5/7/25.-Staff 38 (CNA) was hired on 3/28/23. The last annual performance review was completed on 5/16/25.-Staff 40 (CNA) was hired on 3/22/22. The last annual performance review was completed on 5/13/25.-Staff 39 (CNA) was hired on 4/22/24. The last annual performance review was completed on 5/9/25.On 8/10/26 at 12:23 PM Staff 1 (Administrator) acknowledged Staff 38, Staff 39, Staff 40 and Staff 41 worked at the facility for over one year and did not receive an annual performance review in the past 12 months.

Based on observation, interview and record review it was determined the facility failed to provide a comfortable and homelike environment for 2 of 2 resident halls reviewed for environment. This placed residents at risk for uncomfortable room temperatures. Findings include: A facility census document indicated Residents 23, 36, and 63 resided in the 100 Hall and Residents 8, 9, and 18 resided in the 300 Hall. A 3/2023 Resident Rights Policy indicated the facility was to provide comfortable room temperatures for all residents. A 7/22/2026 Resident Council meeting note indicated residents were not comfortable due to the high temperatures within the facility. The staff responded indicated staff would check temperatures, relocate residents to the common areas and provide fluids.Local weather records indicated high temperatures from 8/3/26 through 8/7/26 ranging from 83 to 95 F. During the survey from 8/3/26 through 8/10/26, the facility was observed to have a centralized cooling system for the hallways and common areas, but did not have a cooling system for resident rooms. On 8/3/26 at 10:58 AM, Resident 18 stated temperatures in her/his room were intolerable. Resident 18 stated staff were aware of the temperatures; staff provided fans for her/his room and suggested to leave the windows open. Resident 18 had the fans on and the windows were open. Resident 18 stated she/he was not comfortable, and portable air conditioners were not allowed in her/his room.On 8/4/26 at 12:40 PM, Staff 60 (CNA) stated resident rooms were really hot during hot weather, especially when care was provided. Staff 60 stated residents were not able to have portable air conditioners in their rooms. Staff 60 stated if portable air conditioners were installed, the power went out. Staff 60 stated residents stayed cool by opening resident room windows and staff provided fans.On 8/4/26 at 12:42 PM, Resident 9, who was dependent on staff for all care, including mobility, stated she/he was hot. Resident 9's face was red and had visible moisture. On 8/5/26 at 7:05 AM, Resident 9 stated her/his room felt hot daily. On 8/5/26 at 4:52 PM, Resident 8 was observed leaving her/his room. Resident 8's face was red. Resident 8 stated she/he was uncomfortable and her/his room was always hot. Resident 8's room was observed to have fans and the windows were opened, even though the outside air was hot at that time. On 8/5/26 at 4:53 PM, Resident 18 stated she/he was hot and uncomfortable in her/his room. Resident 18's face was red and she/he looked flushed and had moist skin. Resident 18's room was observed to have fans on and the windows were open. On 8/5/26 at 5:25 PM, Resident 23 was observed leaving her/his room and her/his face was red. Resident 23's room was observed to have fans and the windows were open. On 8/5/26 at 5:26 PM, Staff 55 (Maintenance Director) obtained the room temperature for Residents 8, 18, and 23. The room temperatures ranged from 82 to 84 F. Staff 55 acknowledged the rooms were not comfortable and stated all rooms were expected to have the windows closed to keep the room cool. Staff 55 stated he and other staff ensured windows remained closed, but acknowledged the windows were not currently closed.On 8/7/26 at 9:02 AM, Staff 55 (CNA) stated portable air conditions were not available to residents due to the electrical set up of the facility. On 8/7/26 at 10:11 AM, Staff 34 (CNA), stated during that week's high heat, Resident 36 and Resident 63 were unable to communicate their needs and their faces were red and sweaty. Staff 34 stated she told the nurse and she was instructed to open the windows and keep the fans on. Staff 34 stated she was not instructed to keep the windows closed.On 8/7/26 at 10:15 AM, Staff 61 (CNA) stated staff were not provided guidance on how to maintain comfortable room temperatures during high heat. Staff 61 stated residents were unable to install a portable air conditioner because the building was old. During interviews with Staff 1 on 8/7/26 at 9:11 AM, and 8/10/26 at 4:00 PM, these findings were shared. Staff 1 (Administrator) indicated staff were expected to check temperature ranges daily. Staff 1 stated staff were expected to ensure residents had a comfortable environment by relocating residents to the common areas. Staff 1 stated all rooms were able to have portable air conditioners.

Based on observation, interview and record review it was determined the facility failed to ensure resident medical records were kept secured and confidential for 3 of 3 medication carts observed. This placed residents at risk for lack of privacy and confidentiality. Findings include: 1. On 8/4/26 at 12:44 PM the medication cart on the 300 Hall was observed to be unattended, the computer screen was open and displayed resident information. On 8/4/26 at 12:48 PM Staff 52 (Agency LPN) acknowledged the medication cart was left unattended and the computer screen displayed resident information. On 8/4/26 at 12:59 PM the same medication cart on the 300 Hall was observed to be unattended, the computer screen was open and displayed resident information. On 8/4/26 at 1:06 PM Staff 52 acknowledged the medication cart was left unattended and the computer screen displayed resident information. On 8/10/26 at 1:15 PM Staff 2 (DNS) stated the expectation was for staff to lock the computer screen when the computer was unattended. 2. On 8/5/2026 at 1:26 PM the computer screen on the unattended medication cart for 300 hall was observed in hallway and displayed private resident information while Staff 29 (LPN) was in a resident room. On 8/5/2026 at 1:27 PM Staff 29 (LPN) confirmed the computer screen was to be locked whenever the nurse left the cart to protect resident information. On 8/10/26 at 1:15 PM Staff 2 (DNS) stated the expectation was for staff to lock the computer screen when the computer was unattended. 3. On 8/5/2026 at 2:03 PM the computer screen on the unattended medication cart for the 200 hall displayed private resident information while Staff 30 RN was in a resident room. On 8/5/2026 at 2:05 PM Staff 30 RN confirmed the computer screen displayed private resident information when she left the medication cart. Staff 30 agreed the computer screen to be locked when the nurse left the medication cart. On 8/10/26 at 1:15 PM Staff 2 (DNS) stated the expectation was for staff to lock the computer screen when the computer was unattended.

Based on observation and interview it was determined the facility failed to maintain an effective pest control program for 1 of 1 sampled facility reviewed for environment. This placed residents at risk for lack of a sanitary environment. Findings include:On 8/3/26 at 9:36 AM, multiple flies were observed in room [ROOM NUMBER]-B. The flies landed in Resident 38's lemonade and on the straw in her/his health shake. Resident 38 was noted to have a fly swatter on her/his bedside table. Resident 38 stated she/he was frequently bothered by flies in her/his room.On 8/3/26 at 2:20 PM flies were observed in room [ROOM NUMBER]-B, landing on Resident 46's meal tray and cup.On 8/4/26 at 11:55 AM and 1:22 PM, flies were observed in the 100 Hallway. The flies landed on the surveyor's laptop, hand, and face. On 8/5/26 at 9:31 AM Resident 34 was observed in the 100 Hallway with a fly around her/his head. Resident 34 stated the facility had an issue with flies, and she/he got a fly swatter for her/his room. Resident 34 indicated the flies were a daily issue and bothered her/him. On 8/7/26 at 9:53 AM Staff 54 (CNA) stated she noticed a lot of flies in resident rooms and the hallways.On 8/7/26 at 9:55 AM Staff 7 (CNA) stated she observed flies throughout the facility, including resident rooms. On 8/7/26 at 11:45 AM Staff 55 (Maintenance Director) stated a pest control company inspected the facility monthly or when he contacted them about a specific issue. Staff 55 indicated he was unaware of an issue with flies in the facility and did not alert the pest control company to them.

