Every finding on record at Glenburnie Rehab & Nursing Center

Based on observation, staff interview, and facility documentation review, the facility staff failed to serve food in a sanitary manner by failure to wear proper hair restraints in the main kitchen, which had the potential to affect residents on two of two units. The findings included:Facility kitchen staff failed to wear proper hair restraints while preparing food to prevent contamination. On 6/24/26 at 12:50 PM, observations were conducted in the main kitchen. Facility staff were actively working the tray line, preparing lunch meals for residents. A Dietary Aide (other employee #1) was observed handling the plates of food and had significant facial hair. Other Employee #1 was wearing a procedure mask that was under his chin and did not cover his beard, moustache, or sideburns. On 6/24/26 at 12:55 PM, the dietary manager (DM) was asked what the expectation was for hair restraints. The Dietary Manager stated that all staff are to wear hair nets and men are to wear beard guards. When asked about the dietary aide, the DM said, [Other Employee #1's name redacted] wears a face mask that covers his hairs. The DM was asked to look at the Dietary Aide and how his mask was being worn. The DM stated this was not acceptable and asked the dietary aide to pull his mask up and wash his hands. The Dietary Aide did comply, but even with the mask over his mouth, his sideburns and beard below his chin was not contained. On 6/24/26, during an end of day meeting the above findings were reviewed with the facility's Administrator and Director of Nursing. The facility policy regarding hair restraints in the kitchen was requested. On 6/25/26, the facility document titled, In-Service: Hairnets & [NAME] Guards was provided. This document read in part, Purpose: To ensure all staff understand the proper use of hair restraints (hairnets, caps, and beard guards) to prevent food contamination and remain compliant with state survey expectations, infection control, and sanitation standards. There will be no exceptions, and the rule must be strictly enforced at all times . Why this matters: Hair is a major contamination risk in food service. Improper hair restraint can lead to: Hair in food, Cross-contamination, infection control citations, failed audits/survey deficiencies, loss of resident trust and satisfaction .No additional information was provided. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to accurately code an assessment for one resident (Resident #4-R4) in a survey sample of nine residents. The findings included:For R4 the facility inaccurately coded a minimum data set (MDS) assessment to reflect the resident was receiving dialysis treatment. On 6/23/26, the facility provided the surveyor with a CMS-802, Resident Matrix. The document noted that R4 received dialysis treatments. On 6/25/26, during a clinical record review of R4's chart there was no indication in the physician orders, nursing notes, care plan, or documents tab to indicate that the resident was receiving dialysis services/treatments. The admission MDS with an assessment reference date of 5/31/26 was reviewed and section O0110. Special Treatments, Procedures, and Programs noted on question J1 that R4 had received dialysis on admission and while a resident. Question J2 noted that R4 recieved hemodialysis. The Director of Nursing (DON) was asked to confirm if R4 was a dialysis patient. The DON stated she would have to check her list and get back to the surveyor. The DON returned and confirmed that R4 was not a dailysis patient. On 6/25/26, an interview was conducted with the MDS nurse. The MDS nurse confirmed that R4 was not and had never received dialysis treatments. The MDS nurse reviewed R4's MDS assessment and confirmed that it was inaccurately coded and asked if she could correct it. On 6/25/26, the above findings were reviewed with the facility Administrator, Director of Nursing, and Regional Director of Clinical Services. No additional information was provided.

Based on observation and staff interview, the facility staff failed to uphold one resident's personal privacy to promote dignity for one resident (Resident #3-R3) in a survey sample of nine residents. The findings included: For R3, the facility staff failed to ensure the resident was covered and not exposed to protect her dignity and personal privacy. On 6/24/26 at 1:10 PM, during observations of the lunch meal tray distribution, three staff walked past R3's room to retrieve meal trays from the cart and began distributing meals to residents on the hallway. While observations were being made a resident could be heard making moaning noises, the surveyor went to see what was going on. R3 was observed sitting in a wheelchair at the bedside, door to the room open and no privacy curtain pulled. Full visual observations of the resident could be made from the hallway and noted that R3's full chest and breasts were exposed. Three staff continued distributing meal trays on the unit and two male residents self-propel down the hallway past R3's room. Two nursing staff and dietary manager walk past R3's room to take the meal tray cart to another hallway and did not intervene. On 6/24/26 at 1:15 PM, an interview was conducted with the nursing unit manager. The nursing unit manager stated, Resident dignity is top priority and should be maintained at all times. The unit manager was asked to accompany the surveyor to R3's room. As the surveyor and unit manager were approaching the room, two nursing staff and the dietary manager walk past R3's room to take the meal tray cart to another hallway and did not intervene. Another staff member walked by and entered R3's room to cover the resident. The unit manger walked to the room and confirmed the findings of R3's chest and breasts being exposed. On 6/24/26 during an end of day meeting the above findings were reviewed with the facility Administrator, Director of Nursing, and Regional Director of Clinical Services. No additional information was provided.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent and treat pressure injuries (1) for three of eight residents in the survey sample, Residents #2, #1, and #3.The findings include:1. For Resident #2 (R2), the facility staff failed to implement the wound nurse practitioner's recommendations to treat a pressure injury (1) in a timely manner in September and October 2025.On 10/28/25 at 9:03 a.m., LPN (licensed practical nurse) #2, the facility wound nurse, was observed preparing to provide wound care to R2. As LPN #2 prepared to enter R2's room, no signage or personal protective equipment related to any sort of isolation precautions was observed in plain view. LPN #2 did not don any PPE prior to entering R2's room or providing wound care. LPN #2 sanitized her scissors and cut the dirty dressing on R2's right leg and heel. She placed the scissors on the paper shield she had lain on the bed. The dirty dressing came in direct contact with the scissors. After removing the dirty dressing from the resident's right heel, LPN #2 picked up the dirty scissors and cut the dressing on the resident's left heel. As LPN #2 worked to cleanse and replace dressings on R2's heels, LPN #2 grabbed a handful of clean gloves from the box and laid the gloves down on R2's bed linens. The bed linens contained a large number of brown flakes of dried skin from the resident's legs. LPN #2 used these gloves throughout the wound care process, including when she was placing clean dressings on the resident's heels. At one point, LPN #2 put the bottle of wound cleanser on the bed in direct contact with the dirty bed linens as described above. She later used this wound cleanser to clean R2's sacral wound.On 10/29/25 at 8:13 a.m., ASM (administrative staff member) #3, the wound nurse practitioner, and LPN #2 were observed as they prepared to enter R2's room to provide wound care. Both staff members donned isolation gowns and gloves prior to entering the resident's room. The resident's door contained signage instructing staff and visitors to observe enhanced barrier precautions when providing care to the resident involving physical contact with the resident. During the wound care observation, ASM #3 used scissors which had not been sanitized to cut the dirty dressing on R2's right heel. ASM #3 placed the scissors directly on R2's bedside table, then later picked up and used the same scissors to cut the dirty dressing on R2's left heel. R2 was asked if the facility staff had provided heel boots for her to wear while she was in bed and out of bed in her wheelchair. She stated that they did not. She explained that the staff used pillows to float her heels while she was in bed. A review of R2's admission nursing assessment dated [DATE] revealed no evidence of skin impairment related to a pressure injury when the resident was admitted .A review of ASM (administrative staff member) #3's, the wound nurse practitioner's, progress note dated 9/18/25 revealed, in part: Date of Service: 9/16/25.Sacrum.Stage 2 (3) (present on admission).Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Manuka HD Super Lite (4) to base of the wound. 3. Secure with silicone bordered superabsorb. Change daily and PRN (as needed).Wound 6 Location: Right heel. Primary etiology: Pressure Ulcer/Injury. Stage/Severity: DTI (deep tissue injury) (5).Present on admission.Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Skin Prep to base of the wound. 3. Leave open to air. 4. Change daily and PRN.Recommend floating heels.air mattress.A review of R2's September 2025 TAR (treatment administration record) revealed no evidence that the treatment recommended by ASM #3 on 9/16/25 was implemented until 9/23/25. A review of the October 2025 revealed that an air mattress was not implemented for R2 until 10/3/25.A review of ASM #3's progress note dated 10/1/25 revealed, in part: Date of Service: 9/30/25.Wound 9. Location: Left heel. Primary Etiology: Pressure Ulcer/Injury. Stage/Severity: DTI. Wound Status: New.Recommend applying Manuka HD super lite to wound bed.A review of R2's October 2025 TAR revealed the recommended treatment to the left heel was not implemented until 10/9/25.A review of R2's care plan dated 9/12/25 and updated on 9/25/25 revealed, in part: The resident was admitted with skin impairment.Treatment as ordered. This review revealed no evidence of being updated when the pressure injury on the left heel was identified.On 10/28/25 at 3:46 p.m., ASM #3 was interviewed. She stated Manuka HD is a medical grade honey fiber and she uses it to help break down tissue that is nonviable. She stated the goal is to expose as much wound tissue as available to allow healing to begin. She added that the Manuka HD also helps to keep wounds clean by preventing the discharge from turning into slough. She stated she is still learning about pressure injuries and how to stage them. She explained that when she recommends a treatment or an intervention, her intention is for the facility staff to implement what she has recommended unless the attending physician objects to it for some reason. She stated she was not aware that the treatment for R2's pressure injuries were not implemented in a timely manner and was not aware of the facility's process for implementing her recommendations. She added that when she saw R2's left heel on 9/30/25, she was on the fence between staging it as a DTI or as a Stage 3 (5) pressure injury. She stated she could not recall why she had documented that the sacrum and right heel wounds were present on admission and that she was surprised to learn that the admission nursing assessment did not show any skin impairment related to pressure injuries.On 10/29/25 at 7:54 a.m., ASM #4, a regional director of clinical operations, was interviewed. She stated she did not see any evidence that the treatment recommendations from ASM #3 for R2's pressure injuries were implemented in a timely manner. She stated the care plan did not reveal any evidence of the left heel pressure injury. She stated it is possible that the attending physician reviewed ASM #3's recommendations and did not want them implemented. On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She explained that after ASM #3 evaluates a resident's wounds, she typically enters progress notes directly into the facility's EMR (electronic medical record). The facility's wound nurse (LPN #2) is responsible for entering ASM #3's recommendation into the resident's order set and for updating the resident's care plan. LPN #1 stated it is her job to follow up and make sure the orders and other interventions have been ordered and implemented correctly. She added that sometimes ASM #3's recommendations get lost in translation because not everyone is clear about their role in this process.On 10/29/25 at 10:51 a.m., ASM #5, the attending nurse practitioner, was interviewed. She stated she does not review ASM #3's recommendations for wounds. She explained that ASM #3 is the wound expert, and the facility staff should follow ASM #3's recommendations at all times.On 10/29/25 at 11:53 a.m., ASM #6, the attending physician, was interviewed. He stated he does not review the wound practitioner's (ASM #3's) recommendations, and that the facility wound treatments are at ASM #3's discretion completely.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.No additional information was provided prior to exit.A review of the facility policy, Wounds/Skin Impairment, revealed, in part: Notify provider with updates and/or changes to the skin impairments. Obtain new orders as necessary.Provide treatments as ordered.No additional information was provided prior to exit.REFERENCES(1) A pressure injury (ulcer) is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/orprolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbiditiesand condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). This information is taken from the website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html.(3) Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive relatedskin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.(4) Wound dressing with super-absorbent and cross-linked mesh fibers, impregnated with Manuka honey, pH of 3.0-4.5. Designed for ease of application and DAILY dressing changes for monitoring progress. Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal medical grade honey dosage with every dressing change. Reduces wound bed pH to optimize wound healing. Manuka honey released into wound bed with sustained flow, while exudate and necrotic tissue is absorbed into the dressing. Eschar and debris tissue are taken up by the mesh fiber in the dressing resulting in a clean and viable wound bed. Creates optimal wound bed healing environment and reduces or eliminates wound odor. This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL.(5) Deep tissue pressure injury remains one of the most serious forms of pressure injury. The pressure is exerted at the muscle-bone interface, but due to the resiliency of the skin, the color change is not immediate, in contrast to a bruise. The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin by about 48 hours. Then about 24 hours later, the epidermis lifts and reveals a dark wound bed. This phase of deep tissue injury evolution is often confused with skin tears. Within another week, the wound bed is often necrotic. The lag between the pressure event and the change in color of the skin makes the root cause analysis complex. This information is taken from the website https://npiap.com/news/546664/Evolution-of-Deep-Tissue-Pressure-Injury.htm.(5) Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf .2. For Resident #1 (R1), the facility staff failed to implement the wound nurse practitioner's recommendations to prevent and treat a pressure injury in a timely manner in October 2025.R1 was admitted to the facility on [DATE] and discharged on 10/20/25.A review of R1's admission nursing assessment dated [DATE] revealed the presence of moisture-related skin irritation on his sacrum. A review of R1's TAR (treatment administration record) revealed the facility implemented zinc paste to be applied to the sacrum every shift.A review of R1's skin and wound progress notes revealed the following note dated 10/17/25: Date of Service 10/14/25.Comprehensive skin assessment today. Small abrasions noted to bilateral medial feet. Left buttock stage 3 (2) pressure ulcer noted.RISK FACTORS: Due to.comorbidities.the patient is at an increased risk of skin breakdown. Recommend good hygiene and skin care to prevent skin breakdown.Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. WOUND TREATMENT: Wound #1 Left buttocks Pressure Ulcer/Injury Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Manuka HD Super Lite (3) to base of the wound. 3. Secure with silicone bordered superabsorb. Change Daily and PRN (as needed). Left buttocks stage 3 pressure ulcer.slough present to wound bed.No signs of infection. This note was signed by ASM (administrative staff member) #3, the wound nurse practitioner.A review of R1's TAR revealed no evidence that ASM #3's recommendations for treatment and for floating the resident's heels were ever implemented.A review of R1's care plan dated 10/10/25 and updated 10/16/25 revealed no evidence of the presence of a Stage 3 pressure ulcer, or of interventions to treat this pressure ulcer.On 10/28/25 at 3:46 p.m., ASM #3 was interviewed. She stated Manuka HD is a medical grade honey fiber and she uses it to help break down tissue that is nonviable. She stated the goal is to expose as much wound tissue as available to allow healing to begin. She added that the Manuka HD also helps to keep wounds clean by preventing the discharge from turning into slough. She stated she is still learning about pressure injuries and how to stage them. She explained that when she recommends a treatment or an intervention, her intention is for the facility staff to implement what she has recommended unless the attending physician objects to it for some reason. She stated she was not aware that the treatment for R1's Stage 3 pressure injury was never implemented and was not aware of the facility's process for implementing her recommendations.On 10/29/25 at 7:54 a.m., ASM #4, a regional director of clinical operations, was interviewed. She stated R1 was already being treated with zinc paste, which is appropriate for a Stage 2 pressure injury, when the Stage 3 injury was identified. However, she did not see any evidence that the Manuka HD or the floating of R1's heels were implemented. She stated the care plan did not reveal any evidence of the Stage 3 pressure injury. She stated it is possible that the attending physician reviewed ASM #3's recommendations and did not want them implemented. On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She explained that after ASM #3 evaluates a resident's wounds, she typically enters progress notes directly into the facility's EMR (electronic medical record). The facility's wound nurse (LPN #2) is responsible for entering ASM #3's recommendation into the resident's order set and for updating the resident's care plan. LPN #1 stated it is her job to follow up and make sure the orders and other interventions have been ordered and implemented correctly. She added that sometimes ASM #3's recommendations get lost in translation because not everyone is clear about their role in this process.On 10/29/25 at 10:51 a.m., ASM #5, the attending nurse practitioner, was interviewed. She stated she does not review ASM #3's recommendations for wounds. She explained that ASM #3 is the wound expert, and the facility staff should follow ASM #3's recommendations at all times.On 10/29/25 at 11:53 a.m., ASM #6, the attending physician, was interviewed. He stated he does not review the wound practitioner's (ASM #3's) recommendations, and that the facility wound treatments are at ASM #3's discretion completely.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.No additional information was provided prior to exit.REFERENCES(1) A pressure injury (ulcer) is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/orprolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbiditiesand condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf .(3) Wound dressing with super-absorbent and cross-linked mesh fibers, impregnated with Manuka honey, pH of 3.0-4.5. Designed for ease of application and DAILY dressing changes for monitoring progress. Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal medical grade honey dosage with every dressing change. Reduces wound bed pH to optimize wound healing. Manuka honey released into wound bed with sustained flow, while exudate and necrotic tissue is absorbed into the dressing. Eschar and debris tissue are taken up by the mesh fiber in the dressing resulting in a clean and viable wound bed. Creates optimal wound bed healing environment and reduces or eliminates wound odor. This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL. (4) The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/3. For Resident #3 (R3), the facility staff failed to implement treatment for a pressure injury (1) in a timely manner.A review of R3's admission nursing assessment dated [DATE] revealed no evidence of any skin impairments related to a pressure injury. The findings in this assessment were confirmed by ASM (administrative staff member) #3, the wound nurse practitioner's progress note dated 9/26/25, in which ASM #3 documented the following: No wounds.Further review of R3's clinical record revealed the following progress note dated 10/3/25 and written by ASM #3: Wound 1. Location: Left gluteal fold. Primary etiology: Abrasion. State/Severity: Partial Thickness. Wound Status: New.Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Manuka HD Super Lite (2) to base of the wound. 3. Secure with silicone bordered superabsorb. Change Daily and PRN (as needed). A review of R3's October 2025 TAR (treatment administration record) failed to reveal any evidence treatment for the gluteal fold wound was ever implemented prior to her discharge on [DATE]. A review of R3's care plan dated 9/30/25 revealed no evidence that the care plan was updated with the presence of the wound on the resident's gluteal fold. On 10/28/25 at 3:46 p.m., ASM #3 was interviewed. She stated Manuka HD is a medical grade honey fiber and she uses it to help break down tissue that is nonviable. She stated the goal is to expose as much wound tissue as available to allow healing to begin. She added that the Manuka HD also helps to keep wounds clean by preventing the discharge from turning into slough. She stated she is still learning about pressure injuries and how to stage them. She explained that when she recommends a treatment or an intervention, her intention is for the facility staff to implement what she has recommended unless the attending physician objects to it for some reason. She stated she was not aware that the treatment for R3's gluteal fold abrasion was never implemented and was not aware of the facility's process for implementing her recommendations. She stated the abrasion had the potential to become a pressure injury.On 10/29/25 at 7:54 a.m., ASM #4, a regional director of clinical operations, was interviewed. She stated, she did not see any evidence that the Manuka was ever implemented for R3. She stated the care plan did not reveal any evidence of the gluteal fold injury. She stated it is possible that the attending physician reviewed ASM #3's recommendations and did not want them implemented. On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She explained that after ASM #3 evaluates a resident's wounds, she typically enters progress notes directly into the facility's EMR (electronic medical record). The facility's wound nurse (LPN #2) is responsible for entering ASM #3's recommendation into the resident's order set and for updating the resident's care plan. LPN #1 stated it is her job to follow up and make sure the orders and other interventions have been ordered and implemented correctly. She added that sometimes ASM #3's recommendations get lost in translation because not everyone is clear about their role in this process.On 10/29/25 at 10:51 a.m., ASM #5, the attending nurse practitioner, was interviewed. She stated she does not review ASM #3's recommendations for wounds. She explained that ASM #3 is the wound expert, and the facility staff should follow ASM #3's recommendations at all times.On 10/29/25 at 11:53 a.m., ASM #6, the attending physician, was interviewed. He stated he does not review the wound practitioner's (ASM #3's) recommendations, and that the facility wound treatments are at ASM #3's discretion completely.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.No additional information was provided prior to exit.REFERENCES(1) A pressure injury (ulcer) is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/orprolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbiditiesand condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.(2) Wound dressing with super-absorbent and cross-linked mesh fibers, impregnated with Manuka honey, pH of 3.0-4.5. Designed for ease of application and DAILY dressing changes for monitoring progress. Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal medical grade honey dosage with every dressing change. Reduces wound bed pH to optimize wound healing. Manuka honey released into wound bed with sustained flow, while exudate and necrotic tissue is absorbed into the dressing. Eschar and debris tissue are taken up by the mesh fiber in the dressing resulting in a clean and viable wound bed. Creates optimal wound bed healing environment and reduces or eliminates wound odor. This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL. (4) The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/

Based on staff interview, facility document review, and clinical record review, the facility staff failed to revise the care plan for three of eight residents in the survey sample, Residents #2, #1, and #3.The findings include:1. For Resident #2 (R2) the facility staff failed to revise the care plan when the resident developed pressure injuries (1).A review of R2's admission nursing assessment dated [DATE] revealed no evidence of skin impairment related to a pressure injury when the resident was admitted .A review of ASM (administrative staff member) #3's, the wound nurse practitioner's, progress note dated 9/18/25 revealed, in part: Date of Service: 9/16/25.Sacrum.Stage 2 (2) (present on admission).Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Manuka HD Super Lite (3) to base of the wound. 3. Secure with silicone bordered superabsorb. Change daily and PRN (as needed).Wound 6 Location: Right heel. Primary etiology: Pressure Ulcer/Injury. Stage/Severity: DTI (deep tissue injury) (4).Present on admission.Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Skin Prep to base of the wound. 3. Leave open to air. 4. Change daily and PRN.Recommend floating heels.air mattress.A review of ASM #3's progress note dated 10/1/25 revealed, in part: Date of Service: 9/30/25.Wound 9. Location: Left heel. Primary Etiology: Pressure Ulcer/Injury. Stage/Severity: DTI. Wound Status: New.Recommend applying Manuka HD super lite to wound bed.A review of R2's care plan dated 9/12/25 and updated on 9/25/25 revealed, in part: The resident was admitted with skin impairment.Treatment as ordered. This review revealed no evidence that the care plan was updated when the pressure injury on the left heel was identified.On 10/29/25 at 7:54 a.m., ASM #4, a regional director of clinical operations, was interviewed. She stated the care plan did not reveal any evidence of the left heel pressure injury. She stated the care plan should be updated with the presence of all current wounds.On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated that the care plans map out what is done to care for a resident while they are in the facility. She stated the care plan considers the resident's diagnoses, concerns, behaviors, wounds, medications, and more, and lays out the interventions the facility is taking to meet the resident's needs. She stated all floor nurses have the ability to update a resident's care plan and it is her job to make sure the updates are being completed.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.A review of the facility policy, Care Planning, revealed, in part: Care plans will be updated on an ongoing basis as changes in the patient occur, and reviewed quarterly with the quarterly assessment.No additional information was provided prior to exit.REFERENCES(1) A pressure injury (ulcer) is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/orprolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbiditiesand condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.(2) Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf .(3) Wound dressing with super-absorbent and cross-linked mesh fibers, impregnated with Manuka honey, pH of 3.0-4.5. Designed for ease of application and DAILY dressing changes for monitoring progress. Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal medical grade honey dosage with every dressing change. Reduces wound bed pH to optimize wound healing. Manuka honey released into wound bed with sustained flow, while exudate and necrotic tissue is absorbed into the dressing. Eschar and debris tissue are taken up by the mesh fiber in the dressing resulting in a clean and viable wound bed. Creates optimal wound bed healing environment and reduces or eliminates wound odor. This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL. (4) Deep tissue pressure injury remains one of the most serious forms of pressure injury. The pressure is exerted at the muscle-bone interface, but due to the resiliency of the skin, the color change is not immediate, in contrast to a bruise. The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin by about 48 hours. Then about 24 hours later, the epidermis lifts and reveals a dark wound bed. This phase of deep tissue injury evolution is often confused with skin tears. Within another week, the wound bed is often necrotic. The lag between the pressure event and the change in color of the skin makes the root cause analysis complex. This information is taken from the website https://npiap.com/news/546664/Evolution-of-Deep-Tissue-Pressure-Injury.htm.2. For Resident #1 (R1), the facility staff failed to review and revise the care plan when the resident developed a pressure injury (1).A review of R1's skin and wound progress notes revealed the following note dated 10/17/25: Date of Service 10/14/25.Comprehensive skin assessment today. Small abrasions noted to bilateral medial feet. Left buttock stage 3 (2) pressure ulcer noted.RISK FACTORS: Due to.comorbidities.the patient is at an increased risk of skin breakdown. Recommend good hygiene and skin care to prevent skin breakdown.Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. WOUND TREATMENT: Wound #1 Left buttocks Pressure Ulcer/Injury Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Manuka HD Super Lite (3) to base of the wound. 3. Secure with silicone bordered superabsorb. Change Daily and PRN (as needed). Left buttocks stage 3 pressure ulcer.slough present to wound bed.No signs of infection. This note was signed by ASM (administrative staff member) #3, the wound nurse practitioner.A review of R1's care plan dated 10/10/25 and updated 10/16/25 revealed no evidence of the presence of a Stage 3 pressure ulcer, or of interventions to treat this pressure ulcer.On 10/29/25 at 7:54 a.m., ASM #4, a regional director of clinical operations, was interviewed. She stated the care plan did not reveal any evidence of the resident's pressure injury. She stated the care plan should be updated with the presence of all current wounds.On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated that the care plans map out what is done to care for a resident while they are in the facility. She stated the care plan considers the resident's diagnoses, concerns, behaviors, wounds, medications, and more, and lays out the interventions the facility is taking to meet the resident's needs. She stated all floor nurses have the ability to update a resident's care plan and it is her job to make sure the updates are being completed.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.No additional information was provided prior to exit.REFERENCE(1) A pressure injury (ulcer) is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/orprolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbiditiesand condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website (3) Wound dressing with super-absorbent and cross-linked mesh fibers, impregnated with Manuka honey, pH of 3.0-4.5. Designed for ease of application and DAILY dressing changes for monitoring progress. Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal medical grade honey dosage with every dressing change. Reduces wound bed pH to optimize wound healing. Manuka honey released into wound bed with sustained flow, while exudate and necrotic tissue is absorbed into the dressing. Eschar and debris tissue are taken up by the mesh fiber in the dressing resulting in a clean and viable wound bed. Creates optimal wound bed healing environment and reduces or eliminates wound odor. This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL. (4) The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/3. For Resident #3 (R3), the facility staff failed to update the resident's care plan when the resident developed an abrasion requiring treatment.A review of R3's admission nursing assessment dated [DATE] revealed no evidence of any skin impairments related to a pressure injury. The findings in this assessment were confirmed by ASM (administrative staff member) #3, the wound nurse practitioner's progress note dated 9/26/25, in which ASM #3 documented the following: No wounds.Further review of R3's clinical record revealed the following progress note dated 10/3/25 and written by ASM #3: Wound 1. Location: Left gluteal fold. Primary etiology: Abrasion. State/Severity: Partial Thickness. Wound Status: New.Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Manuka HD Super Lite (2) to base of the wound. 3. Secure with silicone bordered superabsorb. Change Daily and PRN (as needed). A review of R3's care plan dated 9/30/25 revealed no evidence that the care plan was updated with the presence of the wound on the resident's gluteal fold.On 10/29/25 at 7:54 a.m., ASM #4, a regional director of clinical operations, was interviewed. She stated the care plan did not reveal any evidence of the resident's pressure injury. She stated the care plan should be updated with the presence of all current wounds.On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated that the care plans map out what is done to care for a resident while they are in the facility. She stated the care plan considers the resident's diagnoses, concerns, behaviors, wounds, medications, and more, and lays out the interventions the facility is taking to meet the resident's needs. She stated all floor nurses have the ability to update a resident's care plan and it is her job to make sure the updates are being completed.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.No additional information was provided prior to exit.REFERENCES(1) A pressure injury (ulcer) is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/orprolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbiditiesand condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.(2) Wound dressing with super-absorbent and cross-linked mesh fibers, impregnated with Manuka honey, pH of 3.0-4.5. Designed for ease of application and DAILY dressing changes for monitoring progress. Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal medical grade honey dosage with every dressing change. Reduces wound bed pH to optimize wound healing. Manuka honey released into wound bed with sustained flow, while exudate and necrotic tissue is absorbed into the dressing. Eschar and debris tissue are taken up by the mesh fiber in the dressing resulting in a clean and viable wound bed. Creates optimal wound bed healing environment and reduces or eliminates wound odor. This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL. (4) The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to implement infection control procedures for one of eight residents in the survey sample, Resident #2. The findings include:For Resident #2 (R2), the facility staff failed to implement enhanced barrier precautions (1) to protect residents from infection.On 10/28/25 at 9:03 a.m., LPN (licensed practical nurse) #2, the facility wound nurse, was observed preparing to provide wound care to R2. As LPN #2 prepared to enter R2's room, no signage or personal protective equipment related to any sort of isolation precautions was observed in plain view. LPN #2 did not don any PPE prior to entering R2's room or providing wound care. Further review of R2's clinical record revealed the resident had chronic wounds and a Foley catheter (2). This review revealed no orders for or evidence of enhanced barrier precautions being implemented since the resident was admitted to the facility on [DATE] (a total of 47 days).On 10/29/25 at 7:54 a.m., ASM (administrative staff member) #2, the director of nursing, and ASM #4, the regional director of clinical operations, were interviewed. ASM #2 stated enhanced barrier precautions are implemented to prevent the spread of harmful bacteria from resident to resident. ASM #4 stated enhanced barrier precautions are implemented when any resident has any kind of chronic wound and/or invasive medical device such as a Foley catheter.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.A review of the facility policy, Enhanced Barrier Precautions, revealed, in part: Employees providing high-contact patient care activities will follow Enhanced Barrier Precautions for patients who meet the criteria.May be indicated for patients.with chronic wounds.with indwelling medical devices.[Enhanced Barrier Precautions] require the use of gown and gloves by staff during high-contact patient care activities.[including] wound care for chronic wounds.No additional information was provided prior to exit.REFERENCES(1) Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). This information is taken from the website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html.(2) Foley catheters are small flexible tubes inserted into the urethra to drain urine from the bladder. This information is taken from the website https://www.ncbi.nlm.nih.gov/books/NBK564404/

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory services for one of eight residents in the survey sample, Resident #1.The findings include: For Resident #1 (R1), the facility staff failed to implement a CPAP (1) device.A review of R1's hospital Discharge summary dated [DATE] revealed, in part: Acute.respiratory failure [secondary to] CHF (congestive heart failure).OSA (obstructive sleep apnea).CPAP at night.A review of R1's clinical record revealed the following progress note: 10/14/2025 11:20 Health Status Note.Note Text: Writer spoke with NP (nurse practitioner) in regards to Bipap (3) placement d/t (due to) rsd (resident) was on Cpap during stay in the hospital. NP.stated she will place and order for Bipap. Writer notified.respiratory therapist.he stated he will come to the facility and set up the machine.Further review of R1's clinical record failed to reveal any evidence that a CPAP was ever initiated for R1 during his stay at the facility.On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated that if a resident needs a CPAP on admission, this information is usually in the hospital discharge summary. She stated the admitting nurse should verify the order with the physician and the physician should be informed that the facility does not have CPAP machines in stock. At that time, the physician might want to put some other type of order in place until the CPAP can be obtained by the central supply clerk and provided to the resident. She stated most residents who need a CPAP have a device at home that they bring to the facility. She explained that even if the resident has a CPAP at home, it is still the facility's responsibility to provide one at the facility if the resident is unable to bring the device from their home.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A CPAP policy was requested.No additional information was provided prior to exit.REFERENCES(1) CPAP (Continuous Positive Airway Pressure) is a treatment that uses mild air pressure to keep your breathing airways open .It involves using a CPAP machine that includes a mask or other device that fits over your nose or your nose and mouth, straps to position the mask, a tube that connects the mask to the machine's motor, and a motor that blows air into the tube. CPAP is used to treat sleep-related breathing disorders including sleep apnea. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/cpap.(2) Obstructive sleep apnea, also called OSA, happens when your upper airway becomes blocked many times while you sleep. The blockage can reduce or completely stop airflow. This is the most common type of sleep apnea. This information is taken from the website https://www.nhlbi.nih.gov/health/sleep-apnea.(3) Biphasic Positive Airway Pressure (BIPAP) can be described as pressure controlled ventilation in a system allowing unrestricted spontaneous breathing at any moment of the ventilatory cycle. It can also be described as a Continuous Positive Airway Pressure (CPAP) system with a time-cycled change of the applied CPAP level. This information is taken from the website https://pubmed.ncbi.nlm.nih.gov/8143712/.

