Every finding on record at Good Samaritan - Red Oak

Based on clinical record review, resident interviews, family interviews, staff interviews, hospital document review and provider interview, the facility failed to provide quality nursing care by not completing an assessment or intervention when a resident had low oxygen saturation (Resident #16) and for a resident who was coughing/spitting up blood (Resident #41) for 2 of 3 residents reviewed. The facility reported a census of 34 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented Resident #16 had diagnoses of chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, anxiety, paroxysmal atrial fibrillation and sleep related hypoventilation in conditions classified elsewhere. The Care Plan dated 12/8/25 for Resident #16 documented the resident has altered respiratory status related to sleep apnea, diagnosis of hypoxic respiratory failure and COPD. The care plan directed staff to monitor for signs and symptoms (s/s) of respiratory distress and report to her provider as needed: increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion. Review of Resident #16's April 2026 Medication Administration Records - Treatment Administration Records (MAR-TAR) documented physician's orders for albuterol sulfate nebulization solution 2.5mg / 3mL give one dose inhaled orally via nebulizer every 24 hours as needed for dyspnea document oxygen saturation, pulse, respirations and lung sounds pre and post administration, albuterol-budesonide inhalation aerosol 2 puff inhaled orally every 6 hours as needed for wheezing and oxygen at 2LPM per nasal cannula via oxygen concentrator or tank to maintain saturation above 92% every shift for shortness of breath. Review of Resident #16's April 2026 MAR-TAR lacked documentation as needed albuterol sulfate nebulization solution or albuterol-budesonide inhalation aerosol were administered. Review of Resident #16's electronic health record (EHR) titled, Progress Notes documented the following: On 4/15/26 at 10:50 AM a call was placed to Resident #16's primary care physician's nurse regarding residents' oxygen saturation. Left a message with a call back number. On 4/15/26 at 12:04 PM, a return call from Resident #16's primary care physician's (PCP) nurse regarding Resident #16 unsure of what could be going on. Notified that vitals are stable and oxygen saturation was fine at that time that resident was laying down with BiPAP on. PCP was notified to see if he can stop and see the resident tomorrow. On 4/15/26 at 10:41 PM Resident #16 called 911 thinking she was at another place of residence and the person beside her had a stroke. 911 called the facility saying she called them and 2 ambulance employees arrived at the facility. Resident #16 was taken to the hospital. Husband was notified. DON was notified. On 4/16/26 at 1:06 AM, the hospital was called in reference to Resident #16 for an update. The resident had an exacerbation of CHF. The resident was being transferred to another hospital for care. The Progress Notes for Resident #16 lacked documentation of a comprehensive respiratory assessment on 4/15/26. Review of Resident #16's EHR titled, Oxygen Saturation Summary documented on 4/15/26 at 4:29 AM Resident #16 had an oxygen saturation of 96% on room air, on 4/15/26 at 8:11 AM Resident #16 had an oxygen saturation of 90% on BiPAP, on 4/15/26 at 10:55 AM Resident #16 had an oxygen saturation of 93% on BiPAP and on 4/15/26 at 7:32 AM Resident #16 had an oxygen saturation of 93% on BiPAP. Review of Resident #16's EHR dated 4/15/26 titled, Assessments documented the only assessments completed on 4/15/26 were weekly skin assessment and infection assessment. Neither assessment documented a respiratory assessment. Review of Resident #16's document dated on 4/15/26 at 10:04 PM titled, Prehospital Care Report documented Fire Department was initially dispatched to Resident #16's previous residence for a report of a female possibly experiencing a stroke. Unit 115 responded emergent and arrived on scene without incident or delay. Upon arrival, EMS personnel knocked on multiple apartment doors and announced their presence; however, no residents reported calling 911. Dispatch then updated EMS that Resident #16 was located at the current skilled nursing facility. Unit 115 responded to the facility and arrived without delay. Upon arrival at the skilled nursing facility, EMS attempted entry. Staff members were visible at the nursing station observing the entrance. EMS knocked, and staff opened the door. When questioned about the situation, one staff member stated, I don't know, I just got here, and later added, Well, she's been like this all day. EMS requested staff to direct them to the patient. As EMS approached the patient's room, audible screams for help were heard. A housekeeping staff member was observed entering the room asking if everything was okay. EMS entered shortly after. The patient was found lying supine in a bed, alert enough to visually track EMS personnel upon entry. The patient appeared pale and cool to the touch, with an altered mental status. The patient expressed confusion and stated concern about a lady that fell in the corner, the patient was informed there was no one else there. EMS and nursing staff briefly stepped into the hallway for clarification. Nursing staff reported the patient had been in this condition throughout the day and were unsure why 911 had been called. Initial vital signs revealed oxygen saturation levels in the high 60s to low 70s. The patient consented to transport. The patient was transferred to the EMS stretcher, secured, and moved to the ambulance. Once inside, a full set of vital signs was obtained, including blood pressure. CPAP was initiated with high-flow oxygen at 5 cm H2O PEEP. Due to continued respiratory distress and minimal improvement in oxygen saturation, PEEP was increased to 7.5 cm H2O, resulting in a slight improvement to 82%. Due to continued shortness of breath, PEEP was further increased to 10 cm H2O. Auscultation of lung sounds revealed rales in the bilateral lower lobes. The patient has a significant medical history including COPD, CHF, and diabetes. Transport to the receiving facility was initiated. The Prehospital Report further documented at 10:27 Resident #16 had a blood pressure of 154/78, a pulse of 101, respirations of 36 and oxygen saturation of 62% on room air. Review of Resident #16's hospital report provided by the facility with a date of 4/16/26 documented Resident #16 was transferred to the hospital for possible pneumonia, possible CHF exacerbation, rales and rhonchi bilaterally. Chest x-ray showed possible pneumonia. Resident #16 was hallucinating but was alert and oriented x 3. Resident #16 explained she was at the emergency department (ED) because her breathing felt heavy. Resident #16 explained she has had heavy breathing for about a week. Resident #16 stated she was not usually wheezy but had noticed wheezes over the past couple days. Oxygen saturations reported in the 70's at the nursing facility. On 4/20/26 at 2:15 PM Staff Y, Medical Personnel Ambulance Crew stated the 911 call center was notified at 10:03 PM on 4/15/26 and arrived at the facility to Resident #16 at 10:19 PM. Staff Y explained Resident #16 was on her bipap and had low oxygen saturation of 62% on the bipap and respirations of 36. Staff Y said Resident #16 stated she was getting tired of breathing so hard and Staff Y asked if Resident #16 stopped breathing if he could place a tube to help and she said yes. Staff Y stated he had previous interactions with Resident #16 at her house and this was not her normal. Staff Y explained Resident #16 appeared hypoxic as she was confused. Staff Y explained Resident #16 was taken to the in town Emergency Department (ED) and she was then transferred to another hospital ED for a higher level of care than what the original hospital could provide. Staff Y explained she turned Resident #16 onto their oxygen with cpap and ended up going to 5 then 7.5 cm of water then at 10 for Positive End-Expiratory Pressure (PEEP) setting. On 4/21/26 at 3:50 PM Staff G, Registered Nurse (RN) acknowledged she did have interactions with Resident #16. Staff G stated Resident #16 was alert and oriented but before she was sent to the hospital she was hallucinating a little bit. Staff G stated Resident #16's hallucinations were seeing people that were not in the room. Staff G explained Resident #16 was not sent out on her shift. Staff G stated she thought that Resident #16 called 911 herself. Staff G stated Resident #16 was alert and oriented for most of the shift with a couple of hallucinations. Staff G explained when therapy sat Resident #16 up on the side of the bed she could not get enough air. Staff G stated Resident #16's oxygen saturation was checked and it was 68% and at that time she was put back on her bipap. Staff G explained Resident #16 was on the bipap prior to sitting up. Staff G stated therapy was in the room about 10:30 AM on 4/15/26. Staff G stated she was Resident #16's nurse that morning. Staff G explained once the bipap was applied Resident #16's oxygen saturation increased within a couple of minutes. Staff G stated she completed an assessment but did not remember if she documented the assessment. Staff G stated the assessment would probably be in the progress notes. Staff G explained guaifenesin was given because Resident #16 had complaints of a cough. Staff G stated she did not know how long Resident #16 had been complaining of a cough. Staff G stated Staff Z, RN had administered the medication for the cough and stated Resident #16 had been complaining of a cough. Staff G stated she called Resident #16's Primary Care Physician's (PCP) office and spoke with a nurse about the oxygen level. Staff G stated the nurse said to keep monitoring and if it did not seem it was getting better to send her out to the ED. Staff G said the nurse explained for her to utilize breathing treatments and supplemental oxygen as needed. She stated she did not give any breathing treatments because she was fine before she left. Staff G stated she continuously checked her oxygen saturation and listened to her lungs but did not think she charted it. Staff G stated she thought she should have charted the oxygen saturation and lung sounds. Staff G stated Resident #16 was supposed to wear her bipap when she was in bed and the oxygen was on then. Staff G stated at 8:11 AM on 4/15/24 she did not increase the oxygen with the 90% oxygen saturation noted. Staff G stated Resident #16 at 90% was a concern because she typically ran higher. Staff G stated that 90% did prompt her to increase the oxygen to 2.5 L but she did not document it or call the physician for orders. Staff G stated she could have got an order but she would have notified the physician. Staff G stated she did notify the physician for the increase to 2.5L of oxygen on the bipap. Staff G stated at that time she did retake the oxygen and did not document the results. Staff G stated the oxygen level had increased to 94% at that time. Staff G stated Resident #16 was not showing any signs of respiratory distress once on the bipap she was just fine. Staff G stated she stayed in bed that day but that was not abnormal. Staff G said Resident #16's husband was at the nursing home that morning. Staff G explained Resident #16 was not requesting to be sent out of the facility at that time. Staff G stated the physician called back and that was when she was told to monitor. Staff G stated the as needed medication use would be prompted if the oxygen was ineffective. Staff G stated she would transfer to the hospital if she was unable to maintain an appropriate oxygen level with what they had available. Staff G stated she did not show any signs and symptoms she needed to be sent to the hospital that day. On 4/21/26 at 10:35 PM Staff H, Licensed Practical Nurse (LPN) stated she was familiar with Resident #16. Staff H stated she had cared for Resident #16. Staff H said she worked with Resident #16 on the night of 4/15/26. Staff H stated she was called by the ambulance crew that they were coming to the facility because Resident #16 called them. Staff H stated the ambulance crew told her that Resident #16 called and told the ambulance crew someone by her was having a stroke. Staff H stated she had not seen Resident #16 that evening. Staff H stated Staff K was the female nurse that was on duty the shift prior. Staff H explained Staff K, RN never said a word about her or any concerns with Resident #16. Staff H said she had no report there were concerns with Resident #16 earlier that day. Staff H stated if she found a resident with the oxygen saturation under 80% she would complete an assessment. Staff H stated the assessment would consist of the oxygen level, look at antibiotic, stress level, head of bed, and lung sounds. Staff H stated Resident #16 wore a bipap that had oxygen from the concentrator. Staff H stated the ambulance guys entered the room and she removed the bipap when they entered the room. Staff H stated she did not remember what the oxygen level that the ambulance driver obtained. Staff H explained Resident #16 became short of breath the moment she removed the bipap. Staff H stated she had worked with Resident #16 on Sunday. Staff H explained Resident #16 was not ill, short of breath and did not require any as needed medication. Staff H stated she would apply the oxygen and utilize the as needed Albuterol and follow the documentation recommendation. On 4/22/26 at 9:31 AM Staff AA, Physician's clinic nurse stated she told the nurse at the facility a steroid or antibiotics could be started but if further trouble the facility should transfer Resident #16 to the ED. The clinic nurse stated the nurse at the facility never told her that Resident #16 had an oxygen saturation of 68%. The clinic nurse stated the facility staff were having trouble keeping Resident #16's oxygen saturation above the 90's. She stated the facility nurse explained Resident #16's oxygen saturation was only 80's. The clinic nurse stated the facility nurse explained once the bipap was on Resident #16's oxygen saturation was stabilized at 90%. She stated she explained that Resident #16 did have an as needed order for oxygen. The clinic nurse stated when she called the facility back the nurse explained that Resident #16 was stable and using oxygen. She explained if she was notified that Resident #16 had an oxygen saturation of 68% the physician would have probably had said she needed to be evaluated in the ED. The clinic nurse stated Staff G's initial voice mail sounded like she was a little concerned. She stated the supplemental oxygen would be utilized when she was not asleep. She stated she did not think Resident #16 needed to be in bed wearing the bipap all day. The clinic nurse stated when she verified the orders from the nursing home she verified there was as needed oxygen and Staff G was reminded that it could be utilized and it was there for a reason. The clinic nurse stated the as needed oxygen should have been utilized, or the as needed nebulizer treatment, or the hand held inhaler. On 4/22/26 at 10:43 AM Resident #16's husband acknowledged he was at the hospital with Resident #16 at that time and would be returning 4/23/26. Resident #16's husband stated Resident #16 left the faciity on 4/15/23. He explained Resident #16 had pneumonia and it was bad. He stated Resident #16 had pressure on her heart and had to get rid of fluid. Resident #16's husband explained Resident #16 was telling the nurses at the facility on 4/15/26 that she had a fluid overload problem. He stated they gave her compression gloves and arms. Resident #16's husband stated the facility nurses did not seem concerned about it. He stated Resident #16 was telling them that she was not feeling good that day. Resident #16's husband stated they wanted Resident #16 to go to therapy and do 45 minutes worth of therapy. He stated Resident #16 was gasping for air so bad that she was seeing things. Resident #16's husband explained his wife told him the facility staff were not answering her call so she called 911. He stated Resident #16 had felt ill for several days and that she had told staff she felt ill every day. Resident #16's husband stated the nurses really did not do any assessments on his wife during those days. He said he was not at the facility when Resident #16 was transferred to the Emergency Department (ED). Resident #16's husband stated Staff H, Registered Nurse (RN) called him and said Resident #16 was going to the hospital. He explained he was at the facility around 9:30 AM - 10:00 AM and left at around 8 pm on 4/15/26. He stated he did not remember any nurse completing an assessment on his wife the whole day of 4/15/26. He explained the facility nurses did not offer Resident #16 an as needed breathing treatment or increase her oxygen. Resident #16's Husband stated it did appear his wife was struggling to breath and did not have the air to do what they wanted her to do. He stated his wife's oxygen was never checked. Resident #16's husband said Staff D, Certified Nurse Assistant (CNA) and Staff X, Physical Therapy were in the room when his wife was struggling to breathe. He explained that Staff D said let's put her back to bed. Resident #16's husband said Resident #16 was just sitting on the side of the bed and she could not even get out of bed. He stated he did not ask for her to go to the hospital. He stated Resident #16 was hallucinating while he was sitting there in the room. He acknowledged Resident #16 had never had hallucinations prior to that day. Resident #16's husband stated he was worried for his wife but he was not a medical person he relied on the nursing judgement of the nurses at the facility. He stated she had edema in her legs that was so tight that he had to apply lotion because they itched. Resident #16's husband stated Resident #16 had swelling in her hands as well. He stated it was not common for her to have that much swelling. Resident #16's husband stated Staff H told him that his wife was being transferred to the hospital, she was hallucinating and he might want to get up there as soon as he could. On 4/22/26 at 10:43 AM Resident #16 acknowledged she was at the hospital and there were plans for her to return home tomorrow 4/23/26. Resident #16 said she left the faciity on 4/15/26 to the emergency room. Resident #16 said she had pneumonia and it was bad. Resident #16 explained she told the nurses at the facility that she had a fluid overload problem on the day of 4/15/26. Resident #16 said the nursing staff gave her compression gloves and compression sleeves. Resident #16 stated the facility nurses did not seem concerned about it. Resident #16 said she told them she was not feeling good that day. Resident #16 stated the staff wanted her to go to therapy and do 45 minutes of therapy that day. Resident #16 said she could not even get up, she finally told them to stop and her body told her that she cannot do this anymore. Resident #16 said there were 4 of them there and they finally put her back to bed. Resident #16 said she was gasping for air so bad that she was seeing things. Resident #16 said the facility staff were not answering her call light so she called 911. Resident #16 stated she felt ill for several days. Resident #16 stated she had told staff she felt ill every day. Resident #16 explained the nurses at the facility really did not do any assessments when she said she was ill. Resident #16 stated she did not remember the exact oxygen level but it was probably in the 70's because she was seeing things. Resident #16 stated she had so much fluid on her chest that her heart could not beat appropriately. Resident #16 explained on 4/15/26 when she said she could not breath very well the nursing staff did not offer her a breathing treatment or increase her oxygen. Resident #16 stated it felt like she was struggling to breath and gasping for air. Resident #16 stated she was hallucinating that a nurse was hot, took her clothes off and fell behind the chair. Resident #16 explained she was sucking for air so she just called 911. Resident #16 stated she did not remember that much from the rest of the day because she was out of it. On 4/22/26 at 11:42 AM Resident #16's Primary Care Physician explained oxygen levels in the 60's was a very big concern and if Resident #16's oxygen saturation was that low she should have been transferred to the ED. The Physician stated one of Resident #16's as needed respiratory medications should have been utilized. He stated he should have been notified of oxygen saturation in the 60's. He stated he was not made aware Resident #16 had oxygen saturation levels in the 60's. He stated he expected if the resident's oxygen level was in the 60's or the 70's he would expect to have been notified of the vitals and current vitals. He stated if Resident #16 was transferred to the ED earlier; she might not have been as ill but it would not have prevented the hospitalization and would not have changed the outcome. The Physician acknowledged knowledge of Resident #16's diagnoses and history. He stated if the ambulance was not called when it was the mortality rate of Resident #16 would have increased but it would be difficult to determine if death would have occurred before being noticed by other facility staff. He stated Resident #16 did not have hallucinations that he was aware of. He stated hallucinations from hypoxia made logical sense. On 4/22/26 at 3:27 PM Staff K, RN stated she worked with Resident #16 daily. Staff K stated when she was at the facility, she was always on the far west hall with Resident #16. Staff K stated she worked with Resident #16 the day of 4/15/26. Staff K stated Resident #16 was fine that day. Staff K stated Resident #16 took her medications and was not confused at all. Staff K stated Resident #16 was in bed most of that day. Staff K stated that was kind of normal for her. Staff K stated Resident #16's husband was usually at the facility with her. Staff K stated he was at the facility that day. Staff K explained Staff E did not mention any concerns about Resident #16 at shift change with the shift report. Staff K stated she did not complete any assessment on Resident #16 that day. Staff K acknowledged she did not check a pulse, oxygen saturation level or lung sounds on 4/15/26. Staff K stated she had mentioned that the physician was notified of Resident #16's oxygen saturation level was lower and she had been in bed all day. Staff K stated Staff G did not mention any oxygen saturation percent to her. Staff K stated if there was low oxygen saturation levels or difficulties breathing, she would utilize the as needed nebulizer treatment and or the inhaler. Staff K stated Resident #16 did not appear any different than any other day. Staff K stated if Resident #16 had an oxygen saturation level of 68% she would turn on the oxygen from the concentrator from the nasal cannula and send her out immediately to the ED. Staff K stated she would not keep any resident at the facility with oxygen levels in the 60's or 70's. Staff K stated she would have documented an assessment for sure. On 4/22/26 at 3:54 PM the Director of Nursing (DON) stated she was working on 4/15/26 and had interactions with her every day. The DON explained any time Resident #16 had therapy she does not want to go to therapy. The DON explained therapy staff came out and got Staff G and noted her oxygen saturation was low. The DON stated Staff G should have done a better job documenting what intervention was in place for the oxygen level of 90% at 8:10 AM. The DON stated she would expect the as needed albuterol would have been utilized and would have been documented if the resident refused and that was not documented. The DON stated if the oxygen level was low it should have been documented in the vitals or progress notes. The DON stated at times Resident #16 had behaviors and would take her bipap mask off and that would drop her oxygen. The DON stated Staff G noted a low oxygen level of 68%, put the bipap on and her oxygen level stabilized; she did not think it would require the transfer to the ED. On 4/23/26 at 11:28 AM Staff D, Certified Nurse Assistant (CNA) acknowledged he worked with Resident #16 frequently. Staff D explained Resident #16 would have him write a note and hang it on the door because she had a migraine and did not want to do therapy. Staff D stated him and one of the therapy girls tried to get Resident #16 up on 4/15/26. Staff D stated Staff G offered her the portable oxygen tank but she did not want it. Staff D stated before they even stood her up she said you guys are making me do stuff I do not want to do. Staff D stated Resident #16 said she could not breathe and that it was around 10:00 AM or 11:00 AM that day. Staff D stated they laid her back down and she seemed fine. Staff D stated she went to the hospital that evening. Staff D stated other than her insisting she wanted to lay down and saying she was having a difficult time breathing she did not have any other complaints. Staff D stated he did not remember if the vitals were good or bad. Staff D stated he thought that her oxygen was low because she could not breathe well but did not remember the exact number. Staff D stated Resident #16's husband was not in the room at that time. Staff D stated therapy had asked him to help because sometimes they need a second person to help. Staff D explained when Staff G came in Resident #16 said she was having a difficult time breathing. Staff D stated Resident #16 was talking alright. Staff D explained Resident #16 was talking very slowly but seemed really weak and really tired. Staff D stated that time it might be because she could not breathe. Staff D stated she did take long deep breaths between words and that was when Staff G offered her the portable concentrator. Staff D stated he had to do other tasks and was not sure if Staff G completed an assessment he did not see. Staff D explained Resident #16 stayed in bed all day on 4/15/26 and usually does not eat breakfast but usually eats lunch. Staff D said Resident #16 did not eat the day before and did not eat lunch that day. Staff D said Resident #16 stayed in bed 2 days in a row was very unusual. Staff D said she never stayed in bed for 2 days and that was not normal for her. Staff D stated Resident #16 had not had hallucinations in the past except after surgery with anesthesia. Staff D stated she would complain of migraines. Staff D stated Resident #16 had not ever complained about difficulties breathing until that day. On 4/23/26 at 12:42 PM Staff V, Registered Nurse (RN) / Infection Preventionist (IP) stated he had worked the floor as a nurse and had been on the overnight shift for the last 6 months. Staff V explained if a resident had an oxygen saturation of 80% he would ask the resident for subjective data like if it was difficult to breathe or how they felt. Staff V explained he would then obtain vital signs. Staff V stated if the resident's oxygen saturation was lower than 80% the physician would probably want the resident sent to the Emergency Department (ED). Staff V explained he would attempt to utilize an as needed medication if there was an order such as a nebulizer treatment, an inhaler or oxygen. Staff V stated if the resident's oxygen saturation was 70% he would complete all of that in the room and if the resident was coherent he would ask the resident for subjective data. Staff V explained might need to call 911 and get an order from the physician at the same time. Staff V explained a resident could be sent out without a physician order in an emergency. Staff V said a resident with an oxygen saturation of 68 would be an emergency and that resident would have been sent to the ED. Staff V stated even if he was able to get the resident to baseline he would definitely let the physician know the oxygen saturation level of 68 percent because it might change the outcome of what the physician might want done. Staff V explained an oxygen saturation of 68% would indicate more of a potential issue than just low oxygen saturation. 2. Resident #41's Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of high blood pressure, pneumonia, chronic obstructive pulmonary disease (COPD), and atrial fibrillation (irregular heart beat). It revealed the resident was independent with eating, required setup assistance with personal hygiene, was dependent with toileting hygiene, bathing, and footwear, and required maximal assistance with all other Activities of Daily Living (ADLs) and mobility. It also revealed he was short of breath with activity and lying flat but not while at rest. It further revealed he received an anticoagulant (blood-thinner) medication during the 7-day look-back period. The Electronic Health Record (EHR) included a physician's active order dated 2/28/25 for apixaban oral tablet 5 MG; 1 tablet by mouth every morning and at bedtime related to atrial fibrillation. The Care Plan revised 1/08/26 included altered respiratory status/difficulty breathing related to COPD and directed staff to monitor for signs and symptoms of respiratory distress and report to the health care provider PRN (as needed): increased respirations, decreased blood-oxygen level, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, hemoptysis (coughing up blood), cough, pleuritic pain (sharp, stabbing chest pain that worsens with breathing, coughing, or sneezing). A subsequent Care Plan revision on 1/09/26 included anticoagulant medication use and directed staff to report observations of blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs to the nurse. Another subsequent revision on 3/17/26 indicated the resident had pneumonia that resolved 3/17/26. A document titled Fax Communication to Physician dated 3/30/26 at 8:05 AM marked Response Required indicated Staff E, Registered Nurse (RN) faxed the resident's physician the following information: re