Based on observation, interview and record review it was determined the facility failed to ensure licensed nurses were certified in and proficient with Basic Life Support (BLS) for 10 of 21 licensed nursing staff (#s 3, 8, 28, 31, 43, 44, 45, 46, 47, 48) reviewed for Cardio-Pulmonary Resuscitation (CPR). This placed residents at risk for not receiving full life-saving measures. Findings include:The 2025 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Adult Basic Life Support Algorithm indicated to send someone to get the AED after checking patient responsiveness and activating the emergency response system (call 911), and to use AED as soon as it is available. The 3/2026 Cardio-Pulmonary Resuscitation (CPR) facility policy stated: When cardiac or respiratory arrest occurs, facility staff will initiate basic life support and CPR for residents who do not show obvious clinical signs of irreversible death and who have requested CPR in their advance directive.The facility's 3/2026 CPR Certification policy stated all licensed nurses will have CPR certification for health care providers validated upon employment and will maintain current CPR certification during employment. From [DATE] through [DATE] an AED device was observed in the facility at the nurses station. The device was clearly marked and visible. On [DATE] at 11:01 AM and [DATE] at 2:00 PM Staff 3 (LPN) stated on [DATE] she performed CPR on Resident 61 with Staff 4 (LPN) and Staff 5 (CNA). Staff 3 stated 911 was called because the resident had trouble breathing, but after calling 911 the resident stopped breathing, had no pulse, and needed BLS. Staff 3 indicated chest compressions and breathing were completed, but the AED was not used. Staff 3 stated approximately four cycles of compressions and breathing were completed before paramedics arrived and took over. Staff 3 expressed belief that it was appropriate to provide at least five rounds of compressions and breaths before getting the AED, and the AED was not needed for Resident 61. (This information is contrary to AHA guidelines for BLS.)On [DATE] at 1:18 PM Staff 28 (LPN) indicated he did not know where the AED was located in the facility.On [DATE] at 10:03 AM Staff 8 (LPN) was unable to articulate the process of using an AED as part of BLS, indicated she was not trained in BLS, did not know how to use the AED, or where the AED was located in the facility. On [DATE] the facility provided copies of Basic Life Support certifications for facility and agency staff. A review of these certifications revealed the following licensed nurses did not have current BLS certifications:Staff 28 (LPN): expired 1/2026Staff 31 (LPN): expired 2/2026Staff 43 (LPN): expired, unknown date. Staff 44 (LPN): expired 10/2023Staff 45 (LPN): expired 1/2024Staff 46 (LPN): expired 3/2026Staff 47 (RN): expired 2/2026Staff 48 (RN): expired 12/2024On [DATE] at 11:11 AM and [DATE] at 9:27 AM Staff 2 (DNS) stated licensed nurses were responsible for performing BLS and were required to have current BLS certification. Staff 2 stated the AED was to be obtained and used as soon as possible when CPR was administered. Staff 2 acknowledged the facility did not provide oversight to ensure all licensed nurses working in the facility had current BLS certification and were proficient in providing BLS, including the use of an AED. Refer to F678.

Based on interview and record review it was determined the facility failed to ensure residents received pain medication as ordered for 1 of 2 sampled residents (#18) reviewed for pain. This placed residents at risk for increased pain. Findings include:Resident 18 readmitted to the facility in 7/2026 with diagnoses including pain and weakness.The 8/3/26 physician order indicated Resident 18 was to receive oxycodone 5 mg every four hours for pain. On 8/3/26 at 10:58 AM Resident 18 stated she/he had chronic pain, and the oxycodone was often administered late. Resident 18 stated it was recently administered two hours after it was due.The Medication Audit Report indicated Resident 18 received oxycodone late on the following occasions.-8/3/26 due at 4:00 PM, administered at 5:11 PM.-8/5/26 due at 8:00 AM, administered at 10:22 AM.-8/5/26 due at 12:00 AM, administered at 1:19 AM.-8/5/26 due at 12:00 PM, administered at 1:51 PM.-8/5/26 due at 4:00 AM, administered at 5:40 AM.-8/6/26 due at 4:00 AM, administered at 5:15 AM.-8/6/26 due at 8:00 AM, administered at 9:07 AM. On 8/10/26 11:57 AM Staff 2 (DNS) acknowledged Resident 18's oxycodone was administered late on the identified dates.

Based on observation, interview, and record review, it was determined the facility failed to medically justify or remove a catheter, complete a urology referral as ordered, and provide education on risks of long-term catheterization for 1 of 2 sampled residents (#6) reviewed for urinary catheter. This placed residents at risk for infection and loss of normal bladder function. Findings include: Resident 6 was admitted to the facility in 10/2025 with an indwelling foley catheter. Resident 6 had a history of diabetes and urine retention.The facility's indwelling catheter policy, dated 7/2026, stated, The resident will not be catheterized unless the resident's clinical condition demonstrates that catheterization is necessary. The policy stated residents were to receive care as ordered by a physician.The 10/3/25 admission orders indicated a referral to urology. A review of the resident's clinical record revealed no evidence the urology appointment was completed. NSG Bowel and Bladder Screener forms dated 10/6/25, 1/5/26, and 4/14/26, indicated the resident was assessed by the facility as a candidate for scheduled toileting (timed voiding).Physician progress notes dated 2/16/26 and 2/18/26 indicated the facility was to arrange an appointment with urology and another request for a referral was made.In a physician progress note dated 3/31/2026, the Staff 42 (NP) wrote, Does not appear urology consult ever got placed. Patient denies needing/wanting this at this time. The progress note does not include documentation of resident education on potential risks of long-term catheterization or the necessity for a urology referral.On 8/3/26 at 9:46 AM Resident 6 indicated it was her/his choice to have the urinary catheter and was unable to demonstrate understanding of the potential effects of long-term catheterization.On 8/6/26 at 1:48 PM Staff 17 (LPN Unit Manager) confirmed the prior documentation for 10/06/25, 01/05/26, and 04/14/2026 NSG Bowel and Bladder Screener indicated Resident 6 was a candidate for timed voiding. Staff 17 stated Resident 6 did not receive bladder training or voiding trials and was unable to find documentation to support education was provided to Resident 6 regarding the need for a urology consult or voiding trials. Staff 17 reported the facility recently identified referrals were not being completed as ordered.On 8/10/26 at 9:28 AM Staff 42 (NP) reported discussing an order for a urology referral with Resident 6 and the resident declined the referral. Staff 42 stated she wasn't comfortable with ordering a voiding trial until the resident was seen by a urologist. Staff 42 was unable to confirm if any additional education on long-term catheterization or the necessity of a urology referral was completed during her visits with Resident 6. Staff 42 agreed her documentation does not include if education on necessity of urology referral or potential consequences of long-term catheterization.

Based on observation, interview and record review it was determined the facility failed to maintain oxygen equipment for 1 of 1 sampled resident (#34) reviewed for respiratory. This placed residents at risk for respiratory infection. Findings include:Resident 34 admitted to the facility in 2026 with diagnoses including oxygen dependence.The 7/22/26 care plan indicated Resident 34 used oxygen therapy related to COPD (Chronic Obstructive Pulmonary Disease), asthma and sleep apnea. Interventions included use of oxygen at two liters per minute. On 8/3/26 at 11:00 AM Resident 34 was observed to have oxygen in use. An observation of the oxygen concentrator revealed on the top a layer of dust. The filter had a layer of dust with long hairs laid across and caught between several of the filter slats. Resident 34 stated she/he used oxygen continuously.Continued observations on 8/4/26 at 9:13 AM and 8/10/26 at 11:39 AM revealed the concentrator to still be dirty.On 8/10/26 at 11:01 AM Staff 10 (CNA) stated she did not know who was responsible for cleaning oxygen concentrators. Staff 10 stated all she knew was when the concentrators were dirty it was taken into a room and someone cleaned it.On 8/10/26 at 11:13 AM Staff 32 (CNA) stated she believed the nurses were responsible for cleaning oxygen concentrators.On 8/10/26 at 11:29 AM Staff 31 (LPN) stated night shift staff were responsible for cleaning oxygen concentrators.On 8/10/26 at 11:39 AM Staff 2 (DNS) acknowledged Resident 34's oxygen concentrator was dirty and needed to be cleaned.

