Every finding on record at Golden Years Center for Rehab and Healthcare

Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out Activities of Daily Living (ADLs-fundamental self-care tasks like bathing or eating) received the necessary services to maintain good personal hygiene by failing to ensure bathing was completed and documented according to the residents individual preference and facility policy for four sampled residents (Resident #2, #3, #4, and #5) out of six sampled resident's. The facility census was 62 residents.Review of the facility's Activities of Daily Living (ADLs) Policy revised 5/16/25, showed:-The facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs did not deteriorate unless deterioration was unavoidable.-Care and services would be provided for the following activities of daily living:--Bathing, dressing, grooming and oral care.--Transfer and ambulation.--Toileting.--Eating to include meals and snacks; and--Using speech, language or other functional communication systems.-A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's Resident Showers Policy revised 6/10/25, showed:-It was the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per in accordance with current standards of practice.-Residents would be provided with showers in accordance with the residents' preferences, care plan, and safety needs, as well as the facility's scheduled bathing protocol. 1. Review of Resident #2's admission Record showed he/she re admitted to the facility on [DATE] and had the following diagnoses:-Chronic Kidney Disease, stage 4 (severe- kidneys are moderately or severely damaged and are not properly filtering waste from the blood). -Dependance on renal dialysis (a treatment that filters waste and excess fluid from your blood when your kidneys are failing).-Type 2 diabetes mellitus with diabetic neuropathy (a chronic, progressive condition where high blood sugar (hyperglycemia) and high levels of fat (triglycerides) cause damage to peripheral nerves over time). -Peripheral vascular disease (a slow, progressive circulation disorder involving damage or blockage to blood vessels outside the heart and brain, primarily affecting arteries and sometimes veins in the legs and feet. It restricts blood flow, causing leg pain, cramping, and non-healing wounds). -Major Depressive Disorder (a serious mental health condition characterized by a persistent low mood, loss of interest in activities, and low energy). -Anxiety Disorder (a group of mental health conditions characterized by excessive, persistent, and uncontrollable fear, worry, or dread regarding everyday situations). Review of the resident's task list report dated 7/20/25 showed his/her scheduled bath days were on Monday, Wednesday and Friday and PRN (as needed) during the day shift. Review of the resident's bedside Kardex dated 7/20/25 showed he/she required partial to moderate assistance with washing, rinsing, and drying self. Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/11/26 showed:-He/She was cognitively intact. -He/She was able to make his/her needs known.-He/She required partial to moderate assistance with bathing.-He/She was occasionally incontinent with bowel and bladder. Review of the resident's Care Plan initiated on 3/23/26 showed:-He/she requires additional assistance with ADL's. -He/She was at risk for impaired skin integrity related to occasional incontinence, impaired mobility related to his/her below the knee amputation, and decreased sensation due to diabetic neuropathy.-Staff were to provide partial to moderate assistance with washing, rinsing, and drying self.-Staff were to encourage the resident to change clothes daily. Review of the resident's Point of Care (POC) documentation dated 4/1/26-4/30/26 showed no baths or showers documented for the month of April. During an interview on 4/10/26 at 4:10 P.M., Social Worker A said:-The resident was observed on several occasions at his/her dialysis clinic wearing the same clothes multiple days in a row.-The resident received dialysis on Monday and Fridays each week.-The resident commonly arrived on Fridays in the same clothes he/she was wearing on Monday.-The resident's clothing was dirty at each visit and was observed being soiled with bodily fluids on numerous occasions. -The resident had a strong odor of urine when observed at his/her dialysis appointment.-The resident reported that the facility was not bathing him/her.-He/She contacted the facility to address the hygiene and bathing concerns, and nothing was done to fix the issue. -The resident was at a higher risk of infection due to receiving dialysis through a dialysis access port. Observation on 5/1/26 at 4:20 P.M., showed:-The resident was wearing unclean clothing that that had what appeared to be blood spots and other spills on both his/her shirt and jeans.-The resident was wearing a hat.-The resident's hair was long, unkept, and appeared to be greasy and dirty.-The resident had an odor of urine. During an interview on 5/1/26 at 4:20 P.M., the resident said:-He/she required assistance from facility staff for bathing and hygiene. -He/She wanted at least two showers per week. -He/she was not getting showers two times a week. -He/She was lucky to get one shower in a week.-He/She has gone several weeks without getting showered at all.-He/She recently went 6 weeks without getting a shower.-He/she did not remember when his/her last shower was. -He/She requested showers and did not get one on several occasions.-He/She was embarrassed by the lack of hygiene and the way he/she smelled.-He/She felt unclean and had a bad odor at times due to lack of showering. 2. Review of Resident #3's admission Record showed he/she re admitted to the facility on [DATE] and had the following diagnoses:-Dementia (a decline in mental ability-such as memory, reasoning, and behavior severe enough to interfere with daily life, caused by physical changes in the brain). -Cognitive communication deficit (a communication impairment resulting from underlying cognitive issues rather than primary language or speech muscle dysfunction). -Abnormalities of gait and mobility (unusual walking patterns, such as limping, shuffling, or instability, caused by pain, injury, neurological conditions, or muscular weakness).-Difficulty in walking.-Muscle weakness.-Need for assistance with personal care-Ulcer of the right foot (a chronic, non-healing open sore or lesion on the skin, often extending into deeper tissues). -Cellulitis of right lower limb (a serious bacterial infection of the deep dermis and subcutaneous tissue of the right leg, often caused by streptococci or staphylococci bacteria entering through skin breaks).-Tinea Unguium (a contagious fungal infection of the nail bed, plate, or matrix). Review of the resident's bedside Kardex dated 1/2/25 showed:-His/Her scheduled bath days were Tuesday, Thursday, Saturday, and PRN (as needed) during the day shift.-He/She required partial to moderate assistance to wash, rinse and dry herself. Review of the resident's annual MDS dated [DATE] showed:-He/She was cognitively intact. -He/She could not make needs known.-He/She required partial to moderate assistance with bathing.-He/She was frequently incontinent with urine and occasionally incontinent with bowel. Review of the resident's Care Plan initiated on 4/21/26 showed:-He/She was dependent on staff for meeting emotional, intellectual, physical, and social needs related to activity participation.-He/She had an ADL self-care performance deficit.-He/She was at risk for impairment to skin integrity.-He/She had bowel incontinence.-He/She had bladder incontinence. -Staff was to provide partial to moderate assistance to washing, rinsing and drying during bathing. Review of the resident's POC documentation dated 4/1/26-4/30/26 showed no baths or showers documented for the month of April. 3. Review of Resident #4's admission Record showed he/she re admitted to the facility on [DATE] and had the following diagnoses:-Dementia.-Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).-Anxiety Disorder.-Adult failure to thrive (a syndrome of progressive physical, functional, and cognitive decline, most common in frail older adults). Review of the resident's bedside Kardex dated 5/28/24 showed he/she was able to bathe and shower with setup and supervision. Review of the resident's Care Plan initiated on 6/4/24 showed:-He/She was at risk for impaired skin integrity related to a history of falls, physical conditionand dementia.-He/She had ADL self-care performance deficit related to activity intolerance.-Staff was to set up and supervise bathing. Review of the resident's task list report dated 7/1/25 showed his/her scheduled bath days were on Tuesday, Thursday, Saturday, and PRN (as needed) during the day shift. Review of the resident's annual MDS dated [DATE] showed:-He/She had moderate cognitive impairment. -He/She required partial to moderate assistance with bathing. Review of the resident's POC documentation dated 4/1/26-4/30/26 showed no baths or showers documented for the month of April. During an interview on 5/1/26 at 2:20 P.M., the resident said:-He/she required assistance from facility staff for bathing and hygiene. -He/She wanted more showers than he/she was getting.-He/She was not getting two showers per week on any week.-He/She showered daily before coming to the facility.-He/She liked to be clean.-He/She did not get a shower for over 4 weeks, prior to the one that he/she got yesterday. -He/She was embarrassed and felt dirty when not getting showered for a long period of time. -He/She requested showers often but was never given one when requested. 4. Review of Resident #5's admission Record showed he/she re admitted to the facility on [DATE] and had the following diagnoses:-Hemiplegia (partial or total paralysis) and Hemiparesis (weakness on one side of the body). -Anxiety disorder. -Depression.-Neuromuscular Dysfunction of the bladder (a person does not have bladder control because of brain, spinal cord, or nerve problems). -Muscle Weakness.-Cognitive communication deficit.-Diarrhea (passing loose, watery stools three or more times in a day). Review of the resident's bedside Kardex dated 9/11/25 showed his/her scheduled bath days were on Tuesday, Thursday, Saturday, and PRN (as needed) during the day shift. Review of the resident's Care Plan initiated on 11/5/25 showed:-He/She had ADL self-care performance deficit.-Staff was to provide sponge bath when a full bath or shower cannot be tolerated. Review of the resident's quarterly MDS dated [DATE] showed:-He/She was cognitively intact. -He/She could make needs known.-He/She required substantial to maximal assistance with bathing.-He/She had an indwelling urinary catheter (a flexible, sterile tube inserted through the into the bladder to drain urine continuously into a drainage bag). -He/She was frequently incontinent with bowels. Review of the resident's POC documentation dated 4/1/26-4/30/26 showed no baths or showers documented for the month of April. Observation on 5/1/26 at 3:30 P.M., showed:-The resident was laying in his/her bed eating snacks.-The resident had dirty clothes on that showed where food and drinks had spiled his/her clothing.-The resident's hair was unkept and greasy.-The resident had a foul body odor. During an interview on 5/1/26 at 3:30 P.M., the resident said:-He/she required assistance from facility staff for bathing and hygiene. -He/She wanted more showers than he/she was getting.-He/She was not getting two showers per week.-Some weeks, he/she was not showered once. -He/She wanted to have two or three showers per week.-He/She was supposed to get three showers a week. -He/She requested a shower today but did not get one.-He/She had not had a shower for almost two weeks.-His/Her last shower was on 4/20/26. -He/She only got 2 showers in the whole month of April. -It upsets him/her that he/she was not getting bathed. -He/She felt unclean and embarrassed due to not getting bathed. -Staff did not perform bed baths or sponge baths when his/her shower was missed. 5. During an interview on 5/1/26 at 1:00 P.M. Certified Nurse Assistant (CNA) A said:-There was one CNA who was responsible for giving baths and showers to all the residents in the facility.-When a CNA gave a resident a bath or shower, they were supposed to fill out a shower sheet and document the bath or shower in the resident's POC charting.-When a resident refused a bath or shower, the shower aide was supposed to fill out a shower sheet and write refused on it and tell the nurse on duty.-When a resident refused a bath or a shower, the bath aide was supposed to document the refusal in the resident's electronic medical record. -On an average day, the bath aide was able to give about 9 showers per day.-The bath aide worked 5 days per week and did not work on the weekends.-The bath aide gave about 45 baths and showers per week.-Each resident in the facility should get at least two showers or baths per week.-The residents were not getting a minimum of two baths or showers a week due to being short staffed.-The facility needed more than one bath aide because one could not keep up with the minimum standards or the facility policy of 2 bath or showers per week.-The residents are upset about not getting their baths and showers.-The bath aide often gets pulled to work the floor and that puts the showers and baths behind.-Some of the residents have gone weeks without getting bathed or showered due to not having the staff to help them. -There was only the one full-time bath aide that was giving the residents their baths and showers.-The evening staff did not help with baths or showers.-The weekend staff did not give baths or showers.-If the bath aide was not working or pulled from bathing to work the floor, the baths and showers were not being done.-The missed baths and showers were not rescheduled; they were just missed.-None of the residents in the facility were getting a minimum of two showers or baths per week. During an interview on 5/1/26 at 1:30 P.M. CAN B said:-The facility only had one bath aide for the entire facility. -The bath aide was the one responsible for bathing all the residents. -Residents should be getting a minimum of two baths per week.-Most residents would prefer to get three baths or showers per week.-The residents in the facility are not getting bathed at least twice per week.-The one bath aide can't keep up with the entire facility.-He/She did not give showers or baths to the residents.-He/She gave no showers or baths to any of the sampled residents in the month of April.-When a resident gets bathed, the CNA was supposed to fill out a bathing sheet and turn it into the charge nurse for the nurse to sign.-He/She was unsure who audited the bathing sheets.-CNA's were supposed to chart in the resident's POC charting any time a resident received a shower or bath.-If a resident refused a shower or bath, the CNA was supposed to chart the refusal on a bath sheet and in the POC charting. During an interview on 5/1/26 at 4:15 P.M., Licensed Practical Nurse (LPN) A said:-Residents should be getting a minimum of 2 showers per week.-The facility policy stated that if resident request more than two showers or baths, they should get more.-The Director of Nursing (DON) was the one who audited the showers and shower sheets.-She would expect that each resident in the facility to receive a minimum of 2 showers or baths per week, and more if requested.-He/She did not give baths or showers to the residents.-The bath aide was the one responsible for giving the residents their baths and showers.-The facility had one bath aide for the entire facility. -Baths and showers were not being assigned in the evenings and weekends as they used to be. -The one bath aide that worked Monday through Friday was the only aide giving the residents their scheduled baths and showers.-Sometimes, another aide would help if the bath aide was not working and a resident needed a PRN shower or bath. -It was hard for the one bath aide to keep up with bathing needs of the facility.-It would take more than one aide to be able to give all of the residents in the facility at least two showers or baths per week. -When a shower is given, it should be documented on the facility shower sheets by the CNA who is giving the shower.-The CNA then brings the shower sheets to the nurse who was on duty at the time of the shower to sign the sheets.-Both the CNA that gave the shower and nurse who worked the shift should have their names signed on the sheet.-If a resident refused bathing, the CNA should fill out the shower sheet and write on the sheet refused.-When bathing sheets are completed, they should be scanned into the resident's electronic medical record under the miscellaneous tab. -The baths and showers should be charted in the POC task sheet in the resident's electronic medical records when they are given and when the resident refused. -The one shower aide was pulled from giving showers and baths to work the floor when the facility is short staffed.-When the shower aide got pulled from giving showers and baths, the showers that were supposed to be given that day were all missing. -The facility had no alternative or back up plan when the bath aide was pulled to work the floor.-When the bath aide was pulled to work the floor or was not working, baths and showers were not getting done and were not rescheduled to get done. -With 62 residents in the facility,124 showers were needed to be given weekly, to meet minimum standards and facility policy of two showers per week. -It was not possible for the one bath aide to complete the showers that are needed. -No other staff are helping the bath aide with the showers and baths. During an interview on 5/1/26 at 5:00 P.M., DON said:-Residents should be offered 2 showers a week at minimum and more if asked.-They currently have one bath aide for the whole facility. -When a shower or bath is given, the CNA filled out a shower sheet on the day that the shower was given.-Once the shower sheet was filled out, the CNA gave the shower sheet to the charge nurse on duty that day or sometimes gave the sheet to him/her. -When a bath or shower was given to a resident or a resident refused a bath or shower, the CNA documented the resident's baths and showers in the resident's electronic medical record in the POC charting. -He/She was the one responsible for auditing the baths and showers.-He/She could not provide documentation or proof of auditing for any baths or showers. -The facility had no policy on documentation of showers.-He/She was not aware if the facility had a resident bathing schedule. -He/She was not sure how the bath aide made her bathing schedule for the week. -He/She was not sure if a schedule even existed, if the schedule was being followed. Complaint number: 2980493

Based on interview and record review, the facility failed to ensure all residents' medical records were complete and accurate for four sampled residents (Resident #2, #3, #4, and #5) out of six sampled residents, when on 5/1/26 the Director of Nursing (DON) advised Certified Nurse Assistant (CNA) B and CNA C to retroactively complete and sign Skin Monitoring: Comprehensive CNA shower sheets for prior dates. The facility census was 62 residents. Review of the facility's Documentation in Medical Record Policy revised 6/6/25, showed:-Each resident's medical record would contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.-Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.-Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.-Documentation may be performed manually or as per the facility's specific electronic medical record software program.-Principles of documentation included, but were not limited to:--Documentation shall be factual, objective, and resident centered.--False information shall not be documented.--Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.-Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.-Documentation shall be timely and in chronological order.-When documentation occurred after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry. 1. Review of Resident #2's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/11/26 showed:-He/She was cognitively intact. -He/She was able to make his/her needs known.-He/She required partial to moderate assistance with bathing. Review of the resident's Skin Monitoring: CNA shower sheets that were provided by the DON on 5/1/26 at 12:00 P.M., showed:-On 4/6/26 and 4/9/26 CNA B documented a completed CNA visual assessment on the resident's skin during a shower and documented No new skin issues.-On 4/13/26 and 4/28/26 CNA B documented a completed CNA visual assessment on the resident's skin during a shower and documented Refused.-CNA B signed the shower sheet and dated the shower sheet 4/6/26, 4/9/26, 4/13/26, and 4/28/26. --The DON signed at the bottom of the shower sheet.--The date next to the DON's signature was left blank. During an interview on 5/1/26 at 1:30 P.M. CNA B said:-He/She did not give and or attempt to provide the resident a shower or assess the resident's skin on 4/6/26, 4/9/26, 4/13/26, 4/13/16, and 4/28/26.-He/She did not give the resident any showers or complete any skin assessments on the resident in the month of April. During an interview on 5/1/26 at 4:20 P.M., the resident said:-He/she required assistance from facility staff for bathing and hygiene. -He/she was not getting showers two times a week. -He/She recently went 6 weeks without getting a shower.-He/she did not remember when his/her last shower was but knew it had been at least 2 weeks since he/she had a shower. -He/She did not refuse any showers in the month of April. 2. Review of Resident #3's annual MDS dated [DATE] showed:-He/She was cognitively intact. -He/She could not make needs known.-He/She required partial to moderate assistance with bathing. Review of the resident's Skin Monitoring: CNA shower sheets that were provided by the DON on 5/1/26 at 12:00 P.M., showed:-On 4/2/26, there was a shower sheet completed that stated No issues, with no CNA signature or date.-On 4/4/26, 4/7/26, 4/9/26, 4/13/26, 4/16/26, 4/20/26, 4/24/26, 4/27/26, 4/30/26 CNA B documented a completed CNA visual assessment on the resident's skin during a shower.-CNA B signed the shower sheet and dated the shower sheet 4/4/26, 4/7/26, 4/9/26, 4/13/26, 4/16/26, 4/20/26, 4/24/26, 4/27/26, 4/30/26. --The DON signed at the bottom of the shower sheet.--The date next to the DON's signature was left blank. During an interview on 5/1/26 at 1:30 P.M. CNA B said:-He/She did not give the resident a shower or assess the resident's skin on 4/2/26, 4/4/26, 4/7/26, 4/9/26, 4/13/26, 4/16/26, 4/20/26, 4/24/26, 4/27/26, 4/30/26.-He/She did not give the resident any showers or complete any skin assessments on the resident in the month of April. 3. Review of Resident #4's annual MDS dated [DATE] showed:-He/She had moderate cognitive impairment. -He/She required partial to moderate assistance with bathing. Review of the resident's Skin Monitoring: CNA shower sheets that were provided by the DON on 5/1/26 at 12:00 P.M., showed:-On 4/1/26, 4/10/26, 4/14/26, 4/24/26, 4/27/26 and 4/30/26 CNA B documented a completed CNA visual assessment on the resident's skin during a shower.-CNA B signed the shower sheet and dated the shower sheet 4/1/26, 4/10/26, 4/14/26, 4/24/26, 4/27/26 and 4/30/26. --The DON signed at the bottom of the shower sheet.--The date next to the DON's signature was left blank. During an interview on 5/1/26 at 1:30 P.M. CNA B said:-He/She did not give the resident a shower or assess the resident's skin on 4/1/26, 4/10/26, 4/14/26, 4/24/26, 4/27/26 and 4/30/26.-He/She did not give the resident any showers or complete any skin assessments on the resident in the month of April. During an interview on 5/1/26 at 2:20 P.M., the resident said:-He/she required assistance from facility staff for bathing and hygiene. -He/She was not getting two showers per week on any week.-He/She did not receive any showers for the entire month of April. 4. Review of Resident #5's quarterly MDS dated [DATE] showed:-He/She was cognitively intact. -He/She could make needs known.-He/She required substantial to maximal assistance with bathing. Review of the resident's Skin Monitoring: CNA shower sheets that were provided by the DON on 5/1/26 at 12:00 P.M., showed:-On 4/1/26, CNA B documented a completed CNA visual assessment on the resident's skin during a shower and documented 0 new skin issues.-On 4/3/26, 4/7/26, 4/16/26, 4/23/26 CNA B documented a completed CNA visual assessment on the resident's skin during a shower and documented No new skin issues.-On 4/11/26, CNA B documented a completed CNA visual assessment on the resident's skin during a shower and documented 0 skin.-On 4/28/26, CNA B documented a completed CNA visual assessment on the resident's skin during a shower.-CNA B signed the shower sheet and dated the shower sheet 4/1/26, 4/3/26, 4/7/26, 4/11/26, 4/16/26, 4/23/26 and 4/28/26. -The DON signed at the bottom of the shower sheet.-The date next to the DON's signature was left blank. During an interview on 5/1/26 at 1:30 P.M. CNA B said:-He/She did not give the resident a shower or assess the resident's skin on 4/1/26, 4/3/26, 4/7/26, 4/11/26, 4/16/26, 4/23/26 and on 4/28/26.-He/She did not give the resident any showers or complete any skin assessments on the resident in the month of April. During an interview on 5/1/26 at 3:30 P.M., the resident said:-He/She had not had a shower since 4/20/26. -He/She only received 2 showers in the whole month of April. 5. During an interview on 5/1/16 at 12:00 P.M., the DON said:-The shower sheets reflected the showers the four sampled residents received in the last 30 days.-He/She was sorry that it took so long to provide the documentation, he/she had a hard time finding the shower sheets. During an interview on 5/1/26 at 1:00 P.M. CNA A said:-When a CNA gave a resident a bath or shower, they were supposed to fill out a shower sheet and document the bath or shower in the resident's POC charting on the day that the shower was given.-When a resident refuses a bath or shower, the shower aide was supposed to fill out a shower sheet and write refused on it, document the refusal in the resident's POC charting, and tell the nurse on duty.-All documentation regarding showers and refusals of showers were supposed to be documented on the day the cares were given to the residents. -CNA B did not give any baths or showers to residents #2, #3, #4, or #5 in the month of April. During an interview on 5/1/26 at 1:30 P.M. CNA B said: -He/She was told to sign the Skin Monitoring: Comprehensive CNA shower sheets by the DON on 5/1/26.-The DON called him/her into the DON's office and advised him/her to document the CNA visual assessments, sign his/her name, and document a date on all of the shower sheets today. -When a resident was bathed, the CNA was supposed to fill out a bathing sheet and turn it into the charge nurse for the nurse to sign on the day that the cares were completed.-CNA's were supposed to chart in the resident's POC charting any time a resident received a shower or bath, on the day the cares were performed.-If a resident refused a shower or bath, the CNA was supposed to chart the refusal on a bath sheet and in the POC charting, on the day that the refusal occurred. During an interview on 5/1/26 at 1:00 P.M. CNA C said:-He/She was asked by the DON on 5/1/26 to complete resident's #2, #3, #4, and #5's shower sheets. -The DON had him/her look up all the dates that the resident's should have received their showers and place those dates on a blank shower sheet for CNA B to sign on 5/1/26.-None of the residents received the cares that the shower sheets had documented as being received in April.-All the shower sheets were created and documented on 5/1/26.-All shower sheets should be documented, signed, and completed by the CNA on the days that the service was given. -All of the resident's bathing should be documented in the resident's POC charting on the day that the bathing was completed. -Making up dates, false cares, and signing a bathing sheet when cares were not received by the resident was considered unethical and false documentation. During an interview on 5/1/26 at 4:15 P.M., Licensed Practical Nurse (LPN) A said:-The DON was the one who audited the showers and shower sheets.-When a shower was given, it should be documented on the facility shower sheets by the CNA who was giving the shower.-The CNA then brought the shower sheet to the nurse who was on duty at the time of the shower to sign the sheets.-Both the CNA that gave the shower and nurse who worked the shift should have their names signed on the sheet.-If a resident refused bathing, the CNA should fill out the shower sheet and write on the sheet refused.-When bathing sheets are completed, they should be scanned into the resident's electronic medical record under the miscellaneous tab. -The baths and showers should be charted in the POC task sheet in the resident's electronic medical records when they are given and when the resident refused. -He/She would expect all bathing sheets to be accurate and completed on the day that the CNA performed the cares for the residents. During an interview on 5/1/26 at 5:00 P.M., DON said:-When a shower or bath is given, the CNA filled out a shower sheet on the day that the shower was given.-Once the shower sheet was filled out, the CNA gave the shower sheet to the charge nurse on duty that day or sometimes gave the sheet to him/her. -When a bath or shower was given to a resident or a resident refused a bath or shower, the CNA documented the resident's baths and showers in the resident's electronic medical record in the POC charting. -He/She was the one responsible for auditing the baths and showers.-He/She could not provide documentation or proof of auditing for any baths or showers. -The facility had no policy on documentation of showers.-All of the shower sheets requested were signed and completed by CNA B on the day that CNA B gave the residents their showers. -The documentation for shower sheets should be completed on the day the shower was provided by the aide who provided the shower.