Based on observations, staff interview, and policy review the facility failed to post in a prominent place, readily available to residents, staff, and visitors, the facility's daily staff data consisting of the total number of staff (registered nurses (RNs), licensed practical nurses (LPNs), certified nurse aides (CNAs), certified medication assistants (CMAs)), actual hours worked by the staff, and resident census. The facility reported a census of 34 residents.Findings include: Observed on 4/19/26 at 9:20 AM the facility's posted daily staffing sheet was dated Saturday, 4/18/26.Observed on 4/19/26 at 3:00 PM the facility's posted daily staffing sheet was dated Saturday, 4/18/26.Observed on 4/19/26 at 4:30 PM the facility's posted daily staffing sheet was dated Saturday, 4/18/26.Observed on 4/20/26 at 7:10 AM the facility's posted daily staffing sheet was dated Saturday, 4/18/26.Observed on 4/20/26 at 9:25 AM the facility's posted daily staffing sheet was dated Monday, 4/20/26. In an interview on 4/21/26 at 4:05 PM the Director of Nursing (DON) stated the overnight nurse was responsible for updating the staffing sheet. The DON stated on 4/20/26 mid morning she discovered the staffing sheet had not been updated, and through that discovery it was found the overnight nurse did not have access to complete the staffing form. In an interview of 4/21/26 at 4:20 PM the Administrator acknowledged the nurse staffing sheet should have been updated on 4/19/26. The facility's Nursing Staff Daily Posting Requirements reviewed on 12/1/25 revealed that the facility will post daily at the beginning of each shift and update as appropriate the document with the location name, current date, resident census, total number and actual hours for RNs, LPNs, CNAs, and CMAs.

Based on observations, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with food service safety for general practices of mealtime service. The facility failed to identify and date opened packages of food in the kitchen, properly store food, and complete infection control practices while assisting residents during mealtimes. The facility reported a census of 34 residents.Findings include: On 4/19/26 at 9:33 AM, an initial kitchen tour revealed the following items: a. An undated, previously opened bottle of ranch dressing b. An undated, previously opened carton of liquid eggs c. A box of squash, sliced bread loaves, french fries, potato taters stored on the freezer floor d. Three (3) opened, undated, unlabeled, clear bags of breaded meat products e. A case of six (6) cans of chili con carne stored in the delivery carton on the floor in the dry goods storage room f. Two (2) undated plastic cereal containers On 4/22/26 at 2:33 PM, the Director of Nursing (DON) stated staff should've labeled, dated, and stocked items correctly. A policy titled Food-Supply Storage-Food and Nutrition Services revised 3/13/26 indicated all food/supply items are stored six inches off the floor and foods that have been opened or prepared are placed in an enclosed container, dated, labeled and stored properly. Continuous observation of the meal service on 4/19/26 at 12:00 PM revealed the following: a. There were 30 residents and 3 staff in the dining room. b. Resident #36 coughing frequently throughout the meal. c. Staff L, Certified Nursing Assistant (CNA) sat next to Resident #36 without hand hygiene. d. Staff I, CNA, seated at table with Resident #25 providing total assistance for meal consumption. e. Staff I stopped assisting Resident #25 and turned to a table behind her to assist Resident #15. The staff cut Resident #15's food. No hand hygiene between assisting Resident #25 and Resident #15. f. Staff M, CNA, moved from 1 assisted dining table to another to assist Resident #9 without completing hand hygiene. The staff obtained a beverage, returned to another table and provided total assistance for intake to Resident #12. g. Staff L left the dining room to assist residents back to their rooms. h. Staff I moved between Resident #25 and Resident #15 providing assistance to both (different tables). Staff I provided verbal, visual and tactile assistance to Resident #15 and total assistance to Resident #25. Staff I did not complete hand hygiene between the residents. i. Staff M changed tables to assist Resident #23 without hand hygiene. j. Resident #12 attempted self feeding and dropped her plate to her lap and subsequently the floor. k. Staff M observed the Resident #12's plate on the floor, picked up the spilled food from the floor, placed it on the plate, placed the plate on the table and picked up additional food from the resident's clothing protector. The staff left the table, obtained a wet paper towel, wiped the floor, touched the resident's plate, threw the trash away and returned to the table. Staff M then picked up Resident #12's glass by the rim and assisted the resident with a drink. Staff M moved Resident #12's dessert plate closer to her. Staff M did not offer Resident #12 additional food or complete hand hygiene. l. Staff I assisted Resident #25 without hand hygiene after touching Resident #15's arms and providing assistance. m. Staff L returned to the dining room and began assisting Resident #23 and #9 without hand hygiene prior to assisting and between residents. n. Staff L moved between Resident #23 and Resident #36 without completing hand hygiene. o. Staff L moved to assist Resident #18 without hand hygiene. p. Staff M had left the dining area and returned to assist Resident #18 without hand hygiene. q. Staff I left the assisted dining table area to assist another resident in the dining room, returned to assisting Resident #15 without hand hygiene. r. Staff N, Housekeeping/CNA, entered the dining room and sat at the assisted table with residents without completing hand hygiene. Continuous observation on 4/21/26 at 11:53 AM revealed the following: a. Staff I provided assistance to Resident #25. Staff turned to assist Resident #15 at another table without completing hand hygiene. b. Staff C, Certified Medication Aide (CMA), entered the dining room, applied Resident #36's clothing protector, touched her shirt, glasses, Resident #12's silverware and provided total assistance for the meal to the resident. Staff C did not complete any hand hygiene. c. Staff P, CNA, entered the dining room, touched a stool and proceeded to provide assistance to Resident #25. The staff did not complete any hand hygiene. In an interview on 4/21/26 at 2:45 PM Staff I stated staff should not go between residents without completing hand hygiene. In an interview on 4/21/26 at 3:00 PM Staff S, CNA, stated if a resident spilled food they may pick up the food if necessary or notify the dietary staff. The staff stated if they move between residents to provide assistance, staff must sanitize their hands. In an interview on 4/21/26 at 4:05 PM the Director of Nursing (DON) stated if the staff move between residents they should complete hand hygiene with either hand sanitizer or by washing hands. The DON stated if a resident had spilled their food, staff should notify the Dietary Department to assist with cleanup and/or provide a new plate of food. The DON stated if the staff assist with cleanup then hand hygiene should be completed. In an interview on 4/21/26 at 4:20 PM the Administrator concurred that hand hygiene should be performed between residents. The facility's Hand Hygiene Policy, reviewed 11/13/25, identified hand hygiene included either the use of antiseptic hand sanitizer or antiseptic hand wash. The document revealed that hand hygiene is routinely monitored in all patient care areas. The policy disclosed that hand hygiene was the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings. On 4/21/26 at 1:04 PM Staff R, Certified Dietary Manager (CDM) stated she worked between 2 facilities but was at this facility Monday and Tuesday every week. Staff R stated if a family member requested a resident have bite size food with meals she was not aware of it. Staff R explained to her knowledge no resident family members had requested a resident receive bite size food. Staff R explained mechanically altered diets can always be downgraded for medical reasons or personal preference. Staff R said the beef / broccoli stir fry served for lunch on 4/21/26 was bigger than bite size. On 4/23/26 at 3:52 PM Staff U, CDM stated she worked between 2 facilities with Staff R. Staff U explained everything in the kitchen as far as food items should have been labeled and marked when the item was opened. Staff U said there should not have been any food items on the floor.