Based on observation, interview, and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for 1 of 1 sampled resident (#30) reviewed for positioning and mobility. This placed residents at risk for contracture progression and joint pain. Findings include: Resident 30 was admitted to the facility in 8/2025 with diagnoses including hemiplegia (paralysis on one side of the body).Resident 30's 8/14/25 Annual MDS revealed the resident was cognitively intact and experienced upper and lower extremity impairment on one side of the body.An 8/25/25 OT note indicated Resident 30 was fitted for a resting hand splint.No evidence was found in Resident 30's clinical record to indicate a care plan was developed to address the resident's left-sided weakness or use of the hand splint.On 8/3/26 at 9:46 AM, Resident 30 was observed to hold her/his hand in a tight fist. The resident's four fingers on her/his left hand pressed into the palm of her/his hand and the resident's right thumb pushed tightly under her/his right index finger. Resident 30 stated she/he used a splint in the past at the previous facility and wanted a hand splint to prevent her/his hand from tightening further. On 8/5/26 at 9:18 AM, Staff 18 (Director of Rehab) stated Resident 30 was fitted for a resting hand splint on 8/25/25. She indicated the resident was expected to wear the resting hand splint for one hour, three times a day. There was no evidence the directive to use the hand splint was communicated to the nursing staff.On 8/10/26 at 9:27 AM, Staff 51 (LPN Unit Manager) confirmed the order for the hand splint was not implemented for Resident 30. Staff 51 stated therapy orders were expected to be implemented to a resident's care plan immediately upon receipt.

Based on interview and record review it was determined the facility failed to ensure residents received adequate monitoring of anticonvulsant medication for 1 of 2 sampled residents (#51) reviewed for hospitalization. This placed residents at risk for adverse medication side effects and seizures. Findings include:Resident 51 admitted to the facility in 2025 with diagnoses including depression. On 5/18/26 the resident was diagnosed with epilepsy.The 5/19/26 physician note indicated Resident 51 received Depakote (anticonvulsant medication) and to track Depakote levels as indicated.The 5/22/26 pharmacy recommendation indicated a valproic acid level (measures the amount of Depakote in the system) was recommended as the last level was completed on 3/5/26. This was signed by the physician on 5/22/26. The 6/23/26 physician order indicated Resident 51 received Depakote 250 mg once daily and Depakote 500 mg at bedtime for epilepsy. The order indicated the start date was 5/19/26. The 6/3/26 physician order indicated a valproic acid level was to be completed for Resident 51. The 6/3/26 valproic acid lab results labeled urgent indicated the lab was not completed because the wrong test tube was used and another sample was requested. The 6/10/26 pharmacy recommendation indicated Resident 51 had a valproic acid level completed on 6/2/26 that did not result properly, and an additional order was requested to obtain the lab. There was no indication in the clinical record that a valproic acid level was obtained after 3/5/26. On 8/10/26 at 10:30 AM Staff 2 (DNS) stated Resident 51's last valproic acid lab was completed on 3/5/26. Staff 2 acknowledged the physician order for a valproic acid level and the pharmacy recommendations were not followed.

Based on interview and record review it was determined the facility failed to implement pharmacist recommendations for 1 of 5 sampled residents (#9) reviewed for medication. This placed residents at risk for adverse side effects of medication. Findings include:Resident 9 was admitted to the facility on [DATE] with diagnoses including COPD (lung disease). A 6/29/26 MDS indicated Resident 9 had a BIMS score of 9 indicating the resident was moderately cognitively intact. The MDS indicated Resident 9 was dependent for all cares. A 6/2026 pharmacy review indicated staff to change scheduled oxybutynin 10mg extended release via PEG tube to oxybutynin 10mg immediate release via PEG tube. The pharmacy review indicated staff to change cetirizine 10mg to cetirizine 5mg. A 7/2026 pharmacy review indicated the same repeated recommendation as the 6/2026 review. An 8/2026 MAR indicated staff the pharmacist recommendations from 6/2026 and 7/2026 were no implemented. On 8/7/26 at 11:40 AM, Staff 20 (Former LPN) stated staff were expected to contact the provider to update the pharmacy recommendations. Staff 20 acknowledged the pharmacy recommendations for Resident 9 were not completed. On 8/7/26 at 11:48 AM, Staff 2 (DNS) stated pharmacy recommendations were to be completed within 72 hours. Staff acknowledged the 6/2026 and 7/2026 pharmacy recommendations were not completed for Resident 9.

Based on interview and record review it was determined the facility failed had systems in place to ensure medication was available to administer for 1 of 7 sampled residents (#48) reviewed for medications. This placed residents at risk for adverse medical side effects. Findings include:Resident 48 was admitted to the facility on [DATE] and discharged on 7/31/26 with diagnoses including a stroke.A 6/7/26 physician order indicated the use of Cresemba (antifungal medication) one time a day for a fungal infection.Review of Resident 48's 6/2026 and 7/2026 MARs revealed the medication was not administered on 6/12/26, 6/19/26, 7/14/26, 7/21/26 and 7/22/26.Review of Resident 48's progress notes revealed the following:-6/12/26 Staff 26 (RN) documented no indication medication was given and no indication the provider was notified.-6/19/26 Staff 20 (LPN) documented medication was on order with no indication the provider was notified.-7/14/26 Staff 21 (LPN) documented medication was on order with no indication the provider was notified.-7/21/26 Staff 22 (RN) documented medication was not available with no indication the provider was notified.-7/22/26 Staff 23 (RN) documented waiting for delivery of the medication with no indication the provider was notified.On 8/5/26 at 10:32 AM an attempt was made to contact Staff 23 with no return call.On 8/5/26 at 11:27 AM Staff 22 stated it was a stressful and overwhelming shift on 7/21/26. Staff 22 stated there were issues with medications not being available. Staff 22 stated because she was scrambling, she did not notify the provider of Resident 48's missed medication.On 8/5/26 at 1:50 PM Staff 26 stated on 6/12/26 she was passing medications. Staff 26 stated she could not recall if she administered the medication. Staff 26 stated she could not recall if she notified the provider.On 8/6/26 at 12;24 PM Staff 21 stated it was the first time she worked on Resident 48's hall on 7/14/26 and there were issues with nursing staff not reordering medications timely and medications not being available. Staff 21 stated if she did not document the provider was notified of Resident 48's missed medication then it did not occur.On 8/7/26 at 9:42 AM Staff 20 stated she administered medications on 6/19/26 for Resident 48. Staff 20 acknowledged she did not administer Resident 48's medication due to it not being available and she did not notify the provider.On 8/7/26 Staff 17 (Unit Manager) stated she was aware of Resident 48's missed medication. Staff 17 stated she was unable to find documentation the provider was notified of Resident 48's missed medication for the identified dates.

Based on observation, interview and record review it was determined the facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments for 1 of 1 sampled resident (#53) reviewed for dialysis. This placed residents at risk for complications from dialysis. Findings include:A 6/2026 Dialysis (life-saving medical procedure to clean the blood) Policy indicated staff administered medications timely. The policy indicated staff assessed for complications before and after dialysis.Resident 53 was re-admitted to the facility on [DATE] with diagnoses including end stage renal disease.The 7/31/26 Quarterly MDS indicated Resident 53 had a BIMS score of 15 indicating the resident was cognitively intact. A 11/1/24 physician order indicated Resident 53 was scheduled dialysis on Monday, Wednesday and Friday.A 11/1/24 physician order indicated staff completed pre-assessment and post-assessment dialysis forms when Resident 53 left to dialysis and when she/he returned. The dialysis forms included assessing Resident 53's upper thigh fistula (a connection between an artery and vein used in dialysis).A 4/26/26 physician order indicated staff to monitor Resident 53's left upper thigh daily and to check for thrill (a whooshing sound heard through a stethoscope) and bruit (vibration felt when hand is placed over the fistula). Staff were expected to notify the nephrologist if thrill and bruit were absent. A 7/2026 and 8/2026 dialysis binder contained pre and post dialysis assessments for Resident 53. The pre dialysis assessments were missing for four days and the post dialysis assessments were missing for 13 days.A 8/2026 physician order indicated staff were to administer Resident 53's medication prior to leaving for dialysis. On 8/5/26 at 9:39 AM Resident 53 stated she/he was waiting for staff to administer morning medications prior to leaving for dialysis. On 8/5/26 at 11:43 AM, Staff 45 (Agency RN) stated she did not administer Resident 53's scheduled medications prior to the resident leaving for dialysis. Staff 45 stated she was unaware Resident 53 left for dialysis. On 8/5/26 at 4:41 PM and 4:47 PM, Staff 45 was observed visualizing Resident 53's fistula when the resident returned from dialysis, but she did not assess for thrill and bruit. Staff 45 acknowledged she did not assess for thrill and bruit. On 8/7/26 at 10:30 AM, Staff 2 (DNS) stated staff were expected to complete pre-assessment and post-assessment dialysis forms before and after dialysis, including checking for thrill and bruit. Staff 2 stated staff were expected to administer scheduled medications prior to leaving to dialysis.