Based on observation and interview, the facility failed to maintain the inside laundry wall on the parking lot side in good repair to prevent water from entering the laundry area and failed to prevent the growth of moldlike substance on the laundry wall. This practice affected one non-resident use area. The facility census was 62 residents.1. Observation with the Administrator and the Maintenance Person on 5/1/25 at 10:57 A.M., showed:-An area of the wall that was 8 feet (ft.) 7 inches (in.) high by 15 ft. wide that was covered in a moldlike substance.-One area behind a large stainless-steel sink with the presence of a moldlike substance on the wall that was 14 in. high by 4 ft. wide. During an interview on 5/125 at 11:03 A.M., Laundry Aide (LA) A said:-He/she has worked at the facility as a Laundry Aide for six years.-He/she has not seen any moldlike substances in the laundry area.-He/she has not seen standing water in the basement. During an interview on 5/1/26 at 11:26 A.M., the Maintenance Person said he/she noticed the moldlike substance on the wall and said he/she could mitigate the area by using cleaners. During an interview on 5/1/25 at 11:59 A.M., the Housekeeping Supervisor said: -Sometimes, water comes in through the window with the board on it, from the parking lot side, when it rains. -He/she has seen water standing in the laundry area after heavy rainstorms. -In the past, there may have been a leak on the wall behind the stainless-steel sink, but the moldlike substance remained even after the leak may have been fixed. During an interview on 5/1/26 at12:29 P.M., the Former Laundry Supervisor said water would come through the dumbwaiter (a small freight elevator or lift designed to transport food, dishes, laundry, or supplies between floors) area. During an interview on 5/1/26 at 2:53 P.M., the Administrator said he/she had the maintenance department clean the wall behind the washing machine with bleach and a mold killer, then paint the wall with a coating designed to block stubborn stains, seal odors, and ensure paint adhesion on surfaces like wood, drywall, and masonry. During an interview on 5/1/26 at 3:09 P.M., the Maintenance Person said:- The walls in the laundry sweat ( a term used to explain when condensation, which occurs when warm, humid air touches cold surfaces, often caused by high indoor humidity, poor insulation, or inadequate ventilation).-He/she has not seen water gushing down through the walls. -He/she has not seen any water come through the windows. There was a pipe which leaked in the past, at the area behind the stainless-steel rinse sink. During a phone interview on 5/3/26 at 5:07 P.M., Former Laundry Aide (LA) B said:-He/she was at the facility in March 2026, when a rainstorm caused flooding.-Over by the back door, water came in through the bottom of the walls.-The only flooding that happens is when it rains. During a phone interview on 5/4/26 at 11:18 A.M., LA C said:-Water came into the laundry when it rained and-He/she didn't report any issues to management about the water in the basement. During written communication on 5/4/26 at 12:12 P.M., the Administrator communicated that the/she had only worked 8 days at the time of the investigation, and no one had brought any environmental concerns to him/her. During a phone interview on 5/4/26 at 1:36 P.M., the Maintenance Assistant said:-He/she has worked at the facility for 11 years-No one had brought the moldlike substance on the wall behind the washers to his/her attention in the past and he/she had not really paid attention to it in the past. -He/she has not heard of water coming in through the window. Complaint 2992609.

Based on observation, interview and record review, the facility failed to ensure the facility van used to transport residents to appointments was currently licensed. The facility census was 62 residents. Review of the facility's policy dated [DATE], Transporting a Resident - Facility Van showed:-It is the policy of this facility to provide residents safe, non-emergency transportation to physician's appointments, activity outings, and any other trips the faculty deems necessary.-The van would be well maintained. -Facility liability and insurance would have covered staff transportation of residents. 1. Review of emails between the Administrative Team at the facility and the parent company showed:-On [DATE] needing to register the van. The license plates expires on Friday. Will need the title and a bill of sale to do this.-On [DATE] Are you able to track down the van title.-On [DATE] The parent company said: Have we received the needed titles yet? To be in compliance with the law, we need to be able to register our vehicles and we need the titles to register the vehicles. -On [DATE] they were reviewing which facilities currently had expired registrations.-On [DATE] the Accounting Department asked if they had been able to get the duplicate titles for the vans. Review of the Transportation Log for February 16, 2026, to February 23, 2026 showed:-On [DATE] two residents were transported to physician's appointments.-One resident was transported to a physician's appointment via a different transportation company.-On [DATE] one resident was transported to a physician's appointment.-On [DATE] two residents were transported to physician's appointments.-On [DATE] two residents were transported to physician's appointments.-On [DATE] one resident was transported to a physician's appointment.-One resident was transported to a physician's appointment via a different transportation company.-On [DATE] two residents were transported to physician's appointments.-One resident was transported to a physician's appointment via a different transportation company. Observation of the facility's van on [DATE] at 1:00 P.M. showed:-It was a white Dodge Van with the license plate VF3 L9X parked in the front of the facility.-The sticker on the license plate was green and the date was 25. During an interview on [DATE] at 1:10 P.M. the facility Van Driver identified that van as the one he/she used to transport residents to appointments.-He/She said that the van was used several times a week.-He/She said the license on the van had expired last year.-He/She had asked the facility what would happen if he/she was pulled over for an expired license plate.-He/She was told the facility would pay for the ticket.-He/She said there were other transportation services in the area that could have been utilized to take the residents to their appointments.-He/She would not have driven his/her personal vehicle with expired tags. During an interview on [DATE] at 1:30 P.M. Licensed Practical Nurse (LPN) A said:-The facility's van license had expired last year, and the Administration knows about it.-The Van Driver uses the van a couple times a week to transport residents to appointments.-There was a logbook to write down when a resident needed transportation.-There were other transportation companies available to transport the residents to appointments.-He/She would not drive a vehicle with expired tags.-The Administration was responsible for keeping the van's license current and they probably should not have been driving it with expired tags. During an interview on [DATE] at 3:00 P.M. the Administrator said:-The new company had purchased the van when they purchased the facility last year.-The license on the van had expired last year in [DATE].-The parent company had an issue obtaining the title from the old company, now it was in the legal department's hands.-He/She has asked the parent company about the title to obtain a current license for the van several times. -The van was used by residents several times a week.-There were other transportation companies in the area that they have occasionally used when the van was not available.-They probably should not have used the facility van to transport residents when the license was expired.-The parent company was responsible for ensuring the van had a current license. 2743911

Based on observation, interview, and record review, the facility failed to keep the walk-in freezer floors clean; failed to ensure food preparation equipment were kept in a sanitary condition; failed to maintain plastic cutting boards and plate covers in good condition to avoid food safety hazards (cross-contamination); and failed to separate damaged foodstuffs, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 67 residents with a licensed capacity for 119 residents at the time of the survey. 1. Observation on 1/21/26 between 12:29 P.M. and 12:43 P.M. during the initial kitchen inspection with the Dietary Manager (DM) showed the following:-The white and green cutting boards were excessively scored to the point of shedding small plastic particles.-A microwave had spills, splatters, and food debris inside on its rotating plate, the bottom, and sides.-There was a 6-pound (lb.) can of Mandarin oranges on the large-can dispenser rack, second from the top row, that had its edge dented.-In the walk-in freezer there was paper, plastic, and food debris on the floor and under racks.Observation on 1/23/26 at 12:03 P.M. during a follow-up kitchen inspection with the DM showed the following:-The white and green cutting boards were excessively scored.-The manual can opener blade had a sticky substance built up on it.-The 6 lb. dented can was still on the dispenser rack.-Several maroon plastic plates covers on the bottom shelf of a Baker's rack in the northwest corner had chipped edges.Observation on 1/27/26 at 9:35 A.M during the final kitchen inspection with the DM showed the following:-The cutting boards were still excessively scored.-The maroon plate covers' edges remained chipped.During an interview on 1/27/26 at 12:45 P.M. the DM said:-If food stuffs had damaged packaging, they were separated out for return to the food vendor.-The staff was pretty good about noticing things like that as they put things away after delivery.-He/She would expect prepared food to be free of any foreign substances.-Electrical food preparation items were cleaned after every use.-The walk-in freezer's floor was cleaned at least twice a day.During an interview on 1/28/26 at 12:37 P.M. the Administrator said the kitchen staff should be following best industry sanitation practices.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 67 residents with a licensed capacity for 119 residents at the time of the survey. 1. Review of the facility's water-borne pathogen prevention program paperwork, last reviewed in October of 2022 and removed by the Administrator from a binder entitled Disaster Plan, showed the following:-There was no facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.-Their CDC toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens, was missing pages 6 through 36.-There was no completed CDC Legionella Environmental Assessment Form.-There was a flowchart of the facility's water system, but no written explanation of the water flow throughout the facility that identified and indicated specific potential risk areas of growth within the building with assessments of each individual area's potential risk level.-There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens.-No testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility was present.-There were no facility-specific interventions or action plans for when control limits are not met.-There was no documentation included of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned.Observation on 1/22/26 from 8:39 A.M. to 1:49 P.M. during a Life Safety Code (LSC) walk-through inspection with the Director of Maintenance (DOM) showed the following:-The water main supply entered in the basement of an older attached building and first spread out through their laundry, a dry fire sprinkler system, and former administrative offices, then over to the newer building addition.-There were at least two commercial clothes washers being used in the older building's basement and numerous sinks and unused water pipes throughout the rest of the building.-The newer building was equipped with a complete wet fire sprinkler system with sprinkler heads located throughout the facility and its riser room (a fire sprinkler riser room is a dedicated space for fire protection equipment situated on an outside wall at grade with direct exterior access) located inside the Service Kitchen on 500 Hall.-Public restrooms were located by the Central Nurse's Station with additional one's northeast of the Therapy Hall entrance.-There were housekeeping closets with floor mop sinks or ceramic service sinks (mop/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water), eyewash stations, water boilers, hot water storage tanks, and hot/cold running water piping throughout the six resident room hallways.-There were at least 55 resident rooms with private and/or shared bathrooms and sinks throughout those hallways.-There was a Beauty Shop with a sink and at least three used and/or unused Bathing Rooms in the facility.Observation on 1/27/26 at 9:35 A.M during the initial facility LSC kitchen inspection with the Dietary Manager (DM) showed there was a sanitizing three-sink area, a chemical, low-heat dish-washing machine, a hand-washing sink, and a steam table (also referred to as a hot food table, is specifically designed to hold food at steady, safe serving temperatures, and not designed to cook or warm foods from a raw state), with an ice machine in the adjacent service hallway.During an interview on 1/27/26 at 10:49 A.M. the Administrator said:-They had talked with others about having a water-borne pathogen prevention program last week.-There really was not anything for Legionella except for what he/she had taken out of their disaster manual.-That documentation was old and outdated; they thought it was from 2022.During an interview on 1/28/26 at 11:59 A.M. the Director of Maintenance said:-He/She had no responsibilities regarding any Legionella prevention practices.-They had no training on that.

Based on observation, interview and record review, the facility failed to post the facility census and actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift and to update the posting as necessary for view by residents, family members and visitors. The facility census was 67 residents. Review of the facility Nurse Staffing Posting Information policy dated 5/13/2025 showed:-The Nurse Staffing Sheet would be posted on as daily basis and would contain the facility census, the total number and the actual hours worked for licensed and unlicensed nursing staff responsible for resident care per shift.-The facility would post the Nurse Staffing Sheet at the beginning of each shift. -After the start of each shift, the information posted would reflect staff absences and actual hours worked would be updated.Observation on 1/21/26, 1/22/26, 1/27/26, 1/28/26 and 1/29/26 of the posting of staffing showed it did not include the resident census and did not show actual hours worked for licensed and unlicensed staff for each shift 12-hour shift.During an interview on 1/29/26 at 10:40 A.M. the facility Staffing Coordinator said:-He/she posted staffing sheets at the beginning of the day shift Monday through Friday.-He/she had not included the resident census on the staff posting since the first of January 2026.-Staffing sheets were not updated on weekends.-He/she posted weekend staffing sheets each Friday and he/she made changes to weekend staffing sheets on Mondays.During an interview on 1/29/2026 at 1:00 PM the Director of Nursing said:-The facility staffing sheets should have included two 12-hour shifts, the resident census and the actual hours worked for licensed and unlicensed nursing staff.-Licensed charge nurses were responsible for updating staffing sheets at the beginning of each shift.

Based on interview and record review, the facility failed to ensure a drug regimen review (DRR) was completed monthly for four sampled residents (Resident #7, #10, #6, and #69) out of 17 sampled residents. The facility census was 67 residents. Review of facility policy entitle Quality Reporting: Drug Regimen Review revised 6/30/25 showed:-It was the policy of this facility document whether a drug regimen review was conducted upon a residents Skilled Nursing Facility (SNF) Prospective Payment System (PPS) admission and throughout the resident's stay, and to document whether any clinically significant medication issues identified were addressed in a timely manner. -Documentation of a drug regimen review may be located in various locations throughout the medical record. Examples included, but were not limited to:-- A nurse might have documented the review in nurses' notes or on a designated form.--A pharmacist might have documented the review in a designated location such as a medication regimen review form. --A physician might have documented the review in the resident's history and physical, physician progress notes, or discharge summary. -Documentation would have included whether any clinically significant medication issues were identified, and how the issues were addressed. -Documentation to support follow-up on identified issues would have included:--Two-way communication between the clinician(s) physician by midnight the next Calander day, and--All-physician-prescribed/recommended actions were completed by midnight of the next Calendar Day.-Frequency of drug regimen reviews, coincident with the resident's medical chart, would be in accordance with the facility's policy for such reviews. 1. Review of Resident # 69's admission Record showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/10/26 showed:-Was cognitively intact. -Received injections every day of the look back period. -Received high risk medications during the look back period. Review of the requested copies of the monthly DRR showed: -There were no drug regimen reviews for January 2025, February 2025, March 2025, April 2025, May 2025, and June 2025. 2. Review of Resident # 10's admission Record showed the resident admitted to the facility on [DATE].Review of the resident's quarterly Minimum Data Set, dated [DATE] showed:-Was moderately cognitively impaired. -Received high risk medications during the look back period. Review of the requested copies of the monthly DRR showed there were no drug regimen reviews for January 2025, February 2025, March 2025, April 2025, May 2025, and June 2025. 3. Review of Resident #7's admission Record showed the resident initially admitted to the facility on [DATE] and was most recently readmitted on [DATE] with diagnoses that included:-Chronic Kidney Disease, Stage 4 (severe).-Type 2 Diabetes.-Retention of urine.-Hypertension (high blood pressure).-Major Depressive Disorder. Review of the resident's comprehensive care plan showed, since at least 7/2/24, he/she was on several high-risk medications (medications that had a heightened risk of causing significant harm, especially when used in error) to treat his/her diagnoses. Review of the resident's requested monthly DRRs showed there were no drug regimen reviews available for January2025, February 2025, March 2025, April 2025, May 2025, June 2025 and December 2025. Review of the resident's quarterly MDS, dated [DATE], showed the resident:-Was moderately cognitively impaired. -Received injections daily. -Received several high-risk medications. 4. Review of Resident #6's admission Record showed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included:-Anxiety disorder.-Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems).-Bipolar disorder, mixed, severe, with psychotic features (a mental health disorder featuring extreme mood fluctuations, racing thoughts, irritability, perceptions that are not related to environmental reality, and false beliefs).-Major depressive disorder.-Hypertension (high blood pressure). Review of the resident's comprehensive care plan showed, in 2025 the resident had been on several high-risk medications for his/her diagnoses. Additionally, interventions were added on 6/26/25 related to a diagnosis of bladder cancer for which the resident received chemotherapy (powerful drugs intended to kill or stop the growth of rapidly dividing cancer cells). Review of the resident's requested monthly DRR showed there were no drug regimen reviews for January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, September 2025, October 2025, and November 2025. Review of the resident's significant change MDS, dated [DATE] showed the resident:-Was cognitively intact. -Received several high-risk medications. 5. During an interview on 1/28/26 at 11:36 A.M., Certified Medication Technician (CMT) A said:-He/She did not participate in the monthly drug regimen review.-He/She thought the nurse handled the monthly drug regimen review. During an interview on 1/28/26 at 11:42 A.M., Licensed Practical Nurse (LPN) B said:-The Assistant Director of Nursing (ADON) was responsible for ensuring the monthly drug regimen review was done. -He/She did nothing with the pharmacist recommendations. -The ADON was responsible to ensure the recommendations were followed up in the time frame. During an interview on 1/28/26 at 11:53 A.M., ADON said:-He/She used to the monthly DRR and would give monthly medication regimen to the doctors if there were recommendations on them.-The former Director of Nursing (DON) took the responsibility of the monthly DRR from him/her.-The DRR was to be done monthly with recommendations followed up in a timely manner. -He/She was unaware of what the former DON did the DRR. -He/She had looked an could not find the requested DRRs for Resident #69, #10, #7, and #6.-It would have to be assumed that since he/she could not find them the reviews must not have been done and not documented as not done. During an interview on 1/29/26 at 1:01 P.M., the DON said:-The DRR would have been done monthly. -He/She had only been at the facility for two weeks.-He/She was only able to provide the drug regimen reviews and follow ups since the new company took over the facility in July 2025.-He/She could not provide the drug regimen reviews or any follow ups prior to July 2025. -He/She knew the DRR should be retrievable. -He/She had no idea where the former DON put the previous DRRs, he/she had looked all over and the DRRs were not found. -Residents #69, #10, #7, and #6 should have had DRR available for review.

Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (5%) when staff failed to prime the insulin pen needles prior to administering Insulin for three sampled residents (Residents #27, #61 and #56) out of three sampled residents observed for Insulin administration resulting in a medication error rate of 11.54%. The facility census was 67 residents. Review of the facility Insulin Pen policy dated 5/16/2025 showed:-The facility would use Insulin pens to improve accuracy of insulin dosing.-A new needle would be used for each injection.-Insulin pens would be primed prior to each use to avoid collection of air in the Insulin reservoir.-Attach the needle to the Insulin pen.-Remove the outer cover from the pen needle.-Dial two (2) units of Insulin by turning the dose selector to clockwise to 2 units.-With the needle pointing up, push the plunger and watch that at least one drop of Insulin appears on the tip of the needle, if not, repeat until at least one drop of Insulin appears.-Then set the Insulin dose by turning the dose selector to the ordered Insulin dose.1. Review of Resident #27's Medication Administration Record (MAR) dated January 2026 showed:-He/she had a diagnosis of Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of Insulin secretion in the pancreas or resistance to Insulin resulting in elevated blood sugar levels).-A physician's order for Lispro Insulin (a fast acting form of Insulin) 100 units/milliliter (ml) one unit dial, inject 5 units subcutaneously (under the skin) three times a day.-A physician's order for Lispro Insulin 100 units/ml one unit dial, inject subcutaneously before meals per sliding scale, including to administer 3 units of for a blood sugar of 179.Observation on 1/21/2026 at 11:07 A.M. showed Licensed Practical Nurse (LPN) D:-Obtained the resident's blood glucose level result of 179.-Removed the resident's Lispro Insulin pen from the medication cart, applied the needle to the Insulin pen, and dialed 8 units of Insulin without priming the pen prior to administration.2. Review of Resident #61's MAR dated January 2026 showed:-He/she had a diagnosis of Diabetes Mellitus.-A physician's order for Lispro Insulin 100 units/ ml one unit dial, inject 16 units subcutaneously before meals.-A physician's order for Lispro Insulin 100 units/ml one unit dial, inject subcutaneously three times a day per sliding scale, including to administer 9 units of for a blood sugar of 280.Observation on 1/21/2026 at 11:23 A.M. showed LPN D:-Obtained the resident's blood glucose level result of 180.-Removed the resident's Lispro Insulin pen from the medication cart, applied the needle to the Insulin pen, and dialed 25 units of insulin without priming the pen with 2 units of insulin prior to administration.3. Review of Resident #56's MAR dated January 2026 showed:-He/she had a diagnosis of Diabetes Mellitus.-A physician's order for Lispro Insulin 100 units/ml one unit dial, inject 12 units subcutaneously before meals.Observation on 1/21/2026 at 11:49 A.M. showed LPN E:-Removed the resident's Lispro Insulin pen from the medication cart and prior to attaching the needle to the Insulin pen he/she dialed two units of insulin and depressed the pen's plunger.-Put the needle on the Insulin pen, dialed the pen to 12 units, uncapped the needle and without having properly primed the pen administered the resident's insulin.4. During an interview on 1/21/26 at 1:50 P.M. LPN D said:-He/she would not have done anything differently related to administering Insulin to resident #56.-When he/she administered Insulin to Resident #27 and Resident #61 he/she had not primed the Insulin pens.-He/she had never dialed any Insulin pen to two units with the needle on the pen and uncapped and expelled the Insulin to prime the Insulin pen.-He/she did not know that Insulin pens were to be primed with two units of Insulin prior to dialing the intended dose of Insulin and did not know what priming Insulin pens meant.During an interview on 1/21/2026 a 2:17 P.M. LPN E said:-He/she would not have done anything differently related to administering Insulin to residents #56.-Prior to putting the needle on Resident #56's Insulin pen he/she had dialed the resident's Insulin pen to two units and pushed the pens plunger to expel the Insulin.-He/she did not know that priming the Insulin pen meant to prime the needle of the pen.During an interview on 1/29/2026 at 1:00 P.M. the Director of Nursing (DON) said:-He/she expected licensed nurses to prime Insulin pens with two units of Insulin prior to dialing the intended dose of Insulin.-The needle needed to be on the pen, the pen was to be dialed to two units, the needle cap needed to be removed and when depressing the pen plunger, the licensed nurse was to observe for at least one drop of Insulin on the tip of the needle.-Priming the Insulin pen meant priming the needle of the pen.-The facility did not monitor for competency of licensed nurses in the use of Insulin pens.

Based on observation, interview and record review, the facility failed to ensure smoking assessments were completed in a timely manner to ensure resident safety for three sampled residents (Resident #20, #65, and #4) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Resident Smoking dated 6/10/25 showed:-All residents would be asked about tobacco use during the admission process, and during each quarterly or comprehensive Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) assessment process.-Residents who smoked would be further assessed to determine whether supervision was required for smoking, or if a resident was safe to smoke at all.-If a resident who smoked experienced any decline in condition or cognition. He/she would be reassessed for ability to smoke independently and/or to evaluate whether any additional safety measures were indicated. 1. Review of Resident #20's care plan dated 7/2/25 showed:-The resident smoked as of 8/9/23, and his/her son would bring in the cigarettes.-Staff were to assist to and from the designated smoking area as needed.-The resident smoked cigarettes, he/she was alert and able to hold his/her cigarette without difficulty. Review of the resident's Smoking Safety Screen dated 8/22/25 showed the resident was safe to smoke with supervision. Review of the resident's Smoking Safety Screen dated 9/20/25 showed the resident was safe to smoke with supervision. Review of the resident's Significant Change MDS dated [DATE] showed:-The resident was cognitively intact.-The resident currently used tobacco. Review of the resident's Electronic Medical Record (EMR) on 1/23/26 showed the resident had no other smoking assessments. During an interview on 1/28/26 at 11:36 A.M., Certified Medication Technician (CMT) A said:-Special interventions for resident's who smoked were documented in the care plan. -Right now, only two residents needed smoking aprons.-There was a list of residents who smoked and interventions at the nurse's desk for all to review. During an interview on 1/28/2026 11:38 A.M., Certified Nurse's Aide (CNA) E said:-He/She would go to the nurse to find out what interventions or protection would be needed for the residents.-Interventions for smoking would also be listed in the care plan. -If he/she saw anything that changed the interventions he/she would have informed the nurse. During an interview on 1/28/26 at 11:42 P A.M. Licensed Practical Nurse (LPN) B said:-Residents who smoked needed to be assessed for safe smoking on admission, quarterly, and as needed if changes occurred. -The nurses would have done the smoking assessments. -When the safe smoking assessment was done, the corresponding interventions would populate based on answers to the questions. -Smoking interventions were in the care plan. During an interview on 1/29/26 at 1:47 P.M. the Director of Nursing (DON) said:-Residents should have a smoking assessment completed upon admission, quarterly, and with significant changes.-Resident #20 should have had more than two safe smoking assessments in his/her EMR. 2. Review of Resident #65's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included:-Parkinson's disease (a chronic neurological disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait).-Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception).-Abnormal posture. Review of the resident's Nicotine Habit care plan, initiated 3/2/23 showed:-The resident smoked cigarettes.-A smoking assessment would be done upon admission, reviewed quarterly, and with any significant change in condition. -Staff were to assist the resident to and from the smoking destination.-Resident was to wear a smoking apron when smoking. Review of the resident's Smoking Safety Screen dated 8/22/25 showed the resident:-Had a cognitive loss.-Had visual deficits. -Had dexterity problems.-Smoked two to five cigarettes daily.-Could not light his/her own cigarette.-Required a smoking apron.-Was safe to smoke with supervision. Review of the resident's Significant Change MDS dated [DATE] showed the resident:-Had moderately impaired vision.-Was moderately cognitively impaired.-Used tobacco. Review of the resident's EMR on 1/23/26 showed the resident had no other smoking assessments for 2025 through 1/23/26. During an interview on 1/21/26 the resident said he/she went outside to smoke multiple times a day. Observation on 1/23/26 at 1:13 P.M. showed:-The resident was in his/her wheelchair on the smoking patio wearing a smoking apron holding a cigarette in his/her right hand. -His/Her left hand was under the smoking apron.-The lit end of the cigarette was approximately two to three inches from the resident's stomach (covered by the apron) and the resident's eyes were closed. -His/Her head hung downward with the resident's chin close to his/her chest. During an interview on 1/27/26 at 12:26 P.M. CNA C said:-Staff had to remind the resident to hold his/her cigarette up because he/she sometimes fell asleep.-He/She wore a smoking apron for safety. Observation on 1/28/26 at 10:06 A.M. showed:-Staff placed a smoking apron on the resident covering his/her left hand and gave him/her a cigarette and lit it.-Within a few minutes the resident's head hung downward, and the lit end of the cigarette was a couple of inches from his apron-covered stomach. During an interview on 1/28/26 at 2:25 P.M. CNA D said:-The resident had to wear a smoking apron for his/her safety.-Staff had to take his/her cigarette away when it got to be a stub, so he/she didn't burn his/her fingers. During an interview on 1/29/26 at 11:23 P.M. LPN C said:-The resident needed to wear a smoking apron for his/her safety.-He/She would smoke the cigarette all the way down and needed prompts that he/she was at the end of his/her cigarette, so he/she didn't get burned.-Staff should place the non-smoking hand under the apron or make sure it didn't rest under the lit end of the resident's cigarette.-Smoking assessments should be completed upon admission, quarterly, with any change in a resident's condition, or any time staff noticed it needed to be done, such as when they thought a person could benefit from a smoking apron. 3. Review of Resident #4's admission Record showed he/she admitted to the facility on [DATE] with a diagnosis of Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain). Review of the resident's Smoking Safety Screen dated 8/22/25 showed the resident was safe to smoke with supervision. Review of the resident's Significant Change MDS dated [DATE] showed:-The resident had moderately impaired cognition.-The resident currently used tobacco. Review of the resident's care plan on 1/23/26 showed he/she didn't have a care plan focus or interventions in place related to the resident's smoking status. Review of the resident's EMR on 1/23/26 showed the resident had no other smoking assessments in place. During an interview on 1/29/26 at 11:51 A.M. CNA A and CNA B said:-They were unsure when smoking assessments were completed for the residents who smoked but assumed it should be completed before the residents smoked at the facility.-They were unsure of who completed the smoking assessments.-The smoking assessments should be completed per facility policy.-If the smoking assessment policy showed the assessment should be completed upon admission, then Resident #4's smoking assessment was completed too late. During an interview on 1/29/26 at 12:12 P.M. Agency LPN A said:-He/She was unsure when smoking assessments were completed at the facility.-He/She assumed the smoking assessments were completed upon admission to the facility once it was known that the resident smoked.-The smoking assessments should be completed per facility policy.-If the smoking assessment policy showed the assessment should be completed upon admission, then Resident #4's smoking assessment was completed too late. During an interview on 1/29/26 at 12:38 P.M. LPN B said:-Smoking assessments should be completed per facility policy.-He/She was newly hired to the facility and was unsure of what the smoking assessment policy showed.-He/She assumed it would get completed as soon as it was known the resident smoked.-If the smoking assessment policy showed the assessment should be completed upon admission, then Resident #4's smoking assessment was completed too late. During an interview on 1/29/26 at 1:47 P.M. the DON said:-Resident #4 should have had a smoking assessment completed upon admission.-Resident #4's smoking assessment was completed too late after admission to the facility.