Based on clinical record review, policy review, pharmacist interview and staff interviews the facility failed to offer the residents at the facility COVID-19 immunizations and the residents did not receive the COVID-19 immunizations for 2025 year for 5 of 5 residents reviewed (Resident #9, #10, #12, #14, and #15). The facility reported a census of 34 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment.Review of Resident #9's electronic health record (EHR) titled, Immunizations documented Resident #9 was last offered a COVID-19 immunization on 12/10/24.On 4/23/26 at 12:42 PM Staff V, Registered Nurse (RN) / Infection Preventionist (IP) stated for resident immunizations a nurse got the order to give the vaccine, obtained the consent or declination and administered the vaccine at the facility. Staff V explained the COVID-19 vaccine was usually offered every year. Staff V said the immunization / vaccine tracking system had been integrated into the EHR system. Staff V said he could not find a declination or consent for Resident #9. Staff V stated the formulation for COVID-19 vaccination was changed for the 2025 year and the facility did not get the guidelines for the 2025 year. Staff V stated COVID-19 vaccines were not given to residents at the facility at all unless the resident specifically requested the vaccine. 2. The MDS dated [DATE] documented Resident #10 had a BIMS of 12 indicating moderate cognitive impairment. Review of Resident #10's EHR titled, Immunizations documented Resident #10 was last offered a COVID-19 immunization on 12/10/24.3. The MDS dated [DATE] documented Resident #12 had a BIMS of 2 indicating severe cognitive impairment.Review of Resident #12's EHR titled, Immunizations documented Resident #12 was last offered a COVID-19 immunization on 12/10/24.4. The MDS dated [DATE] documented Resident #14 had a BIMS of 13 indicating no cognitive impairment.Review of Resident #14's EHR titled, Immunizations documented Resident #14 had not been offered a COVID-19 immunization since he entered the facility on 4/2/26.5. The MDS dated [DATE] documented Resident #15 had a BIMS of 7 indicating moderate cognitive impairment.Review of Resident #15's EHR titled, Immunizations documented Resident #15 was last offered a COVID-19 immunization on 7/17/24.On 4/23/26 at 1:16 PM the Director of Nursing (DON) stated the facility did not administer the COVID-19 vaccine at all for 2025. The DON explained the vaccine was in-between formulary. The DON stated the facility had been talking to the pharmacy back and forth. The DON explained the pharmacy could not get the new vaccine. The DON acknowledged the COVID-19 should be offered yearly if available. The DON explained the COVID-19 vaccine would have been administered in December 2025. The DON explained the Center for Disease Control (CDC) had not given any guidance on the COVID-19 vaccination for the 2025 yearOn 4/23/26 at 2:31 PM Staff W, Pharmacist explained the facility has always ordered from them. Staff W stated she had talked to the DON and was able to order the vaccine for 4/24/26. Staff W explained the DON stated she was waiting for a new formula guidance. Staff V stated the DON might have been thinking back to when the COVID-19 vaccine was not recommended for anyone under 65. Staff V stated there was a resident at the facility that had requested the vaccine and the vaccine was given if the resident had requested one. Staff V explained if the vaccine was given this month then in 6 months after the first one they should have a second for residents that were 65 years. Staff V stated if the residents received the COVID-19 now they will be caught up for the 2026-2027 year.Review of policy provided by the facility with a review date of 9/21/23 titled, Immunization / Vaccinations for Resident, Pneumococcal, Influenza, COVID-19 documented it was recommended that all clients and residents receive COVID-19 Vaccination per CDC Guidelines for eligibility and timing.Review of the Center for Disease Control website dated 11/19/26 documented it was especially important to get the 2025-2026 COVID-19 vaccine for ages 65 and older, are at high risk for severe COVID-19 or had never received a COVID-19 vaccine.

Based on clinical record review, staff interview, and policy review, the facility failed to fully inform the resident and/or representative of alternative psychotropic medication options by failing to identify target behaviors or non-pharmacological interventions on psychotropic medication (medications that affect a person's mental state, emotions, and behavior) consent forms for 3 of 5 residents (#4, #7, and #30) reviewed. The facility reported a census of 34 residents. 1.Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was admitted to the facility on [DATE]. It also identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety and depression. It further revealed the resident took antianxiety and antidepressant medications in the 7-day look-back period.The Electronic Health Record (EHR) included two (2) physician's orders dated 12/02/25 for an antianxiety medication three (3) times per day for anxiety and an antidepressant medication daily for depression.An eAdmin Record (Default Note) Progress Note dated 12/02/25 revealed the antianxiety medication was on order.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident was educated on 12/02/25 regarding the use and side effects of the antianxiety and antidepressant medications. The form did not include the resident's anxiety or depression related behaviors nor facility attempted non-pharmacological alternatives.2. Resident #7's MDS assessment dated [DATE] indicated the resident was admitted to the facility on [DATE]. It also identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, and depression. It further revealed the resident took antianxiety, antidepressant, and antipsychotic medications in the 7-day look-back period and exhibited verbal behavioral symptoms directed toward others.The EHR included a physician's order dated 8/08/25 for an antidepressant medication in the mornings.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident was educated on 8/08/25 regarding the use and side effects of the antidepressant medication. The form indicated sadness was the symptom but did not include the resident's sadness related behavior nor the facility attempted non-pharmacological alternatives.The EHR included a physician's order dated 2/13/26 to increase the antidepressant medication dose.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 2/13/26 regarding the use and side effects of the antidepressant medication. The form did not include the resident's depression related behavior nor the facility attempted non-pharmacological alternatives.The EHR included two (2) physician's orders dated 3/23/26 for an antianxiety medication every six (6) hours as needed for restlessness and to increase the antidepressant medication dose.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 3/23/26 regarding the use and side effects of the antianxiety and antidepressant medications. The form did not include the resident's anxiety or depression related behavior nor the facility attempted non-pharmacological alternatives.The EHR included three (3) physician's orders dated 3/26/26 for an antipsychotic medication at bedtime, to increase the antianxiety medication to every 4-6 hours as needed, and to decrease the antidepressant medication dose.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 3/27/26 regarding the use and side effects of the antidepressant medication. The form did not include the resident's psychosis, anxiety, or depression related behavior nor the facility attempted non-pharmacological alternatives.3. Resident #30's MDS assessment dated [DATE] indicated the resident was admitted to the facility on [DATE]. It also identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety and cognitive communication deficit (communication impairment caused by cognitive issues). It revealed the resident took an antidepressant medication in the 7-day look-back period.The EHR included a physician's order dated 4/22/25 for an antidepressant medication at bedtime.Two (2) documents titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 4/22/25 regarding the use and side effects of the antidepressant medication. The form did not include the resident's anxiety related behavior nor the facility attempted non-pharmacological alternatives.The EHR included a physician's order dated 6/26/25 for an antianxiety medication every 8 hours as needed for agitation for 7 days.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 6/26/25 regarding the use and side effects of the antianxiety medication. The form did not include the resident's anxiety related behavior nor the facility attempted non-pharmacological alternatives.The EHR included a physician's order dated 1/27/26 for an antianxiety medication every 8 hours as needed for anxiety for 7 days.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident was educated on 1/27/26 regarding the use and side effects of the antianxiety and antidepressant medication. The form did not include the resident's anxiety or depression related behavior nor the facility attempted non-pharmacological alternatives.On 4/22/26 at 10:39 AM, the Social Services Coordinator stated she was not aware the resident's behaviors and facility attempted non-pharmacological alternatives had to be listed on the consent form.On 4/22/26 at 11:57 AM, the MDS Coordinator stated she was not aware the resident's behaviors and facility attempted non-pharmacological alternatives had to be listed on the consent form.On 4/22/26 at 2:38 PM, the Director of Nursing (DON) stated staff should've completed the consent form in its entirety.A policy titled Psychotropic Medications - Rehab/Skilled revised 12/09/25 revealed before administration of non-emergency psychotropic medications, the following must be completed:a. Documentation in <the EHR> observations of mood, symptoms or behaviors that cause the resident distress and/or endanger the resident or others and response to interventions used.b. The behavior committee and/or care plan team will ensure the care plan is updated. This update will reflect non-pharmacological interventions to be used.

Based on observations, staff interviews, clinical record review, and policy review the facility failed to provide a clean and homelike environment when a visibly soiled pillow case was observed two days in a row for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 35 residentsFindings Include:Review of Resident #6 Minimum Data Set (MDS) dated [DATE] revealed an admission date of 7/31/20. The MDS documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact mental status. The MDS indicated diagnoses of stroke, hemiplegia and hemiparesis.Observation on 4/20/26 at 9:18 AM noted a large u-shaped body pillow present on Resident #6's bed on top of the comforter with the white pillow case observed to have yellow and brown discoloration to both bottom sections of the u-shaped body pillow's white pillow case.On 4/20/26 at 9:18 AM Resident #6 explained she requested the u-shaped body pillow from her family because she was afraid she would fall out of bed.Observation on 4/21/26 at 1:23 PM revealed a large u-shaped body pillow observed on Resident #6's bed on top of the comforter with yellow and brown discoloration noted on both lower sections of the u-shaped body pillow's white pillow case. Observation on 4/21/26 at 1:49 PM revealed a large u-shaped body pillow on top of the comforter on Resident #6's bed with yellow and brown discoloration noted to both lower sections of the u-shaped body pillow's white pillow case. Staff D, Certified Nurse Assistant / Certified Medication Aide (CNA/CMA) turned the u-shaped body pillow over revealing the other side had a yellow and brown discoloration to both lower sections of the u-shaped body pillow's pillow case. Staff Q, Environmental Service Director entered the residents room while Staff D was turning the u-shaped body pillow over and Staff Q requested that Staff D remove the pillow case and replace it with a new one. Staff D removed the first pillow case revealing a second pillow case with yellow and brown discoloration observed to the lower sections of the u-shaped body pillow pillow case. Staff Q then removed the second pillow case and replaced it with a clean white pillow case. Interview on 4/21/26 at 1:23 PM Resident #6 stated she had not seen anyone remove the u-shaped body pillow pillow case and wash it. She explained when the CNA's made her bed they would move the u-shaped body pillow into her recliner. She said they make her bed and after the linen change is completed they will place the u-shaped body pillow back on the bed on top of the comforter. She stated the sheets are cleaned when she showers because the staff tells her they were changed but does not know if they were changed as she does not see them do it. States she would like her u-shaped body pillow case and her sheets to be cleaned regularly and when visibly dirty.On 4/21/26 at 1:36 PM with Staff O,CNA/CMA explained that Resident #6 uses a big u-shaped body pillow when in bed and that Resident #6 prefers to use it. Staff O explained the u-shaped body pillow pillow case is supposed to be removed and washed weekly with her bed linens. She stated there is a list behind the nurses station to show weekly bed linen changes for each of the residents. Staff O stated the last time the u-shaped body pillow was changed was on 4/20/26 with her bed linens per the list behind the nurses station. Staff O stated the u-shaped body pillow is currently on Resident #6's bed at this time.On 4/21/26 at 1:55 PM Staff Q explained the u-shaped body pillow case is supposed to be changed weekly according to the list behind the nurses station. Staff Q stated there should only be one pillow case on the u-shaped body pillow at a time. She stated she came into the residents room because Staff O told her she did not know where the pillow cases were kept after her interview with the surveyor. Staff Q stated after reviewing the change linen task sheet it revealed the u-shaped body pillow pillow case was changed on 4/20/26. Staff Q stated that she was not sure if it had been changed because of the double pillow case's present and the visible stains present when she observed the u-shape body pillow on 4/21/26. Staff Q stated the u-shaped body pillow pillow case is expected to be changed on shower/bath days and when visibly dirty.On 4/23/26 at 1:26 PM Staff T, Director of Nursing (DON) explained the u-shaped body pillow pillow case is changed on Resident #6's shower day. Staff T stated there is an organization sheet for linen changes for the pillow case. She stated she would expect the u-shaped body pillow pillow case to be changed if soiled in-between Resident #6's shower days. On review of Policy provided by the facility with an updated review date of 12/29/25 titled, Bedmaking-R/S, LTC documented to provide a clean bed for each resident. To promote physical comfort when a resident is in bed. Clean bed linens included: sheets, draw sheets, pillowcase's, bedspread's, blanket's and mattress cover's or pad's. Policy included bedmaking clinical skills checklist of an occupied and unoccupied bed procedure with instructions to remove soiled linen from residents bed and place in laundry bag or hamper.