Based on observation, interview, and record review it was determined the facility failed to identify, assess, treat, and implement contact precautions for residents with symptoms of clostridioides difficile (c-diff, a bacterium that can cause severe diarrhea and inflammation of the colon) and failed to utilize appropriate contact precautions to prevent the spread of c-diff for 4 of 4 sampled residents (#s 31, 32, 40 and 109) with diagnoses of c-diff. This failure, determined to be an Immediate Jeopardy situation, placed all residents at risk for exposure to c-diff, which is highly contagious and requires treatment including the use of a toxic anti-infective medication with potential to cause serious side effects. Findings include: According to the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/c-diff/prevention/index.html), washing your hands with soap and water is the best way to prevent hte spread of c-fiff from person to person. Healthcare professionals are to clean their hands before and after caring for residents with c-diff. 1. Resident 31 admitted to the facility in 2024 with diagnoses including chronic obstructive pulmonary disease. Bowel records from 4/9/25 through 4/16/25 indicated Resident 31's bowel movements were loose/diarrhea each time the resident had a bowel movement. A 4/11/25 progress note indicated Resident 31 had abdominal discomfort. There were no progress notes from 4/12/25 through 4/14/25. A 4/15/25 progress note indicated Resident 31 had abdominal discomfort. No evidence was found in the resident's clinical record to indicate the resident was assessed or the physician was contacted regarding the resident's consistent loose stools/diarrhea. A 4/16/25 progress note indicated Resident 31 was sent to the hospital for difficulty breathing. A 4/21/25 hospital discharge summary indicated Resident 31 was diagnosed with c-diff on 4/19/25. A 4/21/25 progress note indicated Resident 31 returned to the facility. The 4/22/25 care plan for c-diff indicated Resident 31 was on isolation precautions for c-diff. On 4/23/25 at 7:53 PM Staff 17 (Agency CNA) was observed to don a gown and gloves to assist another CNA to provide pericare for Resident 31. On 4/23/25 at 8:08 PM Staff 17 was observed to doff gloves and gown while exiting Resident 31's room. Staff 17 then walked to the 100 hallway, donned gloves, and retrieved a shower chair. Staff 17 acknowledged she did not wash her hands after leaving Resident 31's room. Staff 17 stated she was aware that Resident 31 was on precautions because of the sign on the door. On 4/23/25 at 8:48 PM Staff 24 (LPN) was observed to doff a gown and gloves while exiting Resident 31's room. Staff 24 used an alcohol-based hand rub (ABHR), then picked up a water pitcher and headed toward another resident's room. Staff 24 stated he was not aware he needed to wash his hands with soap and water after exiting Resident 31's room, and thought ABHR was enough. On 4/24/25 at 11:48 AM Staff 25 (LPN) stated after residents had three reported loose stools, it was charted in the medical record, and the resident was to be assessed for bowel tones and symptoms, and reported to the provider. On 4/24/25 at 1:50 PM these findings were shared with Staff 2 (DNS). Staff 2 indicated residents with repeated loose stools were to be assessed for the need to contact a physician and to determine if contact precautions were needed. Staff 2 acknowledged there were concerns with staff not following appropriate infection control practices for residents with c-diff. 2. Resident 32 admitted to the facility in 4/2024 with diagnoses including Parkinson's Disease and stroke. Bowel records from 4/4/25 through 4/17/25 indicated Resident 32's bowel movements were loose/diarrhea most of the time the resident had a bowel movement. No evidence was found in the resident's clinical record to indicate the resident was assessed or the physician was contacted regarding the resident's consistent loose stools/diarrhea. A 4/17/25 progress note indicated Resident 32 was sent to the hospital for weakness and confusion. A 4/17/25 hospital visit note indicated Resident 32 was diagnosed with c-diff on 4/17/25. A 4/21/25 progress note indicated Resident 32 returned to the facility and was placed on alert. The 4/22/25 care plan for c-diff indicated Resident 32 was on isolation precautions for c-diff. On 4/24/25 at 3:42 PM Staff 31 (Agency CNA) was observed to don gloves and a gown and then enter Resident 32's room. At 3:48 PM Staff 31 exited Resident 32's room with PPE doffed and Staff 31 used an alcohol-based hand rub (ABHR). Staff 31 was then observed to enter the visitor's bathroom and exit. On 4/24/25 at 3:49 PM Staff 31 stated she was aware Resident 32 was on contact precautions and she needed to wash her hands with soap and water after care was provided. Staff 31 stated she did not wash her hands with soap and water before exiting the resident's room because she was told to not use the resident's bathroom, but to wash her hands in the closest bathroom after exiting the resident's room, which was the visitor's bathroom. During multiple interviews with Staff 2 (DNS) on 4/24/25, Staff 2 acknowledged the staff were unclear regarding how to properly sanitize their hands after leaving the rooms of residents with c-diff. 3. Resident 40 admitted to the facility in 2/2025 with diagnoses including stroke and cellulitis of left leg (a bacterial infection beneath the skin). Bowel records from 4/14/25 through 4/20/25 indicated Resident 40's bowel movements were loose/diarrhea each time the resident had a bowel movement. A 4/17/25 provider progress note indicated Resident 40 was assessed by the physician assistant for a follow-up visit for lower extremity cellulitis. There was no indication the provider was aware or informed Resident 40 had loose/diarrhea for several days. A 4/20/25 progress note indicated Resident 40 had a fall while rushing to the bathroom due to diarrhea. Resident 40 was sent to the hospital for an elevated temperature and three loose bowel movements earlier in the day. On 4/24/25 at 10:50 AM Staff 27 (Admission Director) stated Resident 40 was admitted to the hospital with a new diagnosis of c-diff, and stated the the infection was acquired in the facility prior to the resident's hospital admission. 4. Resident 109 admitted to the facility on [DATE] with diagnoses including multiple falls, and a chronic upper abdominal wound. A 4/15/25 progress note indicated Resident 109 reported severe and abrupt abdominal pain. A 4/23/25 hospital discharge summary indicated Resident 109 was diagnosed with c-diff on 4/22/25. A 4/23/25 progress note indicated Resident 109 returned to the facility. The 4/24/25 care plan for c-diff indicated Resident 109 was on isolation precautions for c-diff. On 4/23/25 at 7:45 PM Staff 11 (CNA) was observed to exit Resident 109's room, which was identified as a contact precautions room. Staff 11 used an alcohol-based hand rub (ABHR) and then entered another resident's room, which was not identified with any transmission-based precautions. On 4/23/25 at 7:46 PM Staff 12 (CNA) exited Resident 109's room, used ABHR, and entered the clean linen closet to retrieve clean linens. On 4/23/25 at 7:48 PM Staff 11 stated the contact precautions signage on Resident 109's room indicated staff needed to do hand cleaning. When asked what type of hand cleaning, Staff 11 pointed to the ABHR dispenser. Staff 11 stated she was too busy answering call lights and assisting residents, and did not have time to do any other type of hand cleaning, specifically with soap and water. Staff 12 acknowledged contact precautions indicated staff were to wash their hands in a sink with soap and water. Staff 12 acknowledged she used ABHR and did not wash her hands with soap and water prior to handling clean linens and providing care to other residents. Staff 12 stated she was too busy providing resident care and answering call lights to walk down the hall and around the corner to the soiled utility room to wash her hands with soap and water. On 4/24/25 at 11:48 AM Staff 25 (LPN) stated after residents had three reported loose stools, it was charted in the medical record, the resident was assessed for bowel tones and symptoms, and it was reported to the physician. On 4/24/25 at 1:50 PM Staff 2 (DNS) indicated residents with repeated loose stools were to be assessed for the need to contact a physician and to determine if contact precautions were needed. Staff 2 acknowledged there were concerns with staff not following appropriate infection control practices for residents with c-diff. On 4/24/25 at 1:50 PM Staff 2 and Staff 1 (Administrator) were informed the facility's failure to implement appropriate precautions to prevent the spread of c-diff constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 4/24/25 at 4:08 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: - Identification and assessment of any residents with suspected c-diff. Any affected residents were placed on contact precautions with appropriate signage posted, and reviewed by a physician. - Shared equipment was sanitized or removed from use by affected residents. - Affected residents would be monitored daily. - Staff currently working were inserviced on c-diff precautions and infection control practices. - Oncoming staff would be inserviced prior to their shift. - Nurses were inserviced on assessing residents with signs and symptoms of c-diff. - Daily PPE competency testing would be conducted. - Daily and weekly infection control audits and monitoring. - Weekly reporting to QAPI. - Monthly governing body review. - Immediate retraining and disciplinary action for non-compliant staff members. The immediacy was removed on 4/26/25 after onsite verification of the IJ removal plan.