Based on observation, interview and record review, the facility failed to ensure orders were clarified for one sampled resident (Resident #7), who was receiving hemodialysis (a process of cleansing the blood of wastes, toxins and excess fluid by passing it through a special machine - necessary when the kidneys were not able to filter the blood), out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Hemodialysis policy, dated 5/2/25, showed:-The facility will assure each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.-The facility will ensure the physician's orders for dialysis include the location and type of access for dialysis (e.g. graft (uses a surgically implanted tube to connect an artery to a vein for hemodialysis access), arteriovenous shunt (directly connects the patient's artery and vein for hemodialysis access), external catheter (soft tubing inserted into a large vein for dialysis, with a portion remaining outside the body to connect to dialysis machines).-Residents with external dialysis catheters will be assessed every shift to ensure the catheter dressing is intact and not soiled. 1. Review of Resident #7's admission Record showed the resident was admitted to the facility with diagnoses that included:-Chronic Kidney Disease (CKD a condition in which the kidneys are damaged and can't filter blood as well as they should) Stage 4 (severe).-Dependence on renal (pertaining to the kidney) dialysis.Review of the resident's Stage 4 Kidney Disease, Requiring Dialysis care plan, dated 7/2/24, showed:-The resident had a port for dialysis on his/her right chest. Monitor dialysis shunt site for signs and symptoms of bleeding and/or infection every shift.-Nursing to monitor shunt site for warmth, color, edema, and bleeding. -Monitor shunt site right upper chest for bruits (in a dialysis fistula or graft, a continuous low-pitched whooshing sound, indicating proper functioning) and thrills (in a dialysis fistula or graft, a buzzing or vibrating sensation felt by placing fingers over the length of the site) twice daily. -If no bruits or thrills were heard, call the doctor and chart.Review of the resident's Physician Orders dated September 2025 showed:-Monitor dialysis shunt site for signs and symptoms of bleeding and/or infection every shift starting 9/10/25.-Monitor shunt site, right upper chest, for bruits and thrills every day and night shift for shunt care. If no bruits/thrills were heard, notify the doctor and chart starting 9/10/25.Review of the resident's progress notes dated November 2025 showed no documentation the orders were discussed with the physician for further clarification.Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/9/25 showed the resident:-Was moderately cognitively impaired.-Was diagnosed with renal (kidney) failure/end stage renal disease (ESRD).-Received dialysis treatments.Review of the resident's progress notes dated December 2025, and January 2026 showed no documentation the orders were discussed with the physician for further clarification.Review of the resident's Medication Review Report, dated 1/23/26 showed:-Monitor dialysis shunt site for signs and symptoms of bleeding and/or infection every shift starting 9/10/25.-Monitor shunt site, right upper chest, for bruits or thrills every day and night shift for shunt care. If no bruits or thrills were heard, notify the doctor and chart starting 9/10/25.Review of the resident's Medication Administration Record (MAR), dated January 2026 showed:-Monitor the dialysis shunt site for signs and symptoms of bleeding and/or infection every day and night shift. --The day and night shifts both documented daily monitoring was being completed.-Monitor shunt site, right upper chest, for bruits or thrills every day and night shift for shunt care. If no bruits or thrills were heard, notify doctor and chart. --Staff documented daily on both shifts they were following the order.During an interview on 1/28/26 at 10:25 P.M. the MDS Coordinator said:-The resident's Dialysis Care Plan should be specific and accurate.-He/She used the physician orders to put the resident's interventions into the resident's care plan.-The resident's physician orders should be accurate, so the care plan was accurate.During an interview on 1/28/26 at 11:13 A.M. the Assistant Director of Nursing (ADON) said:-The resident's bruit and thrill was checked twice a day, once by the day shift and once by the night shift. -The resident had a port on his/her chest related to his/her bradycardia (too slow heartrate).-Staff looked for discoloration or bruising on the resident's chest.-The resident's dialysis access site was on his/her arm. -He/She listened for the swish noise and felt for the throb.-The resident's orders said to check the bruit and thrill.Observation on 1/28/26 at 11:23 A.M. showed:-The ADON got a stethoscope and headed towards the resident's room.-While the resident was lying in bed, the ADON looked at both the resident's arms for the dialysis access site and then said he/she was incorrect about the location of the resident's access site. It was another dialysis resident who had the access site in their arm and the resident's access site was in his/her chest.-He/She put the end of the stethoscope and his/her fingers at the resident's upper right chest.During an interview on 1/28/26 at 11:30 A.M. the ADON said:-He/She checked the resident's access site for signs and symptoms of infection and drainage and made sure the dressing was clean, dry, and intact. -He/She also listened with the stethoscope for a whooshing sound and felt for good blood flow with his/her fingers.-The nurse needed to listen with the stethoscope and feel with his/her fingers no matter if the resident's access site was the arm or upper chest.During an interview on 1/29/26 at 10:50 A.M. Licensed Practical Nurse (LPN) B said:-A fistula and a port were not the same thing.-With a graft or fistula in the arm the nurse would check the bruit and thrill. -With a port in the chest the nurse did not check the bruit and thrill.-The nurse use to document on the Treatment Administration Record (TAR) when they checked the dialysis access site and now, they documented on the MAR. -If they had a port in the upper chest there would be no orders to check the bruit and thrill so that wouldn't be checked on the MAR.-The resident had a fistula in the past, but it failed and now he/she had a port in his/her upper chest.-He/She didn't work the resident's hall and didn't check his/her port site. Whoever was the nurse for the resident's hall would do that.-If the orders for checking the dialysis access site didn't make sense the charge nurse should contact the physician to clarify the orders.-He/She wasn't sure if the facility provided education within the past year on caring for the dialysis residents.During an interview on 1/29/26 at 11:06 A.M. LPN C said:-A dialysis fistula was under the skin, and a port was external tubing.-The nurse should check the bruit and thrill no matter if it was a fistula in the arm or a port in the chest.-If a nurse thinks an order needed to be clarified they should immediately check with the doctor and let the Director of Nursing (DON) know why they were contacting the physician. -After clarifying an order, the nurse should rewrite it as appropriate.-He/She never noticed anything unusual about the resident's orders related to checking his/her dialysis access site. -The resident had a port in his/her chest with external tubing.-He/She checked the bruit and thrill in the resident's chest. -He/She used his/her fingers to feel there was good blood flow and listened for the bruit which should be a beeping sound.-He/She checked to make sure the site was not red, irritated or infected and that the tubing was in place.-The facility provided training on caring for dialysis residents three or four years ago. At the time nurses were told to monitor the dialysis access site for infection every shift.During an interview on 1/29/26 at 1:50 P.M. the DON and Administrator said:-Orders should show the resident's type of access site.-If the resident had a graft or fistula in the arm the orders should show they needed to check the bruit and thrill. If the access site was in the chest, they would not check the bruit and thrill.-There had been no education provided to nurses since the new corporation took over a number of months back.-The resident's orders needed to be clarified and the nurses should have contacted the physician immediately.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident #13) tracheostomy (a surgical procedure that creates an opening (stoma) through the neck into the trachea (windpipe), to provide a direct airway) suctioning supplies were stored appropriately and that staff were trained and competent in the correct method of suctioning out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Tracheostomy (trach) Care dated 6/10/25 showed:-The facility would provide necessary respiratory care and services, such as oxygen therapy, treatments, tracheostomy care and/or suction.-Tracheostomy care would be provided according to physician's orders, comprehensive assessment, and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs, as well as suctioning as appropriate.-General considerations included maintaining a suction machine, a supply of suction catheters (a thin, flexible tube used to remove bodily fluids from a resident's airway), correctly sized cannulas (a curved, hollow tube inserted into the stoma to maintain an open airway), and an Ambu bag (a handheld, manual resuscitation device to provide ventilation to people who are not breathing adequately) easily accessible for immediate emergency care.Review of Chapter 22 Tracheostomy Care & Suctioning - Nursing Skills - NCBI Bookshelf dated 2021 showed tracheostomy suctioning uses a sterile catheter that is inserted through a tracheostomy tube into a patient's trachea. 1. Review of Resident #13's admission Record showed he/she admitted to the facility with the following diagnoses:-Diffuse Traumatic Brain Injury (TBI- widespread brain damage caused by rapid acceleration, deceleration, or rotational forces that stretch and tear white-matter nerve fibers (axons).-Other Tracheostomy Complication.Review of the resident's care plan dated 11/7/25 showed:-The resident had a tracheostomy related to a motor vehicle accident with the following interventions:--Change suction cannister as needed when it was three quarters full or as needed.--Suction as needed to remove excessive secretions.--Staff were to perform tracheostomy care every day and night shift.Review of the resident's Order Summary Report dated January 2026 showed:-An order to change the suction cannister pro re nata (PRN- as needed) when it was three quarters full.-An order for staff to suction secretions from the trach PRN to help clear the airway and maintain oxygen levels above 90 percent (%).-An order for staff to suction via trach PRN related to congestion every shift.Review of the resident's significant change Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/21/26 showed:-The resident was severely impaired-never/rarely made decisions regarding tasks of daily life.-It did not indicate that the resident had a tracheostomy.Observation on 1/21/26 at 3:02 P.M. showed:-The suction cannister was not labeled with a date.-The suction catheter was hanging off the suction machine uncovered.Observation on 1/22/26 at 10:22 A.M. showed:-The suction cannister was not labeled with a date.-The suction catheter had been used and placed back into the original packaging.Observation on 1/23/26 at 9:01 A.M. showed the suction machine was covered with a pillowcase.Observation on 1/23/26 at 12:13 P.M. showed:-The suction cannister was not labeled with a date.-The suction catheter had been used and placed back into the original packaging.During an interview on 1/29/26 at 12:14 P.M. Agency Licensed Practical Nurse (LPN) A said:-The suction catheter could continue to be used once it was cleansed with sterile water.-It was okay for staff to store the suction catheter in its original packaging.-When staff suctioned the resident's tracheostomy it was not a sterile procedure.-The suction cannister needed to be labeled with a date.-He/She had not been educated on tracheostomy care while working at the facility.During an interview on 1/29/26 at 12:44 P.M. LPN A said:-The suctioning equipment used in tracheostomy care needed to be clean and covered.-When staff suctioned the resident's tracheostomy it was not a sterile procedure.-He/She would follow facility policy related to all tracheostomy care.-Suction catheters were one time use only.-If he/she were to go into the resident's room and see the suction catheter back into its original packaging, he/she would go get a new suction catheter and throw away the one that had been used.During an interview on 1/29/26 at 1:48 P.M. the Director of Nursing (DON) said:-The procedure of suctioning a tracheostomy was considered a sterile procedure, so the suction catheters were to be thrown away after each use.-The suction cannister needed to be labeled with the date.-The resident's order for the suction cannister was incorrect and staff should have clarified the order with the resident's physician. -He/She was unaware that staff were storing the suction catheter back in the original container after use.-If a nurse walked into the resident's room and observed the resident's suction cannister not labeled, then he/she would expect the nurse to dispose the cannister and get a new one.-If a nurse walked into the resident's room and observed the resident's suction catheter opened and stored in its original packaging, he/she would expect the nurse to dispose of the used catheter and get a new one.-He/She was unaware that staff were covering the suction equipment with a pillowcase.-The suction equipment did need to be covered per facility policy.

Based on interview and record review, the facility failed to collaborate with one sampled resident (Resident #6) who experienced past trauma, to identify triggers which may re-traumatize the resident and develop care plan interventions to decrease the resident's exposure to triggers and to minimize the effect of the trigger on the resident out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Trauma Informed Care (TIC) policy, dated 6/10/25, showed:-The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as their cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event as well as using screening and assessment tools.-The facility will collaborate with residents, and as appropriate, their family, friends, physician, and other health care and mental health professionals to develop individualized care plan interventions.-In some cases, if the facility has more than one trauma survivor, as appropriate, social services will make a good faith effort at establishing a support group that is run by a qualified professional or will assist the resident in locating a support group in the community as appropriate and feasible.-The facility will identify triggers which may retraumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which retraumatize the resident, as well as identify ways to mitigate or decrease the effects of the trigger on the resident. These will be added to the resident's care plan.-Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety.-The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident. The resident. and/or his/her family/representative will be included in this evaluation to ensure clear open discussion and to better understand if interventions must be modified.-In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.1. Review of Resident #6's admission Record showed he/she was admitted with diagnoses that included:-Post Traumatic Stress Disorder (PTSD - a mental health condition caused by an extremely stressful event. Symptoms may include flashbacks, nightmares, avoidance behaviors, negative thinking and/or mood, severe anxiety, and uncontrollable thoughts about the event. The symptoms may vary over time.)-Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety).-Major depressive disorder (MDD - a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable).-Mood disorder (a variety of conditions characterized by a disturbance in mood as the main feature).-Borderline personality disorder (BPD-a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior).-Bipolar disorder (a chronic mental health condition characterized by extreme mood swings ranging from extreme highs to deep lows impacting energy, sleep, and daily functioning).-Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems), depressive type.Review of the resident's Pre-admission Screening and Resident Review, Level II (PASRR Level II - an in-depth person-centered assessment triggered by a positive Level I screen, designed to confirm if nursing facility applicants have a serious mental illness (SMI), intellectual disability (ID), or related condition; and determines if the individual needs specialized services and ensures appropriate placement), dated 11/10/21, showed:-Recommendations for psychiatric rehabilitative services of a lesser intensity which could be provided by the nursing facility.-The resident's psychiatric history included MDD, recurrent; PTSD; bipolar disorder; alcohol abuse with alcohol induced psychotic disturbance with hallucinations (occurs within two weeks after long-term abuse of heavy alcohol consumption, characterized by difficulties perceiving one's environment and interactions with others, persisting after the effects of alcohol have worn off and lasting from 48 hours to up to six months).-The resident had a history of sexual and emotional abuse by his/her ex-spouse and reported nightmares and flashbacks in the past. He/She was also attacked by another resident at his/her current nursing home before moving to another unit.-He/She had a long history of receiving both in-patient and out-patient psychiatric services.-The resident had thoughts of self-harm in the past and overdosed on prescriptions medications.-He/She reported a history of feeling sad, hopeless, anxious, and of polysubstance abuse.Review of the resident's Trauma Informed Care (TIC) Assessment, dated 1/4/25 showed the resident:-Felt guilty for past events.-Experienced a frightening or traumatic event.-Was triggered by violence or acting out that caused him/her to re-experience the traumatic event or flashback.Review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 11/21/25, showed the resident:-Was cognitively intact.-Felt down and depressed.-Was diagnosed with anxiety disorder, depression, and PTSD.-Took medications for anxiety and depression.Review of the resident's Mental Health care plan, initiated 11/30/25 showed:-The resident had multiple mental health diagnoses including a history of suicidal ideation, mood disorder, anxiety, depression, bipolar disorder, schizoaffective disorder, and PTSD that affected his/her mood, behavior, and daily functioning.-Interventions included:--Encourage compliance with prescribed medications and psychiatric follow-up--Maintain safety if concerning behaviors arise.--Monitor behavioral changes, mood instability, or suicidal statements and report immediately.--Offer emotional support and engage resident in calming activities.--Provide re-assurance and structured daily routine to reduce anxiety.Review of the resident's comprehensive care plan showed no plan related specifically to PTSD that included:-Triggers that might re-traumatize the resident.-Interventions/instructions on how best to avoid triggering the resident.-Interventions/instructions on how staff should respond when the resident was triggered.-There were no interventions related to who the resident should receive personal cares from related to toileting hygiene, showers, and dressing.-There were no interventions showing if the resident might benefit from counseling services or a support group.Review of the resident's medical record showed there was no TIC assessments completed in 2025 after 1/4/25.Review of the resident's medical record showed in 2025:-The resident was seen by geriatric psychiatric services for review of psychotropic medications (medications that affect brain function and/or alter mood, perception, or behavior). -The resident did not receive counseling services.Review of the resident's TIC assessment, dated 1/7/26 showed the resident experienced a frightening or traumatic event with no known symptoms (e.g. nightmares, being constantly on-guard, feelings of guilt) within the past month. Review of the facility Behavior Book showed:-Residents with behaviors were divided by name in a three-ring binder.-There was a tabbed section for Resident #6 in the binder. -There was no information on the resident's behaviors or PTSD.During an interview on 1/21/26 at 3:09 P.M. the resident said:-He/She was diagnosed with PTSD many years ago. -The facility was aware of his/her PTSD diagnosis.-He/She saw a psychiatrist who oversaw his/her medications, but the psychiatrist didn't ask about his/her PTSD and didn't provide counseling.-He/She had seen a counselor in the past.-He/She would like to see a female counselor, but nobody at the facility had ever asked him/her if he/she wanted to see a counselor and he/she never mentioned it to anyone.-He/She experienced physical, sexual, and emotional abuse as an adult by his/her ex-spouse, but he/she was no longer in his/her life and the childhood physical, sexual, and emotional abuse still bothered him/her the most.-Triggers which could make him/her think of past trauma and upset him/her were having a male care-giver, especially for getting dressed, showering, and toileting assistance; bowel movement smells; and people yelling or criticizing him/her. --It reminded him/her of when he/she was a child and how his/her abusers treated him/her.-He/She didn't like being spoken to in a harsh or critical manner by staff or being jerked around quickly when assisted out of bed.-He/She asked facility staff for only female caregivers but couldn't remember who he/she asked. So far only female staff had ever provided cares to him/her. -Nobody at the facility had ever talked to him/her about any PTSD needs or care planning.During an interview on 1/27/26 at 12:16 P.M. Certified Nurse Assistant (CNA) C said:-He/She was not aware the resident had a diagnosis of PTSD.-The Behavior Book was accessible to all nursing staff, including the CNAs. -If someone was diagnosed with PTSD the Behavior Book should show the diagnosis and what staff could do to help avoid triggering the PTSD symptoms.-The care plan should be comprehensive and have everything in it to show what the resident's triggers were and how staff could help the resident with a PTSD diagnosis.During an interview on 1/27/26 at 12:16 P.M. CNA D said:-He/She wasn't sure what Trauma Informed Care was.-If a person was diagnosed with PTSD their triggers should be in the Behavior Book accessible to all nursing staff. It should also be in the resident's PTSD Care Plan.-The PTSD Care Plan should show how to tell if a resident had been triggered and what to do if they were triggered as well as how to try to prevent triggering the resident.-He/She wasn't sure if the Behavior Book showed the resident's triggers or how staff could help him/her.During an interview on 1/28/26 at 10:42 A.M. the MDS Coordinator said:-He/She hadn't received TIC education at the facility.-The Social Worker provided information for the PTSD care plan.-A PTSD care plan should show the resident's past trauma and include the resident's triggers. During an interview on 1/28/26 at 10:50 A.M. the MDS-in-Training said:-A PTSD care plan should include the resident's triggers and show what staff could do to try to avoid triggering the resident. -It should also have interventions that show how staff could reduce the effects of the trigger on the resident.During an interview on 1/28/26 at 11:42 A.M. the Assistant Director of Nursing (ADON) said:-He/She had received TIC education at the facility. -Staff were taught that a resident may be triggered by different things. They may not want a male aide to provide cares or might be triggered by smells or loud noises such as the fire alarm. -Something they saw on television could also trigger the resident.-PTSD should be care planned and the care plan should show the resident's triggers and how staff could reduce the chance of the resident being triggered and what to do if they were triggered.-The information from the PTSD Care Plan should be reflected in the Behavior Book which all nursing staff have access to. -The CNAs have been told where to find the Behavior Books on both units.-He/She didn't know what the resident's triggers were.-He/She knew the resident didn't like his/her door shut or people in his/her space but didn't know if it was related to PTSD.-He/She didn't know the resident requested to not have male caregivers, but there were currently no male caregivers at the facility. -The resident was seen by a psychiatrist related to his/her psychotropic medications and was not currently seeing a counselor. -He/She thought counseling had been offered once to the resident and at the time the resident didn't want to go.During an interview on 1/28/26 at 12:02 P.M. the Social Services Director said:-The PTSD care plan should show a resident's triggers, how staff could avoid triggering the resident, and what to do if the resident was triggered.-The resident told him/her PTSD didn't bother him/her anymore and never said he/she wanted counseling services. -He/She never asked the resident what services or interventions the resident could benefit from related to his/her PTSD diagnosis.-There were a couple of mental health service providers in the area that could be set up for the resident if he/she wanted that.-The resident had a TIC assessment on 1/4/25 and another one on 1/7/26. The TIC assessment should have been done quarterly for any resident with a PTSD diagnosis.During an interview on 1/29/26 at 1:50 P.M. the Director of Nursing (DON) said:-Resident interventions should be individualized.-A PTSD care plan should include the resident's triggers and show what staff could do to minimize the chances of triggering the resident and how they could help if the resident was triggered.

Based on observation, interview and record review, the facility failed to ensure one sampled resident's (Resident #13) gastrostomy tube (also known as G-tube, percutaneous endoscopic gastrostomy/PEG tube/feeding tube - a flexible tube inserted through the wall of the abdomen directly into the stomach that is used to give medications, fluids and liquid food) placement was confirmed prior to administration of medication in accordance with facility policy and current professional standards of practice. The facility census was 67 residents. Review of https://www.ncbi.nlm.nih.gov/books/NBK593216/ the National Institutes of Health, National Library of Medicine, Enteral (also known as tube feeding) Tube Management, dated 2021 showed:-The placement of an enteral tube is immediately verified after insertion by an X-ray; after X-ray verification, the tube should be marked to indicate the point on the tube where the feeding tube penetrates the abdominal wall; the mark or number on the tube at the entry point should be documented in the resident's medical record.-At the start of every shift, nurses evaluate if the incremental marking or external tube length has changed. If a change is observed, bedside tests such as visualization or pH testing of tube aspirate can help determine if the tube has become dislocated. If in doubt, a radiograph should be obtained to determine tube location.-Older methods of checking tube placement included observing aspirated (using a syringe, a tube with a nozzle and piston or bulb for sucking in and ejecting liquid) contents or the administration of air with a syringe while auscultating listening with a stethoscope (a medical instrument for listening to sounds in the body) - however, research has determined these methods are unreliable and should no longer be used to verify placement.Review of the facility Care and Treatment of Feeding Tubes policy dated 5/2/2025 showed:-The facility would utilize feeding tubes in accordance with current clinical standards of practice with interventions to prevent complications.-Feeding tubes would be utilized according to physician orders.-Licensed nurses would monitor and check that the feeding tube is in the right location (the stomach or small intestine depending on the type of tube), including before beginning feeding and before administration of medications.Review of the facility Medication Administration via Enteral Tube (a tube that delivers nutrients or medication directly into the stomach or small intestine) policy dated 5/8/25 showed:-Verify physician's orders.-Enteral tube placement must be verified prior to administering any fluids or medication.Review of the facility Flushing a Feeding Tube policy dated 5/16/2025 showed:-Prior to flushing a feeding tube, administration of medication or providing tube feedings, the licensed nurse would verify the proper placement by noting the length of the tubing or performing a measure of the pH (a measure of how acidic or alkaline/base a substance is) of gastric secretions, if performed at the facility.Review of the facility Verifying Placement of Feeding Tube policy dated 5/30/25 showed:-For gastrostomy tubes, check that the tube is properly approximated to the abdominal wall by taking note of the marking on the tube or by measuring the length of the tube from insertion site to the tip of the tube and comparing the measured length to the recorded measurement of the tube on admission to the facility or with a new/replacement tube.1. Review of Resident #13's admission Record showed:-He/she was admitted to the facility on [DATE].-He/she had a diagnosis of gastrostomy status.Review of the resident's care plan, updated 5/30/25 showed:-He/she had a G-tube for nutrition.-Instruction to check the placement of his/her G-tube prior to flushes (introduction of water into the tube to clear feeding contents), medications and feedings, via integrity of tube, tube length from ostomy to end of tube 33 to 35 centimeters (cm) and residual, if more residual than 70 milliliters (ml) notify the resident's physician.Review of the resident's care plan, updated 5/30/25 showed:-He/she had a G-tube for nutrition.-Instruction to check the placement of his/her G-tube prior to flushes (introduction of water into the tube to clear feeding contents), medications and feedings, via integrity of tube, tube length from ostomy to end of tube 33 to 35 cm and residual, if more residual than 70 ml notify the resident's physician.Observation on 1/21/2026 11:06 PM showed:-Licensed Practical Nurse (LPN) D prepared the resident's Gabapentin 300 milligram (mg) for administration, obtained water for flushing the resident's G-tube, turned the feeding pump off and uncovered the resident's abdomen.-Without first measuring or observing the length of the residents G-tube he/she disconnected the resident's extension tubing (the tubing that extends from the outside end of the feeding tube to the feeding tube pump) from the residents G-tube.-He/she then attached a syringe to the resident's G-tube, attached the plunger to the syringe and pulled back on the plunger (aspirated) resulting in a small amount of tan liquid to appearing at the medication port of the G-tube.-He/she did not measure the pH of the contents that had been aspirated with the syringe.-He/she then removed the syringe plunger and flushed the resident's G-tube by pouring about 30 ml of water into the syringe.-He/she then poured the residents medication which had been mixed with a small amount of water into the syringe and allowed the medication to flow into the resident's G-tube.-He/she then flushed the resident's G-tube with about 30 ml of water and reconnected the resident's extension tubing to the resident's G-tube and turned on the residents feeding pump to resume his/her tube feeding.During an interview on 1/21/2026 at 1:12 P.M. LPN D said:-He/she had not looked at or measured the length of the resident's G- tube to confirm correct placement prior to flushing the resident's G-tube and administering the resident's medication.-He/she knew that licensed nurses were no longer to check placement of G-tubes by auscultation (listening over the stomach with a stethoscope for the sound of air being introduced into a G-tube) and since learning that a few years ago, the only method he/she had been using to assess for correct placement of G-tubes was to aspirate contents from the G-tube.-He/she knew that if aspirating was used as a method used for confirming correct placement of a G-tube, the pH of the fluid aspirated would have to be checked.-He/she had never tested the pH of the fluid aspirated from G-tubes and did not think that was done at the facility.Review of the resident's Physician's Order Summary Report dated January 2026 showed:-Check PEG tube placement before flushes, medications and feedings via integrity of tube, tube length from ostomy to the end of his/her feeding tube, length was 33 to 35 cm and residual, if residual was more than 70 ml, notify the resident's physician.-Nutren (tube feeding formula) 1.5 at 55 ml per hour continuous via feeding pump; stop continuous feedings for four (4) hours from 1:00 P.M. until 5:00 P.M.-The PEG tube was to be flushed with 30 ml of water before any medication administration, then flush with 15 ml of water after each medication, then after all medications flush with 30 ml of water for patency (keep open); stop continuous feedings for four hours from 1:00 P.M. to 5:00 P.M. for showers and activities then restart.-Gabapentin 300 milligrams (mg), one capsule via PEG tube three times a day for neuropathy (nerve damage).During an interview on 1/29/2026 at 1:00 P.M. the Director of Nursing said:-He/she expected licensed nurses to check placement of G-tubes, including prior to medication administration by aspiration.-He/she would have to check what the current standard of practice was regarding checking placement of G-tubes.-At this time, facility licensed nurses were to check placement of G-tubes by aspiration and the facility did not check pH when checking placement by aspiration.-Currently there was no monitoring in place to ensure licensed nurses correctly checked placement of G-tubes including prior to medication administration.