Based on staff interview and clinical record review it was determined that the facility staff failed to maintain a complete and accurate record for two of 11 residents in the survey sample, Residents #101 and Resident #109. The findings include:1. For Resident #101 (R101), the facility staff failed to document the eMAR (electronic medication administration record) that the medication, Protonix (1), was administered. R101 was admitted to the facility with diagnosis that included but were not limited to gastro-esophageal reflux disease (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/09/2025, R101 scored 2 (two) out of 15 on the BIMS (brief interview for mental status), indicating R101 was severely impaired of cognition for making daily decisions. The physician's order for R101 documented in part, Protonix Tablet Delayed Release 40 MG (milligrams) (Pantoprazole Sodium). Give 1 (one) tablet by mouth one time a day for gastritis Order Date:10/7/2025. 0630 and 1630 (6:30 a.m. and 4:30 p.m.) The facility's nursing note for R1010 dated 12/09/2025 at 9:06 a.m. documented, Patient went upstairs for dialysis at 0420 (4:20 a.m.), she took her medication as ordered and her folder. The eMAR for R101 dated December 2025 documented the physician's order for Protonix as stated above. Further review of the eMAR revealed a blank under 12/09/2025 at 6:30 a.m. On 12/10/2025 at approximately 2:00 p.m. an interview was conducted with RN (registered nurse) #2 regarding the procedure for documenting the administration of a medication on an eMAR. she stated that when a resident's medication is administered there is a check mark for the medication under the date it was given. On 12/11/2025 at 7:46 a.m. an interview was conducted with ASM (administrative staff member) #2, director of nursing, regarding the blank on 12/09/2025 for R101's Protonix. ASM #2 stated that LPN #4 phoned her last evening about not signing the off the eMAR for the administration of R101' s Protonix. ASM #2 stated that LPN #4 told her that the Protonix was administered while R101 was waiting in the dialysis unit and forgot to sign the eMAR. She further stated that LPN #4 left a written statement this morning under the door of her office because LPN #4 was leaving out of town for vacation. ASM #2 stated that the eMAR should be signed immediately after administering the medication to the resident. On 12/11/2025 at approximately 7:30 a.m. ASM #2 provided the surveyor with a copy of the written statement by LPN #4. The written statement by LPN #4 documented in part, .I had (R101) on 12/08/25 before dialysis, her skin prep (preparation) and skin barrier were all done before dialysis during ADL (activities of daily living). At 0420 she was taken upstairs by me. At 0531 (5:31 a.m.) I took her Protonix upstairs and gave it to her while she was waiting to be seated. It was an oversight that her MARs were not signed immediately. On 12/11/2025 at approximately 2:05 p.m. ASM (administrative staff member) #1, interim administrator, ASM #2, director of nursing and ASM #4, vice president of operations, were made aware of the above findings. No further information was provided prior to exit. Reference:(1) Used to treat damage from gastroesophageal reflux disease (GERD). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601246.html. (2) Stomach contents to leak back, or reflux, into the esophagus and irritate it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/gerd.html. 2.Resident # 109 (R109) was admitted to the facility with diagnosis that included but were not limited to pain. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/27/2025, R109 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R109 was cognitively intact for making daily decisions. Section J0300 Pain Presence coded R109 as not having pain in the past five days. (2) For R109, the facility staff failed to accurately document the administration of Oxycodone (1) on the Controlled Drug Administration Record dated 08/06/2025. R109 was admitted to the facility with diagnosis that included but were not limited to nerve damage. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/27/2025, R109 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R109 was cognitively intact for making daily decisions. The physician's order for R109 documented in part, Oxycodone HCl (hydrochloride) Oral Tablet 5 (five) MG (milligrams). Give 1 (one) tablet four times a day for chronic pain management. Order Date: 7/11/2025. The eMAR (electronic medication administration record) for R109 dated August 2025 documented the physician's order as stated above. Further review of the eMAR revealed R109 received five milligrams of oxycodone on 08/06/2025 at 9:00 a.m. and 5:00 p.m. The facility's Controlled Drug Administration Record for R109 documented the physician's order for Oxycodone as stated above. Further review of the record failed to document the administration of Oxycodone on 08/06/2025 at 9:00 a.m. and 5:00 p.m. On 12/11/2025 at approximately 2:00 p.m. an interview was conducted with ASM (administrative staff member) #2, director of nursing, regarding the controlled drug administration record and eMAR for R109. After reviewing the eMAR and controlled drug administration record for the dates and times stated above ASM #2 stated that the nurse forgot to accurately document controlled drug administration record indicating that R109 received the physician ordered Oxycodone on 12/06/2025 at 9:00 a.m. and 5:00 p.m. She further stated that the nurse should immediately document the controlled drug administration record when the medication is removed for administration. On 12/11/2025 at approximately 2:05 p.m. ASM #1, interim administrator, ASM #2, director of nursing and ASM #4, vice president of operations, were made aware of the above findings. No further information was provided prior to exit. Reference:(1) Used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide 24 hour on-call physician services for one of eight residents in the survey sample, Resident #3.The findings include:For Resident #3 (R3), the facility staff failed to provide on-call physician services on 10/21/25 when a critical laboratory test result was communicated to the nursing staff.A review of R3's clinical record revealed the following progress note dated 10/21/25 at 1:10 a.m Critical lab called in from lab. Potassium 2.9 (1). Contacted on call physician to make aware. No call returned. 0145AM (1:45 a.m.) Contacted on call physician again, no returned call. 0658 (6:58 a.m.), no call returned, will have nurse follow-up with physician.On 10/29/25 at 7:54 a.m., ASM (administrative staff member) #4, the regional director of clinical operations, was interviewed. She stated the facility nurses should always be able to reach an on-call physician. She explained that if the nurses cannot reach an on-call physician in a reasonable amount of time, the medical director should be contacted.On 10/29/25 at 11:53 a.m., ASM #6, the attending physician, was interviewed. After reviewing R3's progress note, he stated that in this context, there is always a back up for the provider who is on call. He explained that the on call service has the contact information for the back up provider in case the person on call is unable to respond right away. He stated the nurse is responsible for asking the telephone on-call personnel to notify the back up person. He stated he was never aware that the resident's potassium level was 2.9. He stated the risks of low potassium include heart rhythm dysfunction and neurological fogginess. He stated he would have ordered an immediate oral supplement to be given.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A policy regarding 24 hour physician coverage was requested.No additional information was provided prior to exit.REFERENCE(1) This [laboratory] test measures the amount of potassium in the fluid portion (serum) of the blood. Potassium (K+) helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells.The normal range is 3.7 to 5.2 milliequivalents per liter (mEq/L) 3.70 to 5.20 millimoles per liter (millimol/L). This information is taken from the website https://medlineplus.gov/ency/article/003484.htm.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain program for one of eight residents in the survey sample, Resident #2.The findings include:For Resident #2 (R2), the facility staff failed to treat a resident's report of severe pain on [DATE].R2 was admitted to the facility on [DATE] with a history of fractures in the left hip, and right leg. On admission the resident was documented to have recent surgical wounds on both knees.On the following dates and times, R2 was observed in her room and was both alert and conversant: [DATE] at 1:54 p.m. and 4:19 p.m.; [DATE] a.m. at 9:03 a.m.; and [DATE] at 8:15 a.m. At each observation, the resident reported pain in her knees. She stated the staff usually treated her pain effectively, but that she had experienced severe pain once or twice that the medication did not help.A review of R2's progress notes revealed the following note dated [DATE] at 11:57 p.m.: Patient c/o (complained of) 10/10 (ten out of ten) bilat (bilateral - both left and right) knee pain and requesting prn (as needed) Oxycodone (1). This writer explained that it was no longer on her current medication list. Patient requesting MD (medical doctor) review meds and add it back if appropriate. MD Communication Book updated for this request. The nurse who wrote this note was not interviewed during the survey.Further review of R2's progress notes failed to reveal any immediate intervention by the facility staff to address R2's severe pain in both knees.A review of R2's medication orders revealed that an as needed order for Oxycodone was added to R2's medication regimen at 6:45 p.m. on [DATE]. Further review of R2's progress notes revealed no evidence that either ASM (administrative staff member) #5, the attending nurse practitioner or ASM #6, the attending physician ever was made aware of or addressed R2's specific report of severe pain on [DATE]. On [DATE] at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. After reviewing R2's progress note, she stated that it was almost midnight, and the physician/NP (nurse practitioner) coming to the facility until the next morning, at the earliest. She explained that if the resident was reporting 10/10 pain, the nurse should have called the on-call physician and obtained an order for a pain medication that could be administered immediately. She stated the resident should not have been left without any medication until the resident could be seen by the physician or NP. She added: At 10/10, we need to get the on-call doctor on the phone. She could not explain why the physician/NP never addressed the 10/10 pain. She stated that even if the report of pain had been listed in the physician's book of concerns to be addressed at the next visit, this concern should have been passed along in the shift to shift nursing report.On [DATE] at 10:51 a.m., ASM #5 was interviewed. After reviewing R2's progress note, she stated she assumed the Oxycodone fell off the resident's medication list because the order expired as an as needed medication. She stated she did not remember anything being written in the physician concern book about R2 having 10/10 knee pain. She stated she would hope that the nurse would have called the physician on call to get an order for a pain medication that could be administered immediately. On [DATE] at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.A review of the facility policy, Pain Management Assessments, revealed, in part: Initiate a pain assessment any time.a patient experiences pain that is not usual for the patient.No additional information was provided prior to exit.REFERENCES(1) Oxycodone is used to relieve moderate to severe pain . Oxycodone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682132.html.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide incontinence care for one of eight residents in the survey sample, Resident #4.The findings include:For Resident #4 (R4) the facility staff failed to provide incontinence care on 10/28/25 from 10:07 a.m. through 5:30 p.m.On 10/28/25 a.m., R4 was observed without interruption from 10:07 a.m. until 5:30 p.m. During this time, R4 was sitting in her wheelchair. A staff member moved her from her room to the day room at 10:10 a.m. Following the move to the day room, the resident was moved by staff back and forth between the day room, activities room, and dining room. This observation was continuous with no interruptions. At no time did any staff member wheel the resident back to her room to provide incontinence care.On R4's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/9/25, she was coded as being severely cognitively impaired for making daily decisions, having scored only two out of 15 on the BIMS (brief interview for mental status). She was coded as sometimes understanding others and as sometimes being understood by others for communication. She was coded as always incontinent of both bladder and bowel, and as requiring the assistance of staff for toileting.On 10/29/25 at 10:07 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated if she cares for a resident who is incontinent and cannot walk independently to the bathroom, she checks the resident for incontinence every hour or two. She stated that two hours is the maximum amount of time that should elapse between incontinence checks. She stated that after two hours, a resident's skin can begin to break down. She stated if a resident refuses an incontinence check, the charge nurse should be notified, and multiple attempts should be made to convince the resident to allow the care.On 10/29/25 at 10:16 a.m., CNA #2 was interviewed. She stated she is the lead CNA on the unit where R4 resides. She stated that as a lead CNA, she is responsible for making sure the floor and residents' rooms are clean and tidy. She also is responsible for doing walking rounds at the end of every shift with all the CNAs to make sure they have completed all the tasks for their shift that is ending. She explained that incontinent residents should be checked a minimum of every two hours, with some residents requiring more frequent checks. She stated that when she is responsible for caring for R4, she checks her more frequently than every two hours because the resident is not able to tell the staff if she needs incontinence care. She stated that even if R4 is in the activities room or the dining room, incontinence checks are still a priority and should be done at least every two hours.On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated that residents who are incontinent and require assistance should be checked every two hours. She stated that once a staff member gets to know the residents' needs better, they may check on them more frequently than every two hours. She stated a resident's skin starts to break down after two hours.On 10/29/25 at 11:59 a.m., CNA #3 was interviewed. She was assigned to care for R4 on 10/28/25 from 7:00 a.m. until 3:00 p.m. She stated she checks incontinent residents about every two hours. She stated she takes the residents to their rooms to perform the incontinence checks. She stated if a resident is left in wet or soiled incontinence briefs for a long period of time, it can lead to skin breakdown. She stated she checked R4 for incontinence multiple times on 10/28/25. After being informed of the constant observations of R4 throughout the day on 10/28/25, CNA #3 stated she actually had not taken R4 to her room to check her for incontinence at any time during her shift. She stated she walked by the resident multiple times and checked in on her throughout the shift.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were interviewed. All three management staff members agreed that if a resident is not offered incontinence care for an extended period of time, they may suffer emotional distress and a lack of a dignified quality of life. Additionally, they agreed that a resident may also experience skin impairment after more than two or three hours in a wet or soiled incontinence brief, and that it would not feel good physically or emotionally. At this time, these management staff members were informed of the concerns related to the lack of incontinence care for R4.A review of the facility policy, Urinary Elimination, failed to reveal information related to the frequency in which incontinence care should be provided to a resident.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of eight residents in the survey sample, Resident #1.The findings include:For Resident #1 (R1), the facility staff failed to bathe the resident on two days in October 2025.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/15/25, the resident was coded as being completely dependent on facility staff for bathing/showering.A review of R1's October 2025 point of care records revealed no evidence that he received a shower or a bath on 10/12/25 and 10/13/25. This review revealed no evidence that the resident refused being bathed on either of these days.On 10/29/25 at 10:07 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated she bathes every resident assigned to her each and every morning. She stated this is simply part of her job of taking care of the residents. She stated she wants to bathe every day and her residents deserve the same care she gives to herself. She stated she documents the baths she gives in the electronic medical record.On 10/29/25 at 10:16 a.m., CNA #2 was interviewed. She stated she is a lead CNA and is responsible for checking to make sure all the residents on her unit receive the care they need. She stated she bathes and dresses all residents assigned to her every day. She stated she documents the bath/shower in the electronic medical record. She stated if the bath is not documented in the record, there is no way to verify that the bath actually occurred.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.A review of the facility policy, Bathing, revealed, in part: Bathing usually occurs after breakfast or the evening meal. The person's choice of type of bath and time of day is respected when possible.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of eight residents in the survey sample, Resident #2.The findings include:For Resident #2 (R2), the facility staff failed to implement the resident's care plan regarding pressure injuries (1).A review of ASM (administrative staff member) #3's, the wound nurse practitioner's, progress note dated 9/18/25 revealed, in part: Date of Service: 9/16/25.Sacrum.Stage 2 (2) (present on admission).Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Manuka HD Super Lite (3) to base of the wound. 3. Secure with silicone bordered superabsorb. Change daily and PRN (as needed).Wound 6 Location: Right heel. Primary etiology: Pressure Ulcer/Injury. Stage/Severity: DTI (deep tissue injury) (4).Present on admission.Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Skin Prep to base of the wound. 3. Leave open to air. 4. Change daily and PRN.Recommend floating heels.air mattress.A review of R2's September 2025 TAR (treatment administration record) revealed no evidence that the treatment recommended by ASM #3 on 9/16/25 was implemented until 9/23/25. A review of the October 2025 revealed that an air mattress was not implemented for R2 until 10/3/25.A review of ASM #3's progress note dated 10/1/25 revealed, in part: Date of Service: 9/30/25.Wound 9. Location: Left heel. Primary Etiology: Pressure Ulcer/Injury. Stage/Severity: DTI. Wound Status: New.Recommend applying Manuka HD super lite to wound bed.A review of R2's October 2025 TAR revealed the recommended treatment to the left heel was not implemented until 10/9/25.A review of R2's care plan dated 9/12/25 and updated on 9/25/25 revealed, in part: The resident was admitted with skin impairment.Treatment as ordered. On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated that the care plans map out what is done to care for a resident while they are in the facility. She stated the care plan considers the resident's diagnoses, concerns, behaviors, wounds, medications, and more, and lays out the interventions the facility is taking to meet the resident's needs. She stated all staff members are responsible for implementing all elements of the resident's care plan.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.A review of the facility policy, Care Planning, revealed no information related to the importance of following a resident's care plan.No additional information was provided prior to exit.REFERENCES(1) A pressure injury (ulcer) is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/orprolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbiditiesand condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.(2) Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf .(3) Wound dressing with super-absorbent and cross-linked mesh fibers, impregnated with Manuka honey, pH of 3.0-4.5. Designed for ease of application and DAILY dressing changes for monitoring progress. Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal medical grade honey dosage with every dressing change. Reduces wound bed pH to optimize wound healing. Manuka honey released into wound bed with sustained flow, while exudate and necrotic tissue is absorbed into the dressing. Eschar and debris tissue are taken up by the mesh fiber in the dressing resulting in a clean and viable wound bed. Creates optimal wound bed healing environment and reduces or eliminates wound odor. This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL. (4) Deep tissue pressure injury remains one of the most serious forms of pressure injury. The pressure is exerted at the muscle-bone interface, but due to the resiliency of the skin, the color change is not immediate, in contrast to a bruise. The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin by about 48 hours. Then about 24 hours later, the epidermis lifts and reveals a dark wound bed. This phase of deep tissue injury evolution is often confused with skin tears. Within another week, the wound bed is often necrotic. The lag between the pressure event and the change in color of the skin makes the root cause analysis complex. This information is taken from the website https://npiap.com/news/546664/Evolution-of-Deep-Tissue-Pressure-Injury.htm.

Based on clinical record review and staff interview, the facility staff failed to develop a baseline care plan for one of 11 residents in the survey sample, Resident #103. The finding include:For R103, facility staff failed to develop a baseline care plan to address the use of a C-PAP (continuous positive airway pressure) machine (1). R103 was admitted to the facility with diagnosis that included but not limited to sleep apnea (2). The MDS (minimum data set) assessment was not due at the time of the survey. The facility's admission assessment for R103 dated 12/08/2025 documented in part, Cognitively intact. Oriented to person. Oriented to place. Oriented to situation.On 12/09/2025 at approximately 2:11 p.m. an observation of R103's room revealed a C-PAP machine and mask on R103's over-the-bed table.The facility's nurse's note for R103 dated 12/08/2025 at 8:50 p.m. documented in part, Use of CPAP/BiPAP (bilevel continuous positive airway pressure): Yes.The discharge summary from (Name of Hospital) documented in part, Details of Hospital Stay. Sleep - CPAP.Review of the baseline care plan for R103 dated 12/08/2025 failed to evidence documentation for the use of a C-PAP.On 12/10/25 at 1:20 PM, an interview was conducted with LPN (licensed practical nurse) #1. Asked the purpose of the care plan, LPN #1 stated, the purpose is to make sure everyone is on the same page for the care for that resident. When asked if C-PAP should be on the care plan, LPN #1 stated, yes, it should. On 12/10/2025 at approximately 3:55 p.m. ASM (administrative staff member) #1, interim administrator, ASM #2, director of nursing and ASM #4, vice president of operations, were made aware of the above findings.No further information was provided prior to exit.References:(1) The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm. (2) Sleep apnea is a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. This information was obtained from the website: https://medlineplus.gov/sleepapnea.html.