Based on observation, interview and record review it was determined the facility failed to ensure the resident environment was free from accident hazards for 1 of 1 sampled resident (#199) reviewed for accidental injury. This failure, determined to be an Immediate Jeopardy (IJ) situation, resulted in Resident 199 sustaining third degree burns requiring acute care intervention when her/his foot sustained prolonged contact with an electric baseboard heater. Findings include: Resident 199 admitted to the facility with hospice services on 1/12/24 with diagnoses including congestive heart failure and dementia. An Admission MDS dated [DATE] revealed Resident 199 had a BIMS score of three, which indicated the resident had severe cognitive impairment. The Admission MDS indicated Resident 199 had upper and lower extremity ROM impairment on one side, she/he required total assistance with bed mobility, and sitting to lying on the side of the bed required maximum assistance (helper does more than half the effort). A review of Resident 199's 2/19/24 care plan and progress note revealed no safety assessment regarding the resident's safety in her/his room relative to the electric baseboard heater. A public complaint was received on 2/20/24 which alleged Resident 199 was sent to the hospital with third degree burns (full-thickness burn that destroys the outer layer of skin and the entire layer beneath) on her/his right foot sustained from an electric baseboard heater at the facility. On 2/22/24 at 10:29 AM Witness 2 (Complainant) stated Resident 199 was sent to the hospital at approximately 6:35 AM on 2/19/24. The resident had a rapid heart rate, was in severe pain and had a large burn on her/his right foot. Witness 2 stated the facility reported Resident 199 sustained the burn from a heater, and the resident was monitored for safety every two hours. However, given the severity of the injury, it appeared to be the result of prolonged low-temperature heat exposure. Witness 2 stated Resident 199's toes were black and dry, and the bottom of her/his right foot resembled leather with an indentation across the mid-section of her/his foot that the facility could not explain. On 2/22/24 at 11:23 AM Staff 16 (LPN) stated she was called by Staff 7 (CNA) immediately to Resident 199's room at approximately 4:45 AM on 2/19/24. Staff 16 stated Resident 199 was laying on her/his back because Staff 7 moved the resident's right foot off the baseboard heater. Staff 16 stated the resident's right foot appeared to be bluish and purplish in the area of her/his 3rd, 4th, and 5th toes from the tip of the toes extending to the arch of the foot; top and bottom of the foot were discolored. Staff 16 stated she immediately assessed Resident 199 and she called 911 to send the resident to the hospital. Staff 16 stated Resident 199 did not appear to be in distress and was calm. On 2/22/24 at 11:39 AM Staff 7 (CNA) stated she was assigned to Resident 199 and checked on her/him about two hours per the care plan. Staff 7 stated at approximately 3:30 AM on 2/19/24 Resident 199 had her/his feet dangling off the bed close to the baseboard heater. Staff 7 stated Resident 199's feet were fine and not discolored, they were warm to the touch, but appeared normal in color. Staff 7 stated she repositioned Resident 199's feet back into the bed and moved the bed away approximately 18 inches away from the baseboard heater. Staff 7 returned the bed back to the low position (close to the floor) because she/he was a fall risk. Staff 7 stated she returned at approximately 5:15 AM on 2/19/24 to check on Resident 199 before the end of her shift and found her/his right foot on the baseboard heater and her/his right toes were darkened and discolored. Staff 7 stated she immediately removed Resident 199's right foot from the heater and yelled for Staff 16. During an observation of Resident 199's room on 2/22/24 at 10:50 AM the thermostat for the electric baseboard heater, located on the long wall next to the first hanging TV closest to the door, was set at 70 degrees F. Resident 199's bed was located by the window, there was blue tape approximately 13-inches away from the baseboard heater placed by the facility after the incident to mark a safe distance from the baseboard heater and the bed was approximately two inches away from the blue tape. The bed when in the low position was approximately 14 inches tall and baseboard heater was approximately six inches tall and extended 72-inches in length. The baseboard heater featured a metal casing on the top, front and sides, with an approximately 1.5-inch opening at the front from which hot air emanated to warm the room. The metal casing was hot to the touch. A review of Resident 199's 2/19/24 hospital admission note revealed the resident sustained third degree burns to her/his right foot. The hospital notes indicated significant injury necrotic (dead tissue) of fourth and fifth toes, third degree burn to plantar (bottom of the foot) surface of foot that looks older than stated .has associated blistering and dryness of right foot. The top of Resident 199's right foot appeared to have dark purple discoloration from mid-foot towards the toes which appeared dark purple with aspects of black. The plantar surface appeared to be dark purple to brown discoloration with dry skin with texture of leather and a linear indentation from the arch of the foot to the right 5th toe on the plantar surface. The hospital concluded based on their assessment a full thickness or third degree burn to the right foot from prolonged heat exposure. On 2/22/24 at 11:39 AM Staff 7 stated she found Resident 199 several times attempting to put her/his feet on or in the baseboard heater. Staff 7 stated the week prior she reported to Staff 18 (RN) that Resident 199 sat at the edge of her/his bed and, while wearing socks, placed her/his feet on and in the baseboard heater. Staff 7 stated she moved Resident 199 away from the heater and moved the bed and repositioned the resident. On 2/22/24 at 12:45 PM Staff 18 (RN) stated she recalled Staff 7 reported to her Resident 199 was found sitting at the edge of the bed putting her/his feet with socks on in the baseboard heater. Staff 18 stated she asked Staff 7 to move Resident 199's bed away from the baseboard heater and Staff 18 assessed the resident's skin to ensure it was intact. Staff 18 stated she did not document the incident or her assessment. Staff 18 stated at the end of her shift she informed the oncoming nurse, Staff 19 (LPN), of the incident. On 2/22/24 at 12:56 PM Staff 19 stated she did not recall any incidents of Resident 199 putting her/his feet on or in the baseboard heater. Staff 19 did not recall Staff 18 giving her report of the incident or assessment. On 2/22/24 at 2:01 PM Staff 21 (Maintenance Director) observed Resident 199's room with the surveyor. The thermostat was set at 90 degrees F. Staff 21 confirmed he placed the blue tape on the floor but did not recall if there was tape on the floor prior to the incident. Staff 21 agreed the metal casing on the baseboard heater was hot to the touch and used a temperature gun to check the temperature of the top of the baseboard heater which was 145 degrees F, and the hot air emitting was 144 degrees F. Staff 21 stated the baseboard heater was operating as intended. Staff 21 stated the blue tape was a visual reminder for the staff to keep residents and items out of that area because the baseboard heater gets hot enough to melt items. Staff 21 stated he conducted staff in-services and presented melted items that were in or too close to the baseboard heaters. On 2/23/24 at 10:52 AM Staff 14 (CNA) stated, prior to the incident of 2/19/24, she found Resident 199 several times facing the window with her/his feet on the wall above the heater. Staff 14 was educated and repositioned Resident 199 away for the baseboard heater. On 2/23/34 at 1:33 PM Staff 15 (CNA) stated she recalled the charge nurse told her when she was the assigned to Resident 199 to ensure she/he did not place her/his feet on the baseboard heater. Staff 15 stated the facility provided in-services not to place items on or near the baseboard heaters because staff were shown pillows and linen that were burned from contact with the baseboard heaters. On 2/22/24 at 6:45 PM, the facility administrative staff, including Staff 2 (Assistant Administrator) and Staff 3 (DNS), were notified of the (IJ) situation and an immediacy removal plan was requested. On 2/22/24 at 8:22 PM the facility submitted an acceptable immediacy removal plan to address the IJ situation. The immediacy removal plan included the following: 1. Resident 199 was no longer in the facility. 2. All baseboard heaters would be turned off and replaced with a safe alternative. 3. Staff would check room temperature every two hours to verify each room was at a comfortable temperature. The immediacy was removed on 2/23/24 based on onsite verification of the removal plan.