Based on interview and record review, the facility failed to ensure two sampled residents (Resident #44 and #75) physician's orders were followed out of 17 sampled residents. The facility census was 67 residents. A policy related to following physician orders was requested and not received prior to exit on 1/20/26.1. Review of Resident #44's admission Record showed he/she was admitted to the facility with the following diagnoses:-Retention of Urine (the inability to completely empty your bladder), Unspecified.-Neuromuscular Dysfunction of Bladder (occurs when nerve damage disrupts the brain-bladder communication, causing problems with storage or emptying), Unspecified.Review of the resident's Order Summary Report dated December 2025 showed:-The resident had an order for a Urinary Analysis (UA- a test of your urine that checks and screens for diagnoses such as a UTI), ordered on 12/16/25.--The status of the order showed it had been completed.-The resident had an order for a UA to be completed between 12/21/25 through 12/28/25.--The status of the order showed it had been completed.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility for care planning) dated 1/8/26 showed:-The resident had severely impaired cognition.-The resident did not have a Urinary Tract Infection (UTI-an infection caused by bacteria that enters and multiplies within any part of the urinary system).Review of the resident's care plan dated 1/19/26 showed:-The resident required an Indwelling Catheter (a thin, flexible tube left inside the body, most commonly in the bladder, to continuously drain urine into an external bag when a person cannot urinate on their own) due to his/her diagnosis of Neuromuscular Dysfunction of Bladder with an intervention for staff to monitor/record/report to the resident's physician signs and symptoms of a UTI.-On 12/22/25 the resident had a fixation with his/her private area causing complications with his/her catheter.-The resident would refuse catheter care at times. Review of the resident's Electronic Medical Record (EMR) on 1/23/26 showed:-No notes in place related to collecting the UA that was ordered on 12/16/25 and 12/21/25.-No results were found related to the results of any UA completed in December 2025.2. Review of Resident #75's admission Record showed he/she admitted to the facility on [DATE] with the following diagnoses:-Enterocolitis (inflammation of both the small intestine and the colon) due to Clostridium Difficile (C. diff- a bacteria that causes severe, contagious diarrhea and colon inflammation).-Morbid Obesity due to Excessive Calories.Review of the resident's Un-witnessed Fall report dated 1/20/26 showed:-The resident had been using the commode and tried to stand.-He/She lost his/her balance and fell to the floor.-An X-ray (a photographic or digital image of the internal composition of the body) had been ordered.-The X-ray was unable to be obtained due to the resident's abdomen size.-The resident's physician had been notified and had ordered a Computed Tomography (CT) scan (a noninvasive, diagnostic imaging that combines a series of X-rays with computer technology to create detailed, cross-sectional, 3D images of bones, soft tissues, and blood vessels).-The order had been faxed to the local hospital.Review of the resident's Order Summary Report dated January 2026 showed an order for the resident to have a CT scan of Back and Right Side due to a fall, which was ordered on 1/23/26.During an interview on 1/28/26 at 11:22 A.M. the resident said:-He/She was unaware that a CT scan had been ordered after his/her fall.-He/She had not been given a date in which the CT scan had been scheduled.During an interview on 1/29/26 at 10:25 A.M. a hospital scheduler from the local hospital said:-He/She was the manager of scheduling procedures at the hospital.-He/She did not see a CT order for the resident until 1/27/26.-The CT scan had not been scheduled yet because the facility sent in an invalid order.-Once the order was corrected, then the CT scan could get scheduled.3. During an interview on 1/28/26 at 1:03 P.M. the Administrator said:-To his/her knowledge, Resident #44 would not let staff collect the urine for the UA to be completed.-He/She expected staff to document a progress note if the UA had been attempted/refused and that staff were unable to collect a sample.During an interview on 1/29/26 at 11:49 A.M. Certified Nursing Assistant (CNA) A and CNA B said:-All physician orders should be followed.-All physician orders should be followed as written.-CNAs and nurses could collect UAs depending on the order.-If they were unable to collect a sample for a UA to be completed, then they would let the nurse know.During an interview on 1/29/26 at 12:07 P.M. Agency Licensed Practical Nurse (LPN) A said:-All physician orders should be followed.-All physician orders should be followed as written.-If a licensed staff member could not collect a UA, then a note needed to be documented somewhere in the resident's EMR.-Sometimes the UA orders could be seen on the Treatment Administration Record (TAR) and nurses could document on the TAR whether the sample had been collected.-When he/she received an order for a CT scan, he/she would call the location that the CT scan was to be completed and document who he/she spoke to.-He/She would also inform the resident about when the procedure was scheduled for.-If the CT order needed to be faxed, then he/she would wait for a fax confirmation number and put a note in the resident's EMR.-He/She was unsure of when the CT scan had been ordered and when the order was sent to the local hospital.-If the order was placed on 1/23/26, then the facility should have the CT scan scheduled by that point in time.During an interview on 1/29/26 at 12:30 P.M. LPN A said:-All physician orders should be followed.-All physician orders should be followed as written.-Staff should follow all facility policies related to following physician orders and sample collection.-If staff were unable to collect a UA, then a note should have been documented in Resident #44's EMR.-If he/she needed to send an order for a CT scan, then he/she would confirm the location that the order needed to be sent to.-He/She would then send the order and wait for confirmation that the order had been received.-He/She would then document a progress note with the order confirmation number.-Resident #75's CT scan order should have been sent on the day it was ordered.During an interview on 1/29/26 at 1:41 P.M. the Director of Nursing (DON) said:-All physician orders should be followed.-All physician orders should be followed as written.-When a UA was ordered, the order would show on the nurse Medication Administration Record (MAR).-He/She expected the nurses to document in the MAR or in a progress note if a UA could not be collected.-He/She was unsure why staff did not document a note that indicated that a UA could not be completed as ordered.-There should have been a note documented in Resident #44's EMR to indicate that a UA could not be collected.-He/She was unsure when Resident #75's CT scan order was sent.-He/She did not have any documentation to confirm that Resident #75's order had been sent prior to 1/27/26.-He/She would have expected staff to get confirmation that the order was received and document a progress note.2713401

Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #44) rights remained intact when he/she had to move to a different room out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Resident Rights dated 6/10/25 showed Information about resident rights and responsibilities would be given to the resident both orally and in writing.1. Review of Resident #44's admission Record showed he/she admitted to the facility with diagnoses that included:-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance.-Anxiety (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats).Review of the resident's care plan dated 1/7/26 showed:-The resident had dementia.-On 1/6/26 the room move was discussed with the resident and the resident agreed.-On 1/7/26 the staff were assisting the resident with the room move when the resident became upset and said that he/she wanted to leave the facility.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/8/26 showed:-The resident had severely impaired cognition.-The resident did not have any wandering behavior.During an interview on 1/21/26 at 1:57 P.M. the resident said:-He/She did not agree to the room move.-He/She was very upset about the move and became tearful.-He/She did not understand why he/she had been moved to the locked unit.-He/She felt trapped when he/she was in the locked unit.-He/She was unable to answer whether he/she had received written notice of the room change.Review of the resident's Electronic Medical Record (EMR) on 1/27/26 showed:-The resident did not have a Guardian or Durable Power of Attorney (DPOA- a legal document giving someone authority to make financial, legal, or medical decisions for you that remains valid even when you become incapacitated).-The resident was his/her own responsible party.-No signed agreement had been uploaded related to the resident's room move.During an interview on 1/29/26 at 11:44 A.M. Certified Nursing Assistant (CNA) A and CNA B said:-The resident had moved rooms recently, but they did not realize that the resident had been moved to the memory care unit before moving into his/her current room.-All residents needed to be informed in writing when a room move occurred.-They were unsure if the resident had received a written notice.-If the resident did not receive a written notice, then he/she should have been provided with a written notice.-All parties needed to agree before a room change could be completed.During an interview on 1/29/26 at 11:55 A.M. Agency Licensed Practical Nurse (LPN) A said:-All residents needed to be informed in writing when a room move occurred.-He/She was unsure if the resident had received a written notice.-The resident should have been provided a written notice related to his/her room move.-He/She had been the nurse who assisted the resident the day of his/her original move.-The resident was upset about the room move.-The resident was refusing to move rooms once they started walking down the hall with the resident.During an interview on 1/29/26 at 12:24 P.M. LPN A said:-He/She was unfamiliar with the resident and was not aware that the resident had been originally moved to the memory care unit.-All residents were to be informed in writing when a room move occurred.-The resident should have received a written notice of the room move.-The facility needed to follow all policies and regulations related to resident's rights.During an interview on 1/29/26 at 1:34 P.M. the Director of Nursing said:-The resident had not been notified in writing about the room move.-He/She was not sure why the resident had not received a written notification.-He/She was unaware of the regulation.-The resident should have been notified in writing related to his/her room move.2713401

Based on observation, interview and record review, the facility failed to ensure documentation of non-pharmacological behavioral interventions were attempted prior to administering pro re nata (PRN as needed ) antianxiety medication (medication to address the symptoms of anxiety); to document events/triggers preceding behaviors; to ensure the PRN antianxiety medication had a stop date; and failed to include comprehensive symptoms and/or target behaviors and individualized interventions for one sampled resident (Resident #12) who was taking multiple psychotropic medications (drugs which affect psychic function, behavior, or experience) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Behavioral Health Services policy, revised 6/10/25 showed:-The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. -Staff will share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior and document the frequency of occurrence and potential triggers in the resident's record.-The facility will provide for meaningful activities which promote engagement and positive relationships. -Behavioral health training will include competencies and skills necessary to provide meaningful activities and individualized non-pharmacological approaches to care.Review of the facility's Use of Psychotropic Medications policy, revised 5/7/25 showed:-Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications.-Psychotropic medications used on a PRN basis must have a diagnosis specific condition and indication for the PRN use documented in the resident's medical record and is subject to limitations.-PRN orders for psychotropic medications, excluding antipsychotics (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis), shall be limited to no more than 14 days unless the prescribing practitioner believes it is appropriate to extend the order beyond the original 14 day order. The medical record should include documentation from the prescriber for the rationale for the extended time period and indicate a specific duration.-PRN orders for antipsychotic medications shall be limited to 14 days with no exceptions. If the prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.1. Review of Resident #12's admission Record showed the resident was admitted with diagnoses that included dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with agitation.Review of the resident's Psychotropic Medications Related to Dementia care plan, dated 10/24/25, showed:-Administer psychotropic medications as ordered by physician and report any adverse reactions.-Psychiatry to follow resident.Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 10/28/25 showed the resident:-Was severely cognitively impaired.-Felt down and depressed two to six days out of 14.-Had difficulty concentrating daily or nearly daily.-Had delusions (firmly held beliefs contrary to reality).-Had behaviors not directed towards others one to three days a week which significantly interfered with the resident's social interactions.-Wandered daily, potentially placing the resident at risk.-Found it very important to be able to listen to his/her preferred type of music and to get fresh air, weather permitting.-Had a primary diagnosis of progressive neurological conditions (acquired conditions such as dementia or brain damage characterized by a decline in mental function).-Was diagnosed with dementia. Was not diagnosed with anxiety, depression, or a psychotic disorder (a mental disorder in which there is a severe loss of contact with reality).-Was taking the following scheduled psychotropic medications: antianxiety, antidepressant, and antipsychotic. Review of the resident's progress notes, dated 11/4/25 showed:-At 5:49 A.M. the resident had been sexually inappropriate, trying to kiss other residents and staff members, and slapped a staff member on the butt. Easily redirected.-At 1:40 P.M. the resident had been sexually inappropriate with others on the unit. Spoke with the psychiatrist. Order for Paxil (generic name Paroxetine HCI, a potent Selective Serotonin Reuptake Inhibitor (SSRI) classified as an antidepressant (used for symptoms of depression which increases serotonin in the brain to help regulate mood and reduce anxiety).Review of the resident's Sexually Inappropriate Behavior Related to Dementia care plan, initiated 11/5/25, showed:-The resident would attempt to kiss other residents and staff and pat staff on the behind.-Administer medications per order and report any side effects to the physician.-Listen to the resident's concerns and be supportive as the resident missed his/her spouse.-Psychiatric evaluation as indicated.-Reduce stimulation and keep conversion short and simple.-When the resident had behaviors redirect as staff reported he/she was easily redirected.-NOTE: There were no specific interventions showing how staff could proactively engage the resident such as in his/her favorite music, going outside (weather permitting and if safe to do so), or another activity the resident had indicated was meaningful for him/her. It didn't show if the behavior was more pronounced if others were sitting or standing close to the resident.Review of the resident's progress notes dated 11/6/25 showed:-On 11/6/25 at 1:24 P.M. the resident had insomnia. Slept very little at night and paced continuously during day. Caled the physician. New order noted for Melatonin (a supplement to aid with insomnia) 9 milligram (mg) every night for insomnia.-On 11/6/25 at 3:54 P.M. the resident continuously paced up and down the hallways. Rest periods encouraged, but frequently non-compliant.Review of the resident's Secured Unit care plan, initiated 11/6/25 showed:-Encourage participation and provide assistance with dementia-based activities.-Offer frequent snacks and drinks.-Provide consistent staffing.-NOTE: There were no specific preferred activities indicated that engaged the resident. Review of the resident's History of Agitation care plan, initiated 11/10/25 showed-Administer medications as ordered.-Maintain structured daily routine.-Monitor behavioral changes and report patterns.-Provide redirection and reassurance.-NOTE: There were no proactive non-pharmacological interventions showing how best to direct the resident's attention or engage the resident in something he/she had demonstrated was of interest. There was no indication of what events/activities preceded the agitation. There was no indication of what the resident did when he/she was agitated. Review of the resident's Psychiatrist's note dated 11/23/25 showed:-Staff reported the resident was aggressive, and Lorazepam (an benzodiazepine used for short term relief of anxiety medication) wasn't working. Sundowning by 4:00 P.M. Turned the table over the other day. Still sexually inappropriate.-Discontinue 0.5 mg Lorazepam and make it 1 mg every eight hours as needed. -Add Depakote (generic name divalproex sodium, an anticonvulsant medication primarily used to treat seizure disorder, bipolar mania (characterized by persistent periods, lasting at least one week, of abnormally elevated or irritable moods), and to prevent migraines) for sundowning. -Increase Paxil from 10 mg to 20 mg for sexual inappropriateness. Decrease Zyprexa (an antipsychotic medication used to treat schizophrenia, bipolar disorder and treatment resistant depression) from 2.5 mg three times daily to two times daily due to the added Depakote.Review of the resident's orders dated 11/23/25 showed he/she was also on Mirtazapine (brand name Remeron, a tetracyclic antidepressant) 7.5 mg. Give one tablet at bedtime for depression.Review of the resident's progress notes, dated 11/25/25, showed:-At 5:29 P.M. the housekeeping supervisor was getting in his/her car and observed the resident climbing out a window of the Memory Care unit and into the employee parking lot. The resident was in line of sight while staff called for assistance. Another staff member came on the scene and the two staff walked the resident back into the building. The resident was agitated. Nurse administered PRN Ativan. Physician, Administrator, and family member updated.--NOTE: This entry did not indicate what non-pharmacologic interventions were used to calm the resident's agitation. It did not describe what the resident was doing to indicate he/she was agitated. -At 6:12 P.M. Ativan (lorazepam) 1 mg every eight hours as needed for aggression was given and was effective. Review of the resident's Elopement Risk/Wandering care plan, revised 11/26/25 showed:-Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book.-Redirect the resident when he/she went to doors to try to leave.-Educate staff to ensure doors locked behind them.-Maintenance to check the windows on the unit weekly for four weeks and monthly thereafter.-NOTE: The care plan didn't show what type of music the resident liked. The MDS showed music was very important to him/her.Review of the resident's progress notes, dated 11/27/25 to 1/4/26 showed:-On 11/27/25 at 1:37 P.M. the resident was having intermittent episodes of agitation and resisting cares and followed a visitor out of the locked unit. He/She was difficult to redirect. The resident was pacing frequently and was asking to go home. PRN Ativan (lorazepam given after several attempts to redirect earlier this shift. Resident was currently calm and sitting at a table in the dining room.-On 11/29/25 at 12:28 P.M. the client had increased pacing and exit-seeking and was very difficult to redirect. The resident became aggressive towards staff. PRN Ativan (lorazepam) given after multiple attempts to redirect. A note on 11/29/25 at 1:13 P.M. showed the PRN was effective.-On 11/30/25 at 11:04 A.M. the resident was pacing and wanted to go home. Increased agitation and aggression with redirection. PRN Ativan (lorazepam) given at 8:00 A.M. with good results. The resident was currently sitting at a table in the dining room watching TV. Calm at present.-On 12/2/25 at 1:03 P.M. the resident was pacing the unit and exit seeking. Placed on 15-minute checks. The resident was becoming more agitated and aggressive with redirection. PRN Ativan given at 9:15 A.M. with good results. Resident was currently sitting at a table eating a cookie. Calm and denied discomfort.-On 12/4/25 at 8:06 A.M. Ativan (lorazepam) as needed for aggression/increased agitation. 12/4/25 at 9:07 P.M. showed the PRN was effective.-On 12/9/25 at 6:26 A.M. the resident was aggressive with staff, attempted to pick up the TV and throw it. PRN Lorazepam given. Medication effective and resident slept from 10:00 P.M. to the change of shift.-On 12/11/25 at 1:54 P.M. the resident had increased agitation this morning, arguing with staff and attempted to elope. PRN Ativan (lorazepam) was given at 8:00 A.M. with good results. The resident was sitting in the dining room having a snack and watching a movie.-On 12/14/25 at 10:08 A.M. the resident was very unsteady. He/She had not been sleeping much at night and received PRN medications for frequent aggression in addition to scheduled medications. The Physician was on rounds and assessed resident. Medications held, except prescribed antibiotic. -On 12/14/25 at 6:00 P.M. the resident was very aggressive, swinging at and pinching staff. Unable to follow commands. Very unsteady at times. Couldn't get the resident to calm down and PRN Ativan (lorazepam) was given. At 7:31 P.M. the PRN was effective.-On 12/16/25 at 9:04 A.M. the resident had increased aggression and was frequently resistive to cares. PRN Ativan (lorazepam was given at 8:45 A.M. Frequent pacing. Gait becoming more unsteady. Right lower extremity (RLE) had increased edema, redness and warmth to touch. Resident removed support hose and wraps when applied. Non-compliant with resting and elevating legs. The resident was sent to the emergency room (ER) for RLE evaluation and aggression. At 9:48 A.M. the PRN was ineffective.-On 12/16/25 at 5:00 P.M. the resident was combative upon return from the hospital and scheduled medications were given.-On 12/18/25 at 9:03 A.M. Ativan (lorazepam) 1 mg tablet was pulled from the emergency kit due to the resident grabbing random items. At 10:00 P.M. the resident was combative and refused Intravenous (IV) hydration. At 11:48 P.M. the PRN was effective.-On 12/23/25 at 2:23 A.M. the Certified Nursing Assistant (CNA) asked if there was a PRN that could be given to the resident who was complaining of pain. The nurse couldn't find any orders for pain medication, so Ativan (lorazepam) was taken to the resident. The resident was sitting on the edge of his/her bed without a shirt and said he/she didn't want to wear it. After the CNA told the resident it was cold in the dining room the resident put on the shirt. The resident was very shaky when he/she took the Ativan (lorazepam) and drank his/her water. The CNAs told him/her to stand up so they could pull up his/her pants, and the resident was shaky then as well. One CNA felt the resident should be in a wheelchair due to his/her shakiness. The CNA told the resident to sit down in the wheelchair and he/she would not. It took all three staff to guide the resident into the wheelchair. At 3:13 A.M. the PRN Ativan (lorazepam) was effective.--NOTE: The resident received Ativan (lorazepam) for pain, which was not indicated for use for the resident-On 12/25/25 at 6:20 P.M. the resident continued to pace frequently and attempted to climb on things. PRN Ativan (lorazepam) was given at 2:30 P.M. with little effect. Other medications given as scheduled. Assistance given with activities of daily living (ADLs - dressing, hygiene, grooming) and the resident was resistive at times. The resident was tipping tables at times.-On 12/26/25 at 1:21 P.M. the nurse was notified that the resident was agitated and hit a staff person. The resident was assessed and the PRN Ativan (lorazepam) was administered. At 4:14 P.M. the resident was sleeping.-On 12/26/25 at 10:30 P.M. the CNA said the resident was agitated and asked the nurse if the resident had anything PRN. This nurse got the Ativan (lorazepam) and went to assess the resident. The resident was in the bathroom holding the doorknob leading to the next resident room. The resident wouldn't let go of the doorknob. The resident was given Ativan on a spoon with pudding and took it. The CNA left the resident playing with the doorknob and said he/she would check on the resident at 11:00 P.M. At 11:00 P.M. the resident was standing at his/her closet door with his/her hands on the door saying something incomprehensible. The resident was left. He/She seemed calm and content.-On 1/2/26 at 2:00 P.M. the nurse documented at approximately 12:45 P.M. the resident was just outside the Memory Care unit walking towards the main nursing station. The nurse and Certified Medication Technician (CMT) were able to easily redirect the resident back to his/her unit.-On 1/4/26 at 3:24 P.M. the resident continued to get up and walk. Agitated. He/She was given PRN Ativan (lorazepam. At 4:48 P.M. the medication was effective.-NOTE: The resident's progress notes didn't describe the resident's behaviors and only noted he/she was agitated, aggressive, anxious, or combative without showing how staff came to their conclusion. None of the notes showed there was any antecedent event or what appeared to be a trigger for the resident's increased behaviors. The notes didn't show what non-pharmacologic interventions were attempted or the duration of the behaviors prior to giving the PRN Ativan (lorazepam).Review of the resident's current psychotropic orders dated January 2026 showed:-Ativan (lorazepam) oral tablet 1 mg. Give one mg by mouth in the afternoon for anxiety, starting 1/1/26.-Paroxetine HCI (brand name Paxil). Give 20 mg by mouth one time a day for inappropriate behaviors starting 1/1/26.-Alprazolam (brand name Xanax. A fast-acting benzodiazepine) oral tablet disintegrating 0.5 mg. Give 1 mg by mouth in the afternoon for anxiety at 2:00 P.M. daily starting 1/3/26.-Olanzapine (brand name Zyprexa. An atypical antipsychotic which modulates neurotransmitters in the brain, primarily dopamine and serotonin, to improve mood, behavior and thought processes) oral tablet 2.5 mg. Give 2.5 mg by mouth two times daily related to dementia with agitation starting 1/10/26.-Ativan (lorazepam) oral tablet 1 mg. Give 1 mg by mouth every four hours as needed for anxiety/agitation starting 1/22/26. --The order did not contain a stop date/duration date as recommended by the pharmacist and required by facility policy and Centers for Medicare/Medicaid (CMS) regulation. Review of the resident's quarterly MDS, dated [DATE], showed:-The resident was severely cognitively impaired with fluctuating inattention and disorganized thinking.-Felt down and depressed nearly every day and had trouble falling and/or staying asleep more than half the days.-Had physical behaviors towards others and behaviors not directed towards others.-Was diagnosed with dementia. Was not diagnosed with anxiety, depression, seizure disorder, or psychotic disorder.-Received antianxiety, antidepressant, antipsychotic, and anticonvulsant medications.Review of the resident's progress notes dated 1/5/26 to 1/12/26 showed:-On 1/5/26 at 9:58 A.M., PRN Ativan (lorazepam) 1 mg was administered for anxiety and attempting to get up and walk. At 1:46 P.M. the PRN was effective and the resident was resting in his/her wheelchair in the TV area.-On 1/6/26 at 11:46 A.M. PRN Ativan (lorazepam) was given for increased anxiety with agitation. At 12:57 P.M. the PRN was effective.-On 1/12/26 at 10:10 A.M. PRN Ativan (lorazepam) was given for restless behavior. At 11:02 A.M. the PRN was effective.-NOTE: There was no documentation that described the non-pharmacologic interventions used for the anxiety, agitation, and restless behavior prior to administering the PRN Ativan (lorazepam). Review of the resident's Pharmacy recommendation, signed by the physician 1/14/26, showed:-PRN psychotropic drug orders were limited to 14 days and could not be renewed unless the prescribing practitioner evaluated the resident for appropriateness of renewal. If the physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he/she should document their rationale in the resident's medical record and indicate the duration of the PRN order.-The physician indicated he/she discontinued the PRN and reevaluated the resident for continued PRN Ativan (lorazepam) use.Review of the resident's progress notes dated 1/15/26 to 1/22/26 showed:-On 1/15/26 at 9:00 A.M. PRN Ativan (lorazepam) given for increased anxiety with agitation. At 10:20 A.M. the PRN was effective. -At 2:29 P.M. the behavior earlier in the day was described as very restless this morning, pacing continuously, turning over tables and trying to climb on furniture. He/She also attempted to remove his/her pants several times and was resistive with redirection and cares. -On /16/26 at 10:17 P.M. the resident had extreme agitation this shift. He/She was wandering, going through things, grabbing things that weren't his/hers. Upon redirection resident got worse. -On 1/22/26 at 12:10 P.M. the resident appeared anxious. He/She walked in and out of rooms and turned knobs. He/She was taken to the toilet and continued to walk up and down the hall after having been offered a snack. Eventually he/she sat in a chair, but was fidgety, rubbing his/her hands together, lifting his/her pant leg up and down and finally took the snack and drink. Observation on 1/21/26 at 9:32 A.M. showed:-The resident was calmly eating breakfast and appeared alert.-He/She was aware of others in the environment, looked around, and was talking in a pleasant tone, but the content could not be followed.Observation on 1/23/26 at 9:40 A.M. showed:-The resident was calmly sitting by himself/herself at a table in the dining room. -He/She looked around the room and initiated interaction, although the content was nonsensical. The tone of voice was calm and pleasant.-He/She was not fidgeting or showing other signs of restlessness. During an interview on 1/27/26 at 12:03 P.M. CNA F said:-He/She had been working with the resident on walking and walked him/her on the unit.-He/She had no behavioral issues with the resident on the day shift.-He/She didn't know the resident's behaviors.-If the resident seemed anxious or restless staff would give him/her an activity, a book or talk about photos he/she had in his/her room.-The facility provided education on working with residents with behaviors and dementia and what worked for most residents.-Target behaviors should be in each resident's care plan with interventions to address the behaviors. It should show the resident's triggers. Interventions should be unique for each resident. There is a behavioral book on each unit that showed what helped to soothe each resident. It should have the behavioral information found on the care plan.-Symptoms or behaviors related to depression or anxiety should be on the care plan to show staff when the problem was getting worse.-Any resident taking a psychotropic medication needed to have a care plan that showed target behaviors and symptoms and non-pharmacological interventions.During an interview on 1/27/26 at 1:54 P.M. CNA F said:-The resident was acting different than normal earlier in the day. He/She was physically combative and hitting staff. On the day shift he/she usually had few behaviors.-He/She started having loose stools during the night and was sent out to the hospital.-CNAs were able to look at the behavior book which showed what was on the care plan.-The care plan and behavior book should both show a resident's triggers, their specific behaviors, and what interventions worked best for the resident.During an interview on 1/27/26 at 2:11 P.M. CMT B said:-CNAs and CMTs used the behavior book that showed the resident's target behaviors individualized interventions the same as the care plan.-Any resident on psychotropic medications needed to have an individualized care plan that identified the resident's symptoms related to anxiety, depression, or psychosis and any target behaviors they had and what worked best for that individual resident.-Some of the resident's behaviors were triggered by someone who got in his/her space or forced him/her to do something he/she didn't want to do. He/She stayed calm if he/she was given space.-He/She would make inappropriate comments to staff and tried to touch their bottoms or tried to look down their shirt and would remove his/her pants. The psychiatrist put him/her on a medication to address his/her sexually inappropriate behaviors.-The resident thought he/she was at work if given a binder and a pen. He/She used to be an engineer and liked to map things out and write things down.-He/She did better the calmer the unit was and the busier he/she was.-The resident would push furniture and asked to go home. He/She sometimes flipped tables over. Once he/she flipped an oxygen concentrator over and started fiddling with the wheels. There were wheels under the tables as well and he/she liked to fiddle with them. He/She believed he/she was fixing the wheels and got agitated if asked to stop.-The resident won't sit for long or stay focused, he/she went from one thing to another. If staff gave him/her something to do with his/her hands or gave him/her a fidget object or food and drink the resident would focus on it for a while. -He/She might like to have some wheels to spin or locks to manipulate, but nothing like that was on the unit.-The resident's spouse said he/she liked to fix things. Giving him/her something to fix would give the resident something he/she enjoyed doing.-It would be good to specify on the care plan what was usually effective and not just say staff should redirect the resident.-Psychotropic mediations were supposed to be limited to 14 days. Then the resident had to be evaluated by the doctor or psychiatrist before the PRN could be continued. PRN antianxiety medications should have a stop date when they were continued beyond the original 14 days.During an interview on 1/28/26 at 10:32 A.M. the MDS Coordinator said:-He/She tried to describe target behaviors and used individualized interventions on the resident care plans.-The care plan should be specific and unique for the resident.During an interview on 1/28/26 at 10:53 A.M. the MDS-in-Training said:-Symptoms of anxiety, depression and psychosis should be identified in the care plan for each resident who was on psychotropic medications. -Target behaviors should be specific, and interventions should be individualized for each resident.-The care plan should identify any known triggers for behaviors.During an interview on 1/29/26 at 1:50 P.M. the Director of Nursing (DON) said:-Residents on psychotropic medications should have care plans that show symptoms and target behaviors which were specific for the resident.-Progress notes should show specific behaviors the resident was having and there should be documentation of what non-pharmacological interventions were attempted before using a psychotropic PRN.-After the initial 14-day order for PRN psychotropic medications the resident needed to be re-evaluated before continuing the medication. -Any resident on a PRN antianxiety medication needed to have a stop date on their orders for that medication.