Based on clinical record review, staff interview, and policy review, the facility failed to identify and consistently document non-pharmacologic behavior interventions for 3 of 5 residents (#4, #7, & #30) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 34 residents. Findings include:1.Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was admitted to the facility on [DATE]. It also identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety and depression. It further revealed the resident took antianxiety and antidepressant medications in the 7-day look-back period.The Electronic Health Record (EHR) included two (2) physician's orders dated 12/02/25 for an antianxiety medication three (3) times per day for anxiety and an antidepressant medication daily for depression.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident was educated on 12/02/25 regarding the use and side effects of the antianxiety and antidepressant medications. The form did not include the resident's anxiety or depression related behaviors nor facility attempted non-pharmacological alternatives.The Care Plan revised 12/04/25 included antidepressant and antianxiety medication use and directed staff to attempt resident specific, nonpharmacological interventions but did not identify the resident's anxiety or depression related behaviors for staff to monitor.The Progress Notes included behavior monitoring documentation but did not identify what behaviors were observed nor staff attempted, non-pharmacological interventions.The Electronic Health Record (EHR) included an April 2026 Treatment Administration Record (TAR) document for staff to monitor behaviors due to receiving psychoactive medications every shift but did not identify the behaviors for staff to monitor. The TAR did not include staff attempted, non-pharmacological interventions.2. Resident #7's MDS assessment dated [DATE] indicated the resident was admitted to the facility on [DATE]. It also identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, and depression. It further revealed the resident took antianxiety, antidepressant, and antipsychotic medications in the 7-day look-back period and exhibited verbal behavioral symptoms directed toward others.The EHR included a physician's order dated 8/08/25 for an antidepressant medication in the mornings.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident was educated on 8/08/25 regarding the use and side effects of the antidepressant medication. The form indicated sadness was the symptom but did not include the resident's sadness related behavior nor the facility attempted non-pharmacological alternatives.The EHR included a physician's order dated 2/13/26 to increase the antidepressant medication dose.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 2/13/26 regarding the use and side effects of the antidepressant medication. The form did not include the resident's depression related behavior nor the facility attempted non-pharmacological alternatives.The EHR included two (2) physician's orders dated 3/23/26 for an antianxiety medication every six (6) hours as needed for restlessness and to increase the antidepressant medication dose.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 3/23/26 regarding the use and side effects of the antianxiety and antidepressant medications. The form did not include the resident's anxiety or depression related behavior nor the facility attempted non-pharmacological alternatives.The EHR included three (3) physician's orders dated 3/26/26 for an antipsychotic medication at bedtime, to increase the antianxiety medication to every 4-6 hours as needed, and to decrease the antidepressant medication dose.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 3/27/26 regarding the use and side effects of the antidepressant medication. The form did not include the resident's psychosis, anxiety, or depression related behavior nor the facility attempted non-pharmacological alternatives.The Care Plan revised 3/24/26 included antidepressant, antipsychotic, and antianxiety medication use and directed staff to attempt resident specific, nonpharmacological interventions for psychosis and depression but not anxiety. The Care Plan also failed to include resident specific depression or anxiety behaviors for staff to monitor.An eAdmin Record (Default Note) Progress Note dated 3/29/26 at 12:34 PM indicated the resident received an antianxiety medication for agitation/anxiety for stating she needed to get out of the facility. It did not include documented staff attempted, non-pharmacological interventions.The EHR included an April 2026 TAR document that did not identify the behaviors for staff to monitor nor staff attempted, non-pharmacological interventions.3. Resident #30's MDS assessment dated [DATE] indicated the resident was admitted to the facility on [DATE]. It also identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety and cognitive communication deficit (communication impairment caused by cognitive issues). It revealed the resident took an antidepressant medication in the 7-day look-back period.The EHR included a physician's order dated 4/22/25 for an antidepressant medication at bedtime.Two (2) documents titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 4/22/25 regarding the use and side effects of the antidepressant medication. The form did not include the resident's anxiety related behavior nor the facility attempted non-pharmacological alternatives.The EHR included a physician's order dated 6/26/25 for an antianxiety medication every 8 hours as needed for agitation for 7 days.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident's representative was educated on 6/26/25 regarding the use and side effects of the antianxiety medication. The form did not include the resident's anxiety related behavior nor the facility attempted non-pharmacological alternatives.The EHR included a physician's order dated 1/27/26 for an antianxiety medication every 8 hours as needed for anxiety for 7 days.A document titled Permission For Use Of Psychotropic Medications dated 2/25 revealed the resident was educated on 1/27/26 regarding the use and side effects of the antianxiety and antidepressant medication. The form did not include the resident's anxiety or depression related behavior nor the facility attempted non-pharmacological alternatives.On 4/22/26 at 10:39 AM, the Social Services Coordinator stated she was not aware the resident's behaviors and facility attempted non-pharmacological alternatives had to be listed on the consent form.On 4/22/26 at 11:57 AM, the MDS Coordinator stated she was not aware the resident's behaviors and facility attempted non-pharmacological alternatives had to be listed on the consent form.The Care Plan revised 10/28/25 included antidepressant medication use but did not identify anxiety related behaviors nor nonpharmacological interventions for staff to attempt.The Progress Notes did not identify anxiety related resident behaviors nor staff attempted, non-pharmacological interventions.The EHR included an April 2026 TAR document that did not identify the behaviors for staff to monitor nor staff attempted, non-pharmacological interventions.On 4/21/26 at 12:17 PM, Staff A, Registered Nurse (RN) stated residents' target behaviors and non-pharmacological interventions should be documented in the residents' Care Plans. She also stated documented monitoring should be in the resident's TAR.On 4/21/26 at 12:45 PM, Staff B, RN stated she thinks the residents' target behaviors and non-pharmacological interventions should be documented in the residents' Care Plans but wasn't sure they were normally put in there. She added it was always normal to try non-pharmacological interventions before medication use.On 4/22/26 at 2:38 PM, the Director of Nursing (DON) stated staff should identify the target behaviors and use that to determine the appropriate non-pharmacological interventions.Before administration of non-emergency psychotropic medications, thefollowing must be completed:a. Documentation in PCC - POC observations of mood, symptoms or behaviors that cause the resident distress and/or endanger the resident or others and response to interventions used.b. The behavior committee and/or care plan team will ensure the care plan is updated. This update will reflect non-pharmacological interventions to be used.

Based on clinical record review, policy review, and staff interview the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications for 1 of 3 residents reviewed (Resident #40). The facility reported a census of 34 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #40 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment.Review of Resident #40's EHR dated 2/20/26 titled, Discharge Summary documented no recapitulation of stay, final summary of resident's status or reconciliation of pre- and post-discharge medications. Review of Resident #40's document titled, Fax dated 2/20/26 at 3:37 PM documented physician signed discharge summary 2/20/26 with Resident #40's discharge on [DATE] at 1:00 PM.On 4/23/26 at 1:24 PM the Director of Nursing (DON) stated she expected the discharge summary for Resident #40 would be completed after the discharge of Resident #40. The DON acknowledged Resident #40's discharge summary was not completed with recapitulation of stay, final summary of the resident's status or reconciliation of pre- and post-discharge medications. The DON stated she would expect the discharge summary would have been completed by now. Review of a policy provided by the facility reviewed 9/8/25 titled, Admission, Transfer, and Discharge Team documented admissions, transfers and discharges will be conducted according to state and federal regulations.

Based on clinical record review, staff interviews, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents (Resident #33), who was diagnosed with a new mental disorder diagnosis since admission to the facility. The facility reported a census of 34 residents.Findings include:The facility provided document PASRR completed on 10/4/22 identified the following: No mental health diagnoses.No mental health services.No mental health medications.No Level II required. The clinical record census disclosed Resident #33 was admitted to the facility on [DATE].The Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 identified a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The MDS recorded no signs and symptoms of delirium, no mood or behaviors during the reporting period. The MDS documented diagnoses that included:Non-Alzheimer's Dementia, depression, psychotic disorder and visual hallucinations. The MDS documented the resident received antipsychotic and antidepressant medications on 7 out of 7 days of the assessment reference period. The MDS assessment dated [DATE] for Resident #33 recorded the resident had fluctuating inattention and disorganized thinking, feeling of tired or little energy 7-11 days of the assessment period and no delusions or hallucinations. The MDS documented no psychiatric or mood disorder diagnoses. The MDS documented the resident did not receive antipsychotic or antidepressant medications on 7 out of 7 days of the assessment reference period. The Care Plan revised on 3/23/26 identified the resident had behavior symptoms related to hallucinations and accusations of missing items (clothing, money, purse) and then items may be found (initiated 6/27/24 and revised 6/6/25). The Care Plan identified staff interventions to provide positive interaction, assist in locating items and provide encouragement and active support when the resident is having hallucinations. The Care Plan identified antipsychotic medication related to hallucinations and vascular dementia with mood disturbance and delusional disorder (initiated 5/8/25). The Care Plan identified staff interventions with monitoring resident's condition related to Risperdal, and warnings for side effects. The clinical record's medical diagnoses included: Visual hallucinations dated 9/27/22 present on admission.Major depressive disorder, single episode, moderate dated 4/18/24, during stay.Delusional disorders dated 6/6/24, during stay.Vascular dementia, moderate, with mood disturbance dated 4/18/24, during stay. The clinical record's physician orders included:Sertraline HCI Oral Tablet 50 mg, 1 tablet daily (QD) related to major depressive disorder, single episode, moderate 8/15/25.Sertraline HCI Oral Tablet 25 mg, 1 tablet (QD) related to major depressive disorder, single episode 8/14/25. Lorazepam Oral Tablet .5 mg, .5 mg by mouth every 8 hours as needed for anxiety twice daily (BID) 7/30/25. Risperdal Oral Tablet .5 mg, .5 mg by mouth BID for antipsychotic related to visual hallucinations and delusional disorders. The facility document Consent dated 4/17/25 revealed consent for antipsychotic medication, Risperdal and antidepressant medication, Sertraline. In an interview on 4/21/26 at 9:50 AM the Director of Nursing (DON) stated the Social Services Director completed the PASRR. The DON stated residents came into the facility with a PASRR in place.In an interview on 4/21/26 at 9:52 AM the Social Services Director acknowledged she completed PASRRs when required. The staff referred to Resident #33's PASRR and concurred the document did not contain medications or mental health diagnoses. The Social Services Director stated the resident did currently receive psychotropic medications and has mental health diagnoses. The staff stated the resident should have had a new PASRR completed when new mental health diagnoses or medications are initiated. In an interview on 4/21/26 at 10:00 AM the DON concurred that when a new mental health diagnosis or medication is begun a resident should have a new PASRR completed. In an interview on 4/21/26 at 4:00 PM the Administrator acknowledged the facility did not complete a PASRR when a resident had a new mental health diagnosis and/or medication when a resident did not previously have one. The facility policy titled Pre-admission Screening and Resident Review (PASRR) - Rehab/Skilled reviewed 12/29/25 directed staff that a new PASRR evaluation must be initiated when a resident is diagnosed with a mental disorder. The document disclosed the facility should notify the state-designated mental health authority promptly when a resident experiences a significant change.

Based on clinical record reviews, staff interview, and policy review, the facility failed to develop a personalized Care Plan that included resident specific target behaviors or non-pharmacological interventions for 3 of 5 residents (#4, #7, & #30) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 34 residents. Findings include:1.Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety and depression. It revealed the resident received antidepressant and antianxiety medications during the 7-day look-back period.The Electronic Health Record (EHR) included physician's orders dated 12/02/25 for an antidepressant medication one time per day and an antianxiety medication three times per day.The Care Plan revised 12/04/25 included antidepressant and antianxiety medication use and directed staff to attempt resident specific, nonpharmacological interventions but did not identify the resident's anxiety or depression related behaviors for staff to monitor or anxiety-related non-pharmacological interventions for staff to attempt.The April 2026 Medication Administration Record (MAR) revealed Resident #4 received the antidepressant and antianxiety medications since 4/01/26.2. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, and depression. It further revealed the resident took antianxiety, antidepressant, and antipsychotic medications in the 7-day look-back period and exhibited verbal behavioral symptoms directed toward others.The EHR included a physician's order dated 8/08/25 for an antidepressant medication in the mornings; and two (2) orders dated 3/26/26 for an antianxiety medication every 4-6 hours as needed and an antipsychotic medication at bedtime.The Care Plan revised 4/07/26 included antidepressant, antipsychotic, and antianxiety medication use. It identified psychosis related target behaviors but not depression or anxiety related target behaviors. It also directed staff to attempt resident specific, nonpharmacological interventions for psychosis and depression but not anxiety.The April 2026 MAR revealed Resident #7 received the antidepressant, antianxiety, and antipsychotic medications since 4/01/26.3. Resident #30's MDS assessment dated [DATE] identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety and cognitive communication deficit (communication impairment caused by cognitive issues). It revealed the resident took an antidepressant medication in the 7-day look-back period.The EHR included a physician's order dated 4/22/25 for an antidepressant medication at bedtime for generalized anxiety.The Care Plan revised 10/28/25 included antidepressant medication use but did not identify anxiety related target behaviors nor nonpharmacological interventions for staff to attempt.The April 2026 MAR revealed Resident #30 received the antidepressant medication since 4/01/26.On 4/21/26 at 12:17 PM, Staff A, Registered Nurse (RN) stated residents' target behaviors and non-pharmacological interventions should be documented in the residents' Care Plans. She also stated documented monitoring should be in the resident's TAR.On 4/21/26 at 12:45 PM, Staff B, RN stated she thinks the residents' target behaviors and non-pharmacological interventions should be documented in the residents' Care Plans but wasn't sure they were normally put in there. She added it was always normal to try non-pharmacological interventions before medication use.On 4/22/26 at 2:33 PM, the MDS Coordinator stated she did not know the target behaviors and non-pharmacological interventions had to be in the residents' Care Plans.On 4/22/26 at 2:38 PM, the Director of Nursing (DON) stated staff should've included the target behaviors and non-pharmacological interventions in the residents' Care Plans.A policy titled Care Plan - R/S, LTC, Therapy & Rehab revised 12/01/25 indicated each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs.