Based on interview and record review it was determined the facility failed to monitor CBGs for a resident with diabetes for 1 of 1 sampled resident (#32) reviewed for medications. This failure resulted in Resident 32's unmonitored blood glucose which required treatment at the hospital. Findings include: Resident 32 admitted to the facility in 8/2023 with diagnoses including diabetes and sepsis. Resident 32's care plan, revised on 11/16/23, revealed she/he received oral medication and insulin for diabetes management. Interventions were to administer diabetes medication as ordered and to monitor and document for side effects and effectiveness. On 12/6/23 a concern was reported which alleged Resident 32 was admitted to the hospital on 12/5/23 with a CBG count of 600mg/dl (a normal CBG count is between 70-100 mg/dl). A review of Resident 32's daily vital signs, nursing notes and diabetic administration record revealed no CBG checks were completed from 10/27/23 through 10/31/23, from 11/2/23 through 11/4/23, 11/6/23 through 11/12/23 and 11/14/23 through 12/5/23. A nursing note dated 12/5/23 at 2:21 PM revealed Resident 32 complained of abdominal pain and passed kidney stones. She/he requested to be sent to the hospital and was transported to the Emergency Department. Hospital discharge records dated 12/11/23 noted Resident 32 was diagnosed and treated for Hyperosmolar Hyperglycemia State (HHS), one of the most serious complications of type 2 diabetes .HHS is commonly caused by a serious infection or illness, not taking your diabetes medications as prescribed or getting dehydrated. The surveyor attempted to interview nursing staff responsible for administering Resident 32's medications, but was unable to find nursing staff who worked at the facility in 12/2023. On 2/12/24 at 11:01 AM, Staff 5 (DNS) confirmed the CBG checks were not completed.