Based on observation, interview and record review, the facility failed to provide treatment and behavioral health services for three sampled residents (Resident #4, Resident #7, and Resident #3) who had known behavioral health history and mental health diagnoses. The facility staff failed to implement a PASRR for Resident #4 and failed to create a plan of care for Resident #3 and Resident #4 to provide interventions for behaviors. The facility failed to transcribe, order, and administer Resident #4's psychotropic medications from [DATE] - [DATE] followed by an escalation of aggressive behaviors. The facility staff also failed to implement Resident #7's PASRR to create a plan of care for his/her known self-harming behavior suicidal ideation which resulted in the resident experiencing increased agitation and reporting thoughts of suicidal ideation and an elopement from the facility. Twelve residents were selected for sample. The census was 90.The Administrator was notified on [DATE] at 12:40 P.M. of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Nurse Aide Training Program policy, revised [DATE], showed:-The policy ensured that the facility maintained an appropriate and effective nurse aid in service training program for the purpose of ensuring the continuing competencies of nurse aids.-Each nurse aide would be provided with at least 12 hours of in service training annually based on his or her employment date, not calendar year.-In service training would be provided by qualified personnel and would be based on the special needs of the residents in the facility.-Minimum training would include:--Effective communication;--Abuse, neglect, and exploitation prevention;--Residents rights and facility responsibilities;--Safety and emergency procedures;--Behavioral health; --Identification of changes in condition;-Additional training would be provided to each nurse aide based on any areas of weakness as determined in the nurse's aides performance reviews.-The director of nursing would communicate the educational needs of the employee to the staff development coordinator or designee upon final review of the annual performance appraisal.-Education that was needed based on the performance appraisal would be completed within 90 days of the appraisal.-Content of training would be current and reflect professional standards and guidelines.-Content would be reviewed on a regular basis and updated as needed. Review of the facility's Provisions of Quality Care Policy, revised [DATE], showed:-Based on comprehensive assessments, the facility would ensure that residents received treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person centered care plan, and the residents' choices.-Each resident would be provided care and services to attain or maintain his or her highest practical physical mental and psychosocial well-being.-Qualified persons would provide the care and treatment in accordance with professional standards of practice, the residents care plan, and the residents choices to ensure persons are qualified.-Department heads and collaboration with facility leadership would oversight to ensure ongoing employee competency and education regarding areas of employee weaknesses. Review of the facility's Behavioral Health Services Policy, revised [DATE], showed:-Behavioral health training was determined by the facility assessment and would include competency and skills necessary to provide person centered care and services that reflect the resident's goals for care.-All facility staff including contracted staff and volunteers would receive education to ensure appropriate competencies and skill sets for meeting the behavioral needs of the residents. Review of the Facility assessment, dated [DATE], showed:-The current facility census was 90 residents.-There were 31 residents with behavioral health care needs.-Staff competencies required included behavioral healthcare.-Staff competencies required would be auto-filled based on the diagnoses and conditions identified on the resident population sheet. 1. Review of Resident #4's admission Record showed the resident admitted to the facility on [DATE] with the following diagnoses:-Paranoid Schizophrenia (a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior. It is primarily marked by paranoia, intense delusions, and hallucinations, particularly auditory ones, where individuals may hear voices that aren't real).-Anxiety Disorder (a mental health condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).-Delusional Disorder (a type of mental health condition in which a person can't tell what's real from what's imagined).-Personality Disorder (a mental health condition characterized by enduring patterns of thinking, feeling, and behaving that deviate significantly from cultural expectations and cause distress or impairment in daily functioning).-Hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch and taste). Review of the resident's medical record showed the facility did not have the resident's Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) on file. The surveyor obtained a copy from the Department of Health and Senior Services (DHSS) Central Office Medical Review Unit (COMRU), dated [DATE], and it showed:-The resident had serious mental illness.-The resident had paranoid schizophrenia.-The resident had borderline personality disorder (a mental health condition characterized by pervasive patterns of instability in mood, self-image, and interpersonal relationships, as well as marked impulsivity).-The resident had schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania).-The resident had anti-social personality disorder (sometimes called sociopathy, is a mental health condition in which a person consistently shows no regard for right and wrong and ignores the rights and feelings of others).-The resident had depressive disorder (a mental health disorder that involves a depressed mood or loss of pleasure or interest in activities for long periods of time).-The resident had childhood disintegrative disorder (a rare and progressive neurological condition characterized by late onset (>3 years of age) of developmental delays in language, social function, and motor skills).-The resident had psychotic disorder (a severe mental disorder that causes abnormal thinking and perceptions. People with psychoses lose touch with reality).-The resident had polysubstance dependence (a type of substance use disorder in which an individual uses at least three different classes of substances), amphetamine abuse (the repeated, high-dose, nonmedical use of amphetamines, which are potent, highly addictive central nervous system stimulants), cannabis dependence and abuse (involves continued marijuana use despite negative consequences), and alcohol dependence and abuse (alcohol abuse is too much, too often and alcohol dependence is the inability to quit).-The resident required 24 hour protective oversight due to severity of behaviors or mental illness symptoms.-The resident could not be without supervision at any time.-The resident's psychotropic medications included:--Benztropine (anticholinergic drug used to manage uncontrolled movements that can develop as side effects of antipsychotic medications).--Depakote (a mood stabilizer medication that works in the brain. It is approved for the treatment of mania associated with bipolar disorder).--Olanzapine (antipsychotic primarily used to treat schizophrenia and bipolar disorder).--Trazadone (antidepressant medication used to treat major depressive disorder, anxiety disorders, and insomnia).-The resident required medication monitoring.-The resident developed mental health symptoms in his/her teenage years after his/her mother died in 1988.-The resident was [AGE] years old when his/her mother died.-The resident was traumatized when his/her mother died and had to be sent to group homes until 2008.-In 2008, the resident was transferred to a nursing facility.-The resident had a legal guardian through the Public Administrator's Office.-The resident required consistent access to psychiatric follow up and medications to promote maximum stability.-The resident benefited from a stable, structured environment in which his/her mental health conditions were consistently assessed and treated. -The resident required monitoring of behavioral symptoms.-The resident required psychiatric follow up to prescribe and manage psychiatric medications.-The resident required medication set up/administration by staff and monitoring for compliance with prescribed medication.-The resident required monitoring of therapeutic effect in managing mental health symptoms, including therapeutic levels, and/or interaction or adverse effects.-The resident required education and training in drug therapy management.-The resident required an environment with low stimulation, minimum of visual/auditory distractions, and/or sensory supports-The resident required instructions at the individual's level of understanding.-The resident required an environment that supported prevention of elopement.-The resident required consistent routines, providing a schedule of daily tasks/activities, etc.-The resident required individual personal space.-The resident required assessment and planning for meaningful socialization and recreational activities to diminish tendencies toward isolation, withdrawal, etc. Review of the resident's Care Plan, dated [DATE], showed:-The resident had schizophrenia and was easily agitated and annoyed with staff.-The resident would curse and yell at staff and swing his/her fists in the air when agitated.-The resident would wander up and down the hall very fast and slam his/her door.-The resident attempted to go out the door and was very difficult to redirect.-Staff were to administer medications per Dr's order.-Staff were to approach the resident in a calm manner and explain all procedures.-Staff were to obtain a psychiatric evaluation and counseling as indicated.-Staff were to leave the resident alone and approach a little later, when the resident became agitated. -No behaviors or interventions were updated on the resident's care plan after [DATE]. Review of the resident's behavior note, dated [DATE] at 12:39 P.M., showed:-The resident was having behaviors and was making inappropriate comments.-Female residents in the dining room were frightened. Review of the resident's EMR on [DATE], showed:-No incident report was completed by staff on [DATE].-No care plan updates or interventions were completed by staff on [DATE].-No behavior monitoring was documented by staff on [DATE].-No nonpharmacological intervention was documented by staff on [DATE].-No pharmacological intervention was documented by staff on [DATE].-No physician psychiatric evaluation was completed or scheduled as of [DATE]. During an interview on [DATE] at 11:12 A.M., LPN A said:-He/she witnessed Resident #4 having behaviors on [DATE].-The resident was agitated, yelling, cursing people out, air punching walls, pacing, going into other resident's rooms and making other residents fearful. -The resident punched housekeeper A in the face on the same day, [DATE].-He/she was not educated on how to handle the resident and his/her behaviors.-He/She had no recent de-escalation training.-He/she used his/her nursing knowledge to help care for the resident, which did not work.-He/She did not know how to handle the resident. -He/She notified the DON (Director of Nursing) of the incident. During an interview on [DATE] at 12:01 P.M., Housekeeper A said:-The resident punched him/her in the face on [DATE].-He/She reported the incident to the Assistant Director of Nursing (ADON).-He/she was told to sit one on one with the resident after the resident punched him/her in the face.-He/She sat one on one with the resident for about 3-4 days, but did not document the one on one observations.-He/She was told by the administrator and the DON not to document the resident's behaviors during the one on one.-The resident was constantly having behaviors, cursing at other residents, and throwing things at other residents.-He/She reported all of the behaviors to the DON.-He/She witnessed the resident throw a milk cup at another resident and called the other resident a derogatory name.-He/she was told by the DON that one on one was stopped on the resident on 10/8, despite the resident having continued behaviors towards staff and other residents.-He/She sat one on one with the resident from [DATE]-10-/8/25.-He/She never had CNA training and never had training on how to deescalate resident behaviors.-He/She was never told intervention with the resident to perform during his one-on-one time.-He/She told the administrator when the resident's one-on-one was discontinued that the resident should have continued on one-on-ones due to witnessed aggressive behaviors.-He/She always reported the resident's aggressive behaviors to staff and charge nurses when they occurred, and the nurses would always say I will make a report.-Staff and residents were all in danger from the resident's behaviors.-He/She caught the resident masturbating in the lobby in rehab the day after the resident was taken off of one on one.-He/She reported the masturbation to the charge nurse.Further record review of the resident's medical record showed no documentation regarding the resident punching the housekeeper and the resident masturbating in a common area. Review of the Resident #8's Quarterly Minimum Data Set, dated [DATE], showed the resident admitted to the facility on [DATE] and cognitively intact. During an interview on [DATE] at 3:30 P.M., Resident #8 said:-He/She witnessed resident #4's behaviors on [DATE] and it scared him/her.-He/She did not feel safe at the facility due to Resident #4's behaviors.-He/She couldn't sleep well at night because he/she was scared that Resident #4 would harm them. Review of Resident #4's nurses note, dated [DATE] at 11:01 A.M., showed:-The resident displaying combative behavior.-Family member (FM) A was in the facility and attempting to deescalate the resident's behavior.-The resident was screaming profanities, punching at the air in a 5-pattern sequence and then rapidly walking with lateral shuffling and head dropped down going directly at staff.-The resident's speech pattern was non sensical with flight of idea topic content. Review of the resident's nurses note, dated [DATE] at 4:29 P.M., showed:-The resident being verbally abusive towards staff and punching the air in the direction towards staff.-The resident verbally assaulted staff by screaming, you're fat stupid and ugly.-Other residents on the rehab floor stated they were scared and nervous around the resident. Review of the resident's EMR on [DATE] showed:-No incident report completed by staff on [DATE]. -No care plan updates or interventions were completed by staff on [DATE].-No behavior monitoring documented by staff on [DATE].-No nonpharmacological interventions documented by staff on [DATE].-No pharmacological interventions documented by staff on [DATE].-No physician psychiatric evaluation completed or scheduled as of [DATE].During an interview on [DATE] at 2:35 P.M., CNA C said:-He/She witnessed the incident that occurred on [DATE].-The resident attempted to be physically aggressive with him/her on [DATE] and other staff members and residents.-He/She witnessed the resident being belligerent and having outbursts nonstop since the resident's admission on [DATE].-He/She witnessed the resident on several occasions cursing at residents and staff.-He/She never had education on how to handle behaviors or deescalate situations with behaviors.-He/She heard numerous residents state that they were scared of Resident #4 during the [DATE] incident, specifically Resident #9 and Resident #10.-The DON and administrator knew about the resident's behaviors and the way the other residents felt threatened and scared and nothing was ever done to protect them.-He/She was scared to work with Resident #4 and did not feel equipped to keep the other residents safe from Resident #4. Review of Resident #9's Annual Minimum Data Set, dated [DATE], showed the resident admitted to the facility on [DATE] and assessed as cognitively intact. During an interview on [DATE] at 3:40 P.M., Resident #9 said:-He/She did not feel safe at the facility any longer because it does not feel like home.-The facility allowed residents to move in that have bad mental health problems and aggressive behaviors.-He/She has been traumatized by Resident #4's behaviors.-This was his/her home and wanted to feel safe but since Resident #4 was admitted , he/she did not feel safe. Review of the resident #10's Quarterly Minimum Data Set, dated [DATE], showed the resident admitted to the facility on [DATE] and assessed as cognitively intact. During an interview on [DATE] at 3:42 P.M., Resident #10 said:-He/She does not feel safe in the facility because of Resident #4.-He/She was worried about what Resident #4 would do.-He/She felt very anxious, uneasy, and frustrated by Resident #4.-He/She felt staff were never trained on how to handle a resident like this, and staff couldn't keep other residents safe. During an interview on [DATE] at 3:49 P.M., LPN C said:-He/She witnessed the behaviors from Resident #4 on [DATE].-He/She thought it was strange the resident did not have all of his/her antipsychotic or antianxiety medications from the previous facility.-He/She questioned the resident's medication and asked the DON why the resident did not have his/her medication on file from the previous facility.-The DON ignored his/her concern and nothing was done.-He/She pushed to get the residents behaviors managed and so he/she called the physician to have a PRN antianxiety medication ordered.-The resident was at the facility for 3 days having behaviors and outburst and no other staff members or administration attempted to get the resident's medications ordered and administered like they should have been.-No staff knew how to handle the resident.-No staff had behaviors training or knew how to deescalate the resident.-Staff feared the resident and felt they could not keep him/her or other resident's safe.-Other residents were scared of the Resident #4 and fearful.-He/She was told by the administrator, You are a nurse, you should know how to deal with these types of situations. Review of the resident's nurses note, dated [DATE] at 9:08 P.M., showed:-At 11:15 A.M., the nurse wrote a lengthy detailed behavioral note on the resident to the administrator and the Director of Nursing (DON) and did not get a response as to what action or nurse intervention the nurse should do to keep this nurses other residents safe. -At 7:20 P.M., the resident tried to elope from the building.-The resident displayed behaviors of hitting a chair on the seat with his/her fist claiming he/she is killing his/her friend, made sexual advances at the nurse, and told a Certified Nurse Assistant (CNA) he/she will get him/her. During an interview on [DATE] at 11:50 A.M., CNA D said:-He/She witnessed the resident's behaviors on [DATE] and on several other occasions.-He/She has not had facility training about de-escalation or how to handle behaviors.-He/She has not had any in-services or education from the facility for over 6 months.-He/She did not know how to handle the resident and did not feel capable of keep the other resident's safe from Resident #4 due to not being trained on how to deescalate behaviors.-All staff and residents were very stressed out and on edge due to Resident #4's behaviors.-The DON and the administrator knew about Resident #4's behaviors and were not helping staff or educating staff on how to get the resident under control.-He/She was not aware how to access the resident's care plan. Record review of the resident's behavior notes, dated [DATE] at 12:38 P.M., showed:-The resident attempted to punch another resident (Resident #5).-The resident tried to hit the nurse and the CNA on the unit. Review of the resident's EMR on [DATE], showed:-No incident report was completed by staff on [DATE].-No care plan updates or interventions were completed by staff on [DATE].-No behavior monitoring was documented by staff on [DATE].-Medication regimen from transferring facility was not administered by staff on [DATE].-No physician psychiatric evaluation was completed or scheduled as of [DATE]. Review of Resident #5's admission Minimum Data Set, dated [DATE], showed the resident admitted to the facility on [DATE] and assessed with moderate cognitive impairment. During an interview on [DATE] at 3:30 P.M., Resident #5 said:-He/She was verbally and physically attacked by Resident #4 on [DATE].-After the altercation, he/she left the facility with a family member because he/she became angry and scared.-He/She returned the facility after Resident #4 was no longer in the facility to finish his/her rehab stay.-Resident #4 was kicking another resident's wheelchair on or about [DATE] when he/she stood up from his/her wheelchair and told Resident #4 to stop.-Resident #4 then attempted to punch Resident #5 in the face. Resident #5 then lost his/her balance and fell.-He/She felt unsafe when Resident #4 was in the facility.-He/She heard other resident's state that they felt unsafe and were scared of Resident #4.-Resident #4 threatened Resident #5 to cut his/her throat and would come in and out of Resident #5's room throughout the night.-Having to leave the facility due to feeling unsafe put him/her behind on his stroke recovery.-He/She felt safe in the facility now that Resident #4 was gone. Review of the resident's behavior notes, dated [DATE] at 12:00 A.M., showed:-The resident had continued pacing, agitation, and aggression.-The resident was moving furniture and yelling. Review of the resident's EMR on [DATE], showed:-No incident report was completed by staff on [DATE].-No care plan updates or interventions were completed by staff on [DATE].-No behavior monitoring was documented by staff on [DATE].-Medication regimen from transferring facility was not administered by staff on [DATE].-No physician psychiatric evaluation was completed or scheduled as of [DATE]. During an interview on [DATE] at 12:30 P.M., LPN B said:-On [DATE], the resident was very loud and aggressive and constantly moving and sometimes was even running and having abnormal behaviors.-Other residents expressed fear of Resident #4.-He/She recalled Resident #8 expressing fear of Resident #4.-Resident #4 was going in and out of other residents' room constantly and made the other residents fearful.-He/She has not had any de-escalation training or in-services from this facility on how to handle behaviors.-Staff was not prepared to care for Resident #4 safely. Review of the resident #8's Quarterly Minimum Data Set, dated [DATE], showed the resident admitted to the facility on [DATE] and assessed as cognitively intact. During an interview on [DATE] at 3:30 P.M., Resident #8 said:-He/She did not feel safe at the facility due to Resident #4's behaviors.-Resident #4 paced up and down the hallways and into all the resident's rooms.-He/She couldn't sleep well at night because he/she was scared that Resident #4 will harm him/her. Review of Resident #4's behavior notes, dated [DATE] at 3:29 A.M., showed the resident sent to the hospital after an altercation with another resident and law enforcement. Review of the resident's behavior notes, dated [DATE] at 6:27 A.M., showed the resident up most of the night pacing, yelling, threatening staff, making very loud noises, and causing disturbances to other residents, at one point he/she yelled at another resident and grabbed the other resident's wheelchair.During an interview on [DATE] at 2:00 P.M., Police Officer A said: -The police department received a call from the facility they had a resident they could not control on [DATE].-Resident #4 was the resident out of control at the facility.-He/She tazed Resident #4 due to the inability to get the resident to calm down.-He/She and other officers were worried about the residents and staff at the facility.-He/she did not feel facility staff were properly managing the residents in the facility that had behaviors. -The police department had received numerous calls over the past 3 months from the facility staff and residents about different situations of residents being out of control and needing help from the police to gain control.-Staff have reported to them they are not trained. During an interview on [DATE] at 10:30 A.M., CNA A said:-He/She witnessed the resident-to-resident altercation and the police tazing Resident #4 on [DATE].-He/She witnessed Resident #4 karate chop Resident #6 on his/her shoulder on [DATE].-Resident #4 hit Resident #6 hard.-The hit appeared to hurt Resident #6.-Resident #6 was nonverbal.-Resident #6 had a grimaced face after he/she was hit by Resident #4.-Resident #6 went to the hospital via EMS to get checked out per family request after he/she was hit by Resident #4.-Resident #4 did not receive one on one supervision prior to the incident.Resident #4 hit Housekeeper A in the face last week and has attempted to hit numerous other residents and nothing was done about it by the administration.-He/She did not receive behavioral de-escalation training.-He/She did not receive abuse and neglect training.-He/She did not know how to safely care for Resident #4, because the resident had continued violent and aggressive behaviors and he/she was not trained on how to care for the resident. -He/She feared Resident #4 because the resident had continued violent and aggressive behaviors. -All the residents feared Resident #4, because the resident had continued violent and aggressive behaviors. During an interview on [DATE] at 10:50 A.M., CNA B said:-He/She witnessed the incident with the resident on [DATE] and several other occasions since the resident's admission to the facility.-He/She did not receive behavioral de-escalation training.-He/She did not receive abuse and neglect training.-He/She did not feel competent to care for the resident safely, because he/she was not trained on how to do so. During an interview on [DATE] at 11:40 A.M., Housekeeper B said:-He/She intervened on the resident-to-resident altercation initiated by Resident #4 on [DATE].-He/She had not received behavioral de-escalation training.-He/She had not received abuse and neglect training. -He/She did not know how to deescalate the situation safely. During an observation and interview at the hospital on [DATE] at 1:30 P.M., Resident 4 said:- I am going to grab that thing over there (pointing to the hospital counter) and shove it up your butt upon the surveyor entering the room.-The resident started to show signs of increased agitation, therefore the surveyor ended the interview. During an interview on [DATE] at 9:50 A.M., Certified Medication Technician (CMT) A said:-He/She was unsure of the exact date, but believed it to be [DATE], when he/she witnessed the resident walking around poking residents in the back, swinging chairs around, and showing aggressive behaviors.-He/She had not received facility training on behaviors or how to deescalate behaviors.-He/She had not received recent abuse and/or neglect training from this facility.-Staff did not know how to manage the resident.-The resident was out of control.-The other residents were scared of the resident and have been stressed out since the resident admitted to the facility. During an interview on [DATE] at 10:25 A.M., Resident #4's family member A (FM A) said: -He/She believed the resident's behaviors were caused by the resident not having his/her proper medication and staff at the facility not knowing how to care for a resident with behaviors.-He/She believed that the resident spiraled out of control due to the resident not getting medications and appropriate treatment. -He/She believed that the facility failed the resident in many ways and that is why the resident spun out of control and ultimately caused harm other people and to get tazed by the police.-The facility did not have staff who knew how to care for the resident.-He/She felt that the lack of education with staff failed the resident. -The family tried to convince the staff of what the facility needed to do to get the resident in control and they felt not listened to by staff or administration.-He/She spoke to the administrator directly about the things that were failed, and he/she felt the administrator shrugged the family concerns off. 2. Review of Resident #7's admission Record showed the resident admitted to the facility on [DATE] with diagnoses of:-Schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behaviors).-Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts).-Generalized Anxiety (a chronic mental health condition characterized by excessive and persistent worry, tension, and nervousness).-Morbid obesity (body weight is more than 80 to 100 pounds above their ideal body weight).-Muscle weakness. Review of the resident's PASRR, dated [DATE], showed:-The resident had mild mental retardation per the department of mental health.-The resident had depression and was withdrawn.-The resident had moderate amount of suspicion and paranoia.-The resident had hallucinations.-The resident had delusions.-The resident had moderate amount of abnormal thought processes.-The resident was controlled with medication.-The resident was non-compliant with medication.-The resident had limited insight with poor decision making skills.-It was recommended that the resident should reside in secure placement.-The resident had a legal guardian through the public administrator's office-The resident had the following diagnoses:--Major depressive disorder--General anxiety disorder with panic attacks--Post-traumatic stress disorder (PTSD- a mental health condition caused by very stressful, frightening or distressing events).--Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder).--Bipolar disorder (a mental health condition characterized by extreme mood swings, alternating between periods of mania (elevated mood) and depression (low mood).--Schizophrenia--Borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life. It includes a pattern of unstable, intense relationships, as well as impulsiveness and an unhealthy way of seeing themselves).-The resident was diagnosed with PTSD at the age of 19 which causes him/her to constantly worry and be anxious.-The resident had a history of auditory and visual hallucinations.-The resident had nightmares and flashbacks of prior traumatic events that happened in his/her life.-The resident reported frequent worry, muscle tension, impaired concentration, and difficulty focusing.-The resident had suicidal ideation dating back to the age of 25.-The resident attempted to commit suicide in November of 2020 when he/she overdosed on a whole bottle of Valium (benzodiazepine- a group of medications classified as central nervous system (CNS) depressants, meaning they slow down the nervous system).-The overdose attempt required hospitalization.-The resident had multiple inpatient psychiatric admissions through the years dating back to 1993.-The resident became physically and verbally aggressive towards others and herself when he/she had a urinary tract infection.-The resident was an elopement risk.-The resident required 24 hour per day nursing supervision oversight to assure his/her safety.-The resident required ongoing medical and psychiatric follow[TRUNCATED]