Based on observations and staff interview, facility staff failed to maintain a homelike environment for one of 11 resident rooms observed, resident room [ROOM NUMBER]-B. The findings include:For resident room [ROOM NUMBER]-B, facility staff failed to maintain a section of wall in good repair. On 12/09/2025 at approximately 1:50 p.m., an observation of resident room [ROOM NUMBER]-A revealed a section of wall behind the head-of-the-bed roughly plastered, measuring approximately 15 inches wide and 36 long. Further observation revealed white plaster dust coating the top of the headboard of the bed and coating the floor under the head of the bed. Call bell within reach. On 12/10/2025 at approximately 8:05 a.m., an observation of resident room [ROOM NUMBER]-A revealed a section of wall behind the head-of-the-bed roughly plastered, measuring approximately 15 inches wide and 36 long. Further observation revealed white plaster dust coating the top of the headboard of the bed and coating the floor under the head of the bed. On 12/10/2025 at approximately 10:20 a.m., an observation of resident room [ROOM NUMBER]-A revealed a section of wall behind the head-of-the-bed roughly plastered, measuring approximately 15 inches wide and 36 long. Further observation revealed white plaster dust coating the top of the headboard of the bed and coating the floor under the head of the bed. On 12/11/2025 at approximately 1:10 p.m. an observation of R101's room and interview was conducted with OSM (other staff member) #3, maintenance director and OSM # 4, housekeeping director. When asked about the section of wall behind the head-of-the-bed roughly plastered, measuring approximately 15 inches wide and 36 long OSM #3 stated it needed to be sanded, re-mudded, sanded again and painted. When asked if it presented a homelike appearance and if the room was in good repair, he stated no. Regarding the white plaster dust observed coating the top of the headboard of the bed and coating the floor under the head of the bed, OSM #4 stated the room should not be in the condition observed. She further stated it was not clean or homelike. The facility's policy Patient Rooms Inspection documented in part, All patient rooms, beds, and bathrooms will be inspected regularly to verify operational safety and environmental safety for patients. PROCEDURE. Monthly: 2. Inspect room environment including but not limited to sprinkler heads, lights, globes, privacy curtains and tracks, wallpaper, walls, floor tile, carpet, baseboards, door, door hardware, bumper stops, and frames, ceiling tiles, toilet seats, towel bars, grab bars, furniture, windows, blinds, and all electrical appliances and/or equipment including medical devices to verify items are safe and properly maintained. 11. Replace cracked or broken wall/floor tile. On 12/10/2025 at approximately 3:55 p.m. ASM (administrative staff member) #1, interim administrator, ASM #2, director of nursing and ASM #4, vice president of operations, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure resident rights by accommodating the needs of one of eleven residents in the survey sample, Resident #104 (R104). The findings include: The facility staff failed to ensure accommodation of needs for R104's call bell was implemented. R104 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: diabetes mellitus, pressure injury and embolism.R104's most recent MDS (minimum data set) assessment, a five-day Medicare assessment, with an assessment reference date of 10/31/25, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as moderate assistance with bed mobility; total dependence for transfers, dressing, hygiene and bathing. A review of MDS Section M-Skin Conditions: coded the resident as two unstageable pressure injury (PI), POA (present on admission).A review of the comprehensive care plan dated 10/29/25 revealed, FOCUS: Resident is at risk for falls related to weakness. INTERVENTIONS: place common items within reach of the resident, remind the resident to use their call light to ask for assistance with ADLS (activities of daily living).On 12/10/25 at 10:20 AM, observed the call bell in Resident 104 (R104)'s room dangling from side rail to the floor. Resident did not know where the call bell was and could not reach it. An interview was conducted on 12/10/25 at 10:25 AM with LPN (licensed practical nurse) #2, when asked where the call bell was located for R104, LPN #2 stated, it must have fallen off the bed when I was in here earlier. It was on the bed before then. The ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, and ASM #3, the vice president of operations was made aware of the finding on 12/10/25 at 4:00 PM.A review of the facility's Nurse Call System policy revealed, Inspect push button cords in all patient/public restrooms/shower rooms and verify each cord has a clip and that cord is not in contact with the floor.No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care in a dignified manner for one of eight residents in the survey sample, Resident #4.The findings include:For Resident #4 (R4) the facility staff failed to provide dignity to the resident by offering incontinence care on 10/28/25 from 10:07 a.m. through 5:30 p.m.On 10/28/25 a.m., R4 was observed without interruption from 10:07 a.m. until 5:30 p.m. During this time, R4 was sitting in her wheelchair. A staff member moved her from her room to the day room at 10:10 a.m. Following the move to the day room, the resident was moved by staff back and forth between the day room, activities room, and dining room. This observation was continuous with no interruptions. At no time did any staff member wheel the resident back to her room to provide incontinence care.On R4's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/9/25, she was coded as being severely cognitively impaired for making daily decisions, having scored only two out of 15 on the BIMS (brief interview for mental status). She was coded as sometimes understanding others and as sometimes being understood by others for communication. She was coded as always incontinent of both bladder and bowel, and as requiring the assistance of staff for toileting.On 10/29/25 at 10:07 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated if she cares for a resident who is incontinent and cannot walk independently to the bathroom, she checks the resident for incontinence every hour or two. She stated that two hours is the maximum amount of time that should elapse between incontinence checks. She stated that after two hours, a resident's skin can begin to break down. She stated if a resident refuses an incontinence check, the charge nurse should be notified, and multiple attempts should be made to convince the resident to allow the care.On 10/29/25 at 10:16 a.m., CNA #2 was interviewed. She stated she is the lead CNA on the unit where R4 resides. She stated that as a lead CNA, she is responsible for making sure the floor and residents' rooms are clean and tidy. She also is responsible for doing walking rounds at the end of every shift with all the CNAs to make sure they have completed all the tasks for their shift that is ending. She explained that incontinent residents should be checked a minimum of every two hours, with some residents requiring more frequent checks. She stated that when she is responsible for caring for R4, she checks her more frequently than every two hours because the resident is not able to tell the staff if she needs incontinence care. She stated that even if R4 is in the activities room or the dining room, incontinence checks are still a priority and should be done at least every two hours.On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated that residents who are incontinent and require assistance should be checked every two hours. She stated that once a staff member gets to know the residents' needs better, they may check on them more frequently than every two hours. She stated a resident's skin starts to break down after two hours. LPN #1 stated that if a resident is not provided incontinence care for an extended time, the resident is not being treated with personal dignity.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were interviewed. All three management staff members agreed that if a resident is not offered incontinence care for an extended period of time, they may suffer emotional distress and a lack of a dignified quality of life. At this time, these management staff members were informed of the concerns related to the lack of incontinence care for R4. A policy regarding treating residents with dignity was requested.No additional information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to thoroughly investigate the circumstances surrounding a fire and to implement interventions to prevent future fires for a census of 116 residents. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2, widespread. The findings include: On 12/30/24, staff observed a burn smell in Resident #1's (R1's) room and observed the resident with a lighter. On 1/1/25, R1's roommate (R6) reported he extinguished a fire on his mattress. Staff observed a burn area on the lower right side of R6's mattress and some burn spots on the privacy curtains. The facility investigation determined it was highly probable that R1 started the fire. On 3/28/25, staff observed a toilet tissue roll in R1's bathroom was on fire. Since the 1/1/25 incident, the facility staff failed to conduct a thorough investigation into how R1 obtained materials to start the fires, and the facility staff failed to implement current and consistent interventions to prevent future fires and maintain safety for R1 and all other residents. These interventions include monitoring R1 and his room for fire starting materials, and lock boxes for all residents who are deemed safe to retain their smoking materials. Per staff interview, staff members did not understand the need to monitor R1 and his belongings. Also, per observation, resident interview, and other facility documentation, some residents did not utilize lock boxes for their smoking materials. R1's comprehensive care plan, dated 6/19/24 documented, The resident has behaviors. Resident ambulates to other resident's [sic] rooms and collect [sic] items. Resident is at risk for safety concerns related to fire due to collecting and attempting to use smoking devices or lighter. Wandering. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/20/25, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A review of R1's clinical record revealed a nurse's note dated 12/30/24 that documented, Type of Behavior: burn smell observed in room, staff in to assist resident observed with a lighter staff checked room no more lighters observed, and no burning articles observed. Non-pharmacological intervention: education. Effect: effective at the time. PRN (as needed) Medication: na (not applicable). Outcome: left vm (voicemail) for rp (responsible party) and notified MD (medical doctor) per md to monitor oncoming nurse aware A nurse's note dated 1/1/25 documented, This writer was notified by cna (certified nursing assistant) on the floor stating that a 'fire was in the resident's room' This writer attended the room, and resident was there near his bed on the side of the window in standing position. No observation of fire nor smoke filled room observed. This writer asked, 'What happened?' and the resident gave no response just shrugged his shoulders. This writer questioned resident 'Did he have a lighter?' Resident's response was if I give it to you will you give me my lighter back? This writer responded 'No' Resident was asked 'May we search your person, and your personal belongings' Resident allowed his personal area to be checked for fire materials and even assisted by opening the drawers to the dresser/nightstand, but no fire materials was found. Resident allowed his clothing pockets to be checked and again no fire materials such a [sic] matches, cigarette lighter etc., was found. Resident was asked 'Are you okay?' and resident responded with 'I'm fine'. Resident's room was inspected for fire materials with his consent in which none was found on him nor in his personal belongings. Denied pain or discomfort., Resident was assessed for respiratory distress, and he was not observed to have a cough nor SOB (shortness of breath). Skin integrity remained intact. VS (Vital signs) 130/72 (blood pressure)-97.7 (temperature)-80 (pulse)-18 (respirations)-98% RA (oxygen level on room air) Director of Nursing notified. A note signed by the nurse practitioner on 1/2/25 documented, (R1) was seen this morning in his semi-private room at (name of facility). (R1) is reported to have had burned thing in his room and neither him nor his roommate could report how the curtain got burned. (R1) does not have any visible burns. He does not recall events. The note failed to document interventions to prevent future fires. An initial facility synopsis of events submitted to the SA (state agency) on 1/2/25 documented, Incident date: 01/01/2025: Resident (R1) was observed with a lighter, resident set the mattress and privacy curtain on fire in his assigned room. Roommate was not in room during the incident. There are no injuries to report . A psychiatry evaluation dated 1/7/25 documented, This is a [AGE] year-old male with history of depression and dementia. He was last seen by this provider on 12/10/2024 and no changes were made to his psychotropic medications. This is a consultation at the request of staff because patient was involved in setting a fire in his room. He is met in the common room today participating in an activity. He is on 1:1 (one-on-one supervision) because of his recent behaviors. However, it is unknown how his [NAME] [sic] curtain got burned. Patient stated that he does not smoke, and he does not have any lighter. He also stated that he has no intention to burn this place, and he does not have a clue about his curtain burning .Recommendations: 1:1 per facility protocol, may discontinue in 24 hours and do q (every) shift safety checks. Regularly inspect personal belongings and room for any flammable materials. Redirection. Offer opportunities for socialization and participation in activities as tolerated to avoid social isolation. Monitor for changes in mood or behaviors and notify/page (name of psychiatry company) as needed. Will continue to follow and provide consultation . A final facility synopsis of events submitted to the SA on 1/7/25 documented, This letter serves as the final report of the comprehensive investigation into the Facility Reported Incident initially filed on January 1, 2025, regarding an incident resulting in a fire involving residents in room (number) (R1) and (R6). (R1) (room number) is a [AGE] year-old male initially admitted to the facility on [DATE] with a BIMS of 04. (R1) has diagnoses of vascular dementia without behavioral disturbance, dysphasia (difficulty to produce and comprehend verbal language), cognitive communication deficit, muscle weakness, atrial fibrillation (a heart condition), chronic pain, alcohol cirrhosis of the liver, delusional disorders, retention of urine, mild neurocognitive disorder, immunodeficiency, peritonitis (inflammation of the abdomen), acute and gastric ulcer. (R6 [R1's roommate]) (room number) is a [AGE] year-old male admitted to the facility on [DATE] with a BIMS of 15 (indicating the resident was cognitively intact). (R6) has diagnosis of adult hypertrophic (a narrowing of the opening of the stomach to the small intestines), gastrostomy (feeding tube), a neurocognitive disorder with Lewy Bodies, chronic obstructive pulmonary disease (lung disease), severe protein-calorie malnutrition, hemiplegia (paralysis) and hemiparesis (muscle weakness), sequelae of the cerebral infarction (long term effects from a stroke), orthostatic hypotension (a drop in blood pressure), PTSD (post-traumatic stress disorder), cardiac pacemaker, TBI (traumatic brain injury), and gastro-esophageal reflux. On January 1, 2025, (LPN [licensed practical nurse] #6), LPN verbally reported to the Administrator that Resident (R1) was observed with a lighter; Resident set the mattress and privacy curtain on fire in his assigned room. The roommate was not in the room during the incident, there were no injuries to report. Investigation -During an interview with (R6) (room number), with BIMS 15, he stated that at about 6pm on 1/1/25, he was at the nursing station trying to call his wife. After unsuccessful attempts to reach his wife, he decided to return to his room. When he arrived at his room, he noticed his bed was on fire. He balled up some sheets that were at the foot of his bed and used them to put out the fire. He stated that he shouted 'Fire! Fire!' and staff immediately came to his room but arrived when the fire was already out. He does not know how and what started the fire. He denied smoking or having a lighter. -The resident in (room number) (R1) was interviewed. He denied having a lighter and stated that there was no fire. (R1) has a BIMS of 05 and does not recall seeing or lighting a fire. (R1) has a history of wandering and socializing with other residents in the day room, including residents that smoke. He also has a smoking history but stated he stopped smoking about 7 months ago. Although (R1) denies smoking or having a lighter, staff confiscated a lighter from him on 12/30/24. Staff were unable to find any other lighter in his possession after a consented room search. However, the possibility of (R1) getting [sic] lighter from elsewhere cannot be undermined based on his history of wandering and socializing with visitors and other residents. -A statement was obtained from the CNA (certified nursing assistant), (CNA #5), who first heard and responded to the incident. (CNA #5) stated that at about 6:30pm, she was picking up meal trays from rooms in the 200 hallway when she heard (R6) screaming Fire! Fire! (CNA #5) immediately called the other CNAs (CNA #6 and CNA #7) and the nurse (LPN #7) to the room. When they arrived at the room with a fire extinguisher, there was no fire or smoke in the room. (R6) stated to them that his bed was on fire, and he put the fire out. They noticed a burn area on the lower right side of (R1's) mattress and some burn spots on the privacy curtains. Both residents were removed from the room per recommendation of the charge nurse, (LPN #7). The CNA and the nurse searched the room and found a lighter on (R6's) pants that was on his bed. -In an interview with the charge nurse, (LPN #7), she stated that when she arrived at the room, there was no fire or smoke but noticed a palm size burnt area towards the foot of the bed mattress on the right side. She asked what happened and (R6) stated that there was a fire in his bed, and he put it out with a 'balled up' sheet. The nurse asked the CNAs to remove both residents from the room, notified maintenance team, notified the administrator, DON (director of nursing), responsible parties of both residents, instituted safety checks and one-on-one monitoring for (R1), due to his cognitive status, and moved both residents to different rooms. -The facility maintenance team checked the room for safety, conducted the room for safety, conducted a bed inspection in which they found no evidence of an electrical issue. During an interview with the Maintenance Assistant, he stated that the fire alarm system did not trigger due to the lack of smoke to initiate the alarm system as designed. (Name of contractor) came on 1/2/25 to inspect all smoke alarm systems in the building, all systems were cleared and are working appropriately. -The Charge nurse assessed both residents for pain, respiratory distress, and skin integrity. No pain or respiratory concerns were raised by both residents. A skin assessment was performed on (R6), and no burns or bruises were noted on his hands. No skin complication was noticed on either (R1) or (R6). -Social Services completed trauma screening to evaluate psychosocial wellbeing of both residents in (room number). No issues were reported during the trauma screening with regards to the fire incident. -(R1) was also referred to the psych physician for evaluation and review of medication. -Care plan has been updated for both residents. (R6) was educated not to attempt to put out fire using his hands. (R1) was placed on one-on-one staff monitoring and safety checks to monitor or observe his routine and maintain safety. (R1) will continue one-on-one staff assistance until the physician and IDT (interdisciplinary team) team determine that he can no longer have access to a lighter. -A smoking screen has been completed for all residents in the building. Residents who smoke have been provided with lock boxes to store their smoking paraphernalia so as to prevent other residents from accessing them. -The Administrator held an emergency Resident Council Meeting to emphasize safe smoking practices and proper/discreet storage of all smoking-related items. The residents in attendance were educated on not sharing their cigarettes and lighters with other residents. Residents who smoke have been educated on the importance of lock boxes and how to use them. Based on the above findings, the burn area on the mattress in (room number) indicates that there was a fire in the room. Because no electrical malfunctions were noted upon bed inspection, and a lighter was found on the bed, it is highly probable that (R1) may have started the fire in the room. (R1) was the only one present in the room when the fire started, no other resident was observed going into room (number), and a lighter had previously been confiscated from him. He is also unable to recall that there was a fire in his room due to his cognitive status. The facility has provided lock boxes to residents who smoke to store their smoking devices to prevent residents with wandering behaviors from accessing them. The facility staff education on RACE (Rescue, Alert, Confine, Extinguish) has been initiated . The synopsis failed to document a thorough investigation of how R1 obtained fire starting materials. A progress note with an effective date of 1/14/25 and signed by the physician on 1/16/25 documented, Mild vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Attempted Moca (Montreal cognitive assessment) to gather baseline. Had difficulty understanding/following instructions. Will re attempt at future date. Regarding his dementia, there was also an incident a few days back when he was found with a lighter, I discussed this incident with him, and he had no acknowledgement of that situation. He is pleasant but mobile and walks around the facility all day. No behavioral risk to self or others that is intentional. He denies SI/HI (suicidal/homicidal) ideations today. The note failed to document interventions to prevent future fires. A facility synopsis of events dated 1/28/25 regarding another resident (R5) documented that the resident (who smoked) was not properly using his lock box. The report was regarding missing