Based on clinical record review, observations, family interview, staff interviews, and policy review, the facility failed to ensure 1 of 14 residents (Resident #28) activities of daily living (ADL) abilities were maintained or improved. The facility failed to cut a resident's meat prior to serving as the family had requested. The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 identified a Brief Interview for Mental Status (BIMS) of 4/16 indicating severe cognitive impairment. The MDS revealed the resident was independent with eating. The MDS documented no limitations in range of motion of upper or lower extremities. The Care Plan revised 3/11/26 identified the resident had an ADL self care performance deficit that directed staff that resident feeds self after set up. The Care Plan identified a potential nutritional problem that directed staff to cut up all meat and inform the resident what is on her plate and location using the clock method (revised 5/15/24). The clinical record's Physician Orders revealed a regular diet, 7 regular texture, 0 thin consistency dated 5/11/23. The clinical record's Progress Note titled Care Conference Note on 1/29/26 at 1:14 PM revealed the family member requested the resident get more assistance in the morning and night, and that the resident's meat is cut up at meals. The entry revealed the MDS Coordinator, Social Services, the Dietary Manager and the family member were in attendance. Observed during the noon meal on 4/21/26 at 12:02 PM an unidentified kitchen staff serve Resident #28 her meal. The staff placed the plate containing the entree (beef / broccoli stir fry) and dessert plates in front of the resident and walked away. The staff did not have a verbal interaction with the resident. Observed 1 resident independently cut her meat and 2 staff members cut 2 assisted residents' entree prior to initiating consumption. Resident #28 did not make an attempt to cut her meat. Observed the meat pieces on the resident's plate were larger than 1.5 cm x 1.5 cm. Observed on 4/21/26 at 4:20 PM Resident #28's meal ticket. The diet ticket identified the resident had a regular diet, 7 regular texture and thin (0) liquids. The document did not reflect orienting the plate for the resident or cutting the resident's meat prior to serving. In an interview on 4/19/26 at 3:56 PM Resident #28's family member stated she had asked the facility to cut up the resident's meat as the resident's vision was deteriorating. In an interview on 4/21/26 at 1:04 PM Staff R, Certified Dietary Manager (CDM) stated if a family member requested a resident have bite size food she was not aware of it. Staff R stated to her knowledge no resident family members had requested a resident receive bite size food. Staff R explained mechanically altered diets can always be downgraded for medical reasons or personal preference. The staff stated the beef / broccoli stir fry was bigger than bite size. In an interview on 4/21/26 at 2:45 PM Staff I, Certified Nurse Assistant (CNA), stated if residents were seated at the assisted table then the CNA's will assist residents with cutting up food. Staff I stated she was unsure who would assist the residents if they were seated at the independent tables. In an interview on 4/21/26 at 4:05 PM the Director of Nursing (DON) stated the dietary aides were responsible for cutting up the residents' food and orienting the plate(s). The DON stated the information for cutting food, orienting, and adaptive equipment should be on the tray card. In an interview on 4/21/26 at 4:20 PM the Administrator stated all things meal related should be identified on the resident's meal card and completed by kitchen staff. In an interview on 4/21/26 at 4:39 PM Staff J stated Resident #28's meal ticket did not identify set up or cutting meat. The facility's Dining Assistant Policy, reviewed 1/29/26, revealed that dining assistance can be provided to a resident by a member of the nursing staff that included cutting meat, pouring liquids, and providing assistants to consume meals. The International Dysphagia Diet Standardization Initiative (IDDSI) revealed a Level 6 Diet Soft and Bite Sized indicated pieces were no bigger than 1.5 cm and 1.5 cm in size. The IDDSI Level 7 Regular Easy to Chew required no restrictions and normal everyday foods.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to provide appropriate toileting hygiene assistance to prevent a urinary tract infection (UTI) for 1 of 1 resident (#7). The facility reported a census of 34 residents.Findings include:Resident #7's MDS assessment dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, diabetes mellitus, and the need for assistance with personal care. It revealed the resident was frequently incontinent with bladder and bowel, required maximal assistance with toileting transfers, and was dependent with toileting hygiene.The Care Plan revised 4/07/26 included bladder incontinence as a focus and indicated the resident used incontinence briefs. It directed staff to assist with changing as needed or as requested. It revealed the resident had a UTI on 4/02/26 and directed staff to assist the resident with handwashing after being toileted and before and after meals.During a continuous observation on 4/22/26 that began at 10:20 AM, Staff M, Certified Nurse Aide (CNA) transported Resident #7 into her room in her wheelchair. Staff M put on gloves, grabbed a gait belt, put it on the resident, turned on the restroom light, pushed the resident's wheelchair closer to the restroom, moved the resident's wheelchair foot pedals, locked the wheelchair, helped the resident stand up, pulled the resident's pants and briefs down, and assisted the resident to the toilet. While the resident urinated, Staff M grabbed a periwipe packet and paper towels. She removed three periwipes and laid them on the paper towel on the edge of the sink. When the resident was finished urinating, Staff M assisted the resident to a standing position and wiped the resident's perineal area one time from behind and helped the resident pull her briefs and pants up. Staff M removed her gloves, grabbed the gait belt, assisted the resident to her wheelchair, and transported her back into her room. Staff M did not perform hand hygiene or change gloves between touching the objects in the resident's room and wiping the resident's perineal area.At 10:27 AM, Staff M stated she received annual infection prevention education that included hand hygiene and glove use. She stated she imagined touching items in a resident's room could contaminate the gloves and stated maybe she should've changed her gloves and performed hand hygiene after touching the resident's belongings and before wiping the resident's peri area.On 4/22/26 at 2:38 PM, the Director of Nursing (DON) stated staff should've followed the policy.A policy titled Hand Hygiene revised 11/13/25 indicated all employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene.1. Entering Room2. Before Clean Task3. After Bodily Fluid/Glove Removal4. Exiting Room5. Zones: Patient zone and Health-care zones.The policy defined Patient Zone as: concept related to the geographical visualization of key momentsfor hand hygiene. It contains the patient and their immediate surroundings. Typically includes intact skin of the patient and all inanimate surfaces that are touched by or in direct physical contact with the patient.

Based on clinical record, observations, resident interview, staff interviews, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents (Resident #14) reviewed, requiring the use of oxygen. The facility failed to provide a resident's oxygen at the amount as documented in the physician's orders. The facility reported a census of 28 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The MDS recorded diabetes mellitus, chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. The document disclosed the resident had health conditions of shortness of breath with exertion and shortness of breath when lying flat. The MDS revealed the resident utilized oxygen while a resident and during the last 14 days of the assessment period. The Care Plan revised on 2/3/26 identified Resident #14 had COPD with a staff directive to apply oxygen therapy at 2 liters per minute (lpm) via nasal cannula continuous. The Care Plan identified shortness of breath related to hypoxia with staff directives to apply oxygen therapy at 2 lpm via nasal cannula continuous and monitor, report to nurse changes in orientation, increased restlessness, anxiety and air hunger. The clinical record's Physician Orders revealed oxygen via nasal cannula 2 lpm, continuous for dyspnea, hypoxia dated 4/2/25. The Physician Orders revealed to change oxygen tubing on concentrator, tank and nebulizer weekly; place date and initials on tubing. Observed on 4/19/26 at 1:29 PM Resident #14 lying in bed with oxygen via nasal cannula with the concentrator set at 3 lpm. Observed on 4/20/26 at 1:45 PM Resident #14 sleeping in bed with oxygen via nasal cannula with the concentrator set at 3 lpm.Observed on 4/21/26 at 9:11 AM Resident #14 lying in bed with oxygen via nasal cannula with the concentrator set at 3 lpm. In an interview on 4/19/26 at 1:29 PM Resident #14 stated he had used oxygen since before he came into the facility. The resident stated his oxygen order had recently changed to 3 lpm from 2 lpm. In an interview on 4/21/26 at 2:45 PM Staff I stated Resident #14 did not mess with his oxygen settings that she was aware of.In an interview on 4/21/26 at 3:56 PM Staff K, Registered Nurse (RN) stated Resident #14 stayed in his bed all the time and rarely got out of bed. The staff stated the resident did not have a history of changing his oxygen.In an interview on 4/21/26 at 4:05 PM the Director of Nursing (DON) stated the concentrator should be set at the lpm according to the physician orders. The DON stated if the concentrator did not reflect the correct lpm as per physician orders the concentrator setting must be changed. In an interview on 4/21/26 at 4:20 PM the Administrator stated the staff should follow physician orders for the use of oxygen. The facility's Oxygen Administration, Safety, Mask Types Policy, reviewed 7/30/25, revealed oxygen administration is carried out only with a medical order. The policy disclosed the licensed nurse or other employee trained in the use of oxygen will be on duty and is responsible for the proper administration of oxygen of the resident.

Based on clinical record review, family interview, staff interviews and facility policy review, the facility failed to report an allegation of abuse to the appropriate entity for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 40 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. The MDS documented a diagnosis of Alzheimer's disease with early onset. Review of Resident #1's Electronic Health Record (EHR) titled, Progress Note entered by Staff A, Registered Nurse (RN) on 12/20/26 at 11:42 AM documented Staff H, Certified Nurse Assistant (CNA) reported she had observed Resident #1 and Resident #2 sitting at the nurses station with their hands down each other's pants. The residents were both separated. Resident #2 was taken to his room. Both Residents were assessed for trauma and none was observed. The Director of Nursing (DON), Staff G, Social Services Director, and the Administrator are aware of the incident. The Administrator stated the incident was not reportable because both residents had documented dementia.2. The MDS dated [DATE] documented Resident #2 had a BIMS of 03 indicating severe cognitive impairment. The MDS documented a diagnosis of vascular dementia, unspecified severity with other behavioral disturbance. Review of Resident #2's EHR titled, Progress Note entered by Staff A, Registered Nurse on 12/20/26 at 11:42 AM with effective date of 12/20/26 at 10:26 AM documented Staff H reported she had observed Resident #2 and Resident #1 sitting at the nurses station with their hands down each other's pants. The residents were separated and Resident #2 was assisted to his room. Both residents were assessed for trauma and none was observed. The DON, Staff G, and the Administrator are aware of the documented incident. The Administrator called the facility and stated the incident was not reportable because both residents had documented dementia.Review of Resident #2's EHR titled, Progress Note entered by Staff A, Registered Nurse on 12/20/26 at 12:35 PM with effective date of 12/20/26 at 12:16 PM documented Resident #2 observed reaching to touch another resident. Resident #2 was redirected by a CNA. Resident #2 hit the staff several times and told the staff to mind their business and leave him alone.On 2/18/26 at 9:15 AM Resident #1 stated she thought she had eaten breakfast but could not remember. Resident #1 acknowledged she did not know where this area was when asked if she grew up in the area of this facility. Resident #1 stated she kept to herself at the facility and was not friends with any of the residents at the facility. Resident #1 stated the staff treat her with dignity and respect at the facility. Resident #1 acknowledged she felt safe at the facility and was not scared of any of the residents or staff members. Resident #1 stated other residents had not attempted to touch her in any inappropriate ways.On 2/18/26 at 9:05 AM Resident #2 stated he had eaten breakfast that morning. Resident #2 explained that he had sausage, bacon, eggs and oatmeal. Resident #2 said the food was good. Resident #2 explained he did not have any friends that lived at the facility from his childhood. Resident #2 stated he had friends at the facility but could not remember any of their names or how he knew them. Resident #2 said he thought the staff treated him with dignity and respect. Resident #2 stated he felt safe at the facility. Resident #2 explained he had not touched any of the residents in any inappropriate way and none of the residents at the facility had touched him in any inappropriate way.On 2/17/26 at 5:30 PM Staff H, CNA acknowledged she had seen residents at the facility inappropriately touching each other. Staff H stated she had worked on a weekend and there were 2 residents sitting on the wall with their hands in each other's pants. Staff H acknowledged the incident occurred on 12/20/26. Staff H identified the 2 residents as Resident #1 and Resident #2. Staff H explained she did not see any movement in their pants but maybe Resident #1 was holding Resident #2's penis. Staff H said she stopped the 2 residents and assisted Resident #2 to his room. Staff H explained she told Staff A and Staff I, Licensed Practical Nurse (LPN). Staff H explained reported the incident to Staff A. Staff I acknowledged Staff A's Progress Notes entries regarding this incident for Resident #1 and Resident #2 was an accurate record of what happened. Staff H stated she did not see the nurses complete an assessment. Staff H stated she knew the incident had to be reported to the nurse for safety reasons because maybe Resident #2 would do it to someone else. Staff H stated she knew both residents had dementia. Staff H stated neither resident would remember what was discussed 15 minutes later. On 2/17/26 at 3:42 PM Staff G, Social Services Director stated she was informed of an incident where Resident #2 was reaching towards a resident. Staff G explained she called the DON and the DON called the Administrator. Staff G stated the incident was Resident #1 and Resident #2. Staff G stated during the incident Resident #2 was reaching towards Resident #1. Staff G stated she was unaware if the Administrator called the facility back after that. Staff G stated the incident she was talking about happened prior to Christmas of 2025 maybe around the 19th. Staff G explained Staff A did not report to her that the residents had each other's hands in their pants. Staff G said she notified the DON of the incident but she did not say there were hands in pants but could not remember exactly what was said. Staff G acknowledged she did not document the incident. Staff G stated she did not know if Staff A tried calling the DON first but she was not on call. Staff G explained typically those situations are brought to the DON or the Administrator. On 2/18/26 at 1:04 PM Resident #2's son stated his father was struggling with dementia and things have changed in his world with how he conducts himself. Resident #2's son stated he did not know exactly who reached out to talk to him about the incident. Resident #2's son explained he was out of town and the facility called his brother and then he followed up with the facility. Resident #2's son stated they had shared with him the concern of the 2 residents inappropriately touching each other. Resident #2's son explained they had come to a conclusion that it would have been better to have his dad stay in his room and move him to the nurses station to keep an eye on him. Resident #2's son stated he did feel it was inappropriate for the 2 residents but did not think there was any sort of abuse. On 2/18/26 at 1:25 PM Resident #1's daughter said she was only notified of one incident and that incident occurred back in December. Resident #1's daughter stated it was described to her as hands were being held. Resident #1's daughter said the staff described the residents having each other's hands in their waistband. Resident #1's daughter stated she did not remember who had notified her of the incident. On 2/17/26 at 2:38 PM the DON acknowledged there were no married residents living together at the facility. The DON acknowledged there are no residents involved in an intimate relationship with each other both living at the facility. The DON said there are no residents that inappropriately touch other residents. The DON stated she had not been made aware of Resident #2 inappropriately touching any residents of recent. The DON explained if the resident was inappropriately touching another resident such as putting his hands down their pants, up their shirt or touching their breast she would expect to be notified of those situations. The DON further explained once she was notified she would come into the facility and complete an investigation to determine if it was abuse and would have a 2 hour window to self report to the stated agency. The DON acknowledged she was not notified that Resident #2 had his hands down another resident's pants. The DON stated the facility had an algorithm to determine if the situation was reportable to the state or not. The DON stated she was not aware this incident that was documented to have occurred on 12/20/25 between Resident #1 and Resident #2. The DON stated the Administrator could determine if the incident was reportable to the state or not he also had access to the algorithm. The DON said she had not reported the incident to the state agency because she was unaware of the incident. On 2/18/26 at 10:13 AM the DON said Staff G called and said there was an incident. The DON said she called the Administrator and told him to call the facility. The DON stated there were no details provided about the incident to her. The DON explained that the Administrator handled the situation from there. The DON stated she was on vacation over Christmas at that time. The DON acknowledged the incident did not come back up and she had not returned until January. The DON stated she had talked to Staff H 2/18/26. The DON explained that Staff H stated she had walked up to the nursing station and said Resident #1 and Resident #2 had hands in each other's waistband. The DON stated Staff H had explained there was no movement with either resident's hands. The DON stated she asked if Staff H felt it was sexual. The DON said Staff H said no not really but knew she needed to separate them. The DON stated Staff H said she separated them and told Staff A. The DON stated having hands in each other's waistbands did not indicate the activity was sexual in nature but they do not want the residents doing that. The DON explained the residents were not moving their hands while in each other's waistbands. The DON stated Staff A had told the Administrator she had not seen anything. The DON explained if the residents truly just hands in each other's waistbands and nobody was moving or doing anything then no assessment would be required. On 2/18/26 at 9:28 AM the Administrator stated he had read the progress note from 12/20/25 yesterday. The Administrator stated he thought that the situation had occurred on a Saturday and Staff A had called Staff G and said it seemed like Resident #1 and Resident #2 had their hands in each other's pants. The Administrator explained the situation was reported to have happened out at the nurses station. The Administrator explained he called the building and talked to Staff A. The Administrator said Staff A explained that Staff H saw both the residents with their hands in each other's pants. The Administrator stated Staff A acknowledged she didn't see the situation Staff H did. The Administrator explained Staff A would talk to Staff H and after she found out more details she should call him back. The Administrator stated Staff H talked to Staff H and called back. The Administrator said Staff A explained that Staff H reported she was walking down the hallway and it looked like Resident #1 and Resident #2 had each other's hands in each other's pants but the 2 residents were actually holding each other's hands. The Administrator stated Staff A said Staff H thought that was different and she said she separated them. The Administrator stated Staff A explained the 2 residents were not out by the nurses station very long. The Administrator explained he asked Staff A did Staff H actually see hands in the pants. The Administrator stated Staff A had just jumped to that conclusion. The Administrator stated Staff A asked do we need to report this. The Administrator said he told Staff A he would talk to the DON and decide. The Administrator explained what they knew was the 2 residents were holding hands and he was holding her hand in his lap. The Administrator explained Staff A said Staff H had separated the 2 residents and Staff A was going to complete an assessment. The Administrator stated the DON and he had talked and the Progress Note did not seem to add up to what was initially presented. The Administrator stated he called Staff A back at the facility and said they were not going to report it. The Administrator said Staff A kind of argued with him a little. The Administrator stated he explained to Staff A nothing was seen that indicated hands in the pants. The Administrator explained the staff just had to do a better job keeping the two of them separated. The Administrator stated he thought it was Staff H that had reported the situation. The Administrator stated when returned to work on Monday he did not think that he had talked to the nurse or the CNA about the incident. The Administrator explained the facility did have cameras in the front lobby but the DON attempted to look yesterday but the review was short of that date. The Administrator stated they were unable to go back that far in the video footage. The Administrator stated talking to Staff A on Saturday he felt the situation did not warrant an investigation. The Administrator said they did not look at the cameras or talk to the staff about the incident. The Administrator explained if the residents did indeed have each other's hands down each other's pants it would have been a totally different story. The Administrator acknowledged there was only one witness and it went from hands in the pants to hands in the lap during his discussion.Review of policy revised 7/6/23 titled Abuse and Neglect documented the purpose was to ensure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location, to ensure the location has an effective system in place that, regardless of the source, prevents mistreatment, neglect, exploitation and abuse of residents and misappropriation of their property, to ensure that residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals, to ensure that all identified incidents of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated and to ensure a complete review of existing incidents by the investigation team to identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation. The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services. These designated individuals are delegated the authority by the administrator to: Intervene in any situation in order to protect residents. Remove any individual from the location if necessary for the protection of residents or employees, including but not limited to employees, visitors, contractors or family members. The charge nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation. If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury. The charge nurse also will ensure that any potential for further abuse is eliminated. Notification procedures: Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker, etc.). Document this notification in the Risk Management module of PCC. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency. If applicable, Adult Protective Services will be notified where state law provides for jurisdiction in long-term care centers. If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. If there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported no later than 24 hours after the allegation is made. If the designated agency(ies) requests a written report, notify the social worker and administrator. Notify the physician and family regarding the facts of the situation. If there is alleged or suspected abuse/neglect or an injury of unknown origin, inform them that an investigation is in progress. Record this notification. The investigation team (social worker, administrator and director of nursing services) will review all incidents no later than the next working day following the incident.