Based on interview and record review, the facility failed to meet the medical needs of two of three sampled residents (Resident #12 and Resident #4). On 10/15/2025, Resident #12 admitted to the facility with diagnoses including end stage renal disease and post operative right renal kidney transplant. The facility failed to give the resident their ordered anti-rejection medication, failed to provide wound care for their surgical wound for two and a half days, and failed to notify the resident's physician and transplant physician of the missed medications and wound care. The resident admitted to the hospital on [DATE] with an undetectable amount of anti-rejection medication and sepsis (a serious condition in which the body responds improperly to an infection) and an infected necrotic (dead tissue) post operative abdominal wound- requiring IV (intravenous) antibiotics to treat the infection and multiple surgeries. The facility failed to ensure Resident #4's psychotropic medications were reconciled from discharge facility and hospital paperwork, ordered, and administered to the Resident, resulting in multiple verbal and physical outbursts including displays of aggression towards other residents and staff. Resident #4 was tazed and detained by local law enforcement and subsequently hospitalized for inpatient psychiatric care. The facility census was 90 residents.The Administrator was notified on 10/23/25 at 12:40 P.M. of the Immediate Jeopardy (IJ) which began on 10/15/25. The IJ was removed on 10/28/25, as confirmed by surveyor onsite verification.Review of the facility's Consulting Physician/Practitioner Orders Policy, revised 5/7/25, showed:-The attending physician should authenticate orders for the care and treatment of assigned residents.-Consulting physician/practitioners orders were those orders provided to the facility by a physician or practitioner other than the residents attending physician or physician practitioner who is acting on behalf of the attending physician.-A consulting physician/practitioner included but was not limited to: a residents surgeon, dialysis physician, wound clinic physician/nurse practitioner, or clinical nurse specialist.-For consulting physician/practitioner orders received in writing or via fax the nurse in a timely manner would, call the attending physician to verify the order, document the verification order by entering the order and the time date and signature on the physician's order sheet, and follow the facilities procedures for verbal or telephone orders, including noting the order submitting to the pharmacy and transcribing to medication or treatment administration record. Review of the facility's Medication Administration Policy, revised 5/9/25, showed:-Medications were administered by licensed nurses or other staff who were legally authorized to do so in the state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection.-Medication would be administered as ordered in accordance with manufacturer specifications.-Any medication discrepancies would be corrected and reported to the nurse manager. Review of the facility's Wound Treatment Management Policy, revised 5/15/25, showed:-The policy was to promote wound healing of various types of wounds it was the policy of the facility to provide evidence based treatments in accordance with current standards of practice and physicians' orders.-Wound treatment would be provided in accordance with physician's orders including the cleansing method, type of dressing, and frequency of dressing change.-In the absence of treatment orders, the licensed nurse would notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse.-Dressing changes would be provided outside the frequency parameters if a dressing was soiled or wet.-Guidelines for dressing selection would be utilized in obtaining physicians orders.-The facility would follow specific physician's orders provided.-Wound care treatment would be documented on the treatment administration record or in the electronic health record.-The effectiveness of treatments would be monitored through ongoing assessment of the wound.-Considerations for needed modifications included lack of progression toward healing and changes in the characteristics of the wound. Review of the facility's High Risk Medication Policy, revised 6/6/25, showed:-The facility recognized that some medications were associated with greater risk of adverse consequences than other medications.-The policy addressed the facilities collaborative, systematic approach to managing high risk medication for efficiency and safety.-The facility would obtain and document specific parameters for administering or withholding certain high risk medications as per physicians or practitioner orders.-Lab results with the normal limits and within the target range for the individual resident would be communicated via routine procedure.-A resident care plan would alert staff to monitor for adverse consequences of any high risk medication given.-A resident care plan would include interventions to minimize risk of adverse consequences.-Representatives would be educated on the use and risk versus benefits of high risk medications including adverse effects. Review of the facility's Specials Needs Policy, revised 6/10/25, showed:-To address special needs the facility would provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physicians orders, the comprehensive person centered care plan, and the residents goals and preferences.-The facility would utilize a systematic approach for the management of special needs, including efforts to identify risk, stabilize, reduce, or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate-The facility would communicate relevant information with outside providers to ensure safe continuous care of the resident.-Medical conditions would be monitored and managed to prevent complications.-The attending physician would assume responsibility for their overall care and treatment of their residents' medical conditions.-RNs and LPNs would participate in the management of medical conditions by following physician orders, assessment of residents, and reporting changes in condition to the residents physicians. -Interventions would be modified in residents plan of care as needed.-All employees were responsible for following established policies and procedures. Review of the facility's Provisions of Quality Care Policy, revised 6/10/25, showed:-Based on comprehensive assessments, the facility would ensure that residents received treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person centered care plan, and the residents' choices.-Each resident will be provided care and services to attain or maintain his or her highest practical physical mental and psychosocial well-being.-Qualified persons would provide the care and treatment in accordance with professional standards of practice, the residents care plan, and the residents choices to ensure persons are qualified.1. Review of Resident #12's admission Record showed the resident admitted to the facility on [DATE] at 1:00 A.M. with a diagnosis of End Stage Renal Disease (ESRD, also known as kidney failure, is a condition where the kidneys have permanently lost most of their function). NOTE: The resident's admission diagnosis list did not include any other diagnoses, including recent kidney transplant.Review of the resident's discharge summary from the hospital, dated 10/14/25, showed the resident:-Alert and awake.-Had a recent kidney transplant and was on immunosuppressants.-Renal (kidney) function was improving.-discharged to the skilled nursing facility for continued rehabilitation.-To continue the following medications:--Valgaciclov (antiviral medication used for the prevention of disease: In patients who have received a heart, kidney, or kidney-pancreas organ transplant and are at risk of developing disease. Primarily used in immunosuppressed patients) 450 milligrams (mg) : HCl Oral Tablet 450 MG (Give 1 tablet by mouth one time a day).---The resident discharged to the facility with eight Valgaciclov tablets. --Tacrolimus (an immunosuppressant medication used to prevent the body from rejecting a transplanted organ) Oral Capsule 6 mg Give 1 capsule by mouth one time a day.--- The resident discharged to the facility with 180 Tacrolimus tablets. --Myfortic (an immunosuppressant medication primarily used to prevent the body from rejecting a transplanted kidney) Oral Tablet Delayed Release 360 mg (Give 2 tablet by mouth two times a day).-- The resident discharged to the facility with 120 Myfortic tablets. --Prednisone (a corticosteroid medication that plays a crucial role in immunosuppression after organ transplantation) Oral Tablet 20 mg (Give 1 tablet by mouth one time a day).---The resident discharged to the facility with 30 Prednisone tablets. --Bactrim (an antibiotic that is commonly prescribed for kidney transplant recipients, primarily as a prophylactic antibiotic to prevent infections. It is an essential part of post-transplant care) 400 mg/80 mg (Give 1 tablet by mouth every Monday, Wednesday, and Friday).---The resident discharged to the facility with 14 Bactrim tablets. -Had a Tacrolimus (antirejection medication) toxicology level of 9.50, which was a therapeutic and safe level for discharge (In the early transplant phase, target levels are 5 to 20 mg/milliliter (ml).-Had an abdominal post operative site with a healthy wound bed and no sign of infection. Wound care was to be continued per the transplant team with twice a day wound care and dressing changes.--NOTE: No documentation of the wound care orders. -Review of facility records showed no documentation the medication list was reviewed with the resident's facility physician. -Review of facility records showed the facility did not document the meds being sent to the facility from the hospital. Review of the resident's care plan, dated 10/15/25, showed:-The resident at risk for impaired skin integrity related to being admitted with skin impairment in the surgical category.--Staff to complete treatments in all areas of impairment as per ordered.-The resident admitted to the facility on antibiotics related to a urinary tract infection. --Staff to give antibiotic therapy as ordered.-No documentation of the resident's organ transplant, the risk of organ rejection, or interventions put in place.-No documentation of infection control or interventions put in place.-No documentation of high-risk medication or interventions put in place.Review of the resident's Physician Order Sheet (POS), dated 10/15/25, showed the following orders: -Bactrim Oral Tablet 400-80 mg (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth one time a day every Monday, Wednesday, and Friday for prophylaxis. -Ciprofloxacin HCl Tablet 500 mg Give 1 tablet by mouth every 12 hours for Urinary Tract Infection (UTI- an infection in any part of the urinary system. The urinary system includes the kidneys, ureters, bladder and urethra).-Prednisone Oral Tablet 20 mg Give 1 tablet by mouth one time a day for immunosuppression.-Tacrolimus Oral Capsule 1 mg. Give 1 capsule by mouth one time a day for immunosuppression. (Take one 1 mg cap along with one 5 mg cap to equal 6 mg).-Tacrolimus Oral Capsule 5 mg. Give 1 capsule by mouth one time a day for immunosuppression. (Give one 5 mg cap along with one 1 mg cap to equal 6 mg).-Valganciclovir HCl Oral Tablet 450 mg. Give 1 tablet by mouth one time a day for cytomegalovirus (an infection caused by a common herpesvirus that can reactivate and cause serious illness in transplant recipients due to their weakened immune systems). -Myfortic Oral Tablet Delayed Release 360 mg (Mycophenolate Sodium) Give 2 tablet by mouth two times a day for immunosuppression. (Two tabs = 720 mg).-Cleanse right side abdominal wound with wound cleanser, pat dry. Apply skin prep (a barrier product applied to the intact skin surrounding an open wound to protect it) to peri wound. Pack wound bed with 2x2's (a type of medical wound dressing that measures 2 inches by 2 inches) moistened with Dakin's solution 0.125%. Cover with mepilex tape every day and night shift. Review of the resident's Medication Administration Record (MAR), dated October 2025, showed: -On 10/15/25, the day shift wound care treatment marked 9 indicating to see progress note. -The progress note stated wound care was not completed as staff were waiting on confirmation on wound care treatment form the corporate nurse. -On 10/15/25, night shift wound care treatment had a check mark.-On 10/16/25, the day shift wound care treatment marked 9 indicating to see progress note. -The progress note stated wound care not completed as staff were waiting on confirmation on wound care treatment form the corporate nurse. -On 10/16/25, night shift wound care treatment had a check mark.-On 10/17/25, the day shift wound care treatment marked with 9 indicating to see progress note. Review of the resident's Medication Administration Record (MAR), dated October 2025, and observation of the resident's medication in the medication cart on 10/22/25 at 11:30 A.M., showed: -Bactrim Oral Tablet 400-80 mg not given on 10/15/25 and 10/16/25. Staff documented the reason as 9 indicating to review progress note on 10/15/25 and a X documented for 10/16/25, which documented the medication as not given. --The progress note showed that the medication not given as staff were waiting on the medication from the pharmacy.-Ciprofloxacin HCl Tablet 500 mg not given on 10/15/25 in the A.M. and staff documented the reason as 9 indicating to review progress note. On 10/15/25, the P.M. dose, was marked with a check mark as given. On 10/16/25, it was marked with a check mark as given. -Prednisone not given on 10/15/25 and 10/16/25. Staff documented the reason was 9 indicating to review progress note. --The progress note showed the medication not given as staff were waiting on the medication from the pharmacy.--Only one pill showed removed from the medication card.--Two of three opportunities for this medication were missed.-Tacrolimus Oral Capsule 5 mg not given on 10/15/25 and marked 9 indicating to review progress note. MAR documented the medication as given on 10/16/25.--Two of three opportunities for this medication were missed.-Note: Only one pill showed removed from the medication card.-Tacrolimus Oral Capsule 1 mg not given on 10/15/25 and marked 9 indicating to review progress note.--The progress note showed the medication not given as staff were waiting on the medication from the pharmacy.--MAR documented the medication as given on 10/16/25.--Two of three opportunities for this medication were missed. -Note: Only one pill showed removed from the medication card. -Valgaciclov 450 mg not given on 10/15/25 and marked 9 indicating to review progress note. --The progress note showed the medication not given as staff were waiting on the medication from the pharmacy.--MAR documented the medication as given on 10/16/25.--Two of three opportunities for this medication were missed -Note: Only one pill showed removed from the medication card. - Myfortic Oral Tablet Delayed Release 360 mg not given on 10/15/25 and marked 9 indicating to review progress note at 9:00 A.M.---The progress note showed the medication not given as staff were waiting on the medication from the pharmacy.--MAR marked the medication as given 10/15/25 at 9:00 P.M. and given on 10/16/25 at 9:00 A.M. and 9:00 P.M.--Four out of five opportunities for this medication were missed. --Note: Only 1 pocket with two pills showed removed from the medication card. Review of the resident's facility skin note on 10/15/25 at 3:19 A.M., showed: -The resident had a right sided abdominal wound measuring 8.5-centimeter (cm) x 5 cm in size.-The wound dressing was moderately saturated.-The wound had no odor.- No documentation of treatments having been completed. Review of the resident's Clinical admission Screener, dated 10/15/25 at 3:46 A.M., showed:-The resident assessed as alert and admitted to the facility due to weakness.-No documentation of treatments having been completed. Review of the resident's administration note, dated 10/15/25 at 1:21 P.M., showed: -The nurse received a verbal telephone report from the discharging hospital with the following wound care orders: --Cleanse right side abdominal wound with wound cleanser, pat dry. Apply skin prep (a barrier product applied to the intact skin surrounding an open wound to protect it) to peri wound. Pack wound bed with 2x2's (a type of medical wound dressing that measures 2 inches by 2 inches) moistened with Dakin's solution 0.125%. Cover with mepilex tape every day and night shift.--Nursing staff awaiting confirmation from the company's corporate nurse before administering wound care. Review of the resident's Skilled Evaluation, dated 10/15/25 at 4:46 P.M., showed:-The resident's abdominal post operative incision not noted.-Infection control precautions were not noted.-No documentation the resident had specialized medication ordered.-No documentation the resident had antibiotic treatment ordered.-No documentation the resident's provider was notified for clarification of orders or treatments. Review of screen shots sent from the facility's What's App group, dated 10/17/25, showed: -On 10/17/25 at 2:00 P.M., the administrator posted an email from the resident's transplant coordinator RN that stated:-- Good afternoon I was given your e-mail by a family member on behalf of Resident #12. I am his/her transplant coordinator at the hospital, and I have been having a difficult time getting in touch with a nurse and need to discuss the resident. He/She needs to have labs drawn twice a week and I wanted to verify his/her medications. I also wanted to double check to see if your facility has transportation to bring him/her to a follow up appointment. I am unsure who to reach out to and haven't had any luck at the last three days getting ahold of anyone. thank you post-transplant coordinator.-Note: The DON responded at 3:18 P.M., I will. Review of Emergency Medical Services (EMS) Patient Care Report, dated 10/17/25 at 4:00 P.M., showed EMS dispatched to the facility for a fall. The resident was:-experiencing hip pain and back pain after a fall.-found on the floor.-in the facility for rehabilitation after kidney surgery.-alert and orientated and breathing normally.-Facility staff were concerned the resident might have broken his/her hip.-No abnormalities were noticed upon touching and inspection of the areas.-The resident required transport to the emergency room for evaluation after the fall. During an interview on 10/22/25 at 10:52 A.M., the resident's Transplant Team Registered Nurse (RN) said:-He/She attempted to call the facility several times to reach a nurse regarding the care of the resident from 10/15/25-10/17/25.-He/She wanted to ensure the resident was receiving the correct medication and the correct wound care treatments. -He/She called several times and was left on hold for extended periods of time and then would be hung up on.-He/She called the DON's work phone and left several voicemails without a return call.-He/She emailed the administrator for help with ensuring safe care and continuity for the resident and never received a return email or call.-The resident was not getting his/her anti-rejection medications for the three days at the facility as evidenced by the resident's anti-rejection blood levels going from 9.5 on 10/15/25 (when admitted to the facility) to 2.4 on 10/17/25 (when discharged to the hospital).-A level of 2.4 represents a near undetectable amount of anti-rejections medication.-The resident's wound upon return after being in the facility for three days was necrotic which required the resident to have to have two additional surgeries.-The resident was not receiving proper care in the facility and was put at risk for death.-The resident not receiving his/her antirejection medication could have caused his kidney to reject and cause death.-The resident was septic from his/her necrotic surgical site wound which could have caused death. During an interview on 10/22/25 at 11:00 A.M., the resident's transplant team Nurse Practitioner said:-The facility did not administer the resident's anti-rejection medication because it was not detected in his/her blood work upon return to the hospital three days after discharge.-The facility did not complete wound care as ordered on discharge from the hospital as evidence by the resident's wound presented dead and necrotic upon re-admission. -The resident's wound upon discharge and admit into the facility was in good and healthy standing three days prior, with no signs of infection.-Serious harmful outcome and death could have occurred from the resident not receiving his antirejection medications.-The resident not getting his/her wound care treatments resulted in the resident needing two surgeries and possibly a third, to debride the wound.-The surgeon and himself/herself attempted to contact the facility to coordinate care and were never called back.-The resident's transplant team and doctor were not made aware the resident was not getting his/her medication.-Missing even one dose of an antirejection medication could cause a resident harm.-The facility never contacted the transplant team or the doctor to clarify wound care orders.-Wound care for post-transplant patients were very important because the patients were at such a higher risk for infection.-The resident's infection happened even faster because he/she was not getting his/her medications as ordered. During an interview on 10/22/25 at 11:48 A.M., Certified Medication Technician (CMT) E said: -He/She was the only one who gave the resident his/her medication.-The resident received one dose of his/her medication between 10/15/25-10/17/25.-The resident only received one dose because they were waiting on the medication to be delivered from the pharmacy.-He/She did not know what medication the resident was taking or the importance of not missing doses.-He/She had not been educated on the resident's medication.-He/She never cared for a post-transplant resident before.-He/She reported to the DON that the resident missed his/her doses of medication twice. During an interview on 10/22/25 at 9:30 A.M., DON said:-The resident came to facility after getting an organ transplant.-He/She was unsure of which organ was transplanted but believed left kidney.-The resident admitted on [DATE] and he/she believed the resident had the transplant 9/24/25 or 9/25/25.-He/She did not know anything about the resident getting or supposed to be getting transplant rejection medication.-If there were delays in medication from pharmacy or hospital, he/she would expect staff to talk to him/her about the problem.-No one had reached out to him/her about not having medication on site.-To his/her knowledge the resident was getting all of his/her ordered medication from the hospital.-He/She couldn't recall what medications the resident was on or supposed to be getting.-He/She expected nursing staff to get transplant antirejection medication or any other life altering medication within a couple hours of a resident being admitted to the facility.-He/She was unsure who was responsible to ensure the resident's antirejection medication was at the facility. -If medication was not available for a post-transplant resident, he/she would expect the nurse to contact the physician and document a progress note in the resident's electronic medical record. -Staff had no training on how to care for a post-transplant resident. -He/She never received training about high-risk medication administration.-He/She never receive training on the increased infection risk for post-transplant patients.-He/She never received training on the risk of organ rejection and what signs and symptoms to be looking for with a post-transplant patient-He/She has never cared for a post-transplant resident.-He/She had no training on how to care for a post-transplant resident. During an interview on 10/22/25 at 2:00 P.M., the resident's physician, Physician A, said: -He/She would expect a resident to receive his/her antirejection medication as ordered.-A resident not receiving their antirejection medication post operatively could have caused the resident to be an increased risk for infection, caused the resident's organ to be rejected, and caused death. -He/She would expect a post operative wound to be treated at the facility as ordered.-A resident with a postoperative organ transplant wound was at a higher risk for infection.-He/She would expect a call from facility staff if there were any questions regarding the treatment of a post-transplant resident.-He/She was never contacted about the resident. During an interview on 10/22/25 at 2:43 P.M., Licensed Practical Nurse (LPN) A said: -If a resident was admitted for three days, three days of medication would have been removed from the resident's medication card if they received all three days of medication.-The number nine 9 on the MAR meant a progress note was done. -There should have been two days' worth of meds removed out of the card if the MAR showed a number 9 one day and initials two other days. -If the MAR showed a medication given twice, but only one pill removed out of the card then the medication was only given once and that was a medication error. -For a medication like an antirejection med if the medication was not here, the pharmacy should have been called and an emergency delivery arranged. -He/She was not sure who was responsible for ordering the medication for emergency delivery.-He/She would have expected staff to call the doctor to inform them that the resident's medication was not in house and not being administered.-He/She was not sure who was responsible for calling the doctor to inform the doctor that the resident's medication was not being administered.During an interview on 10/22/25 at 3:03 P.M., CMT E said:-If only one medication was removed out of the medication card, then only one dose of medication was given.-He/She was not sure why the MAR indicated he/she gave the resident more than one dose. -The MAR could have made an error, or he/she could have made an unintentional error.-The resident only received one dose on his/her medication from 10/15/25-10/17/25.-He/She reported to the DON the resident was not receiving any medications, and the medications were not available. The DON was aware that the resident was not receiving his/her medication as ordered. During an interview on 10/23/25 at 11:57 P.M., Pharmacy Manager/Pharmacist said: -The pharmacy received the medication orders for the resident on 10/15/25 at 4:00 A.M.-The medication was not ordered STAT (immediately).-He/She would expect organ antirejection medications to be ordered STAT or picked up by the facility staff.-An organ anti-rejection medication dose should not be missed as it could cause serious harm or even death if it's missed.-He/She would expect a facility to have high level medication such as antirejection medication to be on site before the resident arrived at the facility.-The resident's medication was delivered on 10/16/25 at 12:40 A.M. During an interview on 10/22/25 at 3:00 P.M., LPN D said:-He/She had the resident one time, the day that he/she was admitted , 10/15/25.-He/She asked the facility wound nurse to complete the resident's wound care because he/she did not feel comfortable doing so.-He/She never cared for a post-transplant wound.-The wound nurse did not complete the wound care, because he/she also didn't feel comfortable doing so.-Wound care was not done for the three days the resident was at the facility.-The resident was ordered to have wound care and treatment done twice per day. During an interview on 10/22/25 at 3:42 P.M., LPN C wound care nurse said:-He/She was on the floor working as a CNA the week the resident was admitted .-He/She knew there were abdominal wound orders written on the resident upon admission.-He/She never used the solution that was ordered for the wound care, Dakins solution (applied to a wound to clean and debride it, promote healing, and prevent infection) and he/she did not feel comfortable completing the wound care orders without clarification.-He/She asked the administrator for clarification and received no help, so he/she called the corporate nurse.-The corporate nurse instructed him/her not to use the ordered solution.-He/She notified LPN D to call the physician and change the wound care orders.-The physician was never notified.-The administrator got angry with him/her for calling corporate for clarification of the order and terminated him/her the next day on 10/16/25.-He/She did not perform wound care on the resident from 10/15/25-10/16/25.-No other staff were completing wound care on the resident from 10/15/25-10/16/25. -He/She was the facility's only wound care nurse.-Other nursing staff could do wound treatments and were responsible for completing wound treatments when he/she was not at the facility. -The DON and the administrator were aware that the resident was not getting wound care treatments. During an interview on 10/22/25 at 4:08 P.M., Corporate DON said:-He/She was contacted by LPN C and asked about the wound care orders for the resident.-He/She instructed LPN C to reach out to the surgeon to clarify the wound care orders.-The surgeon was never notified by LPN C. During an interview on 10/22/25 at 4:12 P.M., LPN C said:-The administrator terminated him/her before he/she could follow through with clarifying the wound care orders.-He/She would have expected the DON and the administrator to follow through with ensuring that the resident received his/her wound care.-There was a message on What's App from the administrator where he/she posted an email from the resident's transplant RN and asked staff to follow-up but as far as he/she knew, no one ever did. -The DON was supposed to follow up with the resident's organ transplant team to coordinate care between the transplant team and the facility. During an interview on 10/22/25 at 9:30 A.M., DON said:-He/She never knew that a transplant team member was trying to reach a clinical nurse in the facility to coordinate care for the transplant resident.-He/She would have expected good communication to occur between the transplant team and the facility staff.-The administrator never told him/her that anyone from the transplant team or hospital staff was trying to reach a clinical nurse-He/She denied receiving a message from staff regarding the communication with the resident's transplant nurse. -He/She would expect residents to receive their wound care as ordered.-He/She was not aware that the resident was not receiving his/her wound care as ordered. -He/She was not sure who was responsible for completing wound care for the residents. During an interview on 10/22/25 at 4:50 P.M., DON said:-He/She never received a message from the administrator on Whats App or any other means asking him/her to check up on the transplant resident.-He/She was never instructed in person by the administrator to contact the resident's transplant team for coordination of care. Note: When it was told to the DON that an email was observed from transplant team and the resident's family member that was addressed to the administrator and then forwarded to him/her, the DON said:-He/She was working the floor on the day the administrator sent the emails about the resident and was flustered.-The resident was still in the building on the day the emails were received, but he/she forgot to take care of it because he/she worked the floor that day.-He/She felt bad and knew that he/she dropped the ball.-The administrator never followed up with him/her to ensure that the clinical team reached out to the transplant team. During an interview on 10/23/25 at 10:42 A.M., the ADON said:-He/She was never instructed to contact the resident's transplant team.-He/She was not aware that the resident was not receiving his/her medication.-He/She was not aware that the resident was not receiving his/her wound care orders.-He/She would expect wound c