money and documented, On January 24, 2025, the resident reported to the unit manager that $20 had gone missing from his lockbox, which is located in the top drawer of his dresser. The resident stated that he had placed $22.00 in his lockbox the previous evening and had left the lockbox on top of his dresser with the key inside it. When he awoke the next morning, he noticed that his lockbox was turned upside down, and only $2.00 was left inside. Further review of R1's clinical record revealed a note signed by the nurse practitioner on 3/11/25 that documented, Current somewhat stable functional status includes: Ambulatory with equal strength, oriented x 1, and mostly pleasant. Functional in most ADLs (activities of daily living) and conversational. FAST dementia scale 3-4. Unable to complete MoCa (Montreal cognitive assessment) due to inattention. Requires 24/7 supervision as he is dangerous with a lighter or cooking. Wander guard (a device to prevent residents from exiting the building) in place. A facility synopsis of events dated 3/14/25 regarding another resident (R4) documented that the resident (who smoked) was not using her lock box. The report was regarding a missing wallet/money and documented, Although (R4) has a lockbox [sic] at her bedside, she does not use it, preferring to hide her belongings under her pillow or beneath her bed. Further review of R1's clinical record from 1/9/25 through 3/28/25 failed to reveal the resident or resident's room was inspected for fire starting materials. A nurse's note dated 3/28/25 documented, Resident is alert and oriented x2. Skin is dry to the touch. After dinner, resident took his medications as ordered. After dinner around 2030PM (8:30 p.m.) a CNA alerted this nurse of fire sand [sic] smoke coming from this residents [sic] restroom. Resident was removed to a safe location to be assessed. No S/S (signs or symptoms) of smoke inhalation, coughing, no SOB (shortness of breath), and no skin issues. DON (director of nursing) and RP (responsible party) notified. An initial facility synopsis of events submitted to the SA on 3/28/25 documented, Incident date: 3/28/2025. Residents involved: (R1) (R2). Resident [R1] lit a roll of toilet paper on fire in his bathroom. Staff extinguished the fire with water and dropped the paper roll in the toilet. Fire department alert [sic] and arrived to building. A psychiatry evaluation dated 4/1/25 documented, This is a [AGE] year-old male with history of depression and dementia. He was last seen by this provider on 2/18/25 at that time no changes were made to his psychotropic medications. This is a consultation at the request of staff due to patient's increased behaviors in the last week with symptoms that includes starting a fire in his bathroom, refusal of care and treatment, resistance, agitation, increased confusion and anxiety, difficult to redirect. He has been place [sic] on 1:1 per facility protocol. A medical work-up showed bacterial infection and he is currently on antibiotics. Patient is met in his room today, with flat affect. He did not recall the fire incident. He also does not recall his behaviors. There is no evidence that he responds to internal stimuli. He is directable at this time .Recommendations: May discontinue 1:1. Continue q (every) shift safety checks for 24 hours or per facility protocol. Regularly inspect personal belongings and room for flammable materials. Staff to continue to provide appropriate non-pharmacological measures as needed to manage disturbances in mood and behaviors such as redirection, reinforcement and distraction. Continue to offer opportunities for socialization and participation in activities as tolerated to avoid social isolation. Monitor for acute changes in mood or behaviors and notify/page (name of psychiatry company) as needed. Will continue to follow and provide consultation. A note signed by the nurse practitioner on 4/4/25 failed to document information regarding the 3/28/25 incident or interventions to prevent future fires. A final facility synopsis of events submitted to the SA on 4/4/25 documented, This letter serves as the final report of the comprehensive investigation into the Facility Reported Incident initially filed on March 28, 2025, regarding a fire incident in the bathroom of room (number) involving a resident, (R1). (R1) (room number) is a [AGE] year-old male initially admitted to the facility on [DATE] with a BIMS of 04. (R1) has diagnoses of vascular dementia without behavioral disturbance, dysphasia, cognitive communication deficit, muscle weakness, atrial fibrillation, chronic pain, alcohol cirrhosis of the liver, delusional disorders, retention of urine, mild neurocognitive disorder, immunodeficiency, peritonitis, acute and gastric ulcer. On 3/28/2025 at approximately 2030 (8:30 p.m.), staff reported to the Administrator that (R1) have [sic] started a fire in room (number) and that smoke was observed coming from the bathroom of room (number) that immediately triggered the fire alarm and the sprinklers. (R1) was out of the room when staff noticed the fire and his roommate, (R2) was immediately removed from the room with no injuries. The fire was quickly extinguished by staff before the arrival of the fire department. The facility Administrator initiated an investigation into the incident on 3/28/25. Investigation -The CNA (CNA #5), assigned to (R1 and R2's room number) on 3/28/25 was interviewed by the Director of Nursing. The CNA stated that at about 2030 (8:30 p.m.) when conducting routine rounds, she observed (R1) coming out of his room and walking in the hallway towards the dining area. She walked towards (R1's) room and noticed smoke coming out of the bathroom. He [sic] notified the charge nurse who immediately came to the room and noticed there was fire in the bathroom. -A statement was obtained from the charge nurse, (RN [registered nurse] #2), assigned to (R1 and R2's room) on 3/28/25 at the time of the incident. He stated that at about 2030 (8:30 p.m.), (CNA #5) notified him that there was fire and smoke in (R1 and R2's) room. He immediately rushed to the room and noticed that the toilet tissue roll against the wall was on fire. He instructed the CNA to move (R2) to safety and proceeded to extinguish the fire. He stated that (R1) was not in the room when he arrived at the room. -(R1), was interviewed by the Director of Nursing on 3/28/25. He denied having a lighter and stated that he does not recall there was fire in his bathroom. He also denied starting a fire but stated that 'I messed up, I am sorry.' He was unable to state what he did or what made him think he 'messed up.' The CNA and charge nurse conducted a search of (R1 and R2's) room and found no lighter or any device that may have been used to start the fire. (R1) had no smoking device in his possession at the time of the search after the fire was extinguished. Although no lighter was found on (R1), he has a history of wandering, picking up items and attempting to use a lighter in his room. He was in his room when the incident started and quickly walked away prior to staff arriving at the scene. Interventions -(R1) was placed on one-on-one staff monitoring pending assessment by the psych physician. -The facility maintenance team checked the room for safety, conducted an inspection of the bathroom in which they found no evidence of an electrical issue that may have started the fire. -The Charge nurse assessed both residents in (room number) for pain, respiratory distress, and skin integrity. No pain or respiratory concerns were raised by both residents. -Social services completed trauma screening to evaluate psychosocial wellbeing of both residents in (room number). No issues were reported during the trauma screening with regards to the fire incident. -(R1) was also referred to the psych physician for evaluation and review of medication. -Care plan has been updated. (R1) was placed on one-on-one staff monitoring and safety checks to monitor or observe his routine and maintain safety. The Activities department will assist (R1) with outdoor activities for distraction. -A smoking screen has been completed for all residents in the building to identify residents who may not have reported their smoking status to staff. Residents who smoke have been provided with lock boxes to store their smoking paraphernalia so as to prevent other residents from accessing them. -The DON assigned staff to conduct room search of all residents with wandering tendencies to verify there was no lighter in the room. -The DON assigned staff to complete 100% room search in the facility to verify no lighter is accessible to residents with wandering behaviors. -The Administrator held an emergency Resident Council Meeting to emphasize safe smoking practices and proper/discreet storage of all smoking-related items. The residents in attendance were educated on not sharing their cigarettes and lighters with other residents. Residents who smoke have been educated on the importance of lock boxes and how to use them. Based on the above findings, the fire incident in (R1 and R2's) room is substantiated. Because no electrical malfunctions were noted upon room inspection and no lighter was found on (R1), the source of the fire could not be fully determined. However, because (R1) was in the room prior to the incident and has a history of using smoking devices in the room, the facility is implementing measures to ensure (R1), and other residents with wandering behaviors do not have access to lighters. (R1) has been moved to a room closer to the nursing station for increased visibility and monitoring. An Ad-hoc QAPI (quality assurance and performance improvement) meeting was held on 3/31/25 to discuss safety of residents in the facility . The synopsis failed to document a thorough investigation of how R1 obtained fire starting materials. Further review of R1's clinical record from 4/4/25 through 4/15/25 failed to reveal the resident was provided with increased supervision or the resident/resident's room was inspected for fire starting materials. On 4/15/25 at 10:48 a.m., 4/15/25 at 11:40 a.m., and 4/16/25 at 8:48 a.m., R1 was observed unsupervised in the bedroom. On 4/15/25 at 3:59 p.m., and 4/15/25 at 4:16 p.m., R1 was observed wandering in the hall. On 4/15/25 at 11:08 a.m., an interview was conducted with R7 (a resident who smoked). The resident stated staff has never asked if another resident has asked for a lighter or attempted to take his lighter. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/20/25, R7 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 4/15/25 at 11:12 a.m., an interview was conducted with R8 (a resident who smoked). The resident stated staff has never asked if another resident has asked for a lighter or attempted to take his lighter. On the most recent MDS, a quarterly assessment with an ARD of 2/5/25, R8 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 4/15/25 at 11:15 a.m., an interview was conducted with R4 (a resident who smoked). R4 stated she does not use a lock box, and she hides her belongings in her room. R4 further stated staff has never asked if another resident has asked for a lighter or attempted to take her lighter. A lock box was observed under R4's bed. The box was open with the key in the lock. On the most recent MDS, a quarterly assessment with an ARD of 3/16/25, R4 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 4/15/25 at 11:23 a.m., an interview was conducted with OSM (other staff member) #2 (a housekeeper). OSM #2 stated administration staff has never asked her questions or provided education regarding R1. On 4/15/25 at 11:24 a.m., an interview was conducted with CNA #1 (hired in March 2025). CNA #1 stated she had heard a resident started a fire in a room, but she did not know who the resident was and was not provided education. On 4/15/25 at 11:30 a.m., an interview was conducted with CNA #2. CNA #2 stated she was aware R1 had started fires and interventions that were implemented when the incidences occurred (such as safety checks and inspecting the room for lighters). CNA #2 stated she has never been asked questions about how R1 was obtaining lighters she did not know if any interventions were currently being implemented. On 4/15/25 at 11:36 a.m., an interview was conducted with LPN #2 (the nurse caring for R1). R1 stated she has never been asked questions about how R1 was obtaining lighters. LPN #2 further stated she was not aware of any instructions to inspect R1 or the resident's room, but staff had been taking lighters from the resident when they found them. On 4/15/25 at approximately 2:00 p.m., an interview was conducted with CNA #3 (the CNA caring for R1). CNA #3 stated she did not know anything about facility fires. CNA #3 stated R1 was confused, and wanders and she has never been provided instructions to inspect R1 or the resident's room for lighters. On 4/15/25 at 3:31 p.m., an interview was conducted with LPN #5. LPN #5 stated she did not remember the interventions that were implemented for R1 after the fire incidents in January 2025 and March 2025. On 4/15/25 at 4:02 p.m., an interview was conducted with LPN (licensed practical nurse) #8 (the nurse caring for R1). LPN #8 stated she was not aware of any interventions involving R1 and lighters. LPN #8 stated she was not aware if R1 required increased supervision, and she was not aware if she needed to inspect R1 or the resident's room for lighters. On 4/16/25 at 11:33 a.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing). ASM #1 stated that after the 1/1/25 fire, the staff implemented lock boxes for residents who smoke, and staff tried to figure out how R1 obtained lighters because he frequently walks around and takes things. ASM #1 stated she did not include visitors in the fire investigations. ASM #1 further stated that a member of the IDT (interdisciplinary) team checks R1's room for lighters during the daily room rounds. On 4/16/25 at 11:43 a.m., ASM #1 and ASM #2 were notified of Immediate Jeopardy. On 4/16/25 at 11:54 a.m., an interview was conducted with LPN #4 (the minimum data set coordinator). LPN #4 stated that members of the IDT team have certain groups of rooms they go into every day. LPN #4 stated, We look for things out of place. We look to see if there are lighters or anything lying around. We do this once a day. I went in [to R1's room] very early this morning. The time of day varies. LPN #4 provided room round forms for R1's room. The forms documented no lighters were found at the time of rounds and were dated 4/2/25, 4/3/25, 4/4/25, 4/7/25, 4/8/25, 4/9/25, 4/10/25, 4/11/25, 4/14/25, 4/15/25, and 4/16/25. On 4/16/25 at 1:27 p.m., an interview was conducted with RN #1. RN #1 stated R1 is alert and confused, oriented times one or two, and wanders on both units and into other resident rooms. RN #1 stated she has seen R1 take items that didn't belong to him from the common areas. RN #1 stated R1 spends a good portion of the day in the common area where a lot of visitors visit and where the smokers go outside. RN #1 stated staff should keep their eyes on R1 when he is in that area and staff should search R1, with the resident's consent, when the resident returns from other areas of the facility. RN #1 stated she informs nurses about R1 when she gives report but there was nothing specifically documented on the unit to alert staff. The facility presented the following IJ removal plan which was accepted on 4/16/25 at 6:45 p.m. Immediate Jeopardy Abatement Plan Date: 04/16/2025 1. R1 was immediately placed on permanent 1-1 supervision, and the patient's room was thoroughly searched for smoking materials. No smoking paraphernalia was found; had any been discovered, it would have been immediately removed from the resident's room to mitigate further risk. Fire-damaged furniture and the mattress were replaced. Maintenance completed a full safety inspection, and (name of contractor) conducted an external fire inspection. Resident's care [plan] updated. The RP (responsible party) for R1 was contacted and educated about the dangers of providing smoking materials to residents deemed unsafe to retain such items. 2. Current residents in the facility have the potential to be affected by the deficient practice. UM (unit manager) or a designee conducted a facility-wide search on April 16, 2025, to locate and remove all unauthorized smoking and fire-starting materials. The Director of Nursing or a Designee completed a 100% reassessment of smoking risk for all residents with a history of smoking to validate the accuracy of their smoking assessments and ensure proper safeguards are in place. All unsupervised smokers were assessed to determine their capacity to retain and securely store smoking materials. 3. The SDC (staffing development coordinator) or designee[TRUNCATED]

Based on staff interview and facility document review, the facility staff failed to implement an effective QAPI (quality assurance and performance improvement) program for one of one facility. The findings include: The facility staff failed to ensure their 3/28/25 QAPI plan regarding a fire incident was effective. The facility staff failed to ensure a resident who smoked utilized a lock box for her smoking materials and failed to ensure staff were knowledgeable regarding the education documented in the plan. An initial facility synopsis of events submitted to the SA (state agency) on 3/28/25 documented, Incident date: 3/28/2025. Residents involved: (R1) (R2). Resident [R1] lit a roll of toilet paper on fire in his bathroom. Staff extinguished the fire with water and dropped the paper roll in the toilet. Fire department alert [sic] and arrived to building. A QAPI plan dated 3/28/25 documented, PROBLEM: On 3/29/25 [sic] staff observed a fire in the bathroom of room (room number). F689. Immediate Response-what was done at the time. Both residents in the room were safely evacuated. The fire was immediately extinguished by staff and the code was cleared by the fire department. (R2) was moved to a different room. (R1) refused to move as there was no damage to the room. (R1) was placed on one-on-one supervision until cleared by psych because of history of attempting to use a lighter in the room. Pain, skin and respiratory assessments were conducted for both residents in the room. How to Identify other residents that might be impacted. Current residents in the center have the potential to be affected. The DON (director of nursing) or designee conducted a 100% room search to ensure all smoking paraphernalia are stored in lock boxes. Any lighter found outside the lock box shall be placed in a lock box and the resident educated on the need to use the lock box. The Administrator or designee held a safety committee meeting on 3/29/25 with residents who smoke to discuss the importance of ensuring that they use their lock boxes to store their smoking devices to prevent residents with wandering behaviors from having access to smoking paraphernalia. The DON or designee audited residents who wander, resident smoking assessments and care plans to identify need for locked boxes to prevent smoking paraphernalia and lighters being accessible to other residents. What Measures were put in place to prevent reoccurrence. The SDC (staffing development coordinator) or designee will educate facility staff on the processes for implementing interventions such as redirection/distraction to prevent residents with wandering behaviors from having access and/or obtaining lighters to prevent risk for igniting and causing fires. The DON or designee shall audit all residents who smoke to verify they have lock boxes to store smoking paraphernalia. How to monitor to ensure the problem does not reoccur. The DON or designee will complete weekly audits x 4 weeks of residents who smoke to verify they have lock boxes and are storing their smoking devices in the lock box. Findings will be corrected. The administrator or designee will audit weekly x 4 weeks and monthly x 2 residents with wandering behaviors to verify they do not have smoking paraphernalia. QA. The results will be reported to the monthly Quality Committee for review and discussion to ensure substantial compliance is sustained. Once the QA Committee determines the problem no longer exits [sic], then review will be completed on a random basis. On 4/15/25 at 11:15 a.m., an interview was conducted with R4 (a resident who smoked). R4 stated she does not use a lock box, and she hides her belongings in her room. A lock box was observed under R4's bed. The box was open with the key in the lock. On the most recent MDS, a quarterly assessment with an ARD of 3/16/25, R4 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 4/15/25 at 11:23 a.m., an interview was conducted with OSM (other staff member) 2 (a housekeeper). OSM #2 stated administration staff have never asked her questions or provided education regarding R1. On 4/15/25 at 11:24 a.m., an interview was conducted with CNA (certified nursing assistant) 1 (hired in March 2025). CNA #1 stated she had heard a resident started a fire in a room, but she did not know who the resident was and was not provided with education. On 4/15/25 at 11:36 a.m., an interview was conducted with LPN (licensed practical nurse) 2 (the nurse caring for R1). R1 stated she has never been asked questions about how R1 was obtaining lighters. LPN #2 further stated she was not aware of any instructions to inspect R1 or the resident's room, but staff had been taking lighters from the resident when they found them. On 4/15/25 at approximately 2:00 p.m., an interview was conducted with CNA #3 (the CNA caring for R1). CNA #3 stated she did not know anything about facility fires. CNA #3 stated R1 was confused, and wanders and she has never been provided instructions to inspect R1 or the resident's room for lighters. On 4/15/25 at 3:31 p.m., an interview was conducted with LPN #5. LPN #5 stated she did not remember the interventions that were implemented for R1 after the fire incidents in January 2025 and March 2025. On 4/15/25 at 4:02 p.m., an interview was conducted with LPN (licensed practical nurse) 8 (the nurse caring for R1). LPN #8 stated she was not aware of any interventions involving R1 and lighters. LPN #8 stated she was not aware if R1 required increased supervision, and she was not aware if she needed to inspect R1 or the resident's room for lighters. On 4/22/25 at 10:36 a.m., an interview was conducted with ASM #1 (the administrator). ASM #1 stated that she had not noticed the above QAPI plan was not effective. The facility policy titled, QAPI documented, The Administrator is responsible for directing the Center's Quality Assurance/Performance Improvement (QAPI) Plan that focuses on Center specific indicators that measure quality of care, quality of life and patient choice. The QAPI plan will systematically identify actual or potential areas of risk or deficiency and will proactively pursue ongoing performance improvement. No further information was presented prior to exit.