1. Based on interview and record review it was determined the facility failed to promptly assess and respond to a resident's change in condition for 1 of 1 sampled residents (# 78) who was reviewed for death. This resulted in Resident 78 receiving delayed assessment and treatment for [REDACTED]. Resident 78 required urgent medical transport and acute care interventions. Findings include: Resident 78 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 12:24 pm Witness 1 (Complainant) stated Resident 78 was taking [MEDICATION NAME] (diuretic) to get rid of fluid on the resident's lungs. Witness 1 indicated the day the resident was admitted to the facility it was very hot and Staff 1 (Administrator) stated she was looking for an air conditioner and it would be in the next day. Witness 1 stated the resident never received an air conditioner. Witness 1 stated she/he never saw an RN. Witness 1 stated on [DATE] it was a very hot day and Resident 78 was sweating and her/his eyes were rolling back in her/his head. Witness 1 called someone (pill giver) into the room and asked if they knew the resident was sick. The staff member stated they were watching the resident. Witness 1 asked if they had taken the resident's temperature. The staff member stated they were watching the resident. Witness 1 stated Resident 78 was getting worse and asked staff if they called the physician. Staff indicated they had called the physician but the physician had not called back. Witness 1 stated the physician never called back. Witness 1 stated she/he requested staff to check Resident 78's vitals but their machine did not work and they could not find the one that did work. Witness 1 stated she/he told staff either they call for an ambulance or she/he would. Staff indicated they had to go check with someone, then called for an ambulance. While waiting for the ambulance Witness 1 stated there was a crash (loud noise) in a room nearby. When the ambulance arrived they went right past Resident 78's room. Witness 1 stated Resident 78 said she/he just wanted to die because she/he couldn't breath. Another ambulance came and loaded the resident on a stretcher and told Witness 1 not to follow them because they were going to use the lights all the way. Witness 1 stated the hospital put Resident 78 on a ventilator in the ICU (intensive care unit). The resident was on a ventilator for five days before it was removed. The resident died the next day. A POLST (Physician's Order for Life-Sustaining Treatment) signed by the physician on [DATE] (over a month after the resident was discharged from the facility) indicated Resident 78 desired resuscitation/CPR with limited additional interventions including transfer to the hospital if indicated. Resident 78's [DATE] Physician Orders indicated the resident was a full code, and was to have oxygen at 1 liter per minute (L/m) via nasal cannula and maintain oxygen saturation greater than 90%. The order did not indicate staff were to adjust the oxygen delivery rate. The orders indicated the resident received [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) inhaler every four hours PRN. NN's dated [DATE] through [DATE] indicated Resident 78's oxygen was flowing up to 2 L/m every day. Resident 78's clinical record revealed no physician's order for staff to adjust the resident's oxygen flow rate over 1 L/m or any notification to the physician informing him Resident 78 was requiring greater than 1 L/m of oxygen. A physician's office progress note dated [DATE] indicated the physician ordered lab work including a CBC (complete blood count) and chest x-rays to be done at the clinic. No lab or imaging results were found in the resident's clinical record. A NN dated [DATE] at 4:16 pm indicated Staff 16 (PTA - Physical Therapy Assistant) noted Resident 78 was in bed and complained of not feeling well and short of breath. Staff 16 attempted to obtain an oxygen saturation reading but the resident kept removing the oximeter (device for measuring oxygen saturation) and was unable to follow verbal cues. Resident 78 appeared to have difficulty following verbal directions and appeared anxious. The resident's condition was reported to the charge nurse. Resident 78's MAR indicated [REDACTED]. This was one hour and eight minutes after the resident's change in condition was noted by Staff 16. A NN dated [DATE] at 5:43 pm indicated Staff 9 (LPN) entered Resident 78's room and the resident was very short of breath and the resident's lungs sounded very moist with crackles and Rhonchi (coarse rattling sounds). The resident stated she/he was in a different city and the resident's eyes were rolling back in her/his head. The resident's blood pressure was ,[DATE] (,[DATE] to ,[DATE] is normal), temperature was 99.2 (normal average is 98.6), respiratory rate was 24 (normal is ,[DATE]), pulse was 43 (,[DATE] is normal), and oxygen saturation was 73% with the resident on 4 L/m of oxygen (normal pulse oximeter reading is ,[DATE]%). The NN indicated the resident had a history of [REDACTED]. The NN indicated Staff 9 called the on-call physician and was waiting for a call back. The above assessment occurred 1 hour and 27 minutes after Resident 78's change in condition was reported by Staff 16. A NN dated [DATE] at 6:39 pm indicated Staff 9 called Staff 2 (DNS) and Staff 2 instructed Staff 9 if Resident 78's spouse wanted the resident sent to the emergency room to be evaluated then it was okay to send the resident out. The NN indicated Staff 9 spoke to the resident's spouse and non-emergent transport was called to take Resident 78 to the hospital. This was 56 minutes after Staff 9 assessed Resident 78 with significant abnormal vital signs. An ambulance response report dated [DATE] indicated the ambulance arrived at the facility on [DATE] at 6:53 pm. Resident 78 was very short of breath and in severe distress. The resident was placed on a non-rebreather mask at 15 L/m of oxygen, then placed on a [MEDICATION NAME] mask (breathing treatment delivered via mask) and an IV was established. Once in the ambulance the resident was placed on a [MEDICAL CONDITION] (continuous positive airway pressure) machine with slight relief. The resident received a second [MEDICATION NAME] treatment via [MEDICAL CONDITION] while en route to the hospital. Resident 78's vital signs at 6:55 pm were: oxygen saturation 84% with labored breathing, blood pressure ,[DATE], pulse 120, respiratory rate 40. The resident was administered [MEDICATION NAME] (medication for dilating airways in the lungs) and atrovent (medication for dilating airways in the lungs) with no effect. At 7:09 pm atrovent and [MEDICATION NAME] were administered again, also with no effect. The ambulance transported Resident 78 to the hospital using lights and siren. A Physician's Telephone Orders dated [DATE] taken by Staff 9 which indicated to send Resident 78 to ER to be evaluated. There was no time on the order to indicate when it was received from the physician. The order had a physicians signature dated [DATE]. This was over a month after the resident was discharged from the facility. A hospital [MEDICAL CONDITION]/Critical Care Medicine Consult H&P Note dated [DATE] indicated Resident 78 required critical care for management of acute [MEDICAL CONDITIONS], and bilateral pneumonia. The resident was transferred to intensive care and needed urgent intubation. A written statement signed by Staff 1 (Administrator) provided to the survey team on [DATE] indicated Resident 78 had a medical event after 4 pm ([DATE]) and Staff 9 (LPN) called the physician and waited for a response back. Though the resident was better the physician was called a second time because the resident's spouse wanted the resident evaluated in ER. Staff 9 called Staff 2 (DNS) who instructed Staff 9 to call 911 and send the resident out per family request. Note - (Resident 78) was a [MEDICAL CONDITION] patient, of particular focus with Medicare for prevention of re admission to the hospital. On [DATE] at 11:16 am Staff 2 (DNS) acknowledged Resident 78's oxygen order should have been clarified. Staff 2 stated Resident 78 left the facility by ambulance on [DATE] at 7:00 pm because the resident's spouse insisted she/he be transferred to the hospital. Staff 2 acknowledged, based on the vital signs charted on [DATE] at 5:43 pm, a prudent nurse would have sent the resident out to the hospital. Staff 2 acknowledged there was no RN charge nurse on duty [DATE]. Staff 2 acknowledged the NN dated [DATE] at 6:39 pm indicated non-emergent transport was called to take Resident 78 to the hospital, but thought he went out via emergent transport. On [DATE] at 3:05 pm Staff 9 (LPN) stated when she went to check on Resident 78 she/he was not breathing well, the resident's breathing was labored, she increased the oxygen flow rate, and elevated the bed but the interventions did not work. Staff 9 stated the resident's blood pressure was elevated at that time (though the NN on [DATE] at 5:43 pm noted a blood pressure of ,[DATE], which is considered low), temperature was elevated, respiratory rate was highly elevated and the resident's anxiety was so bad they couldn't get (the resident) to breath right. Staff 9 stated she increased the resident's oxygen and the resident's oxygen saturation was in the 80's. Staff 9 stated the physician was called and they were waiting for a call back from him with instructions. While they were waiting she had to respond to an emergency in another room. Staff 13 (LPN) was at the nurses station and was the one who called 911. (No nurses notes were found in the resident's clinical record from Staff 13 regarding Resident 78 and this incident.) Staff 9 stated Resident 78 was not on oxygen all the time. Staff 9 acknowledged the resident's oxygen order was not PRN. Staff 9 stated the reason the on-call physician was called instead of 911 was because they might have been able to stabilize the resident in the facility. On [DATE] at 3:41 pm Staff 13 (LPN) stated Staff 9 was the charge nurse and she was aware of Resident 78's condition. Staff 13 stated she was the one who called 911 for Resident 78, and she stayed with the resident until the paramedics arrived, assessed the resident, and took the resident to the hospital. Staff 13 stated there was a call out to the on-call physician. She was monitoring the resident and trying to calm the resident's spouse who was pleading with staff and was afraid the resident was going to die. On [DATE] at 8:22 am Staff 1 (Administrator) stated the facility is under a lot of pressure from Medicare not to send [MEDICAL CONDITIONS] patients back to the hospital and if there is not support for an emergent condition it can be charged to the family. Staff 1 stated Resident 78 did leave the facility via emergency and there was concern of repercussions. In summary Resident 78 was not promptly assessed by a facility nurse (wait of 1 hour and 27 minutes) for a reported change in condition. EMS was not contacted for 56 more minutes, and then only at the request of the resident's spouse. When paramedics arrived the resident required emergency treatment and transport to the hospital. Once at the hospital the resident required urgent intubation and placement on a ventilator. The resident did not recover and died in the hospital. 2. Based on interview and record review it was determined the facility failed to coordinate care with hospice for 1 of 1 sampled residents (#114) who was reviewed for hospice. This placed residents at risk for unmet needs. Findings include: Resident 114 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident was on hospice. Resident 114's current Care Plan and In Room Care Plan dated [DATE] indicated the resident was on hospice but failed to indicate the services hospice was responsible for. No care plan from the hospice provider was found in Resident 114's clinical record. On [DATE] at 10:06 am Staff 2 (DNS) acknowledged there was no hospice care plan in Resident 114's clinical record and there should have been. On [DATE] at 9:31 am Staff 17 (CNA) stated a hospice aide came in to the facility on [DATE] and gave Resident 114 a bed bath. The hospice aides assisted with transfers, nail care and lotion. Staff 17 stated she had seen hospice nurses visit the resident and they reported to the facility nurses. On [DATE] at 9:38 am Staff 6 (LPN) stated she saw a hospice aide come in to see Resident 114 at least once a week. Staff 6 stated she was not aware what services hospice provided the resident. On [DATE] at 9:49 am Staff 3 (RNCM) acknowledged the POLST should be signed. Staff 3 stated hospice was only providing social services for Resident 114 and he had not seen anyone from hospice come in for bathing support. Staff 3 was unaware if hospice aides visited the resident. Staff 3 was unaware of what services the hospice nurse provided or how frequently they visited the resident. Staff 3 stated he did not know the rules of hospice. Staff 3 stated he did not think the facility necessarily needed to know how often hospice staff came in or what services they provided the resident. 3. Based on interview and record review it was determined the facility failed to follow physician orders for 3 of 4 sampled residents (# 52, 71 and 119) reviewed for [MEDICAL TREATMENT], urinary catheters and PICC lines. This placed residents at increased risk for unmet care needs. Findings include: a. Resident 119 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The [DATE] Physician's Orders revealed Resident 119 had a PICC line (peripherally inserted central catheter) for the administration of an intravenous antibiotic. The PICC line was to be measured upon admission and every week. The orders further noted Notify physician of length changes. Resident 119's TARs for ,[DATE] and ,[DATE] revealed the PICC line measured 16 cm on [DATE] and [DATE]. The [DATE] measurement was documented to be 3 cm. The clinical record lacked documented evidence the physician was notified of the length change. On [DATE] at 12:44 pm, Staff 14 (LPN) stated notification to physicians should be in resident progress notes or in the physician's log book. Staff 14 checked the log book and acknowledged there was no notification documented for Resident 119. On [DATE] at 3:00 pm, Staff 9 (LPN) acknowledged she did the PICC line dressing change and measurement on [DATE]. Staff 9 stated she was not aware she needed to check the previous measurement. Staff 9 acknowledged she did not report a change in PICC line length to the physician. b. Resident 71 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Resident 71's [DATE] care plan included the following intervention with onset date of [DATE]: DAILY WEIGHT: Previous weights may be viewed in the Care Task History. Notify MD if resident gains 2 lbs for 2 days in a row or 4 lbs or more in one week. Resident 71's clinical record revealed the resident's weight was not documented on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 7:59 am, Staff 11 (CNA) stated the resident was weighed every morning on either the Hoyer lift scale or the wheelchair scale. On [DATE] at 1:22 pm Staff 4 (RNCM) acknowledged the missing weights. c. Resident 52 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The [DATE] progress notes revealed the resident's Foley catheter (indwelling catheter) at the base of the penis had large blood clots coming out of it around the catheter. The base where the suprapubic (a tube draining urine from the bladder) catheter meets the body has greenish yellow pus oozing out of it. The Foley catheter urine bag was cranberry in color and the suprapubic urine was amber in color. Staff contacted the physician on [DATE] and received a telephone order to cleanse the penis and stoma three times a day with wound cleanser. The ,[DATE] and ,[DATE] MAR/TAR revealed the facility failed to carry out the orders to cleanse the penis and stoma three times per day. On [DATE] at 12:50 pm Staff 4 (RNCM) stated she did not see the order on the MAR/TAR and stated the nurse should have put it on the MAR/TAR.