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident #12) was free from a significant medication error. The facility failed to order and administer Resident #12's antirejection medication after the resident admitted to the facility post kidney transplant. Resident #12 did not receive ordered medications for immunosuppression (a state in which the body immune system is weekend and less effective in fighting infection) on 10/15/25 and 10/16/25. The resident admitted back to the hospital with an undetectable amount of the anti-rejection medication in his/her bloodwork and with potential rejection of the transplant organ and sepsis (a life-threatening condition that happens when the body's immune system has an extreme response to an infection, causing organ dysfunction). The facility census was 90 residents.The Administrator was notified on 10/23/25 at 12:40 P.M. of the Immediate Jeopardy (IJ) which began on 10/3/25. The IJ was removed on 10/26/25, as confirmed by surveyor onsite verification. Review of the facility's Consulting Physician/Practitioner Orders Policy, revised 5/7/25, showed:-The attending physician should authenticate orders for the care and treatment of assigned residents.-Consulting physician/practitioners orders were those orders provided to the facility by a physician or practitioner other than the residents attending physician or physician practitioner who is acting on behalf of the attending physician.-A consulting physician/practitioner included but was not limited to: a residents surgeon, dialysis physician, wound clinic physician/nurse practitioner, or clinical nurse specialist.-For consulting physician/practitioner orders received in writing or via fax the nurse in a timely manner would, call the attending physician to verify the order, document the verification order by entering the order and the time date and signature on the physician's order sheet, and follow the facilities procedures for verbal or telephone orders, including noting the order submitting to the pharmacy and transcribing to medication or treatment administration record. Review of the facility's Medication Administration Policy, revised 5/9/25, showed:-Medications were administered by licensed nurses or other staff who were legally authorized to do so in the state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. -Any medication discrepancies would be corrected and reported to the nurse manager. Review of the facility's High Risk Medication Policy, revised 6/6/25, showed:-The facility recognized some medications were associated with greater risk of adverse consequences than other medications.-The policy addressed the facility's collaborative, systematic approach to managing high risk medication for efficiency and safety.-The facility would obtain and document specific parameters for administering or withholding certain high risk medications as per physicians or practitioner orders.-Representatives would be educated on the use and risk versus benefits of high risk medications including adverse effects. Review of Resident #12's admission Record showed the resident admitted to the facility on [DATE] at 1:00 AM, with a diagnosis of End Stage Renal Disease (ESRD, also known as kidney failure, is a condition where the kidneys have permanently lost most of their function). NOTE: The resident's admission diagnosis list did not include any other diagnoses, including recent kidney transplant. Review of the resident's discharge summary from the hospital, dated 10/14/25, showed: -The resident to continue the following medications and discharged to the facility with the following medications:--Valgaciclov (antiviral medication used for the prevention of disease in patients who have received a heart, kidney, or kidney-pancreas organ transplant and are at risk of developing disease. Primarily used in immunosuppressed patients) 450 mg: HCl Oral Tablet 450 mg (Give 1 tablet by mouth one time a day).---The resident discharged to the facility with eight Valgaciclov tablets.--Tacrolimus (an immunosuppressant medication used to prevent the body from rejecting a transplanted organ) Oral Capsule 6 mg, Give 1 capsule by mouth one time a day.--- The resident discharged to the facility with 180 Tacrolimus tablets.--Myfortic (an immunosuppressant medication primarily used to prevent the body from rejecting a transplanted kidney) Oral Tablet Delayed Release 360 mg (Give 2 tablet by mouth two times a day).-- The resident discharged to the facility with 120 Myfortic tablets.--Prednisone (a corticosteroid medication that plays a crucial role in immunosuppression after organ transplantation) Oral Tablet 20 mg (Give 1 tablet by mouth one time a day).---The resident discharged to the facility with 30 Prednisone tablets.--Bactrim (an antibiotic that is commonly prescribed for kidney transplant recipients, primarily as a prophylactic antibiotic to prevent infections. It is an essential part of post-transplant care) 400 mg/80 mg (Give 1 tablet by mouth every Monday, Wednesday, and Friday).---The resident discharged to the facility with 14 Bactrim tablets.-The resident had a Tacrolimus (antirejection medication) toxicology level of 9.50, which was a therapeutic and safe level for discharge (In the early transplant phase, target levels are 5 to 20 mg/ml).--NOTE: The hospital discharge documentation showed the resident discharged from the hospital with a bag containing the noted supply of medications to continue at the facility. Record review of the resident's lab values from the hospital on [DATE] showed a tacrolimus (Anti-rejection medication) level of 9.50 ng/ml. (normal 5.0-15.0 ng/mL.Review of the resident's Care Plan, dated 10/15/25, showed: -The resident admitted to the facility on antibiotics related to a urinary tract infection. --Staff to give antibiotic therapy as ordered.- The care plan did not mention of anti-rejection medications or medications to be administered after an organ transplant. Review of the resident's Physician Order Sheet (POS), dated 10/15/25, showed the following orders: -Prednisone Oral Tablet 20 mg. Give 1 tablet by mouth one time a day for immunosuppression.-Tacrolimus Oral Capsule 1 mg. Give 1 capsule by mouth one time a day for immunosuppression. (Take one 1 mg cap along with one 5 mg cap to equal 6 mg).-Tacrolimus Oral Capsule 5 mg. Give 1 capsule by mouth one time a day for immunosuppression. (Give one 5 mg cap along with one 1 mg cap to equal 6 mg).-Valganciclovir HCl Oral Tablet 450 mg. Give 1 tablet by mouth one time a day for cytomegalovirus (an infection caused by a common herpesvirus that can reactivate and cause serious illness in transplant recipients due to their weakened immune systems). -Myfortic Oral Tablet Delayed Release 360 mg (Mycophenolate Sodium) Give 2 tablet by mouth two times a day for immunosuppression. (Two tabs = 720 mg).--NOTE: No documentation by facility staff showing the resident admitted with a supply of medication from the hospital. Review of the resident's Medication Administration Record (MAR) and observation of the medication cart on 10/22/25 at 11:30 A.M., showed the following for the time period of 10/15/25-10/17/25:-No medications in the cart appeared to have originated from the hospital.-Prednisone (Give 1 tablet by mouth one time a day for immunosuppression)- not given on 10/15/25 and 10/16/25. Staff documented the reason as 9, indicating review progress note. The progress note showed the medication not given as staff were waiting on the medication from the pharmacy.--Observation showed one pill removed from the medication card.--Two of three opportunities for this medication were missed.-Tacrolimus Oral Capsule 5 mg (Give 1 capsule by mouth one time a day)- not given on 10/15/25. Staff documented the reason as 9, indicating review progress note.--MAR was marked as given on 10/16/25.--Two of three opportunities for this medication were missed.-Note: Only one pill was removed from the medication card.-Tacrolimus Oral Capsule 1 mg (Give 1 capsule by mouth one time a day) was not given on 10/15/25. Staff documented the reason as 9, indicating review progress note. The progress note showed the medication was not given as staff were waiting on the medication from the pharmacy.--MAR was marked as given on 10/16/25.--Two of three opportunities for this medication were missed.-Note: Only one pill was removed from the medication card. -Valgaciclov 450 mg (Give 1 tablet by mouth one time a day ) was not given on 10/15/25. Staff documented the reason as 9, indicating review progress note. The progress note showed the medication not given as staff were waiting on the medication from the pharmacy.--MAR was marked as given on 10/16/25.--Two of three opportunities for this medication were missed -Note: Only one pill was popped from the medication card. - Myfortic Oral Tablet Delayed Release 360 mg (Give 2 tablet by mouth two times a day) was not given on 10/15/25 at 9:00 A.M. Staff documented the reason as 9, indicating review progress note.---The progress note showed that the medication was not given as staff was waiting on the medication from the pharmacy.--MAR was marked as given 10/15/25 at 9:00 P.M., given on 10/16/25 at 9:00 A.M. and 9:00 P.M., however, observation showed only 1 pocket with two pills removed from the medication card.--Four out of five opportunities for this medication were missed. During an interview on 10/22/25 at 9:30 A.M., DON said: -He/She was not sure what the process was or who was responsible reconciling medications upon admission to the facility. -He/She was not sure what the process was when medications are sent with a resident upon admission.-He/She did not know anything about the resident getting transplant antirejection medication.-If there were delays in medication from pharmacy or hospital, he/she would expect staff to talk to him/her about the problem.-No one reached out to him/her about not having medication onsite.-To his/her knowledge the resident was getting all of his/her ordered medication from the hospital.-He/She couldn't recall what medications the resident was on or supposed to be getting.-He/She expected nursing staff to get transplant antirejection medication or any other life altering medication within a couple hours of a resident being admitted to the facility and that they should be ordered STAT (urgent/immediate).-The resident was sent back to the hospital on [DATE] due to falling. -The resident came to facility after getting and organ transplant.-He/She was unsure of which organ was transplanted but believed left kidney.-The resident was admitted on the 10/15 and believed he/she had the transplant 9/24 or 9/25.-He/She did not know anything about the resident getting or supposed to be getting transplant rejection medication.-If there were delays in medication from pharmacy or hospital, he/she would expect staff to talk to him/her about the problem.-No one has reached out to him/her about not having medication on site.-To his/her knowledge the resident was getting all of his/her ordered medication from the hospital.-He/She couldn't recall what medications the resident was on or supposed to be getting.-He/She expected nursing staff to get transplant antirejection medication or any other life altering medication within a couple hours of a resident being admitted to the facility.During an interview on 10/22/25 at 10:52 A.M., the resident's Transplant Team Registered Nurse (RN) said: -The resident received all of his/her medications prior to discharge from the hospital. -The resident was not getting his/her anti-rejection medications as evidenced by the resident's anti-rejection blood levels going from 9.5 on 10/15/25 (when admitted to the facility) to 2.4 on 10/17/25 (when discharged to the hospital).-A level of 2.4 represents a near undetectable amount of anti-rejections medication.-The resident not receiving his/her antirejection medication could have caused his kidney to reject and caused death. During an interview on 10/22/25 at 11:00 A.M., the resident's transplant team nurse practitioner said: -The resident received all of his/her medications prior to discharge from the hospital. -The facility did not give the resident their medication as evidence by the resident's anti-rejection medication not being detected in his blood work upon return to the hospital three days after discharge. -Serious harmful outcome and death could have occurred from the resident not receiving his/her antirejection medications.-The hospital sent the resident to the facility with a supply of medication to prevent this from happening. -The resident's transplant team and doctor were not made aware that the resident was not getting his/her medication.-Missing even one dose of an antirejection medication could cause a resident harm.During an interview on 10/22/25 at 11:48 A.M., CMT E said: -He/She was the only one who gave the resident his/her medication.-The resident only received one dose of his/her medication between 10/15/25-10/17/25.-The resident only received one dose because they were waiting on the medication to be delivered from the pharmacy.-He/She did not know what medication the resident was taking or the importance of not missing doses.-He/She was not educated on the resident's medication.-He/She reported to the DON that the resident was missing his/her doses of medication twice.-He/She could not explain why the MAR showed he/she documented administering medications on 10/15/25 or 10/16/25. -He/She did not know the process of ordering medications when a resident was admitted or who was responsible for ordering medications upon admission. -He/She did not know the process of what staff should do if a medication was not available. During an interview on 10/23/25 at 11:45 A.M., Interim Administrator A said:-He/She discovered that the hospital discharged the resident to the facility with some medication in a bag, but he/she has not located the medication bag after he/she spoke to the resident's family member and Transplant NP. -He/She did not know what happened to the resident's medication that was with him/her upon admission to the facility.-He/She asked staff, and no one knew or saw the resident's medication bag. During an interview on 10/22/25 at 2:00 P.M. Physician A said:-He/She would expect a resident to receive his/her antirejection medication as ordered.-A resident not receiving his/her antirejection medication post operatively could have caused the resident harm. -He/She was never contacted about the resident not having his/her medication or missing doses. During an interview on 10/22/25 at 2:43 P.M., Licensed Practical Nurse (LPN) A said: -He/She did not see a bag of medication sent with the resident from the hospital. -If a resident was admitted for three days, three days of medication would have been removed from the resident's medication card if they received all three days of medication.-The number nine on the MAR/TAR meant a progress note was done. -There should have been two meds popped out of the card if on the MAR/TAR showed a number 9 one day and initials two other days.-If the MAR/TAR showed a medication was given twice but only one pill was popped out of the card then the medication was only given once and that was a medication error.-For a medication like an antirejection med if the medication was not here, the pharmacy should have been called and an emergency delivery arranged.-He/She would have expected staff to call the doctor to inform them that the resident's medication was not in house and not being administered. During an interview on 10/22/25 at 3:03 P.M., CMT E said:-If only one medication was removed out of the medication card, then only one dose of medication was given. -He/She did not see a bag of medication sent with the resident from the hospital. -The resident only received one dose on his/her medication from 10/15/25-10/17/25.-He/She received the resident's medications when they came in from the pharmacy on 10/16/25. -The DON was aware that the resident was not receiving his/her medication as ordered because he/she reported this to the DON. During an interview on 10/23/25 at 11:57 P.M., Pharmacy Manager/Pharmacist said: -The pharmacy received the medication orders for the resident on 10/15/25 at 4:00 A.M.-The medication was not ordered STAT (immediately).-He/She would expect organ antirejection medications to be ordered STAT or picked up by the facility staff.-An organ anti-rejection medication dose should not be missed as it could cause serious harm or even death if it's missed.-He/She would expect a facility to have high level medication such as antirejection medication to be on site before the resident arrived at the facility.-The resident's medication was delivered on 10/16/25 at 12:40 A.M. During an interview on 10/23/25 with 10:42 A.M., the ADON said: -He/She was not aware that the resident was not receiving his/her medication.-He/She would expect that a post-transplant resident did not miss any doses of anti-rejection medication. -He/She would expect a resident that was a post-transplant resident to have medication already on site prior to admission so doses weren't missed.-He/She would expect staff to order the antirejection medications STAT.-He/She was unsure who was responsible for ensuring the resident's medication were ordered STAT and at the facility upon admission. During an interview on 10/23/25 at 11:15 A.M., the Corporate DON said: -He/She would expect high level medication such as anti-rejection medications to be on site when a patient arrived on site.-He/She would not expect a resident to miss doses of anti-rejection medication. During an interview on 10/23/25 at 4:17 P.M., LPN F said: -He/She cared for the resident at the facility as the charge nurse.-The resident's medications were not administered on 10/15/25 or 10/16/25 as reported to him/her by the CMT. -The DON was aware that the resident's medication were not being administered because he/she told the DON that meds were not available and being administered. -He/She never saw the resident's medication during his/her shifts on 10/15/25 or 10/16/25. During an interview on 10/23/25 at 8:05 A.M., Resident #12 said he/she did not remember receiving any medications while at the facility. During an interview on 10/23/25 at 8:15 A.M., hospital Registered Nurse (RN) said:-Resident #12 was admitted to the hospital with sepsis. -That would mean that the resident was severely sick.-Missing antirejection medication was bad and could cause the transplanted organ to be rejected. During an interview on 10/23/25 at 8:32 A.M., Transplant Doctor said:-The resident received a kidney transplant last month. -From the laboratory results obtained in the hospital from current admission it has appeared that the resident had not received any antirejection medication.-The resident not getting the antirejection medication as ordered could cause the body to reject the transplanted organ requiring another surgery to remove the organ. During an interview on 10/23/25 at 12:57 P.M., the Administrator said: -He/She was responsible for ensuring that the facility was managed in a manner to maintain the highest practicable, physical, mental, and psychosocial wellbeing for all of the residents.-He/She was not aware that the resident was a post-transplant patient.-He/She was not aware that the resident was not receiving his/her medication.-He/She would have expected all medication to be administered and no doses to be missed. During an interview on 10/23/25 at 12:55 P.M., the Chief Operating Officer (COO) said: -He/She would expect that all residents received their medication and treatments as ordered.-He/She would expect the clinical team and the administrator ensured safe medication administration of all of a resident's medication.-He/She expected staff to coordinate care with transferring facilities to ensure that resident's medication were all transcribed and continued.Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at that time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address the Class I violation(s).Complaint numbers: 2645193, 2646488, 2642955, 2633865, 2636127, 2640626, 2646855, 2648264

Based on interview and record review, the facility failed to ensure two sampled residents (Resident #5 and Resident #6) were free from physical abuse when Resident #4 verbally abused and attempted to physically abuse Resident #5 which caused the resident to fall and resulted in feelings of embarrassment and humiliation for Resident #5. In addition, Resident #4 physically abused Resident #6 which caused Resident #6 pain and the need to be sent to the hospital for evaluation. Thirteen residents were sampled. The facility census was 90. Review of the facility policy titled Abuse, Neglect, and Exploitation, revised 6/30/25, showed:-It was the policy of the facility to provide protection for the health welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.-Abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which could include staff to resident abuse and resident to resident altercations.-Abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology.-Mental abuse included but was not limited to humiliation, harassment, threats of punishment, or deprivation.-Physical abuse included but was not limited to hitting, slapping, punching, biting, and kicking.-Verbal abuse meant the use of oral or gesture, communication, or sounds that willfully included derogatory terms to residents or their families or within their hearing distance, regardless of their age ability to comprehend or disability.-The facility would implement policies and procedures to prevent and prohibit all types of abuse.-The facility would identify, correct, and intervene in situations in which abuse was more likely to occur with the deployment of trained and qualified staff.-The facility would ensure that staff had knowledge of the individual residents' needs and behavioral symptoms.-The facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as abuse during and after an investigation. Review of Resident #4's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Paranoid Schizophrenia (a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior. It is primarily marked by paranoia, intense delusions, and hallucinations, particularly auditory ones, where individuals may hear voices that aren't real).-Anxiety Disorder (a mental health condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).-Delusional Disorder (a type of mental health condition in which a person can't tell what's real from what's imagined).-Personality Disorder (a mental health condition characterized by enduring patterns of thinking, feeling, and behaving that deviate significantly from cultural expectations and cause distress or impairment in daily functioning).-Hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch and taste). Record review of the resident's behavior notes, dated 10/11/25 at 12:38 P.M., showed:-The resident attempted to punch another resident (Resident #5). Review of Resident #5's admission Minimum Data Set, dated [DATE], showed he/she:-admitted to the facility on [DATE].-had moderate cognitive impairment. During an interview on 10/16/25 at 2:30 P.M., Anonymous reporter said:-Around 6:00 A.M., on 10/11/25 , Resident #5 left the facility and walked down the street after an incident with Resident #4. -The reason Resident #5 left was because Resident #4 threatened Resident #5 in the middle of the night that he/she was going to slit Resident #5's throat.-The incident was reported to the Director of Nursing (DON). During an interview on 10/17/25 at 12:01 P.M., Housekeeper A said:-Resident #4 attempted to hit Resident #5 on 10/11/25.-Resident #4 verbally assaulted Resident #5 on 10/11/25. -The incidents caused Resident #5 to cut their rehabilitation short and the resident left the facility. During an interview on 10/17/25 at 12:30 P.M., Certified Nurse Assistant (CNA) C said:-Resident #4 was cursing and yelling and attempted to hit Resident #5 on 10/11/25.-Resident #5 became visibly affected by the incident and left the facility.-Resident #5 lost his/her balance when he/she was attempting to avoid a hit by Resident #4 and it caused Resident #5 to fall back in their wheelchair. -He/She notified the DON of the incident. During an interview on 10/21/25 at 8:55 A.M., the Assistant Director of Nursing (ADON) said:-It was reported to the administration there was an incident between Resident #4 and Resident #5.-Resident #5 was no longer a resident at the facility as a result of the incident. During an interview on 10/28/25 at 3:30 P.M., Resident #5 said:-He/She was verbally and physically attacked by Resident #4 on 10/11/25.-Resident #4 was kicking another resident's wheelchair on or about 10/11/25 when he/she stood up from his/her wheelchair and told Resident #4 to stop.-Resident #4 then attempted to punch Resident #5 in the face. He/She then lost his/her balance and fell.-After the altercation, he/she left the facility with a family member because he/she became angry and scared.-He/She was embarrassed and humiliated by the incident.-He/She returned the facility after Resident #4 was no longer in the facility to finish his/her rehab stay.-He/She felt unsafe when Resident #4 was in the facility.-He/She heard other residents state they felt unsafe and feared Resident #4.-Resident #4 threatened to cut Resident #5's throat and would come in and out of his/her room throughout the night.-He/She had to leave the facility due to feeling unsafe which put him/her behind on his/her stroke recovery. Review of the Resident #6's admission Records, dated 10/20/25, showed the resident:-admitted to the facility on [DATE].-cognitively impaired.-had a cerebral infarction due to thrombosis of left middle cerebral artery (a stroke caused by a blood clot forming and blocking the left middle cerebral artery, leading to brain cell death in the left side of the brain due to lack of oxygen).-had hemiplegia (paralysis of one side of the body).-had apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements).-had dysarthria (difficulty speaking).-had aphasia (a language impairment that can impact a person's ability to speak or understand speech).-had Major Depressive Disorder (MDD- a serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed).-had muscle weakness.-had lack of coordination.-needed assistance with personal cares. Review of Resident #4's behavior notes, dated 10/14/25 at 3:29 A.M., showed Resident #4 sent to the hospital after an altercation with another resident and law enforcement. Review of Resident's #4's behavior notes, dated 10/14/25 at 6:27 A.M., showed the resident up most of the night pacing, yelling, threatening staff, making very loud noises, and causing disturbances to other residents. At one point he/she yelled at another resident and grabbed the other resident's wheelchair. Review of Resident #6's emergency room visit note, dated 10/14/25 at 6:20 P.M., showed the resident:-seen in the emergency room due to being the victim of a physical assault.-had pain because of the physical assault.-had a scalp bruise because of the physical assault. During an interview on 10/17/25 at 10:30 A.M., CNA A said:-He/She witnessed Resident #4 karate chop Resident #6 on his/her shoulder on 10/14/25.-Resident #4 hit Resident #6 hard.-The hit appeared to hurt Resident #6.-Resident #6 was nonverbal. Resident #6 had a grimaced face after he/she was hit by Resident #4.-Resident #6 went to the hospital via EMS to get checked out per family request after he/she was hit by Resident #4. During an interview on 10/17/25 at 10:50 A.M., CNA B said:-He/She witnessed the incident between Resident #4 and Resident #6 on 10/14/25.-Resident #4 karate chopped Resident #6 in the neck very hard.-Resident #4 was visibly agitated and hit Resident #6 out of anger. During an interview on 10/17/25 at 11:40 A.M., Housekeeper B said:-He/She was cleaning the hallways when Resident #4 came around a corner really fast pushing Resident #6 in his/her wheelchair on 10/14/25. -Resident #6 was scared and waving his/her arms to get someone's attention to help.-Resident #6 was nonverbal and could not ask for help.-He/she intervened and stopped Resident #4 from pushing Resident #6.-He/She told Resident #4 to stop, and then Resident #4 karate chopped Resident #6 on his/her shoulder hard.-The hard hit hurt Resident #6. Resident #6 moaned in pain and had a painful look on his/her face after he/she was hit. Resident #6 had tears in his/her eyes after he/she was hit.-Resident #4 hit Resident #6 with clear intent and left a red mark on Resident #6. He/She saw the red marks on Resident #6.-Resident #4 was clearly agitated and angry when he/she Karate chopped Resident #6.-Resident #6 was scared, waving his/her hands in the air to get someone's attention, and needed help.-Resident #6 was sent to the hospital for evaluation per family request after he/she was hit. During an interview on 10/20/25 at 4:00 P.M., Certified Medication Technician (CMT) B said:-He/She witnessed the event with Resident #4 and Resident #6.-Resident #4 was running and pushing Resident #6 in his/her wheelchair through the hallway and around a corner.-Resident #6 was scared and waving his/her arms.-Housekeeper B intervened to stop Resident #4 from pushing Resident #6.-Resident #4 became angry and hit Resident #6 hard on the back of the head and the shoulders.-Resident #4 hit Resident #6 two or three times. During an interview on 10/21/25 at 11:14 A.M., Resident #6's responsible party said:-He/She was unhappy about Resident #6 being abused in the facility by another resident.-He/She witnessed Resident #4's behaviors and they were scary.-Resident #6 feared Resident #4.-Other residents in the facility feared Resident #4.-He/She was in a wheelchair himself/herself due to a recent health problem. He/she would have been terrified if what happened to Resident #6, happened to him/her.-He/She believed the physical contact made to Resident #6 by Resident #4 caused the resident pain.-He/She believed the incident caused the resident caused emotional sadness and the resident trauma. -He/She knew Resident #6 well and knew that he/she was scared and traumatized by the incident.-Resident #6 suffered from depression and he/she felt the incident could make the resident's depression worse. During an interview on 10/28/25 at 9:13 A.M., Interim Administrator A and the Corporate DON said:-He/She would expect all residents to be kept safe and free from abuse in the facility.-It was the responsibility of all staff members to ensure the safety and wellbeing of each resident.-He/She would expect all residents to free from abuse in the facility. 2645193, 2646488, 2642955, 2633865, 2636127, 2640626, 2646855