Based on staff interview and clinical record review, the facility staff failed to evidence agreements for contractual services for one of one facility. The findings include: The facility staff failed to maintain agreements for services with the contracted podiatry company and contracted eye care company. A review of the facility contracts failed to reveal agreements for services with the contracted podiatry company and the contracted eye care company. On 4/22/25 at approximately 8:55 a.m., ASM (administrative staff member) #2 (the director of nursing) presented service agreements for a podiatry company and an eye care company. The agreements were dated 4/21/25 and were not signed by a facility representative. On 4/22/25 at 10:36 a.m., an interview was conducted with ASM #1 (the administrator). ASM #1 stated that when services are initiated with an outside company, she has the company sign an agreement and places the agreement in a contract binder. ASM #1 stated the facility began services with the podiatry company and eye care company before her employment at the facility. On 4/22/25 at 11:10 a.m., ASM #1 stated she was unable to locate the original podiatry and eye care contracts. The facility policy titled, Contracts/Agreements documented, All contracts and/or agreements that are initiated between the Health and Rehabilitation Center and any third-party provider and/or vendor must be approved by designated officers of the company prior to engaging in any contractual obligations and/or service .4. Contracts/agreements between the Health and Rehabilitation Center and the negotiating third-party are not valid unless signed by the appropriate officer of the company. No further information was presented prior to exit.

Based on staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to maintain the highest level of well-being for five of 28 residents in the survey sample, Resident #28, Resident #9, Resident #2, Resident #12, and Resident #18. 1. The facility staff failed to notify, consult with and obtain new interventions from the physician when Resident #28 vomited brown colored emesis with a faint stool odor on [DATE] at approximately 10:30 -11:00 p.m., resulting in a delay in treatment for [REDACTED]. On [DATE], at approximately 1:00 a.m. - 2:00 a.m. (approximately two to three hours later), Resident #28, again vomited brown emesis with a stool odor; the physician was then notified and ordered transfer of Resident #28 to a local emergency room . The clinical record documented at approximately 2:50 a.m., when the EMTs (emergency medical technician) arrived to transport Resident #28, the resident was found on the floor face down and unresponsive. The resident then coded (heart stopped beating and breathing stopped) and CPR (cardiopulmonary resuscitation*) was initiated by facility staff and the EMTs, Resident #28 subsequently expired. *Cardiopulmonary resuscitation (CPR) is the manual application of chest compressions and ventilations to patients in [MEDICAL CONDITION] (without a heartbeat or pulse). Obtained from the website: http://medical-dictionary.thefreedictionary.com/CPR 2. Facility staff failed to follow the physician's orders [REDACTED].#9. 3. The facility staff failed to administer a physician-ordered medication to Resident #18 for 26 days. 4. The facility staff failed to administer magnesium oxide to Resident #15 per physician's orders [REDACTED]. The findings include: 1. Resident #28 was admitted to the facility on [DATE] and expired at the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a five day Medicare assessment, with an ARD (assessment reference date) of [DATE] coded the resident as having a 15 out of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring the assistance of one staff member for all activities of daily living. Review of the care plan initiated on [DATE] and revised on [DATE] documented in part, Bowel Elimination Alteration; Constipation related to decrease mobility secondary [MEDICAL CONDITION]([MEDICAL CONDITION], stroke) and decreased mobility. Report signs and symptoms of constipation such as abdominal cramping, diarrhea, nausea/vomiting, no bowel movement for three days. Review of the Resident evaluation nurse's note dated [DATE] at 4:45 p.m. documented in part, Bowel sound normal and present in all 4 quadrants No current conditions/[DIAGNOSES REDACTED]. Review of Resident #28's October, 2015, treatment administration record documented that the resident had not had a bowel movement from [DATE] through [DATE]. Review of the nursing notes dated [DATE] at 15:26 (3:26 p.m.) documented, Resident c/o (complained of) abdominal pain, NP (nurse practitioner) made aware in person, and will assess patient. There was no evidence of an assessment of the Resident's vital signs, abdominal assessment or location of pain. (*Note a note for the NP assessment of the resident was not presented by completion of the survey). Review of the physician progress notes [REDACTED].#28. Review of the physician's orders [REDACTED]. abdominal xray now. [MEDICATION NAME] (1) 20 mg (milligrams) po (by mouth) QD (every day) AC (before meals) breakfast. [MEDICATION NAME] 20mg po NOW. Review of the abdominal x-ray report done by a mobile x-ray company on [DATE] at 5:55 p.m. documented, IMPRESSION: No intestinal obstruction or abnormal calcifications. *Ileus (2) type pattern with distended loops of both small and large bowel. The report was signed by the radiologist at 6:55 p.m. *Ileus, a condition in which the bowel does not work correctly, but there is no structural problem causing it. Symptoms include in part: Abdominal swelling (distention), abdominal fullness, gas abdominal pain and cramping, constipation, inability to pass gas and vomiting. This information was obtained from the website: <https://medlineplus.gov/ency/article/ 0.htm> Review of the physician's orders [REDACTED]. [MEDICATION NAME] (5) 4mg po Q6h (every six hours) prn (as needed) nausea. Review of the Medication Administration Record [REDACTED]. Review of the nurse's notes dated [DATE] 19:23 (7:23 p.m.) documented, Flora Stor (a [MEDICATION NAME]) 250 mg (milligram) po (by mouth) BID (twice a day). RP (responsible party) aware. Resident aware. This note was signed by the RN (registered nurse), Supervisor (RN #4). Review of the nurse's notes dated [DATE] at 19:36 (7:36 p.m.) documented, (Name of nurse practitioner) CALLED AND ORTHOSTATIC VS (vital signs (9)) REPORTED TO HER. VS AS FOLLOWS LYING ,[DATE] -87 (blood pressure and pulse) SITTING ,[DATE]-109 AND ,[DATE]-111. NO NEW ORDERS RECEIVED AFTER GIVING HER THE VS. This note was signed by the RN (registered nurse) Supervisor, (RN #4). Review of the nurse's notes dated [DATE] at 22:11 (10:11 p.m.) documented, Results of the abdominal xray called to on-call MD (medical doctor) Dr (name of doctor) who gave new orders: give MOM (milk of magnesia) 30cc (cubic centimeters) po now. R/P (responsible party) aware resident aware. Review of the nurse's notes dated [DATE] at 22:30 (10:30 p.m.) documented, (Name of nurse practitioner) NP called to check on the CMP and xray results, informed had called and spoke to (name of doctor) who said to give resident MOM 30 cc po. New orders received from (name of NP) for Senna s (6) 2 tabs (tablets) po TID (three times a day) and Mirlax (sic) (7) 17 grams every am. Review of the nurse's notes dated [DATE] at 2:38 a.m. documented in part: SITUATION: Change in condition noted related to vomiting stool, elevated bs (blood sugar), o2 (oxygen) sat (saturation) of 83%*. This change started on [DATE]. Since this started, it has gotten worse. BACKGROUND: (Name of resident) was admitted to the facility for post-acute care. Relevant [DIAGNOSES REDACTED]. Not currently receiving [MEDICATION NAME]/[MEDICATION NAME] (6) medication .ADVANCE DIRECTIVES/LIMITED TREATMENT: Full Code. APPEARANCE: Vital signs: BP (blood pressure) ,[DATE] - [DATE] 02:42 (2:42 a.m.) Position: P (pulse) 127 - [DATE] 02:42 R (respirations) 22 - [DATE] 02:43 (2:43 a.m.); T (temperature) 98.4 - [DATE] 02:43 .MENTAL STATUS: No changes noted to mental status as compared to baseline ABDOMINAL/GI (gastrointestinal): Abdomen is distended. Has had episodes of nausea/vomiting. VOMITING STOOL. PAIN: No evidence of any new or worsening pain noted. REVIEW AND NOTIFICATIONS: (Name of physician's company) . was notified on [DATE] 2:00 AM INTERVENTIONS: Emergency medical transportation. Supplemental Oxygen. No additional recommendations made (contact person) was notified on [DATE] 2:30 AM. * Normal pulse oximeter (measuring the oxygen saturation of your blood using a pulse oximeter - a small device that clips to your finger) readings usually range from 95 to 100 percent. Values under 90 percent are considered low. This information was obtained from the website: <http://www.mayoclinic.org/symptoms/hypoxemia/basics/causes/sym- 930> **Note: A Review of the nurse's notes audit trail (the audit trail in the facility's software is accessed by selecting view next to any progress note. The audit trail documents the name of the staff member and their job position that created the note and the date and time that each note was written into the clinical record. ) documented the above nurses note dated [DATE] at 2:38 a.m. had been written on [DATE] at 11:39 a.m. not [DATE] at 2:38 a.m. and was written by the unit manager not the nurse who cared for the resident. Review of the nurse's notes dated [DATE] at 6:54 a.m. documented, At time of arrival of EMT (emergency medical technician) to transport resident to (name of hospital) resident was found on the floor face down unresponsive, CPR initiated by staff and EMT, RESIDENT WAS PRONOUNCED AT 3:20 AM by emt, rp (responsible party) aware and family was at bedside prior to resident being picked up by (name of funeral home). On call (name of doctor) aware. The nurse's note dated [DATE] at 18:41 (6:41 p.m.), written by ASM (administrative staff member) #2, the director of nursing, documented, Late entry note clarification for ,[DATE] shift [DATE] per (name of LPN (licensed practical nurse) #16); MOM given as ordered around 10:30pm, approx (approximately) 10:,[DATE]pm PT (patient) had small to moderate amt (amount) of emesis x1 (times one) brown color with faint stool odor, abd (abdomen) distended semifirm, no c/o pain, last BM reported Sat. (Saturday ([DATE])) Pt sitting on side of bed. Alert and oriented, new orders implemented per physician, report given to oncoming nurse. There was no documentation of an assessment of Resident #28's vital signs, an abdominal assessment of bowel sounds, and no assessment of the location and level of pain. There was no documentation that the physician was notified of Resident #28 vomiting brown colored emesis with a faint stool odor. Review of the nurse's note dated [DATE] at 05:47 (5:47 a.m.) documented, Addendum: Late entry for [DATE] for ,[DATE] (11:00 p.m.-7:00 a.m.) shift note clarification. Writer received report of pt having emesis on previous shift, received report of new orders obtained and initiated and that physician was notified of abdominal x-ray result and current condition of pt. On first rounds pt assessed with [REDACTED]. Approximately 1:30a (a.m.)-2:00a cna (certified nurse's assistant) reported pt had an episode of emesis brown in color with stool like odor; pt verbalized the brown emesis with poop odor also. Vital signs obtained with hr (heart rate) tachy ([MEDICAL CONDITION], a fast heart beat) 127, resp. 22, o2 sats (oxygen saturations) 83%* room air. H.O.B. (head of bed) elevated pt alert and oriented, o2 applied at 2/lpm (liters per minute) via n.c. (nasal cannula). (Name of doctor) notified of vital signs changes, emesis, o2 sats with n.o. (new order) for o2 at 2/lpm via n.c. and send to ER for evaluation. Informed pt of new orders and were sending him to the hospital for evaluation, in agreement with plan wife called and also notified of orders and sending to the ER for evaluation. Call placed for transport approximately 2:20 - 2:30 (a.m.), EMT and staff (writer) entered room and observed pt on the floor approximately 2:50am with brown emesis on the floor and no head or facial trauma and no bleeding noted. Emt and staff to reposition pt when pt took a breath and coded, CPR initiated. An interview was conducted on [DATE] at 2:00 p.m. with LPN (licensed practical nurse) #6, the dayshift nurse on [DATE], regarding the reasons staff would call a physician about a resident. LPN #6 stated, Anything, an emergency, any changes. When asked if a resident vomited stool like emesis would the doctor be notified, LPN #6 stated, That's a change and I would let him know. When asked if she remembered Resident #28, LPN #6 stated she did. When asked about Resident #28's abdominal pain, LPN #6 stated, He was not in distress, he complained of pain right after lunch approximately 1:30 p.m. LPN #6 stated, I palpated his abdomen, asked him where it was hurting. When asked what she remembered about her abdominal assessment, LPN #6 stated, I don't remember. When asked if this would be documented, LPN #6 stated, I didn't write it. An interview was conducted on [DATE] at 3:20 p.m. with RN (registered nurse) #5, unit manager, regarding what she would do if a resident vomited stool like emesis. RN #5 stated she would definitely notify the doctor. An interview was conducted on [DATE] at 3:21 p.m. with LPN #15. When asked what she would do if a resident vomited stool like emesis, LPN #15 stated, I'm going to get him out of here. Of course, after I assess and call the doctor because he has to go (to the hospital). An interview was conducted on [DATE] at 4:15 p.m. with RN #4, the evening supervisor. When asked if she remembered Resident #28, RN #4 stated she did. RN #4 stated, I took care of him until about 7 p.m. that day because (LPN #16) was going to be late. I remember when I first come in (to a resident's room), I introduce myself and I try to sit and chat with them and get a sense of what's going on. RN #4 was asked if she remembered Resident #28 complaining of pain. RN #4 stated, If I didn't write anything on him then he must have told me he felt fine and had no problems. If he had complained of something I would have documented it. When asked what she would do if a resident vomited stool like emesis, RN #4 stated she would notify the doctor because the resident needed a nasogastric tube (8) and they did not do that at the facility. An interview was conducted on [DATE] at 7:30 a.m. with ASM (administrative staff member) #2, the director of nursing, regarding what she remembered about Resident #28's death. ASM #2, the director of nursing, stated, I came in the next morning and I looked at his notes and I spoke with (LPN #16) and asked her what happened and that is when I wrote the late note from her. ASM #2 stated she had told LPN #17, the night nurse that she needed to come in the next day to write a note about what happened that night. A request was made at this time to interview LPN #16, the evening nurse who cared for the resident and LPN #17, the night nurse who cared for the resident. ASM #2 stated, They don't work here anymore. A request was also made to interview the unit manager who had written the note on [DATE]. ASM #2 stated that this unit manager no longer worked at the facility. ASM #2 stated that she would have a nurse who worked on [DATE] night shift speak to this writer. An interview was conducted on [DATE] at 8:15 a.m. with RN (registered nurse) #6, a night nurse. When asked what she recalled about Resident #28 on [DATE] at 2:30 a.m., RN #6 stated, At the change of shift when the nurse got report she was told he had been throwing up brown stuff, I think the supervisor contacted the physician at the change of shift. During our shift he started to throw up again. I had called the doctor, I can't remember who, and he said, 'Okay let's send him to the hospital.' I contacted the family that we were sending him out. An interview was conducted on [DATE] at 9:50 a.m. with LPN #7, regarding how staff assess pain. LPN #7 stated, I go into the patient's room and ask them where the pain is, have them rate it on a one to ten scale (with ten being the worst pain), or I can watch their facial expressions depending on if they are alert. When asked how staff would assess a resident with complaints of abdominal pain, LPN#7 stated, If it's abdominal pain I would go further. I'd check for bowel sounds, check if they had a BM (bowel movement) and of course palpate the belly. When asked if this would be documented, LPN #7 said it would. An interview was conducted on [DATE] at 10:10 a.m. with LPN #5. When asked how staff assesses a resident who complains of abdominal pain, LPN #5 stated, Listen to the bowel sounds to see if they're underactive or overactive. Do a pain assessment if it's new or if pain had gotten worse, ask the zero to ten number thing (pain rating). See if the abdomen is distended, painful. When asked if a resident note documenting, c/o (complaint/of) abdominal pain was considered a pain assessment, LPN #5 stated, No. An interview was conducted on [DATE] at 10:28 a.m. with LPN #14. When asked how staff assesses a resident who complains of abdominal pain, LPN #14 stated, Ask them were they are hurting, I palpate it (the abdomen), listen to bowel sounds, check for BM and assess the pain rating. When asked if this would be documented, LPN #14 stated it would. A telephone interview was conducted on [DATE] at 11:45 a.m. with ASM (administrative staff member) #6, the nurse practitioner. When asked if she remembered Resident #28, she stated that she did. When asked if she had physically assessed the resident, ASM #6, stated that she had. When asked if she had written a note, ASM #6 stated, We document on (name of company) notes and they get sent to medical records and they put it (note) on the chart. When asked if she remembered writing a note about her assessment, ASM #6 stated, I don't remember. When asked if she had been told that the resident was vomiting stool like emesis, ASM #6 stated she had not. When asked if she would change the resident's treatment plan if she had been made aware of Resident #28's first emesis with a stool odor on [DATE] at approximately 10:30 p.m., ASM #6 stated, Absolutely, I would have sent him out (to the hospital). An interview was conducted on [DATE] at 11:55 a.m. with OSM (other staff member) #4, the medical records manager, regarding the process they follow for placing progress notes on the chart from the medical staff from (name of company). OSM #4 stated, They (notes) are faxed over to us. The receptionist sorts them (the notes) out. If they're (the resident) discharged they (the notes) come to me. If they're (the resident) active they (the notes) go to the floor. A request was made at this time for any progress notes written for Resident #28. A telephone interview was conducted on [DATE] at 12:08 p.m. with ASM (administrative staff member) #7, the doctor. When asked if he remembered Resident #28, ASM #7 stated, I vaguely remember. I do remember report was called to me and told them to send him to the ER (emergency room ). Several hours later I was notified that he had died . When asked if he had been notified on [DATE] sometime around 10:30 p.m. that the resident had vomited stool like emesis, ASM #7 stated, I can't remember exactly. When asked if he would have changed the resident's treatment plan if he had been called on [DATE] at 10:30 p.m. and told the resident vomited stool like emesis, ASM #7 stated, Vomiting stool is very unusual. I definitely would have sent him to the hospital at that time. I am 100 miles away. On [DATE] at 12:55 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern for harm. A telephone interview was conducted on [DATE] at 1:30 p.m. with LPN #17, the resident's night nurse. When asked if she remembered