Based on interview and record review it was determined the facility failed to ensure a nurse's (Staff 9 LPN) actions met professional standards of practice for 2 of 7 sampled residents (#s 78 and 119) who were reviewed for death and unnecessary medications. This resulted in Resident 78 receiving delayed assessment and treatment for [REDACTED]. Resident 78 required urgent medical transport and acute care intervention. Findings include: The Oregon State Board of Nursing Standards and Scope of Practice for the Licensed and Registered Nurse indicated: Conduct Derogatory to the Standards of Nursing Defined (1) (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. (3) (a) Inaccurate recordkeeping in client or agency records. (3) (b) Incomplete recordkeeping regarding client care; including, but not limited, to failure to document care given or other information important to the client's care or documentation which is inconsistent with the care given. 1. Resident 78 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. On [DATE] at 12:24 pm Witness 1 (Complainant) stated on [DATE] it was a very hot day and Resident 78 was sweating and her/his eyes were rolling back in her/his head. Witness 1 called someone (pill giver) into the room and asked if they knew the resident was sick. The staff member stated they were watching the resident. Witness 1 asked if they had taken the resident's temperature. The staff member stated they were watching the resident. Witness 1 stated Resident 78 was getting worse and asked staff if they called the physician. Staff indicated they had called the physician but the physician had not called back. Witness 1 stated the physician never called back. Witness 1 stated she/he requested staff to check Resident 78's vitals but their machine did not work and they could not find the one that did work. Witness 1 stated she/he told staff either they call for an ambulance or she/he would. Staff indicated they had to go check with someone, then called for an ambulance. While waiting for the ambulance Witness 1 stated there was a crash (loud noise) in a room nearby. When the ambulance arrived they went right past Resident 78's room. Witness 1 stated Resident 78 said she/he just wanted to die because she/he couldn't breath. Another ambulance came and loaded the resident on a stretcher and told Witness 1 not to follow them because they were going to use the lights all the way. Witness 1 stated the hospital put Resident 78 on a ventilator in the ICU (intensive care unit). The resident was on a ventilator for five days before it was removed. The resident died the next day. A POLST (physician's orders [REDACTED]. Resident 78's [DATE] Physician order [REDACTED]. The order did not indicate staff were to adjust the oxygen delivery rate. A NN dated [DATE] at 4:16 pm indicated Staff 16 (PTA - Physical Therapy Assistant) noted Resident 78 was in bed and complained of not feeling well and short of breath. Staff 16 attempted to obtain an oxygen saturation reading but the resident kept removing the oximeter (device for measuring oxygen saturation) and was unable to follow verbal cues. Resident 78 appeared to have difficulty following verbal directions and appeared anxious. The resident's condition was reported to the charge nurse. A NN dated [DATE] at 5:43 pm indicated Staff 9 (LPN) entered Resident 78's room and the resident was very short of breath and the resident's lungs sounded very moist with crackles and Rhonchi (coarse rattling sounds). The resident stated she/he was in a different city and the resident's eyes were rolling back in her/his head. The resident's blood pressure was ,[DATE] (,[DATE] to ,[DATE] is normal), temperature was 99.2 (normal average is 98.6), respiratory rate was 24 (normal is ,[DATE]), pulse was 43 (,[DATE] is normal), and oxygen saturation was 73% with the resident on 4 L/m of oxygen (normal pulse oximeter reading is ,[DATE]%). The NN indicated the resident had a history of [REDACTED]. The NN indicated Staff 9 called the on-call physician and was waiting for a call back. The above assessment occurred 1 hour and 27 minutes after Resident 78's change in condition was reported by Staff 16. A NN dated [DATE] at 6:39 pm indicated Staff 9 (LPN) called Staff 2 (DNS) and Staff 2 instructed Staff 9 if Resident 78's spouse wanted the resident sent to the emergency room to be evaluated then it was okay to send the resident out. The NN indicated Staff 9 spoke to the resident's spouse and non-emergent transport was called to take Resident 78 to the hospital. This was 56 minutes after Staff 9 assessed Resident 78 with significant abnormal vital signs. An ambulance response report dated [DATE] indicated the ambulance arrived at the facility on [DATE] at 6:53 pm. Resident 78 was very short of breath and in severe distress. The resident was placed on a non-rebreather mask at 15 L/m of oxygen, then placed on a [MEDICATION NAME] mask (breathing treatment delivered via mask) and an IV was established. Once in the ambulance the resident was placed on a [MEDICAL CONDITION] (continuous positive airway pressure) machine with slight relief. The resident received a second [MEDICATION NAME] treatment via [MEDICAL CONDITION] while en route to the hospital. Resident 78's vital signs at 6:55 pm were: oxygen saturation 84% with labored breathing, blood pressure ,[DATE], pulse 120, respiratory rate 40. The resident was administered [MEDICATION NAME] (medication for dilating airways in the lungs) and atrovent (medication for dilating airways in the lungs) with no effect. At 7:09 pm atrovent and [MEDICATION NAME] were administered again, also with no effect. The ambulance transported Resident 78 to the hospital using lights and siren. A Physician's Telephone Orders dated [DATE] taken by Staff 9 which indicated to send Resident 78 to ER to be evaluated. There was no time on the order to indicate when it was received from the physician. The order had a physician's signature dated [DATE]. This was over a month after the resident was discharged from the facility. A hospital [MEDICAL CONDITION]/Critical Care Medicine Consult H&P Note dated [DATE] indicated Resident 78 required critical care for management of acute [MEDICAL CONDITIONS] (infection throughout the body), and bilateral pneumonia. The resident was transferred to intensive care and needed urgent intubation. A written statement signed by Staff 1 (Administrator) provided to the survey team on [DATE] indicated Resident 78 had a medical event after 4 pm ([DATE]) and Staff 9 (LPN) called the physician and waited for a response back. Though the resident was better the physician was called a second time because the resident's spouse wanted the resident evaluated in ER. Staff 9 called Staff 2 (DNS) who instructed Staff 9 to call 911 and send the resident out per family request. On [DATE] at 11:16 am Staff 2 (DNS) acknowledged, based on the vital signs charted on [DATE] at 5:43 pm, a prudent nurse would have sent the resident out to the hospital. On [DATE] at 3:05 pm Staff 9 (LPN) stated when she went to check on Resident 78 she/he was not breathing well, the resident's breathing was labored, she increased the oxygen flow rate, and elevated the bed but the interventions did not work. Staff 9 stated the resident's blood pressure was elevated at that time (though a NN dated [DATE] at 5:43 pm noted Resident 78 with a blood pressure of ,[DATE], which is considered low), temperature was elevated, respiratory rate was highly elevated and the resident's anxiety was so bad they couldn't get (the resident) to breath right. Staff 9 stated she increased the resident's oxygen and the resident's oxygen saturation was in the 80's. Staff 9 stated the physician was called and they were waiting for a call back from him with instructions. While they were waiting she had to respond to an emergency in another room. Staff 13 (LPN) was at the nurses station and was the one who called 911. (No nurses notes were found in the resident's clinical record from Staff 13 regarding Resident 78 and this incident.) Staff 9 stated Resident 78 was not on oxygen all the time. Staff 9 acknowledged the resident's oxygen order was not PRN. Staff 9 stated the reason the on-call physician was called instead of 911 was because they might have been able to stabilize the resident in the facility. On [DATE] at 3:41 pm Staff 13 (LPN) stated Staff 9 was the charge nurse and she was aware of Resident 78's condition. Staff 13 stated she was the one who called 911 for Resident 78, and she stayed with the resident until the paramedics arrived, assessed the resident, and took the resident to the hospital. Staff 13 stated there was a call out to the on-call physician. She was monitoring the resident and trying to calm the resident's spouse who was pleading with staff and was afraid the resident was going to die. In summary Resident 78 was not promptly assessed by a facility nurse (wait of 1 hour and 27 minutes) for a reported change in condition. EMS was not contacted for 56 more minutes, and then only at the request of the resident's spouse. When paramedics arrived the resident required emergency treatment and transport to the hospital. Once at the hospital the resident required urgent intubation and placement on a ventilator. The resident did not recover and died in the hospital. Refer to F309 example 1 2. Resident 119 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The current Nurse Practice Act [PHONE NUMBER](2)(a)(B) indicates the licensed nurse shall conduct and document initial and ongoing focused nursing assessments of the health status of clients by distinguishing abnormal from normal data, sorting, selecting, recording and reporting the data. The [DATE] physician's orders [REDACTED]. The PICC line was to be measured upon admission and every week. The orders further noted, Notify physician of length changes. Resident 119's TARs for ,[DATE] and ,[DATE] revealed the PICC line measured 16 cm on [DATE] and [DATE]. The [DATE] measurement was documented to be 3 cm. The clinical record lacked documented evidence the physician was notified of the length change. On [DATE] at 3:00 pm, Staff 9 (LPN) acknowledged she did the PICC line dressing change and measurement on [DATE]. Staff 9 stated she was not aware she needed to check the previous measurement. Staff 9 acknowledged she did not report a change in PICC line length to the physician. On [DATE] at 9:18 am Resident 119's PICC line was discussed with Staff 2 (DNS) and Staff 15 (Regional RN). Staff 2 stated she would have an RN assess Resident 119. At 9:45 am, Staff 2 stated Resident 119's PICC line measurement was 16 cm.