Based on clinical record review, family interviews, staff interviews and policy review, the facility failed to complete a comprehensive investigation immediately when an allegation of abuse was reported for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 40 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. The MDS documented a diagnosis of Alzheimer's disease with early onset. Review of Resident #1's EHR titled, Progress Note entered by Staff A, Registered Nurse (RN) on 12/20/26 at 11:42 AM documented Staff H, Certified Nurse Assistant (CNA) reported she had observed Resident #1 and Resident #2 sitting at the nurses station with their hands down each other's pants. The residents were both separated. Resident #2 was taken to his room. Both Residents were assessed for trauma and none was observed. The Director of Nursing (DON), Staff G, Social Services Director, and the Administrator were aware of the incident. The Administrator stated the incident was not reportable because both residents had documented dementia.2. The MDS dated [DATE] documented Resident #2 had a BIMS of 03 indicating severe cognitive impairment. The MDS documented a diagnosis of vascular dementia, unspecified severity with other behavioral disturbance. Review of Resident #2's EHR titled, Progress Note entered by Staff A, Registered Nurse on 12/20/26 at 11:42 AM with effective date of 12/20/26 at 10:26 AM documented Staff H reported she had observed Resident #2 and Resident #1 sitting at the nurses station with their hands down each other's pants. The residents were separated and Resident #2 was assisted to his room. Both residents were assessed for trauma and none was observed. The DON, Staff G, and the Administrator are aware of the documented incident. The Administrator called the facility and stated the incident was not reportable because both residents had documented dementia.Review of Resident #2's EHR titled, Progress Note entered by Staff A, Registered Nurse on 12/20/26 at 12:35 PM with effective date of 12/20/26 at 12:16 PM documented Resident #2 observed reaching to touch another resident. Resident #2 was redirected by a CNA. Resident #2 hit the staff several times and told the staff to mind their business and leave him alone.On 2/18/26 at 9:15 AM Resident #1 stated she thought she had eaten breakfast but could not remember. Resident #1 acknowledged she did not know where this area was when asked if she grew up in the area of this facility. Resident #1 stated she kept to herself at the facility and was not friends with any of the residents at the facility. Resident #1 stated the staff treat her with dignity and respect at the facility. Resident #1 acknowledged she felt safe at the facility and was not scared of any of the residents or staff members. Resident #1 stated other residents had not attempted to touch her in any inappropriate ways.On 2/18/26 at 9:05 AM Resident #2 stated he had eaten breakfast that morning. Resident #2 explained that he had sausage, bacon, eggs and oatmeal. Resident #2 said the food was good. Resident #2 explained he did not have any friends that lived at the facility from his childhood. Resident #2 stated he had friends at the facility but could not remember any of their names or how he knew them. Resident #2 said he thought the staff treated him with dignity and respect. Resident #2 stated he felt safe at the facility. Resident #2 explained he had not touched any of the residents in any inappropriate way and none of the residents at the facility had touched him in any inappropriate way.On 2/17/26 at 5:30 PM Staff H, CNA acknowledged she had seen residents at the facility inappropriately touching each other. Staff H stated she had worked on a weekend and there were 2 residents sitting on the wall with their hands in each other's pants. Staff H acknowledged the incident occurred on 12/20/26. Staff H identified the 2 residents as Resident #1 and Resident #2. Staff H explained she did not see any movement in their pants but maybe Resident #1 was holding Resident #2's penis. Staff H said she stopped the 2 residents and assisted Resident #2 to his room. Staff H explained she told Staff A and Staff I, Licensed Practical Nurse (LPN). Staff H explained reported the incident to Staff A. Staff I acknowledged Staff A's Progress Notes entries regarding this incident for Resident #1 and Resident #2 was an accurate record of what happened. Staff H stated she did not see the nurses complete an assessment. Staff H stated she knew the incident had to be reported to the nurse for safety reasons because maybe Resident #2 would do it to someone else. Staff H stated she knew both residents had dementia. Staff H stated neither resident would remember what was discussed 15 minutes later. On 2/17/26 at 3:42 PM Staff G, Social Services Director stated she was informed of an incident where Resident #2 was reaching towards a resident. Staff G explained she called the DON and the DON called the Administrator. Staff G stated the incident she was Resident #1 and Resident #2. Staff G stated during the incident Resident #2 was reaching towards Resident #1. Staff G stated she was unaware if the Administrator called the facility back after that. Staff G stated the incident she was talking about happened prior to Christmas of 2025 maybe around the 19th. Staff G explained Staff A did not report to her that the residents had each other's hands in their pants. Staff G said she notified the DON of the incident but she did not say there were hands in pants but could not remember exactly what was said. Staff G acknowledged she did not document the incident. Staff G stated she did not know if Staff A tried calling the DON first but she was not on call. Staff G explained typically those situations are brought to the DON or the Administrator. On 2/18/26 at 1:04 PM Resident #2's son stated his father was struggling with dementia and things have changed in his world with how he conducts himself. Resident #2's son stated he did not know exactly who reached out to talk to him about the incident. Resident #2's son explained he was out of town and the facility called his brother and then he followed up with the facility. Resident #2's son stated they had shared with him the concern of the 2 residents inappropriately touching each other. Resident #2's son explained they had come to a conclusion that it would have been better to have his dad stay in his room and move him to the nurses station to keep an eye on him. Resident #2's son stated he did feel it was inappropriate for the 2 residents but did not think there was any sort of abuse. On 2/18/26 at 1:25 PM Resident #1's daughter said she was only notified of one incident and that incident occurred back in December. Resident #1's daughter stated it was described to her as hands were being held. Resident #1's daughter said the staff described the residents having each other's hands in their waistband. Resident #1's daughter stated she did not remember who had notified her of the incident. On 2/17/26 at 2:38 PM the DON acknowledged there were no married residents living together at the facility. The DON acknowledged there are no residents involved in an intimate relationship with each other both living at the facility. The DON said there are no residents that inappropriately touch other residents. The DON stated she had not been made aware of Resident #2 inappropriately touching any residents of recent. The DON explained if the resident was inappropriately touching another resident such as putting his hands down their pants, up their shirt or touching their breast she would expect to be notified of those situations. The DON further explained once she was notified she would come into the facility and complete an investigation to determine if it was abuse. The DON explained she would talk to the residents and talk to the staff as part of the investigation. The DON acknowledged she was not notified that Resident #2 had his hands down another resident's pants. The DON said she should have been informed and started an investigation if an incident like that occurred. The DON stated she was not aware this incident that was documented to have occurred on 12/20/25 between Resident #1 and Resident #2. The DON acknowledged she had not completed an investigation into the report that Resident #2 had his hands down another resident's pants. On 2/18/26 at 10:13 AM the DON said Staff G called and said there was an incident. The DON said she called the Administrator and told him to call the facility. The DON stated there were no details provided about the incident to her. The DON explained that the Administrator handled the situation from there. The DON stated she was on vacation over Christmas at that time. The DON acknowledged the incident did not come back up and she had not returned until January. The DON stated she had talked to Staff H 2/18/26. The DON explained that Staff H stated she had walked up to the nursing station and said Resident #1 and Resident #2 had hands in each other's waistband. The DON stated Staff H had explained there was no movement with either resident's hands. The DON stated she asked if Staff H felt it was sexual. The DON said Staff H said no not really but knew she needed to separate them. The DON stated Staff H said she separated them and told Staff A. The DON stated having hands in each other's waistbands did not indicate the activity was sexual in nature but they do not want the residents doing that. The DON explained the residents were not moving their hands while in each other's waistbands. The DON stated Staff A had told the Administrator she had not seen anything. The DON explained if the residents truly just hands in each other's waistbands and nobody was moving or doing anything then no assessment would be required. On 2/18/26 at 9:28 AM the Administrator stated he had read the progress note from 12/20/25 yesterday. The Administrator stated he thought that the situation had occurred on a Saturday and Staff A had called Staff G and said it seemed like Resident #1 and Resident #2 had their hands in each other's pants. The Administrator explained the situation was reported to have happened out at the nurses station. The Administrator explained he called the building and talked to Staff A. The Administrator said Staff A explained that Staff H saw both the residents with their hands in each other's pants. The Administrator stated Staff A acknowledged she didn't see the situation Staff H did. The Administrator explained Staff A would talk to Staff H and after she found out more details she should call him back. The Administrator stated Staff A talked to Staff H and called back. The Administrator said Staff A explained that Staff H reported she was walking down the hallway and it looked like Resident #1 and Resident #2 had each other's hands in each other's pants but the 2 residents were actually holding each other's hands. The Administrator stated Staff A said Staff H thought that was different and she said she separated them. The Administrator stated Staff A explained the 2 residents were not out by the nurses station very long. The Administrator explained he asked Staff A did Staff H actually see hands in the pants. The Administrator stated Staff A had just jumped to that conclusion. The Administrator stated Staff A asked do we need to report this. The Administrator said he told Staff A he would talk to the DON and decide. The Administrator explained what they knew was the 2 residents were holding hands and he was holding her hand in his lap. The Administrator explained Staff A said Staff H had separated the 2 residents and Staff A was going to complete an assessment. The Administrator stated the DON and he had talked and the Progress Note did not seem to add up to what was initially presented. The Administrator stated he called Staff A back at the facility and said they were not going to report it. The Administrator said Staff A kind of argued with him a little. The Administrator stated he explained to Staff A nothing was seen that indicated hands in the pants. The Administrator explained the staff just had to do a better job keeping the two of them separated. The Administrator stated he thought it was Staff H that had reported the situation. The Administrator stated when returned to work on Monday he did not think that he had talked to the nurse or the CNA about the incident. The Administrator explained the facility did have cameras in the front lobby but the DON attempted to look yesterday but the review was short of that date. The Administrator stated they were unable to go back that far in the video footage. The Administrator stated talking to Staff A on Saturday he felt the situation did not warrant an investigation. The Administrator said they did not look at the cameras or talk to the staff about the incident. The Administrator explained if the residents did indeed have each other's hands down each other's pants it would have been a totally different story. The Administrator acknowledged there was only one witness and it went from hands in the pants to hands in the lap during his discussion.Review of policy revised 7/6/23 titled Abuse and Neglect documented the purpose was to ensure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location, to ensure the location has an effective system in place that, regardless of the source, prevents mistreatment, neglect, exploitation and abuse of residents and misappropriation of their property, to ensure that residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals, to ensure that all identified incidents of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated and to ensure a complete review of existing incidents by the investigation team to identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation. The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services. These designated individuals are delegated the authority by the administrator to: Intervene in any situation in order to protect residents. Remove any individual from the location if necessary for the protection of residents or employees, including but not limited to employees, visitors, contractors or family members. The charge nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation. If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury. The charge nurse also will ensure that any potential for further abuse is eliminated. Notification procedures: Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker, etc.). Document this notification in the Risk Management module of PCC. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency. If applicable, Adult Protective Services will be notified where state law provides for jurisdiction in long-term care centers. If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. If there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported no later than 24 hours after the allegation is made. If the designated agency(ies) requests a written report, notify the social worker and administrator. Notify the physician and family regarding the facts of the situation. If there is alleged or suspected abuse/neglect or an injury of unknown origin, inform them that an investigation is in progress. Record this notification. The investigation team (social worker, administrator and director of nursing services) will review all incidents no later than the next working day following the incident.