Resident #28, LPN #17 stated, Yes. When asked what she remembered about the night the resident died , LPN #17 stated, I remember when I came in, that on the previous shift he had an episode of emesis and the nurse told me she called the doctor. The resident had another emesis that smelled like stool and he said he wasn't feeling too good. I called the doctor and he told me to send him out and I spoke to his wife. When asked how the resident looked at that time, LPN #17 stated, He was in no visual distress, he was alert and verbal, just nauseated. When asked what happened next, LPN #17 stated, I told the CNA (certified nursing assistant) to keep an eye on him and get him ready (to go to the hospital). I went to the desk get the paperwork ready, but I checked on him every few minutes. When EMT got there he was face down on the floor. He had only been left alone for maybe a minute because I could see the CNA was only a couple doors down the hallway. He was alert and verbal, I called his name and he answered me yes and he was making noises like moaning. When we repositioned him he took a breath and coded (no heart beat or breathing). When asked how he was turned, LPN #17 stated, It was three of us, we physically turned him over onto his back. There was emesis on the floor and it still smelled like stool. When asked if they did anything special when they turned him onto his back, LPN #17 stated, We supported his head and neck. A telephone interview was conducted on [DATE] at 2:10 p.m. with LPN #16, the evening shift nurse who cared for the resident on [DATE]. When asked if she remembered Resident #28 she stated she did. When asked what occurred on [DATE], LPN #16 stated, What I can remember is I came in and got report. He was not in distress; they were doing some work on him, some lab (laboratory) work. When asked what else occurred that evening, LPN #16 stated, Probably about 8 (p.m.) to 9 (p.m.), he vomited a small amount and it had a faint fecal (stool) and food odor, it was a very foul odor. When asked what she did next, LPN #16 stated, I did a head to toe assessment and took his vital signs and reported off to the next nurse. When asked if she would document that assessment, LPN #16 did not have a response. LPN #16 stated, He looked fine, his skin color was good, his abdomen was slightly distended and he had faint bowel sounds at the bottom (of his abdomen). I did say something to my supervisor and (name of supervisor) called the doctor. When asked what that doctor said, LPN #16 stated, I don't know. An interview was conducted on [DATE] at 2:10 p.m. with RN #4, the evening supervisor, that worked on [DATE]. When asked if she had called the doctor about Resident #28 vomiting emesis with a stool odor on [DATE] at around 10:30 p.m., RN #4 stated, No, I didn't call the doctor. I overhead her (LPN #16) giving report at the desk and I told her that she needed to call the doctor and report that. As far as I'm concerned if you're the one that witnessed it you need to call the doctor. I am being truthful and honest about everything. On [DATE] at 2:20 p.m. ASM #3, the medical director stated, There's no note from them (the physician or nurse practitioner) about the resident. ASM #3 stated he did get the history and physical from the resident's physician's company but there were no other notes. Review of Resident #28's history and physical dated, [DATE] documented, Pt. evaluated by M.D. (medical doctor) today for admission, pt in high spirits reports he feels much better and is ready for rehab (rehabilitation). Pt reports no cp (chest pain) no sob (shortness of breath), fevers, chills, no nv/d (nausea vomiting/ diarrhea). Does reports (sic) he feels constipated but had a normal bowel movement yesterday. No other complaints at this time. On [DATE] at 2:35 p.m. ASM #2, the director of nursing was made aware of the findings. ASM #2 was asked what nursing standard the staff practiced under. ASM #2 stated, Lippincott (text used for nursing practice). A request was made for a copy of the Lippincott's documentation regarding abdominal assessment. No information was provided. Review of the facility's policy titled, Change in a Resident's Condition or Status documented in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing payments, resident rights, etc.) 1. The Nurse Supervisor/Charge Nurse will notify the resident' Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self limiting). According to Lippincott Manual of Nursing Practice, Eighth Edition 2006, chapter 18, Gastrointestinal Disorders, pages 622, Standards of Care Guidelines: Gastrointestinal Dysfunction. When caring for a patient after abdominal surgery or with any type of GI (gastrointestinal) disorder: - Make sure adequate bowel sounds are present before allowing anything by mouth. Periodically reassess for bowel sounds, bloating, and abdominal tenderness. -Report increase in pain, fever, nausea and vomiting, bloating . to health care provider promptly. Table ,[DATE] Nature of Vomitus: Color /Taste/ Consistency: Fecal components. Possible Source: Intestinal obstruction. Making sense of abdominal assessment: Nursing Made Incredibly Easy! -September/[DATE] - volume 7 - Issue 5 - by O'Laughlen, Mary C. RN, FNP-BC, PhD, - p 1519 <http://journals.lww.com/nursingmadeincrediblyeasy/toc/,[DATE]> © 2009 Lippincott Williams & Wilkins, Inc. documents in part: With abdominal assessment, you inspect first, then auscultate, percuss, and palpate. The importance of assessment: Performing an abdominal assessment will help you detect health problems in your patients earlier and prevent further complications from developing with existing disease. No further information was provided prior to exit. COMPLAINT DEFICIENCY In Basic Nursing, Essential for Practice, 6th edition (Potter and Perry, 2007, pages ,[DATE]), was a reference source for physician's orders [REDACTED]. The best way to avoid being liable for negligence is to follow standards of care, to give competent health care, and to communicate with other health care providers. The physician or health care provider is responsible for directing the medical treatment of [REDACTED]. (1) [MEDICATION NAME] -- [MEDICATION NAME] is indicated for short-term treatment of [REDACTED]. Most patients heal within four weeks. Some patients may require an additional four weeks of therapy. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a1b077e6-b,[DATE]f2-a98e-380cc 9d (2) Ileus -- Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of [REDACTED]. This information was obtained from: http://www.ncbi.nlm.nih.gov/pubmed/ 380. (3) BMP -- A metabolic panel is a group of tests that measures different chemicals in the blood. These tests are usually done on the fluid (plasma) part of blood. The tests provide information about your body's chemical balance and metabolism. This information was obtained from: https://medlineplus.gov/metabolicpanel.html. (4) CBC -- Your blood contains red blood cells (RBC), white blood cells (WBC), and platelets. Blood count tests measure the number and types of cells in your blood. This helps doctors check on your overall health. This information was obtained from: https://medlineplus.gov/bloodcounttests.html (5) [MEDICATION NAME] -- [MEDICATION NAME]® Injection is indicated for the prevention of nausea and vomiting. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d9a71b42-ddfc-49d[DATE]fc0041dba41 (6) Senna S -- Senna is a popular herbal laxative that is available without prescription. This information was obtained from: http://livertox.nih.gov/Senna.htm (7) [MEDICATION NAME] -- Use relieves occasional constipation (irregularity), generally produces a bowel movement in 1 to 3 days. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= (8) Nasogastric tube -- A tube that is inserted through the nose, down the throat and esophagus and into the stomach. It can be used to give drugs, liquids and liquid food, or used to remove substances from the stomach. This information was obtained from: https://www.ncbi.nlm.nihA .gov/pubmedhealth/PMHT 68/l (9) Orthostatic vital signs determination: The measurement of patient blood pressure and pulse rate, first in the supine, then in the sitting, and finally in the standing position. A significant change in both of these vital signs signifies hypovolemia or dehydration. A positive test result occurs if the patient becomes dizzy or loses consciousness, or if the pulse rate increases by 20 or more beats per minute and the systolic blood pressure drops by 20 mm Hg within 3 min of the patient's arising from the supine to the sitting position or from the sitting to the standing position. This information was obtained from the website: <http://medical-dictionary.thefreedictionary.com/orthostatic+vital+signs+determination> 2. Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, an annual assessment, with an ARD of [DATE] coded the resident as having scored 15 out of 15 on the BIMS indicating the resident was cognitively intact to make daily decisions. The resident was coded as needing assistance of staff for dressing and bathing. In Section I titled Active [DIAGNOSES REDACTED]. Review of the care plan initiated on [DATE] and revised on [DATE] documented, Endocrine system related to Non-insulin Dependent Diabetes. Obtain glucometer readings and report abnormalities as ordered. Review of the physician's orders [REDACTED]. IF THE RESIDENT IS AWAKE AND ABLE TO SWALLOW: 1.1. ADMINISTER (APPROXIMATELY) 15 GRAMS (G) OF GLUCOSE OR CARBOHYDRATES FOUND IN ANY ONE OF THE FOLLOWING: * ,[DATE] CUP JUICE, * ,[DATE] CUP APPLE SAUCE, * 1 CUP MILK, * 1 TUBE GLUCOSE GEL, * 3 GLUCOSE TABLETS. 1.2 WAIT 15 MINUTES. 1.3 RECHECK BLOOD GLUCOSE LEVELS. IF LEVEL IS STILL BELOW THE TARGET, GIVE ANOTHER 15 GRAMS OF GLUCOSE OR CARBOHYDRATE. FOLLOW WITH A MEAL OR SNACK WITHIN 1 HOUR . The start date was [DATE]. Review of the April, 2016, [DATE] and [DATE] medication administration records (MAR) documented: HYPOGLYCEMIC (1) PROTOCOL: IF BG (blood glucose) IS LESS THAN 70MG/DL (milligrams per deciliter) (WHETHER OR NOT THE PATIENT IS SYMPTOMATIC) INITIATE treatment for [REDACTED]. IF THE RESIDENT IS AWAKE AND ABLE TO SWALLOW: 1.1. ADMINISTER (APPROXIMATELY) 15 GRAMS (G) OF GLUCOSE OR CARBOHYDRATES FOUND IN ANY ONE OF THE FOLLOWING: * ,[DATE] CUP JUICE, * ,[DATE] CUP APPLE SAUCE, * 1 CUP MILK, * 1 TUBE GLUCOSE GEL, * 3 GLUCOSE TABLETS. 1.2 WAIT 15 MINUTES. 1.3 RECHECK BLOOD GLUCOSE LEVELS. IF LEVEL IS STILL BELOW THE TARGET, GIVE ANOTHER 15 GRAMS OF GLUCOSE OR CARBOHYDRATE. FOLLOW WITH A MEAL OR SNAC

Based on staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that facility staff failed to notify the physician of a change in the condition for two of 28 residents in the survey sample, Resident #28, and Resident #12. 1. a. The facility staff failed to notify, the physician in a timely manner when Resident #28 vomited brown colored emesis with a faint stool odor on [DATE] at approximately 10:30 to 11:00 p.m., resulting in a delay in treatment for [REDACTED].#28, again vomited brown emesis with a stool odor; the physician was then notified and ordered transfer of Resident #28 to a local emergency room . The clinical record documented at approximately 2:50 a.m., when the EMTs (emergency medical technician) arrived to transport Resident #28, the resident was found on the floor face down and unresponsive. The resident then coded (heart stopped beating and breathing stopped) and CPR (cardiopulmonary resuscitation*) was initiated by facility staff and the EMTs, Resident #28 subsequently expired. *Cardiopulmonary resuscitation (CPR) is the manual application of chest compressions and ventilations to patients in [MEDICAL CONDITION] (without a heartbeat or pulse). Obtained from the website: http://medical-dictionary.thefreedictionary.com/CPR b. Facility staff failed to notify the family that Resident #28 vomited stool like emesis and that he had expired at the facility. 2. The facility staff failed to notify Resident #12's RP (responsible party) of a change in condition and new orders on [DATE]. The findings include: 1. Resident #28 was admitted to the facility on [DATE] and expired at the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a five day Medicare assessment, with an ARD (assessment reference date) of [DATE] coded the resident as having a 15 out of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring the assistance of one staff member for all activities of daily living. Review of the care plan initiated on [DATE] and revised on [DATE] documented in part, Bowel Elimination Alteration; Constipation related to decrease mobility secondary [MEDICAL CONDITION]([MEDICAL CONDITION], stroke) and decreased mobility. Report signs and symptoms of constipation such as abdominal cramping, diarrhea, nausea/vomiting, no bowel movement for three days. Review of the Resident evaluation nurse's note dated [DATE] at 4:45 p.m. documented in part, Bowel sound normal and present in all 4 quadrants No current conditions/[DIAGNOSES REDACTED]. Review of Resident #28's October, 2015, treatment administration record documented that the resident had not had a bowel movement from [DATE] through [DATE]. Review of the nursing notes dated [DATE] at 15:26 (3:26 p.m.) documented, Resident c/o (complained of) abdominal pain, NP (nurse practitioner) made aware in person, and will assess patient. There was no evidence of an assessment of the Resident's vital signs, abdominal assessment or location of pain. (*Note a note for the NP assessment of the resident was not presented by completion of the survey). Review of the physician progress notes [REDACTED].#28. Review of the physician's orders [REDACTED]. abdominal xray now. [MEDICATION NAME] (1) 20 mg (milligrams) po (by mouth) QD (every day) AC (before meals) breakfast. [MEDICATION NAME] 20mg po NOW. Review of the abdominal x-ray report done by a mobile x-ray company on [DATE] at 5:55 p.m. documented, IMPRESSION: No intestinal obstruction or abnormal calcifications. *Ileus (2) type pattern with distended loops of both small and large bowel. The report was signed by the radiologist at 6:55 p.m. *Ileus, a condition in which the bowel does not work correctly, but there is no structural problem causing it. Symptoms include in part: Abdominal swelling (distention), abdominal fullness, gas abdominal pain and cramping, constipation, inability to pass gas and vomiting. This information was obtained from the website: <https://medlineplus.gov/ency/article/ 0.htm> Review of the physician's orders [REDACTED]. [MEDICATION NAME] (5) 4mg po Q6h (every six hours) prn (as needed) nausea. Review of the Medication Administration Record [REDACTED]. Review of the nurse's notes dated [DATE] 19:23 (7:23 p.m.) documented, Flora Stor (a [MEDICATION NAME]) 250 mg (milligram) po (by mouth) BID (twice a day). RP (responsible party) aware. Resident aware. This note was signed by the RN (registered nurse), Supervisor (RN #4). Review of the nurse's notes dated [DATE] at 19:36 (7:36 p.m.) documented, (Name of nurse practitioner) CALLED AND ORTHOSTATIC VS (vital signs (9)) REPORTED TO HER. VS AS FOLLOWS LYING ,[DATE] -87 (blood pressure and pulse) SITTING ,[DATE]-109 AND ,[DATE]-111. NO NEW ORDERS RECEIVED AFTER GIVING HER THE VS. This note was signed by the RN (registered nurse) Supervisor, (RN #4). Review of the nurse's notes dated [DATE] at 22:11 (10:11 p.m.) documented, Results of the abdominal xray called to on-call MD (medical doctor) Dr (name of doctor) who gave new orders: give MOM (milk of magnesia) 30cc (cubic centimeters) po now. R/P (responsible party) aware resident aware. Review of the nurse's notes dated [DATE] at 22:30 (10:30 p.m.) documented, (Name of nurse practitioner) NP called to check on the CMP and xray results, informed had called and spoke to (name of doctor) who said to give resident MOM 30 cc po. New orders received from (name of NP) for Senna s (6) 2 tabs (tablets) po TID (three times a day) and Mirlax (sic) (7) 17 grams every am. Review of the nurse's notes dated [DATE] at 2:38 a.m. documented in part: SITUATION: Change in condition noted related to vomiting stool, elevated bs (blood sugar), o2 (oxygen) sat (saturation) of 83%*. This change started on [DATE]. Since this started, it has gotten worse. BACKGROUND: (Name of resident) was admitted to the facility for post-acute care. Relevant [DIAGNOSES REDACTED]. Not currently receiving [MEDICATION NAME]/[MEDICATION NAME] (6) medication .ADVANCE DIRECTIVES/LIMITED TREATMENT: Full Code. APPEARANCE: Vital signs: BP (blood pressure) ,[DATE] - [DATE] 02:42 (2:42 a.m.) Position: P (pulse) 127 - [DATE] 02:42 R (respirations) 22 - [DATE] 02:43 (2:43 a.m.); T (temperature) 98.4 - [DATE] 02:43 .MENTAL STATUS: No changes noted to mental status as compared to baseline ABDOMINAL/GI (gastrointestinal): Abdomen is distended. Has had episodes of nausea/vomiting. VOMITING STOOL. PAIN: No evidence of any new or worsening pain noted. REVIEW AND NOTIFICATIONS: (Name of physician's company) . was notified on [DATE] 2:00 AM INTERVENTIONS: Emergency medical transportation. Supplemental Oxygen. No additional recommendations made (contact person) was notified on [DATE] 2:30 AM. * Normal pulse oximeter (measuring the oxygen saturation of your blood using a pulse oximeter - a small device that clips to your finger) readings usually range from 95 to 100 percent. Values under 90 percent are considered low. This information was obtained from the website: <http://www.mayoclinic.org/symptoms/hypoxemia/basics/causes/sym- 930> **Note: A Review of the nurse's notes audit trail (the audit trail in the facility's software is accessed by selecting view next to any progress note. The audit trail documents the name of the staff member and their job position that created the note and the date and time that each note was written into the clinical record. ) documented the above nurses note dated [DATE] at 2:38 a.m. had been written on [DATE] at 11:39 a.m. not [DATE] at 2:38 a.m. and was written by the unit manager not the nurse who cared for the resident. Review of the nurse's notes dated [DATE] at 6:54 a.m. documented, At time of arrival of EMT (emergency medical technician) to transport resident to (name of hospital) resident was found on the floor face down unresponsive, CPR initiated by staff and EMT, RESIDENT WAS PRONOUNCED AT 3:20 AM by emt, rp (responsible party) aware and family was at bedside prior to resident being picked up by (name of funeral home). On call (name of doctor) aware. The nurse's note dated [DATE] at 18:41 (6:41 p.m.), written by ASM (administrative staff member) #2, the director of nursing, documented, Late entry note clarification for ,[DATE] shift [DATE] per (name of LPN (licensed practical nurse) #16); MOM given as ordered around 10:30pm, approx (approximately) 10:,[DATE]pm PT (patient) had small to moderate amt (amount) of emesis x1 (times one) brown color with faint stool odor, abd (abdomen) distended semifirm, no c/o pain, last BM reported Sat. (Saturday ([DATE])) Pt sitting on side of bed. Alert and oriented, new orders implemented per physician, report given to oncoming nurse. There was no documentation of an assessment of Resident #28's vital signs, an abdominal assessment of bowel sounds, and no assessment of the location and level of pain. There was no documentation that the physician was notified of Resident #28 vomiting brown colored emesis with a faint stool odor. Review of the nurse's note dated [DATE] at 05:47 (5:47 a.m.) documented, Addendum: Late entry for [DATE] for ,[DATE] (11:00 p.m.-7:00 a.m.) shift note clarification. Writer received report of pt having emesis on previous shift, received report of new orders obtained and initiated and that physician was notified of abdominal x-ray result and current condition of pt. On first rounds pt assessed with [REDACTED]. Approximately 1:30a (a.m.)