Based on observation, interview and record review, the facility failed to prevent one (Resident #1) of three sampled residents from developing facility acquired wounds to his/her coccyx (a small triangular bone at the base of the spinal cord) and to his/her left buttock, each of which increased in size and developed into one larger wound, to notify the physician and the Registered Dietician (RD) of the wound on his/her coccyx/buttocks and of it's progression, and to ensure the RD assessed accurately the resident's current condition on 10/22/14 regarding his/her wound; resulting in the resident being transferred to the hospital on [DATE] with an infected wound 5 centimeters (cm) by 6.5 cm in size and 1.5 cm deep on his/her coccyx; and on 11/7/14 he/she required surgical debridement (the removal of dead tissue from a wound) of his/her coccyx wound. The facility census was 96 residents. Record review of the facility's policy and procedure titled Wound and Skin Care Policy and Protocol dated 2/2/09 and 2/1/11, showed it's purpose was to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions, to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown, and to promote healing of pressure ulcers in a cost efficient and timely manner. -Procedures: Risk Identification and Assessment: --The purpose of the assessment is to collect enough information to evaluate the resident's general condition, characterize a pressure ulcer and identify related causes and complications. --A Braden Scale (a pressure sore risk assessment instrument) should be complete for all residents upon admission, readmission, when a significant change of condition occurs, and with each Minimum Data Set (MDS; a federally mandated assessment tool required to be completed by facility staff) assessment. --Resident's with a Braden score of 12 or less should be considered to be "at high risk" for pressure ulcer development. Findings from the weekly skin assessment should be documented by the licensed nurse on a Weekly Skin Assessment form. --Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc, should be assessed and documented weekly by the Wound Nurse, or designee, on the Wound Evaluation Flow Sheet. --Documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling or undermining. -Prevention and Treatment Guidelines: --Any risk factors identified by the Braden Scale, MDS, or other assessment should be reviewed and addressed as determined through the Resident Assessment Instrument (RAI) process, including the resident's care plan. --A nutritional consultation should be completed for residents who are at-risk for malnutrition. --Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher-risk residents, those that do not heal as anticipated, and those that develop complications. --The physician should be notified and consulted if an ulcer does not show signs of healing after 14 days of the same treatment. -Systems for Quality Assurance (QA): --The wound nurse or designee should maintain and update a list of residents who have been identified to be at high risk, and an assessment and documentation schedule. --Residents with wounds should be reviewed during weekly Risk Management Committee meetings for progress, interventions, and care plan revision as appropriate. --The Risk Management Committee should also monitor to assure the facility's policies and protocols are followed. --At the direction of the facility QA committee, a weekly wound report should be completed by the Director of Nursing (DON) or designee, on a weekly basis for review and monitoring by the QA committee to assure the objectives of this policy and protocols are being met. Record review of the facility's policy and procedure regarding Change in a Resident's Condition or Status, dated 1/22/05 and updated 7/18/14, showed in part it's purpose was to ensure the prompt notification of the resident, his/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.), and the supervisory/charge nurse will notify the resident's attending physician or on-call physician when there has been: -A significant change in the resident's physical/emotional/mental condition. 1. Record review of Resident #1's MDS dated [DATE], showed he/she: -Was cognitively intact. -Required limited assistance of one staff for transferring, dressing, toileting, hygiene and bathing. -Was occasionally incontinent of urine, but continent of bowel. -Had [DIAGNOSES REDACTED]. -Weighed 261 pounds. -Was not at risk for pressure ulcers. -Had no pressure ulcers. -Had moisture associated skin damage (MASD; an inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). Record review of the resident's care plan dated 4/17/14, regarding ulcer or type of skin damage showed his/her left buttock was healed, related to decreased sensory perception and moisture-incontinence, excessive sweating, and showed interventions in part to: -Turn and reposition the resident, with no time frame for the frequency of how often to turn him/her. Record review of the resident's Wound/Skin Healing Record dated 4/17/14, showed his/her wound to his/her left buttock was healed. Record review of the resident's physician progress notes [REDACTED]. Record review of the resident's physician progress notes [REDACTED]. Record review of the resident's physician progress notes [REDACTED]. Record review of the resident's plan of care dated 8/7/14, regarding ulcer or other skin damage regarding his/her left great toe-healed, left second toe-(healed), lower left extremity (healed), and left/right buttocks, showed his/her problem related to areas marked as decreased sensory perception, decreased mobility, friction/shearing, and a history of skin breakdown. The goal was to heal his/her ulcer. Interventions directed staff to: -Complete weekly skin assessment per protocol; -Monitor lab values; -Increase mobility as tolerated; -Treat per his/her physician's orders [REDACTED]. -Consult his/her wound doctor per order. -There was no updated date to this care plan. Record review of the resident's physician progress notes [REDACTED]. Record review of the resident's physician progress notes [REDACTED]. -The resident was seen for a readmit History and Physical, had been admitted to the hospital for urinary tract infection [MEDICAL CONDITION] and deconditioning, has returned for managed care. -The nurse reported the resident was no longer self-transferring and had to be transferred by a mechanical lift. -A physical exam showed the buttock wound improved. -Assessment: no sores currently, followed by the wound care team. -A plan for his/her foot wound to be managed by wound care. Record review of the resident's nurse's readmission note dated 8/31/14 at 8:00 P.M., showed, in part: -No documented skin issues on the resident's buttock area. Record review of the resident's lab results dated 9/12/14, showed his/her: -Total protein (measuring the total amount of protein in blood) level was normal at 6.5 (normal 6.4-8.9); and -[MEDICATION NAME] (the main protein of blood) level was low at 2.3 (normal 3.5-5.7). Record review of the resident's lab results dated 9/17/14, showed his/her: -Total protein level was low at 6.2 and -[MEDICATION NAME] level was low at 2.1. Record review of the resident's Nutritional Alert Program record dated 9/17/14, showed he/she weighed 246.1. pounds, which was a 15 pound weight loss since 7/14/14. Record review of the resident's nurse's notes dated 9/18/14 at 10:00 P.M., showed: -The resident Urinalysis (UA) results were called to the physician. Staff received a new physician's orders [REDACTED]. Record review of the resident's nurse's notes dated 9/20/14 at 6:00 P.M., showed: -An open area "times two" was discovered to his/her coccyx/gluteal fold area, and a new physician's orders [REDACTED]. Record review of the resident's telephone orders dated 9/20/14, from the attending physician, showed: -An open area "times two" to his/her coccyx/gluteal fold, and orders for Santyl edge to edge with skin barrier twice daily until healed. Record review of the resident's documentation from the outside wound company dated 9/22/14, showed a missed visit due to schedule changes. Record review of the resident's treatment administration record (TAR) dated 9/15/14 through 10/14/14, for the resident's treatment of [REDACTED]. -On 9/20/14, the treatment initialed as being done on the 7:00 A.M. -3:00 P.M. shift, and no initial for the treatment on the 3:00 to 11:00 P.M. shift. -On 9/21/14, the treatment initialed as being done on the 7:00 A.M. -3:00 P.M. shift, and no initial for the treatment on the 3:00 to 11:00 P.M. shift. -On 9/22/14, the treatment initialed as being done on the 7:00 A.M. -3:00 P.M. shift, and for the 3:00 to 11:00 P.M. shift. -On 9/23, 24/14, the treatment initialed as being done on the 7:00 -3:00 P.M. shift, and for the 3:00 to 11:00 P.M. shift. -This treatment was discontinued on 9/25/14. -The facility did not document three of ten treatments during this five day period. Record review of the resident's nurse's notes dated 9/25/14 at 12:40 P.M., showed: -Discontinue the previous treatment to his/her coccyx/gluteal fold. Cleanse area to coccyx with wound cleanser, apply Santyl and [MEDICATION NAME] three times daily and as needed. Cleanse the area on the left buttock with wound cleanser, apply Santyl and [MEDICATION NAME] three times daily and as needed. Record review of the resident's Nutritional Alert program record dated 9/25/14 showed he/she weighed 247.1 pounds, with comments that his/her weight was stable. Record review of the resident's Nutritional Alert Program dated 10/2/14, showed he/she weighed 253.1 pounds, with a note that he/she had [MEDICAL CONDITION] ([MEDICAL CONDITION], the failure of the heart to pump with normal efficiency). Record review of the resident's documentation from an outside wound company dated 10/2/14, showed, in part: -Wound #6: -MASD/partial thickness. -Body part: left buttock. -Status new. -Pre debridement size: 1.0 centimeter (cm) x 1.5 cm x 0.1 cm. -Wound base color was pink 100%, no odor, no drainage. -Dressings: Clean wound with saline, apply Santyl nickel thick to entire wound edge to edge, [MEDICATION NAME]- apply in a thin layer. -Dressing to be changed by staff at the facility every shift and as needed for soiling. -Wound #7: -MASD/partial thickness. - Body part: right buttock. -Status new. -Pre-debridement: 1.2 cm x 2.10 cm x 0.10 cm. -Wound base color: yellow 50%, pink 50%, total =100%, no odor, no drainage. -Dressings: Clean wound with saline, apply Santyl nickel thick to entire wound edge to edge, [MEDICATION NAME]- apply in a thin layer. -Dressing to be changed by staff at the facility every shift and as needed for soiling. Record review of the resident's nurse's notes dated 10/3/14 not timed, showed: -The physician was notified of the resident's six pound weight gain. New order to increase his/her [MEDICATION NAME] (diuretic) to 40 milligrams (mg) to twice daily. Start potassium 40 milliequivalent (meq) daily. Record review of the resident's physician progress notes [REDACTED]. -The resident was seen for monthly follow-up visit. No new concerns today. Was recently treated for [REDACTED]. -Physical exam showed buttock wound improved. Has an ulcer to the left first toe which has been dressed daily and is healing well. Wound care team on board. -Assessment: No sores currently, followed by the wound team. -Plan: Foot wound managed by wound care. Record review of the resident's lab results dated 10/6/14, showed: -Total protein level low at 6.0 and -[MEDICATION NAME] level low at 2.1. Record review of the resident's Nutrition Alert Program notes dated 10/8/14 showed he/she weighed 246.5 pounds with some weight loss. Record review of the resident's documentation from the outside wound company dated 10/9/14, showed, in part: -Wound #6: -MASD/partial thickness. -body part: left buttock. -Status: not healed. -Quality of tissue: unchanged. -Wound status: unchanged. -Pre debridement: 1.00 cm x 1.5 cm x 0.1 cm. -Wound base color- pink 100%, no odor, no drainage. -Dressings: Clean wound with saline, apply Santyl nickel thick to entire wound edge to edge, [MEDICATION NAME]- apply in a thin layer. -Dressing to be changed by staff at the facility every shift and as needed for soiling. -Wound #7: -MASD/partial thickness. -Body part: right buttock. -Status-not healed. -Quality of tissue-unchanged. -Wound Status- deteriorated. -Pre-debridement: 2.0 cm x 2.60 cm x 0.10 cm. -Wound base color: yellow 50%, pink 50%, total =100%, no odor, no drainage. - Dressings: Clean wound with saline, apply Santyl nickel thick to entire wound edge to edge, [MEDICATION NAME]- apply in a thin layer. -Dressing to be changed by staff at the facility every shift and as needed for soiling. Record review of the resident's TAR dated 9/15/14 through 10/14/14 for the resident's treatment to cleanse area to coccyx with wound cleanser apply Santyl and [MEDICATION NAME] three times daily and as needed, ordered initiated on 9/25/14, showed: -On 9/25/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -On 9/26/14, treatment initialed as being done on the 11:00 P.M. to 7:00 A.M., but not initialed as being completed on the other two shifts. -On 9/27/14, treatment not initialed as being done at any time on this date. -On 9/28/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 9/29/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 9/30/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/1/14, treatment initialed as being done on the 11:00 P.M. to 7:00 A.M., but not initialed as being completed on the other two shifts. -On 10/2/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -On 10/3/14, treatment initialed as being done on the 3:00 P.M. to 11:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 7:00 A.M. to 3:00 P.M. shift. -On 10/4/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/5/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/6/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/7/14, treatment not initialed as being done at any time on this date. -On 10/8/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -On 10/9/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/10/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/11/14, treatment initialed as being done on the 7:00 to 3:00 P.M., and the 3:00 to 11:00 P.M. shift, but not initialed as being completed on 11:00 P.M. to 7:00 A.M. -On 10/12/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/13/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/14/14, treatment not initialed as being done at any time on this date. -Note: The facility staff did not document if they completed 35 treatments to the resident's coccyx during this 20 day period. Record review of the resident's TAR dated 9/15/14 through 10/14/14 for the resident's treatment of [REDACTED]. -On 9/25/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -On 9/26/14, treatment initialed as being done on the 11:00 P.M. to 7:00 A.M., but not initialed as being completed on the other two shifts. -On 9/27/14, treatment not initialed as being done at any time on this date. -On 9/28/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 9/29/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 9/30/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/1/14, treatment initialed as being done on the 11:00 P.M. to 7:00 A.M., but not initialed as being completed on the other two shifts. -On 10/2/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -On 10/3/14, treatment initialed as being done on the 3:00 P.M. to 11:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 7:00 A.M. to 3:00 P.M. shift. -On 10/4/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/5/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/6/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/7/14, it appears as if the treatment was initialed as being done on the 11:00 P.M. to 7:00 A.M., but not initialed as being completed on the other two shifts. -On 10/8/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -On 10/9/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/10/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/11/14, treatment initialed as being done on the 7:00 to 3:00 P.M., and the 3:00 to 11:00 P.M. shift, but not initialed as being completed on 11:00 P.M. to 7:00 A.M. -On 10/12/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/13/14, treatment initialed as being done on the 7:00 to 3:00 P.M., but not initialed as being completed on the other two shifts. -On 10/14/14, treatment not initialed as being done at any time on this date. -Note: The facility staff did not document if they completed 34 treatments to the resident's left buttock during this 20 day period. Record review of the resident's Physician order [REDACTED]. -[MEDICATION NAME] (A fast-acting mealtime insulin that may help you control your high blood sugar, inject 26 units subcutaneous (SQ) (an injection just under the skin) three times daily before meals, hold if blood sugar less than 100 for his/her diabetes. -[MEDICATION NAME] (a long acting form of insulin) 30 units sq twice daily for his/her diabetes. -[MEDICATION NAME]/[MEDICATION NAME] (pain medication) 5/325 mg, two tablets every four hours as needed for his/her pain. -[MEDICATION NAME]/[MEDICATION NAME] 5/325 mg two tablets at bedtime for his/her pain. -Aspirin 81 mg chewable tablet daily for stroke [MEDICATION NAME]. -[MEDICATION NAME] ( an oral, agent used to inhibit blood clots in [MEDICAL CONDITION] and [MEDICAL CONDITION]) 75 mg daily for [MEDICATION NAME]. -Januva (an oral diabetes medicine that helps control blood sugar levels. It works by regulating the levels of insulin your body produces after eating) 50 mg tablet daily for his/her diabetes. -Vitamin C 500 mg tablet daily as his/her supplement. Record review of the resident's care plan for urinary incontinence dated 10/16/14, showed in part: -Monitor his/her skin and report any areas of breakdown. -Provide incontinence care after each incontinent episode as reported by the resident. -Toilet the resident per his/her request. He/she is aware of need to void and occasional incontinent episodes. Record review of the resident's care plan dated 10/16/14 for nutritional status showed he/she had a significant weight gain through the previous year and expresses the desire to lose weight, showed in part: -Monitor monthly weight and as needed; -Provide diet/supplement as ordered by the doctor. -No reference to his/her significant weight loss or any interventions. Record review of the resident's Braden Scale for predicting Pressure Sore Risk dated 10/16/14 showed: -A score of 19 which according to the form, a score of 12 or less is represents high risk for pressure ulcers. -Nutrition- A score of 4 or excellent as he/she eats most of every meal and never refused a meal. Usually he/she eats a total of four or more servings of meat and dairy products. Occasionally eats between meals, and does not require supplementation. Record review of the resident's Nutrition Alert Program notes dated 10/16/14 showed he/she weighed 239.9 pounds which is a 13 pound weight loss in three weeks. Record review of the resident's documentation from the outside wound company, dated 10/16/14, showed, in part: -Wound #6: -MASD/partial thickness. -Body part: buttock left/right. -Status: not healed. -Quality of tissue: deteriorated. -Wound status: deteriorated. - Pre debridement: 4.10 cm x 5.90 cm x 0.1 cm. -Wound base color- yellow 50%, Black 10%, Pink 30%, other -[MEDICATION NAME] tissue (a sheet of cells that covers a body surface or lines a body cavity) 10%, total 100%. no odor, no drainage. -Dressings: Clean wound with saline, apply Santyl nickel thick to entire wound edge to edge, [MEDICATION NAME]- apply in a thin layer. - Dressing to be changed by staff at the facility every shift and as needed for soiling. -Wound #7: -MASD/partial thickness. -Body part: right buttock. -Inactive. -Status: Notes: Combined with other buttock wound. Now bridging. Record review of the resident's care plan updated on 10/16/14, provided no information regarding the resident's wounds on his/her coccyx except a hand written note that stated: -On 10/30/14, [MEDICATION NAME] (a local or topical anesthetic that can be applied to the skin or to mucous membranes to reduce the immediate feeling of pain), 5% gel, apply topically 30 minutes before next visit for debridement, and to get a wound culture. Record review of the resident's TAR for 10/15/14 through 11/14/14, for the resident's treatment of [REDACTED]. -On 10/15/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -On 10/16/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 3:00 to 11:00 P.M. shift but not the 11:00 P.M. to 7:00 A.M. shift. -On 10/17/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -On 10/18/14, treatment not initialed as being done at any time on this date. -On 10/19/14, treatment initialed as being done on the 7:00 A.M. to 3:00 P.M. shift but not initialed as being completed on the other two shifts. -On 10/20/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., there is a mark in the area for the 3:00 P.M. to 11:00 P.M. shift but it looks like it is marked out. -On 10/21/14, treatment initialed as being done on the 7:00 A.M. to 3:00 P.M. shift but not initialed as being completed on the other two shifts. -On 10/22/14, treatment initialed as being done on the 7:00 to 3:00 P.M. and the 11:00 P.M. to 7:00 A.M., but not the 3:00 P.M. to 11:00 P.M. shift. -Note: The facility staff did not document if they completed 12 treatments to the coccyx during this 8 day period. Record review of the resident's TAR for 10/15/14 through 11/14/14, for the resident's treatment of [REDACTED]. This type of dressing is used for dermal wounds that produce exudate), gauze and secure daily and as needed, order initiated on 10/23/14, for the 7:00 A.M. to 3:00 P.M. shift, showed: -On 10/26/14, treatment not initialed as being done at any time on this date. -On 10/28/14, treatment not initialed as being done at any time on this date. -On 10/31/14, treatment not initialed as being done at any time on this date. -On 11/5/14, treatment was circled and note on the back of the treatment record showed supplies not available. -Note: The staff did not document if they completed four treatments during this 13 day period. Record review of the resident's lab results dated 10/22/14 showed his/her: -Total protein level was low at 5.9. -[MEDICATION NAME] level was low at 2.1. Record review of the resident's Registered Dietician (RD) assessment dated [DATE] showed in part: -Labs from 10/6/14: [MEDICATION NAME] 2.1, with arrow pointing down next to value and total protein 6.0 with arrow pointing down next to value. -Nutritional problem #1 - No current problem. -Evaluation of needs/recommendation/interventions for nutrition care: Annual assessment completed. Current plan of care remains appropriate as evidenced by skin intact, good intake and weight stable. -NOTE: At the time of this assessment and documentation, the resident had wounds on his/her buttocks and his/her left great toe and he/she had a significant weight loss in the last 30 days. Record review of the documentation from Registered Dietitian Nutritional Care Form dated 10/22/14 and left with the facility showed: -The resident's weight was 252 pounds, small weight loss, not significant. Diet low concentrated sweets/low sodium. PO (oral) intake good, continue to follow plan of care. Record review of the resident's Nutrition Alert Program notes dated 10/23/14 showed he/she weighed 238.6 pounds which is a 7.5 weight loss in three months. Record review of the resident's documentation from the outside wound company, dated 10/23/14 showed, in part: -Wound #6: -MASD/partial thickness. -body part: buttock left/right. -Status: not healed. -Quality of tissue: deteriorated. -Wound status: deteriorated. - Pre debridement: 5.4 cm x 6.20 cm x 1.3 cm, Sinus tract (a cavity or channel underlying a wound that involves an area larger than the visible surface of the wound) (tunneling, a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound): 1.2 cm at 4 o'clock. - Wound base color- yellow 50%, Black 10%, Pink 30%, other -Epi 10%, total 100%. no odor, no drainage. -Dressings: Clean wound with saline, apply Santyl nickel thick to entire wound edge to edge, calcium alginate. Cover with dry dressing secure with tape. -Dressing to be changed by facility staff daily and as needed for soiling. Record review of the resident's nurse's notes dated 10/23/14, at 12:50 P.M., showed, in part: -Discontinue [MEDICATION NAME] and Santyl to the resident's left and right buttock. -Cleanse area to the resident's left and right buttock with saline, apply Santyl, nickel thick edge to edge, calcium alginate, gauze and secure daily and as needed. Record review of the resident's Nutrition Alert Program notes dated 10/29/14 showed he/she weighed 236.1 pounds. "Weight loss this month." Record review of the resident's documentation from the outside wound company dated 10/30/14, showed, in part: -Wound #6: -MASD/partial thickness. -body part: buttock left/right. -Status: not healed. -Quality of tissue: deteriorated. -Wound status: deteriorated. -Pre debridement 5.0 cm x 6.50 cm x 1.5 cm. No information regarding tunneling status. -Wound base color- yellow 50%, Black 10%, Pink 30%, other -Epi 10%, total 100%. no odor, no drainage. -Dressings: Clean wound with saline, apply Santyl nickel thick to entire wound edge to edge, calcium alginate. -Cover with dry dressing secure with tape. Dressing to be changed by facility staff daily and as needed for soiling. Order given for [MEDICATION NAME] 5% gel. Apply topically 30 minutes before next visit for debridement. Ordered wound culture. Record review of the resident's nurse's notes dated 10/30/14, 4:55 P.M., showed: -[MEDICATION NAME] 5% gel apply topically 30 minutes before next visit (from wound care team) for debridement. Obtain a wound culture. Record review of the resident's wound culture lab result obtained on 10/30/14 and the results received on 11/3/14 at 4:42 P.M., showed, in part: -Rectal swab, moderate growth E. coli (Escherichia coli, bacteria normally live in the intestines of healthy people and animals.), moderate growth P mirabilis (Proteus Mirabilis; a species of anaerobic, motile, rod-shaped bacteria found in putrid meat, abscesses, and fecal material. It is a leading cause of urinary tract infections.) and heavy growth E. faecalis ([MEDICATION NAME] faecalis;a bacterial species found in human feces and in the intestines of many warm-blooded animals; occasionally found in urinary infections and in blood and heart [MEDICAL CONDITION] in cases of subacute endocarditis; a major cause of nosocomial infection, especially in association with gram-negative pathogens.) -A hand written note on the lab form read "On [MEDICATION NAME] IM". Record review of the resident's nurse's notes dated 10/30/14 9:45 P.M., showed: -The resident was up for evening meal. He/she was diaphoretic (sweating) with sheets soaked times two. He/she was weak and ate 10% of dinner. Will continue to monitor. Record review of the resident's nurse's notes dated 11/2/14, 5:50 P.M., showed: -He/she was noted in bed and found very sweaty and cold. When blood sugar was checked it was 62 (normal 100-120). Two glasses of orange juice were given and his/her insulin was held. The physician was called. -He/she was later in the dining room eating dinner. Blood sugar re checked and it was 151. Record review of the resident's nurse's notes dated 11/3/14 not timed, showed: -Continues on [MEDICATION NAME] IM for wound infection. Record review of the resident's nurse's notes dated 11/3/14 at 6:00 P.M., showed: -The resident continues on antibiotic without signs/symptoms of adverse effects. Fluids encouraged.