Based on clinical record review, staff interviews, physician interview, physician assistant interview, policy review, and the National Library of Medicine review, the facility failed to provide assessments and interventions timely with a change in resident condition for 1 of 3 residents (Resident #3). The facility also failed to comprehensively care plan the need for assessment of impaired circulation following a history of a great toe amputation in June of 2025 which lead to the skilled placement at the facility. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident. The facility reported a census of 37 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/6/25 at 9:50 AM. The IJ began on 8/3/25, when the resident exhibited an increase in her level of pain, along with a change in her activities of daily living (ADL) functional ability. Facility staff removed the IJ on 8/7/25 through the following actions:-Resident # 3 was transferred to the local hospital on 8/4/25 with a diagnosis of critical limb ischemia RLE. A thrombectomy was conducted to improve blood flow. Amputation was discussed with resident. -Residents with atherosclerosis, intermittent claudication and recent amputations and signs of DVT are at risk. All other residents diagnosis' were reviewed by nurse manager on 8/7/25 and no other residents present with signs or symptoms of ischemia. -All residents will be assessed at the time of noted changes with notifications to the physician for further direction/orders. All orders will be followed as provided. Nurses educated on 8/7/2025 by Nurse manager on the symptoms of DVT and circulatory assessments. A quiz was completed by all nurses after education to show understanding. No nurse will work until completing education and quiz. Education will be provided to all Certified Medication Assistants to interview resident for pain level prior to giving a prn and to report to charge nurse resident observed status and level of pain each time a PRN analgesic is given, nurse to assess as needed for any changes or concerns. Education done on 8/7/25 by Nursing Management, no medication assistant will work until education is completed. Quiz for understanding will be completed. Oversight will be provided each business day by the nursing management team to review any changes in resident status and ensure that appropriate assessments and documentation are completed and ongoing as necessary with updates to the physician and responsible party.-All residents will be assessed for signs and symptoms of DVT or atherosclerosis. This will be completed 8/7/2025 by nursing. Any residents with a known history of DVT or atherosclerosis will have circulatory assessments twice daily until face to face visit with physician. If symptoms present doctor will be notified immediately for further direction. This will be implemented 8/7/2025 by nursing.-Resident #3 will be assessed upon return from hospital and care plan updated as needed to provide individualized care. This will include physical and psychosocial needs. -An ad hoc QA meeting held 8/7/25 to review the care of this resident and action plan for education and care going forward.-Daily oversight will be completed each business day M-F beginning 8/8/24. Audit of circulatory assessments will be completed daily x5 days and weekly x3 with results taken to QAPI for further review and recommendation.The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #3 scored 15/15 on the Brief Interview for Mental Status (BIMS) score indicating normal cognitive function. The document revealed diagnoses of amputation, coronary artery disease, atherosclerosis native arteries of extremities with gangrene right leg, atherosclerosis native arteries of extremities with resting pain right leg, atherosclerosis native arteries of extremities with resting pain, left leg, presence of other vascular implants and grafts, occlusion and stenosis of right carotid artery, and congenital renal artery stenosis. The MDS noted the resident took antidepressant, anticoagulant, antibiotic, opioid, antiplatelet, and anticonvulsant medications. The document recorded the resident receiving scheduled and as needed (PRN) pain medication, and no non-medication interventions for pain during the last 5 days of the assessment period. The MDS reflected that the resident required partial/moderate assistance for toileting, sitting to/from standing, transfers and utilized a walker and wheelchair. The Care Plan with the initiated date 8/6/25 revealed a focus area related to impaired circulation related to Atherosclerosis of Native Arteries of right and left legs, Peripheral Artery Disease, exhibited by recent Bypass graft to right (R) and left (L) Femoral popliteal arteries was initiated on 8/6/25. The goal of being free from signs/symptoms of complications of poor circulation through the review period was initiated on 8/7/25. Interventions for staff included observing fingers and lower extremities/stumps for pedal pulses, pain, edema, sensation, movement, temperature and color routinely and notify the nurse of any changes and the nurse to immediately notify the primary care provider (PCP) and document abnormal observations in progress notes. The Care Plan lacked any focus area or directions for staff related to impaired circulation prior to 8/6/25.The Care Plan provided a focus area of the resident being on opioid therapy related to post-surgical pain initiated and revised on 6/13/25. The interventions for staff included observe/record/report to the nurse any signs/symptoms of non-verbal pain: (SPECIFY: Changes in breathing (noisy, deep/shallow, labored, fast/slow), vocalizations (grunting, moans, yelling out, silence), mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion), face (sad, crying, worried, scared, clenched teeth, grimacing) and body (tense, rigid, rocking, curled up, thrashing). A focus area of the resident being on anticonvulsant medication therapy related to chronic neuropathic pain initiated and revised on 6/13/25 provided an intervention to monitor the resident condition based on clinical practice guidelines or clinical standards of practice related to use of Gabapentin. A focus area related to acute pain/discomfort related to the incision to groin and right lower extremity (RLE) initiated and revised on 6/13/25 provided interventions to notify the health care provider if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain, the resident was able to notify staff of pain, rate pain level on 0-10 scale, request intervention and report effectiveness of intervention, and observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion (ROM), and withdrawal or resistance to care with an initiation/revision date of 6/13/25. An activities of daily living (ADL) self-care performance related to RLE bypass graft and pain focus area dated 6/13/25 provided staff interventions of ambulation in room with staff assistance and 1 assist with gait belt and front wheeled walker to transfer.The clinical record lacked documentation pertaining to non-pharmacological interventions related to pain.The Wound Data Collection -V2 dated 8/3/25 at 1:10 PM for the unstageable right (R) heel ulcer revealed there were no signs of complications or resident complaint of pain. There was no specific documentation related to a circulatory assessment. The Wound Data Collection -V2 dated 8/4/25 at 1:38 PM for the right groin incision revealed the right lower extremity (RLE) was purple, cold to touch and the resident had extreme pain.The Wound Data Collection - V2 dated 8/4/25 at 1:45 PM for the unstageable R heel ulcer revealed the RLE was purple, mottled, no pedal pulse and the resident had extreme pain in the entire RLE.The Wound Data Collection - V2 dated 8/4/25 at 1:52 PM for the right great toe amputation revealed the RLE was purple, mottled, cold to touch, the resident had extreme pain and was provided pain medication. The Pain Level Summary reviewed from 7/8/25 to 8/4/25 revealed 5/136 entries of the resident having complaints of 10/10 pain. The dates recorded with follow up pain levels included: 7/13/25 at 6:51 PM pain at 10/10 with an entry at 8:07 PM of pain at 5/10 7/14/25 at 2:21 AM, pain at 10/10 with an entry at 8:56 AM of pain 4/10 7/17/25 at 8:30 PM with pain at 10/10 with an entry at 10:12 PM of pain at 0/10 7/24/25 at 6:48 PM with pain at 10/10 with an entry on 7/25/25 at 4:18 AM of pain at 0/10 8/3/25 at 2:35 PM with pain at 10/10, follow up pain level of 10/10 around 4:00 was not documented. The Clinical Physician Orders printed 8/11/25 provided Resident #3 was prescribed: -Acetaminophen Extra Strength Tablet 500 mg 2 tablets every 8 hours PRN for pain not to exceed 3000 mg - start date 7/8/25 -Gabapentin Oral Capsule 100 mg 3 capsules three times a day (TID) for Atherosclerosis of Native Arteries of Extremities with Rest Pain, R leg, Atherosclerosis of Native Arteries of Extremities with Rest Pain, L leg - start date 7/14/25 -Lidocaine Patch 5% apply to affected area topically 1 time a day (QD) for pain - start date 7/9/25 -Lidocaine Path 5% apply to remove patch topically at bedtime for pain - start date 7/8/25 -Oxycodone HCL Oral Tablet 5 mg 1 tablet every 4 hours PRN for pain - start date 8/3/25 The Medication Administration Record (MAR) - Treatment Administration Record (TAR) 8/25 with the Pain Level Summary revealed Resident #3 was provided the following PRN medications and treatment related to pain management from 8/1/25 - 8/4/25: -8/1/25 at 2:23 PM Oxycodone HCL 5 mg 1 tablet every 6 hours PRN for pain (discontinued on 8/3/25) with pain 4/10. -8/1/25 at 3:24 PM pain 0/10 -8/1/25 at 9:20 PM Oxycodone HCL 5 mg 1 tablet every 6 hours PRN with pain 7/10 -8/1/25 at 10:31 PM pain 2/10 -8/3/25 at 11:23 AM Lidocaine Patch 5% bottom L foot -8/3/25 at 11:24 AM Oxycodone HCL 5 mg 1 tablet by mouth every 6 hours PRN with pain 5/10 -8/3/25 at 12:40 PM pain level 2/10 -8/3/25 at 1:21 PM Acetaminophen Extra Strength 500 mg 2 tablets with pain 7/10 -8/3/25 at 2:35 PM Oxycodone HCL 5 mg 1 tablet 1 time only for uncontrolled pain for 1 day (start 8/3/25 2:35 PM) with pain 10/10 -8/3/25 at 7:25 PM pain level 3/10 -8/4/25 at 2:14 AM Acetaminophen Extra Strength 500 mg 2 tablets with pain 5/10 -8/4/25 at 5:04 AM pain level 1/10 -8/4/25 at 8:25 AM OK to send to emergency room (ER) for uncontrolled pain/evaluation of numbness to RLE one time only for pain/numbness for 1 day (start date 8/3/25 2:45 PM) -8/4/25 at 8:26 AM pain level 0/10 -8/4/25 at 8:30 AM Oxycodone HCL 5 mg 1 tablet every 4 hours PRN with pain 4/10 -8/4/25 at 10:20 AM Acetaminophen Extra Strength 500 mg 2 tablets with pain 4/10 The Progress Notes dated 8/3/25 - 8/5/25 revealed the following entries:-8/3/25 at 11:24 AM Oxycodone HCL 5 mg -8/3/25 at 12:40 PM Pain medication was effective pain 2/10-8/3/25 at 1:21 PM Acetaminophen Extra Strength 500 mg 2 tablets. Resident crying, rubbing on R calf.-8/3/25 at 2:30 PM call placed to on-call physician informing of uncontrolled pain, numbness to the R calf. The resident had been provided PRN Oxycodone and Tylenol with no effectiveness. A new order was received for Oxycodone 5 mg now, to increase frequency to every 4 hours, and to send to the emergency room (ER) if pain continues to be uncontrolled, numbness continues to RLE. -8/3/25 at 2:35 PM Oxycodone HCL 5 mg 1 tablet-8/3/25 at 7:25 PM Acetaminophen Extra Strength 500 mg 2 tablets; follow up pain 3/10 and ineffective.-8/4/25 at 2:14 AM Acetaminophen Extra Strength 500 mg 2 tablets -8/4/25 at 5:04 AM PRN administration follow up pain 1/10 and effective. -8/4/25 at 8:30 AM Oxycodone HCL 5 mg 1 tablet-8/4/25 at 9:53 AM PRN administration follow up pain 0/10 and effective.-8/4/25 at 10:20 AM Acetaminophen Extra Strength 500 mg 2 tablets-8/4/25 at 10:30 AM Leg purplish/red in color, cold to touch and no palpable pedal pulse.-8/4/25 at 10:34 AM sent to ER due to RLE being cold to touch.-8/4/25 at 10:38 AM PRN administration follow up pain 4/10 and ineffective.-8/4/25 at 10:39 AM hospital surgical department requesting medication administration record as the resident was going into a surgical procedure to attempt to restore blood flow to RLE.-8/4/25 at 12:33 PM call from ER the resident transferred to a different hospital for Critical Limb Ischemia RLE with no circulation in leg.-8/4/25 at 2:00 PM entry for Transfer to the Hospital Form completion.-8/5/25 at 9:48 AM hospital contacted and a thrombectomy was performed to restore blood flow, with potential amputation in the future. The Point of Care Document Dressing revealed: -8/3/25 8:41 AM independent (no help or staff oversight)-8/3/25 8:05 PM limited assistance (resident highly involved)-8/4/25 8:41 AM total dependence (full staff performance) The Point of Care Document Walk in Room revealed: -8/3/25 8:41 AM (independent)-8/3/25 3:46 PM activity did not occur-8/4/25 8:41 AM extensive assistance The Point of Care Document Personal Hygiene revealed: -8/3/25 8:41 AM independent -8/3/25 3:45 PM independent -8/4/25 8:41 PM total dependence The Point of Care Document Transfers revealed: -8/3/25 8:41 AM independent -8/3/25 3:46 PM limited assistance -8/4/25 8:41 AM extensive assistance The Shift Exchange Documents for 8/1/25 - 8/4/25 disclosed for Resident #3: -8/1/25 Overnight OK -8/1/25 AM pain pill at 2:21 PM -8/2/25 Overnight OK -8/2/25 AM OK -8/2/25 PM OK -8/3/25 Overnight OK -8/3/25 AM 11:25 Oxy, 1:20 PM Tylenol -8/3/25 PM 2:36 PM oxy - new verbal order for increased frequency of Oxy 5 mg to every 4 hours and OK to send to ER if pain remains uncontrolled or numbness to right calf/leg. -8/4/25 Overnight can't stand up will fall -8/4/25 AM pain pill at 8:30 AM, sent to ER, admitted . The Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form (eINTERACT) dated 8/4/25 revealed the resident was transferred to the hospital at 1:58 PM. The document provided a report was called into the hospital at 10:00 AM with the resident's most recent pain medication of Oxycodone HCL 5 mg on 8/4/25 at 8:30 AM. The vital signs provided on the document revealed the last set of vitals was completed on 7/29/25, and pain level was 4/10 on 8/4/25 at 10:38 AM. The document lacked documentation pertaining to the Acetaminophen Extra Strength 500 2 tabs that was provided at 10:20 AM, and the completion of a current set of vitals. The Hospital Medical Record for 8/4/25 revealed Resident #3 arrived at the hospital on 8/4/25 at 11:02 AM via a wheelchair from the facility with chief complaints of right lower leg vein bypass, right big toe amputation, and the resident stating pain had started the previous day, pain was 10/10, sharp and throbbing, the right foot was cool to the touch, and no pedal pulse was found. The document provided the pain was first reported around 2:00 PM on 8/3/25 with orders for additional pain medication provided as ordered. The document reflected that the resident stated that pain continued through the night and into the morning of 8/4/25. The document disclosed the resident stated the RLE is painful, numb, unable to put weight on it without feeling that her leg was collapsing under her. The document's Physical Exam revealed: -The resident's right leg was cool and mottled compared to the left leg extending to just proximal to the knee.-There was neither a Dorsalis Pedis Artery Pulse or Posterior Tibial Pulse obtained by palpation or by Doppler.-The toes were very pale with no cap refill. -A wound VAC was in place at the right groin.-The resident presented with a peripheral heart rate of 73, respirations of 18, blood pressure 184/85 (high). A contrast enhanced computerized tomography scan (CT scan) angiogram of the abdomen and pelvis with bilateral lower extremities dated 8/4/25 recorded: -Occlusion of the R common iliac, internal and external iliac arteries.-Occlusion of the superficial femoral artery bypass graft. The hospital reported that due to the life-threatening nature of the resident's medical problem and the likely delay using ground transportation, air transport was arranged and the resident would go directly to the preop area of the hospital where the Vascular Surgeon practiced. On 8/6/25 at 11:54 AM Staff A, Registered Nurse (RN), stated Resident #3 began complaining of major pain with crying behavior and numbness in the RLE around 2:00 PM on 8/3/25. The staff stated the resident's skin color at the front of the calf where reporting pain was red in color, and a faint pulse was detectable. The staff stated the resident reports of pain previously had been vague, and she had never seen the resident cry with pain even with wound VAC changes. The staff stated she contacted the On-call Physician regarding the uncontrolled pain and not due for another PRN Oxycodone, as well as numbness of the RLE. The staff stated orders were received for a 1 time dose of Oxycodone, increased the frequency of the PRN Oxycodone to every 4 hours from every 6, and to send the resident to the hospital if the uncontrolled pain and numbness continued. The staff stated she did not document in the Progress Notes the resident's crying behavior related to the pain or the complaints of numbness in the RLE, as it was time for shift exchange and she thought she had helped out by calling the physician and getting the new orders. Staff A stated she gave a report to Staff E, RN, and Staff D, Certified Medication Aide (CMA), if the pain medication was not effective or continued numbness there was an order to send the resident to the ER. Staff A indicated that looking back, she wished she would have stayed versus leaving and followed up on the resident's pain since she was crying or even sent the resident to the ER right away. On 8/6/25 at 12:30 PM, Staff B, Certified Nurse Assistant (CNA), stated when she dropped off Resident #3's lunch tray on 8/3/25 the resident had her RLE propped up, complaining of pain, and crying. The staff stated the resident crying with pain was abnormal behavior. The staff stated she recalled the resident having an infection in the lower extremity and did not cry with pain. Staff B stated she contacted Staff A regarding the resident's behavior and complaint of pain. The staff stated when she returned to pick up the resident's tray, it was in the hallway and she heard Staff A state she was sending a fax out to the physician. On 8/6/25 at 12:35 PM, Staff C, CNA, stated the resident began complaining of pain and crying in the afternoon on 8/3/25. The staff stated the resident required more assistance than her normal for transfers in the afternoon on 8/3/25. Staff C stated the resident typically required limited assistance and would self transfer independently, but in the afternoon the resident required moderate assistance. Staff C stated Staff A left around 3:30 PM on 8/3/25 and Staff C took over as the nurse. On 8/6/25 at 12:58 PM Staff D stated she was notified by Staff A of the verbal order for a 1 time dose of Oxycodone HCL 5 mg for pain in the RLE. The staff stated the resident had been crying at the time of the medication dispensing which was unusual for the resident. The staff stated when she returned to the resident around 4:00 PM for medication administration the resident stated her RLE continued to hurt at 10/10 but no longer felt as though someone was stabbing her leg. The staff stated she spoke with the resident again later at an unspecified time, the resident was sitting up and continued to complain of pain. The staff stated she told Staff E if the pain was persisting the resident could be sent to the ER. On 8/6/25 at 1:27 PM the On-call Physician stated he recalled receiving a call from the facility regarding Resident #3 and the resident being anxious and having increased pain. The Physician stated he could not recall if the nurse reported a change in the resident's behavior with crying that was out of the ordinary. The On-call Physician stated he was aware of the resident being in the facility for lower extremity intervention and post-operative care. The Physician stated he was told the resident was on routine pain medications, had taken what was prescribed, and asked for additional medication. The On-Call Physician agreed to provide a 1 time dose of Oxycodone, change the frequency of the PRN Oxycodone medication, and told the nurse if there was any change in the RLE assessment or if the pain medication was not effective the resident needed to go to the hospital. When asked if 10/10 pain at 4:00 PM would be a concern when the additional dose of Oxycodone was provided at 2:30 PM, the On-Call Physician indicated the resident should have gone to the hospital. On 8/6/25 at 2:10 PM Staff E, Registered Nurse, confirmed she worked on 8/3/25. The staff stated she had no contact with Resident 3# as that was not her normal hallway to work. The staff stated she always goes down to listen to the shift exchange report, but did not recall any details about the resident. The staff stated Staff A was on shift until 6:00 PM when the overnight staff came on duty. On 8/6/25 at 2:20 PM the MDS Coordinator stated she completed an assessment on Resident #3 around 10:30 AM on 8/4/25 due to contact by the Wound Care Nurse/LPN stating the resident was crying with pain. The staff stated she requested the Social Services Supervisor/RN to accompany her to assess the resident. Prior to assessing the resident, the staff stated she read the MAR - TAR, saw the orders for sending the resident to the ER, and instructed Staff G to begin the transfer process. The MDS Coordinator stated the resident's RLE present with red/purple color, cold to touch, and no pedal pulse. The staff stated she put her assessment in the Progress Notes, but did not do a formal assessment. The staff reported documentation of the assessment would also be in the SNF/NF Transfer to Hospital Transfer Form dated 8/4/25. When reviewing the document, the MDS Coordinator acknowledged the completion of the document indicating the resident transferred at 1:58 PM when the resident had actually left the facility around 10:34 AM. The staff stated she was unsure if this document was available for the ER review when a resident was transferred from the facility. The MDS Coordinator admitted there was no documentation regarding any assessments on the resident's RLE despite the order from the physician stating to transfer the resident to the ER for uncontrolled pain/evaluation of numbness to the RLE. The MDS Coordinator stated that given the resident's diagnoses assessments should be completed at least once a shift and documented. On 8/6/25 at 2:40 PM the Social Services Supervisor/RN confirmed the Director of Nursing (DON) was on vacation. The staff confirmed she was present with the MDS Coordinator on 8/4/25 when the assessment took place, but could not provide a time except it was after 9:00 AM. The staff acknowledged that Resident #3 was provided a 1 time dose of Oxycodone on 8/3/25 at 2:35 PM, and there was no pain assessment or follow up regarding the pain documented in the clinical record. The staff stated she expected there to be a pain level follow up to ensure the effectiveness of the medication. The staff stated assessments should be completed once per shift and documented. The staff acknowledged there was no documentation of assessments in the Progress Notes. The staff stated Staff A clocked out at 3:11 PM despite being on the schedule until 6:00 PM. The Social Services Supervisor/RN stated it was not uncommon for a nurse to do that if their job duties were done, there was a CMA covering that area, and another nurse on the floor. On 8/6/25 at 2:47 PM Staff F, Wound Care Nurse/Licensed Practical Nurse (LPN), stated when she entered Resident #3's room on 8/4/25 in the morning the resident was crying and complaining of pain in the RLE. The staff stated she obtained Tylenol from Staff G, Registered Nurse (RN), and provided it to the resident. The Wound Care Nurse/LPN stated she could not recall Resident #3 crying previously with pain during treatments. The staff stated she did not consistently complete an assessment that included checking for a pedal pulse when doing the resident's wound care. The staff stated she could not recall a lot about the resident's pedal pulse as she did not complete the admission assessment but felt the pulse was good. The staff could not state what the pulse was like most recently. On 8/6/25 at 6:02 PM Staff G confirmed she worked on 8/4/25. The staff stated she was aware of the resident's order to go to the ER if she had uncontrolled pain and/or numbness in the RLE. The Staff stated the resident complained of pain around 8:00 AM and was provided her PRN Oxycodone. The staff stated a short time later the Wound Care Nurse/LPN contacted her about the resident requesting additional pain medication. Staff G stated as it was too early for additional Oxycodone, PRN Tylenol was dispensed, and provided to the Wound Care Nurse/LPN to provide to the resident. The staff stated she was then contacted by the Administrative Nurse to prepare to send the resident to the hospital as her leg was really cold. Staff G stated she did not recall Staff H, LPN, saying anything about the resident's RLE during shift exchange. The staff stated she discovered the order by reading the TAR as she does every time she comes on shift to ensure knowledge about residents' orders as she only worked 3 days/week. The staff stated she did not do assessments of the RLE on a routine basis unless the resident was complaining of pain. The staff stated if she did an assessment and the resident was skilled she would probably put it on the Skilled Assessment Note. Staff G responded if the resident was not skilled she would put the assessment on the Skin Assessment under the User Defined Assessments (UDAs) if there was something out of the ordinary. The staff continued if it was normal she might put something in the Progress Notes but nothing extensive. The staff stated there was no indication to do pedal pulse assessment. On 8/7/25 at 9:31 PM Staff H confirmed she was the overnight shift staff for 8/3/25 to 8/4/25. The staff stated she was not told anything during the shift exchange report regarding Resident #3 from Staff E. Staff H stated she did not recall anything specific to Resident #3 on the Shift Exchange Document. The staff stated the resident did require pain medication overnight, but that was not uncommon. The staff stated the resident had not cried during her previous shifts when requesting pain medication. The staff stated she was not aware of an order to send the resident to the ER for uncontrolled pain/evaluation of numbness to the RLE. Staff H stated she did not bring anything up to Staff G during the shift exchange on the morning of 8/4/25 as she did not know of the order. On 8/7/25 at 12:00 PM Staff A stated Staff E was aware of the staff leaving early and was the only nurse on the floor. The staff stated during shift exchange on 8/3/25 Staff E asked Staff A to make sure the conversation/order from the physician was written on the Shift Exchange Document. The staff stated she documented the contact with the physician and orders on the Shift Exchange Document. Staff A stated she was really upset that staff had not taken care of the resident, and felt she had done all she could at the end of her shift by calling the physician and getting orders due to the resident's significant complaints of pain and crying behavior. On 8/7/25 at 3:50 PM the Physician Assistant (PA) for the Vascular Surgeon stated Resident #3 had a through the knee amputation on 8/7/25. When asked if sending the resident to the hospital on 8/3/25 instead of 8/4/25 would have made a difference, the PA replied the resident would not have had to suffer as many days in significant pain as the thrombectomy would have been completed sooner as the resident did go immediately into surgery upon admission to the hospital, and the resident had relief from the pain following the procedure. On 8/13/25 at 4:40 PM Staff I, CNA, confirmed she provided care to Resident #3 on the night of 8/3/25 to 8/4/25. The staff stated during that shift the resident turned her call light on and requested to be changed. Staff I disclosed she completed care in bed as the resident was complaining of pain in the RLE. The staff voiced she was careful with moving the resident in bed due to the resident's complaints of pain. Staff I stated Resident #3's normal behavior was to turn her call light on, request to use the bathroom and be changed in the bathroom; the resident's behavior on 8/3/25 to 8/4/25 was outside of her normal behavior. The staff stated the nurse had also been in the resident's room that night to provide pain medication due to the resident's pain in the RLE. The facility policy titled Nursing Documentation Guidelines, Timelines - Rehab/Skilled reviewed/revised 5/7/25 revealed a purpose of systematically and continuously collecting information about the health status of a resident and to ensure appropriate documentation is completed in a timely manner. The document provided that if a change in condition was identified in a resident the nurse would use an eINTERACT Change in Condition Evaluation to collect the data prior to communicating with the medical provider. The document disclosed day-to-day documentation of specific occurrences would be completed in the Progress Notes. The National Center for Biotechnology Information, a service of the National Library of Medicine, National Institutes of Health, revealed the onset of action for Oxycodone is 10 to 30 minutes for immediate-release formulation and 1 hour for the controlled release. The plasma half-life is 3 to 5 hours, and stable plasma levels are reached within 24 to 36 hours. The duration ranges from 3 to 6 hours for immediate release or 12 hours for controlled release.