-2:00a cna (certified nurse's assistant) reported pt had an episode of emesis brown in color with stool like odor; pt verbalized the brown emesis with poop odor also. Vital signs obtained with hr (heart rate) tachy ([MEDICAL CONDITION], a fast heart beat) 127, resp. 22, o2 sats (oxygen saturations) 83%* room air. H.O.B. (head of bed) elevated pt alert and oriented, o2 applied at 2/lpm (liters per minute) via n.c. (nasal cannula). (Name of doctor) notified of vital signs changes, emesis, o2 sats with n.o. (new order) for o2 at 2/lpm via n.c. and send to ER for evaluation. Informed pt of new orders and were sending him to the hospital for evaluation, in agreement with plan wife called and also notified of orders and sending to the ER for evaluation. Call placed for transport approximately 2:20 - 2:30 (a.m.), EMT and staff (writer) entered room and observed pt on the floor approximately 2:50am with brown emesis on the floor and no head or facial trauma and no bleeding noted. Emt and staff to reposition pt when pt took a breath and coded, CPR initiated. An interview was conducted on [DATE] at 2:00 p.m. with LPN (licensed practical nurse) #6, the dayshift nurse on [DATE], regarding the reasons staff would call a physician about a resident. LPN #6 stated, Anything, an emergency, any changes. When asked if a resident vomited stool like emesis would the doctor be notified, LPN #6 stated, That's a change and I would let him know. When asked if she remembered Resident #28, LPN #6 stated she did. When asked about Resident #28's abdominal pain, LPN #6 stated, He was not in distress, he complained of pain right after lunch approximately 1:30 p.m. LPN #6 stated, I palpated his abdomen, asked him where it was hurting. When asked what she remembered about her abdominal assessment, LPN #6 stated, I don't remember. When asked if this would be documented, LPN #6 stated, I didn't write it. An interview was conducted on [DATE] at 3:20 p.m. with RN (registered nurse) #5, unit manager, regarding what she would do if a resident vomited stool like emesis. RN #5 stated she would definitely notify the doctor. An interview was conducted on [DATE] at 3:21 p.m. with LPN #15. When asked what she would do if a resident vomited stool like emesis, LPN #15 stated, I'm going to get him out of here. Of course, after I assess and call the doctor because he has to go (to the hospital). An interview was conducted on [DATE] at 4:15 p.m. with RN #4, the evening supervisor. When asked if she remembered Resident #28, RN #4 stated she did. RN #4 stated, I took care of him until about 7 p.m. that day because (LPN #16) was going to be late. I remember when I first come in (to a resident's room), I introduce myself and I try to sit and chat with them and get a sense of what's going on. RN #4 was asked if she remembered Resident #28 complaining of pain. RN #4 stated, If I didn't write anything on him then he must have told me he felt fine and had no problems. If he had complained of something I would have documented it. When asked what she would do if a resident vomited stool like emesis, RN #4 stated she would notify the doctor because the resident needed a nasogastric tube (8) and they did not do that at the facility. An interview was conducted on [DATE] at 7:30 a.m. with ASM (administrative staff member) #2, the director of nursing, regarding what she remembered about Resident #28's death. ASM #2, the director of nursing, stated, I came in the next morning and I looked at his notes and I spoke with (LPN #16) and asked her what happened and that is when I wrote the late note from her. ASM #2 stated she had told LPN #17, the night nurse that she needed to come in the next day to write a note about what happened that night. A request was made at this time to interview LPN #16, the evening nurse who cared for the resident and LPN #17, the night nurse who cared for the resident. ASM #2 stated, They don't work here anymore. A request was also made to interview the unit manager who had written the note on [DATE]. ASM #2 stated that this unit manager no longer worked at the facility. ASM #2 stated that she would have a nurse who worked on [DATE] night shift speak to this writer. An interview was conducted on [DATE] at 8:15 a.m. with RN (registered nurse) #6, a night nurse. When asked what she recalled about Resident #28 on [DATE] at 2:30 a.m., RN #6 stated, At the change of shift when the nurse got report she was told he had been throwing up brown stuff, I think the supervisor contacted the physician at the change of shift. During our shift he started to throw up again. I had called the doctor, I can't remember who, and he said, 'Okay let's send him to the hospital.' I contacted the family that we were sending him out. An interview was conducted on [DATE] at 9:50 a.m. with LPN #7, regarding how staff assess pain. LPN #7 stated, I go into the patient's room and ask them where the pain is, have them rate it on a one to ten scale (with ten being the worst pain), or I can watch their facial expressions depending on if they are alert. When asked how staff would assess a resident with complaints of abdominal pain, LPN#7 stated, If it's abdominal pain I would go further. I'd check for bowel sounds, check if they had a BM (bowel movement) and of course palpate the belly. When asked if this would be documented, LPN #7 said it would. An interview was conducted on [DATE] at 10:10 a.m. with LPN #5. When asked how staff assesses a resident who complains of abdominal pain, LPN #5 stated, Listen to the bowel sounds to see if they're underactive or overactive. Do a pain assessment if it's new or if pain had gotten worse, ask the zero to ten number thing (pain rating). See if the abdomen is distended, painful. When asked if a resident note documenting, c/o (complaint/of) abdominal pain was considered a pain assessment, LPN #5 stated, No. An interview was conducted on [DATE] at 10:28 a.m. with LPN #14. When asked how staff assesses a resident who complains of abdominal pain, LPN #14 stated, Ask them were they are hurting, I palpate it (the abdomen), listen to bowel sounds, check for BM and assess the pain rating. When asked if this would be documented, LPN #14 stated it would. A telephone interview was conducted on [DATE] at 11:45 a.m. with ASM (administrative staff member) #6, the nurse practitioner. When asked if she remembered Resident #28, she stated that she did. When asked if she had physically assessed the resident, ASM #6, stated that she had. When asked if she had written a note, ASM #6 stated, We document on (name of company) notes and they get sent to medical records and they put it (note) on the chart. When asked if she remembered writing a note about her assessment, ASM #6 stated, I don't remember. When asked if she had been told that the resident was vomiting stool like emesis, ASM #6 stated she had not. When asked if she would change the resident's treatment plan if she had been made aware of Resident #28's first emesis with a stool odor on [DATE] at approximately 10:30 p.m., ASM #6 stated, Absolutely, I would have sent him out (to the hospital). An interview was conducted on [DATE] at 11:55 a.m. with OSM (other staff member) #4, the medical records manager, regarding the process they follow for placing progress notes on the chart from the medical staff from (name of company). OSM #4 stated, They (notes) are faxed over to us. The receptionist sorts them (the notes) out. If they're (the resident) discharged they (the notes) come to me. If they're (the resident) active they (the notes) go to the floor. A request was made at this time for any progress notes written for Resident #28. A telephone interview was conducted on [DATE] at 12:08 p.m. with ASM (administrative staff member) #7, the doctor. When asked if he remembered Resident #28, ASM #7 stated, I vaguely remember. I do remember report was called to me and told them to send him to the ER (emergency room ). Several hours later I was notified that he had died . When asked if he had been notified on [DATE] sometime around 10:30 p.m. that the resident had vomited stool like emesis, ASM #7 stated, I can't remember exactly. When asked if he would have changed the resident's treatment plan if he had been called on [DATE] at 10:30 p.m. and told the resident vomited stool like emesis, ASM #7 stated, Vomiting stool is very unusual. I definitely would have sent him to the hospital at that time. I am 100 miles away. On [DATE] at 12:55 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern for harm. A telephone interview was conducted on [DATE] at 1:30 p.m. with LPN #17, the resident's night nurse. When asked if she remembered Resident #28, LPN #17 stated, Yes. When asked what she remembered about the night the resident died , LPN #17 stated, I remember when I came in, that on the previous shift he had an episode of emesis and the nurse told me she called the doctor. The resident had another emesis that smelled like stool and he said he wasn't feeling too good. I called the doctor and he told me to send him out and I spoke to his wife. When asked how the resident looked at that time, LPN #17 stated, He was in no visual distress, he was alert and verbal, just nauseated. When asked what happened next, LPN #17 stated, I told the CNA (certified nursing assistant) to keep an eye on him and get him ready (to go to the hospital). I went to the desk get the paperwork ready, but I checked on him every few minutes. When EMT got there he was face down on the floor. He had only been left alone for maybe a minute because I could see the CNA was only a couple doors down the hallway. He was alert and verbal, I called his name and he answered me yes and he was making noises like moaning. When we repositioned him he took a breath and coded (no heart beat or breathing). When asked how he was turned, LPN #17 stated, It was three of us, we physically turned him over onto his back. There was emesis on the floor and it still smelled like stool. When asked if they did anything special when they turned him onto his back, LPN #17 stated, We supported his head and neck. A telephone interview was conducted on [DATE] at 2:10 p.m. with LPN #16, the evening shift nurse who cared for the resident on [DATE]. When asked if she remembered Resident #28 she stated she did. When asked what occurred on [DATE], LPN #16 stated, What I can remember is I came in and got report. He was not in distress; they were doing some work on him, some lab (laboratory) work. When asked what else occurred that evening, LPN #16 stated, Probably about 8 (p.m.) to 9 (p.m.), he vomited a small amount and it had a faint fecal (stool) and food odor, it was a very foul odor. When asked what she did next, LPN #16 stated, I did a head to toe assessment and took his vital signs and reported off to the next nurse. When asked if she would document that assessment, LPN #16 did not have a response. LPN #16 stated, He looked fine, his skin color was good, his abdomen was slightly distended and he had faint bowel sounds at the bottom (of his abdomen). I did say something to my supervisor and (name of supervisor) called the doctor. When asked what that doctor said, LPN #16 stated, I don't know. An interview was conducted on [DATE] at 2:10 p.m. with RN #4, the evening supervisorthat was working on [DATE]. When asked if she had called the doctor about Resident #28 vomiting emesis with a stool odor on [DATE] at around 10:30 p.m., RN #4 stated, No, I didn't call the doctor. I overhead her (LPN #16) giving report at the desk and I told her that she needed to call the doctor and report that. As far as I'm concerned if you're the one that witnessed it you need to call the doctor. I am being truthful and honest about everything. On [DATE] at 2:20 p.m. ASM #3, the medical director stated, There's no note from them (the physician or nurse practitioner) about the resident. ASM #3 stated he did get the history and physical from the resident's physician's company but there were no other notes. Review of Resident #28's history and physical dated, [DATE] documented, Pt. evaluated by M.D. (medical doctor) today for admission, pt in high spirits reports he feels much better and is ready for rehab (rehabilitation). Pt reports no cp (chest pain) no sob (shortness of breath), fevers, chills, no nv/d (nausea vomiting/ diarrhea). Does reports (sic) he feels constipated but had a normal bowel movement yesterday. No other complaints at this time. On [DATE] at 2:35 p.m. ASM #2, the director of nursing was made aware of the findings. ASM #2 was asked what nursing standard the staff practiced under. ASM #2 stated, Lippincott (text used for nursing practice). A request was made for a copy of the Lippincott's documentation regarding abdominal assessment. No information was provided. Review of the facility's policy titled, Change in a Resident's Condition or Status documented in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing payments, resident rights, etc.) 1. The Nurse Supervisor/Charge Nurse will notify the resident' Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self limiting). According to Lippincott Manual of Nursing Practice, Eighth Edition 2006, chapter 18, Gastrointestinal Disorders, pages 622, Standards of Care Guidelines: Gastrointestinal Dysfunction. When caring for a patient after abdominal surgery or with any type of GI (gastrointestinal) disorder: - Make sure adequate bowel sounds are present before allowing anything by mouth. Periodically reassess for bowel sounds, bloating, and abdominal tenderness. -Report increase in pain, fever, nausea and vomiting, bloating . to health care provider promptly. Table ,[DATE] Nature of Vomitus: Color /Taste/ Consistency: Fecal components. Possible Source: Intestinal obstruction. Making sense of abdominal assessment: Nursing Made Incredibly Easy! -September/[DATE] - volume 7 - Issue 5 - by O'Laughlen, Mary C. RN, FNP-BC, PhD, - p 1519 <http://journals.lww.com/nursingmadeincrediblyeasy/toc/,[DATE]> © 2009 Lippincott Williams & Wilkins, Inc. documents in part: With abdominal assessment, you inspect first, then auscultate, percuss, and palpate. The importance of assessment: Performing an abdominal assessment will help you detect health problems in your patients earlier and prevent further complications from developing with existing disease. No further information was provided prior to exit. COMPLAINT DEFICIENCY In Basic Nursing, Essential for Practice, 6th edition (Potter and Perry, 2007, pages ,[DATE]), was a reference source for physician's orders [REDACTED]. The best way to avoid being liable for negligence is to follow standards of care, to give competent health care, and to communicate with other health care providers. The physician or health care provider is responsible for directing the medical treatment of [REDACTED]. (1) [MEDICATION NAME] -- [MEDICATION NAME] is indicated for short-term treatment of [REDACTED]. Most patients heal within four weeks. Some patients may require an additional four weeks of therapy. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a1b077e6-b,[DATE]f2-a98e-380cc 9d (2) Ileus -- Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of [REDACTED]. This information was obtained from: http://www.ncbi.nlm.nih.gov/pubmed/ 380. (3) BMP -- A metabolic panel is a group of tests that measures different chemicals in the blood. These tests are usually done on the fluid (plasma) part of blood. The tests provide information about your body's chemical balance and metabolism. This information was obtained from: https://medlineplus.gov/metabolicpanel.html. (4) CBC -- Your blood contains red blood cells (RBC), white blood cells (WBC), and platelets. Blood count tests measure the number and types of cells in your blood. This helps doctors check on your overall health. This information was obtained from: https://medlineplus.gov/bloodcounttests.html (5) [MEDICATION NAME] -- [MEDICATION NAME]® Injection is indicated for the prevention of nausea and vomiting. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d9a71b42-ddfc-49d[DATE]fc0041dba41 (6) Senna S -- Senna is a popular herbal laxative that is available without prescription. This information was obtained from: http://livertox.nih.gov/Senna.htm (7) [MEDICATION NAME] -- Use relieves occasional constipation (irregularity), generally produces a bowel movement in 1 to 3 days. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= (8) Nasogastric tube -- A tube that is inserted through the nose, down the throat and esophagus and into the stomach. It can be used to give drugs, liquids and liquid food, or used to remove substances from the stomach. This information was obtained from: https://www.ncbi.nlm.nihA .gov/pubmedhealth/PMHT 68/l (9) Orthostatic vital signs determination: The measurement of patient blood pressure and pulse rate, first in the supine, then in the sitting, and finally in the standing position. A significant change in both of these vital signs signifies hypovolemia or dehydration. A positive test result occurs if the patient becomes dizzy or loses consciousness, or if the pulse rate increases by 20 or more beats per minute and the systolic blood pressure drops by 20 mm Hg within 3 min of the patient's arising from the supine to the sitting position or from the sitting to the standing position. This information was obtained from the website: <http://medical-dictionary.thefreedictionary.com/orthostatic+vital+signs+determination> 1.b. Review of the nurse's note dated [DATE] at 6:41 p.m., written by ASM (administrative staff member) #2, the director of nursing, documented, Late entry note clarification for ,[DATE] shift [DATE] per (name of LPN (licensed practical nurse) #16); MOM given as ordered around 10:30pm, approx (approximately) 10:,[DATE]pm PT (patient) had small to moderate amt (amount) of emesis x1 (times one) brown color with faint stool odor, abd (abdomen) distended semifirm, no c/o (complaint/of) pain, last BM (bowel movement) reported Sat. (Saturday ([DATE])) Pt sitting on side of bed. Alert and oriented, new orders implemented per physician, report given to oncoming nurse. There was no documentation that the family had been notified of the emesis. Review of the nurse's notes dated [DATE] at 6:54 a.m. documented, At time of arrival of EMT (emergency medical technician) to transport resident to (name of hospital) resident was found on the floor face down unresponsive, CPR initiated by staff and EMT (emergency medical transport), RESIDENT WAS PRONOUNCED AT 3:20 AM by emt, rp (responsible party) aware and family was at bedside prior to resident being picked up by (name of funeral home). On call (name of doctor) aware. An interview was conducted on [DATE] at 3:20 p.m. with RN (registered nurse) #5, a unit manager, regarding notification to the resident's RP (responsible party). RN #5 stated, If they require labs (laboratory tests), any x-rays, when the labs come back, any significant changes. RN #5 was asked when the RP would be notified if a resident vomited stool like emesis. RN #5 stated, I may or may not. When asked when an RP was notified after a death, RN #5 stated, If they're in the middle of a critical situation we call them once they are stable. An interview was conducted on [DATE] at 3:21 p.m. with LPN #15, regarding notification to the residents RP. LPN #15 stated, An unexpected bleeding, not catching their breath a serious change in condition, a skin tear, a cold. We call them for about most everything. When asked if the RP would be notified if the resident vomited stool like emesis, LPN #15 stated, Yes, ma'am. When asked if a family was waiting at the hospital and the resident died at the facility at 3:20 a.m. when would she notify the family, LPN #15 stated, If the resident was pronounces at 3:20 a.m. then I would call as soon as possible. I would not have anybody waiting 30 minutes. An int