Based on observations, staff interviews, record review and facility policy review the facility failed to establish and implement interventions to prevent falls and injuries for 2 of 3 residents reviewed. Resident #20 had a history of confusion and many falls. She tripped on the pedals of the wheel chair on 3/1/25 and staff failed to follow through with an intervention to remove those pedals from the wheelchair when not in use. On 4/2/15 the resident again tripped on the wheel chair pedals, fell and sustained head trauma. Resident #6 had many falls and the facility failed to evaluate for risks and hazards and failed to implement interventions for every fall. The facility reported a census of 43 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #20 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficit). She required supervision with eating, dressing and hygiene and toilet transfers. The resident had two or more falls with injury since admission. She was admitted to the facility on [DATE]. The Care Plan (CP) updated on 4/17/25, showed that Resident #20 was at risk for falls related to confusion, incontinence, osteoporosis, syncope and medication use. The CP listed 11 falls from 1/1/25 through 4/2/25. The resident had self-care performance deficit related to dementia, she was able to ambulate with seated walked, gait belt and assistance of one and she was able to transfer with the assistance of one staff. The resident had behavior symptoms related to dementia, a history of exit seeking and verbal aggression. On 4/7/25 Resident #20 was admitted to Hospice Services after an alteration in neurological status related to head injury with traumatic cerebral hemorrhage. On 4/15/25 at 10:03 AM, observed Resident #20 sitting in her wheelchair with Hospice staff in the dayroom. She had a tall back wheelchair; her feet were on the pedals and it was slightly tilted. There was an open sore on the right side of her face, her forehead and cheek had bruising in various stages of healing. The resident was very calm and the Hospice staff person said that she was just getting to know the resident and she had been told that Resident #20 had days of agitation. The Care Plan (CP) and Fall Scene Huddle Worksheet (FSHW) contained the following information related to falls since January: a. Fall on 1/9/25 the CP included an intervention to check frequently during shifts. The FSHW lacked a root cause or intervention. b. Fall on 1/25/25 unwitnessed in her room no intervention on the CP. FSHW intervention included wearing gripper socks 24 hours a day. c. Falls on 1/26 and 1/27/25 unwitnessed in her room, no interventions listed on the CP. FSHW included a medication change. d. Fall on 2/28/25 intervention on the CP not to leave the resident in the room unattended with foot rest on recliner up. FSHW included a root cause of trying to transfer out of the recliner. e. Fall on 3/1/25 the CP included an intervention to keep in view of staff. The FSHW included the root cause to be that she tripped on the foot pedals of the wheel chair, fall with abrasion to head. The corrective actions taken to prevent recurrence of this incident was to remove the pedals when not in use and all staff would complete the corrective action. f. Falls on 3/6 and 3/7/25 CP intervention was to check often (repeat intervention from 1/9) frequently leave door open. 3/7/25 fall in room when up independently with contusion to head. CP intervention to leave door to room open and check often. No FSHW document. g. Fall on 3/16/25 no intervention added on CP. FSHW documentation; found on floor in another resident's room. Confusion, intervention to keep light on in the bathroom. h. Fall on 4/2/25 in the morning, slid from wheel chair no injury no team meeting i. Fall on 4/2/25 late afternoon. CP included; the resident got up out of wheel chair independently, intervention to remove pedals from the WC unless staff pushing resident in chair. FSHW root cause resident attempting to stand up and tripped over wheel chair pedal. She had been fidgeting with pedals on WC all day, talking to people not there The Nursing Progress Notes for the resident included the following: a. On 3/1/25 at 10:38 AM the resident was sitting at the nurse's station, the Certified Nurse Aide (CNA) saw the resident attempt to get up from wheel chair, became unbalanced, swayed backward, unable to clear foot pedals on the wheel chair falling to the floor and obtained a 5-centimeter (cm) x 3 cm. laceration. b. On 4/2/25 at 1:03 PM, the resident was sitting in common area in wheelchair looking at a magazine, she tore a page out and was taking to someone, and slid to the edge of the wheelchair seat and then slow motion went to the floor, did not hit her head. The pedals were on the wheelchair. She was assessed and sat back it the wheelchair then taken to the front nurse's station. c. On 4/2/25 at 5:54 PM, the resident was sitting in chapel in her wheelchair attempting to get up and she tripped over the pedal on the wheelchair and fell and hit her head. Large amount of blood. Emergency service called and sent to the emergency room . d. On 4/2/25 at 8:50 PM, call to the hospital and told that she had a brain bleed and was being transferred to a larger hospital. e. On 4/5/25 at 1:36 PM, returned to facility from hospital. Scattered bruising on bilateral upper extremities abrasion on right forehead measuring 3 cm. x 1.5 cm. The Incident Reports included the following: a. 4/2/25 at 10:37 AM the resident was in her wheelchair by the nurses station. She had been messing with the pedals on the wheelchair and talking to someone. She had a picture from a magazine in her hand and scooted to the edge of the wheelchair seat and slid to the floor. b. 4/2/25 at 4:30 PM the resident was getting up out of the wheelchair. The nurse tried to get to her but the resident tripped over the pedals before she could get to her. She fell and hit her head. On 4/16/25 at 1:36 PM, Staff K, CNA, said that she was working on 4/2/25 when Resident #20 fell in the chapel. She and another CNA were taking the residents to the chapel to wait for the dining room to open. There was a nurse in the area and it was about 4:00 PM. Resident #20 said that she was cold so they got her a blanket. Staff K said that she had been more agitated and the night before they found her walking down the hallway on her own. She said there had been a time when they used chair alarms but they were no longer able to use them. The resident would also climb out of bed and it helped to have a bed pad that would alarm but they don't have that any more either. Staff K said they usually have two staff in the dining room to monitor residents. On 4/16/25 at 1:44 PM, Staff H, CNA said that she was working on 4/2/25 when Resident #20 fell . That evening, there was a nurse and about 6-7 residents' in the chapel waiting to be taken into the dining room. She said that she was talking to another resident and next thing she knew, Resident #20 was on the floor. Foot pedals on the wheel chair were down and she was covered with a blanket. On 4/16/25 at 2:15 PM, Staff B Licensed Practical Nurse (LPN) said that she was the only one in the chapel that afternoon and she was passing pills. When she saw the resident getting up, she had some pills in her hands and couldn't get to her fast enough to prevent her from falling. She said the resident had been messing around the pedals earlier in the day. On 4/16/25 at 3:03 PM, the Director of Nursing (DON) said that having just one person in the chapel when the residents were waiting to go into the dining room was enough because the CNAs were in and out as they assisted the other residents. She said that after falls, they had a stand-up meeting with the team and come up with ideas on what they can do differently and add those interventions to the care plan. 41783 2. The MDS assessment dated [DATE] for Resident #6 documented she scored 12 on the BIMS indicating she has moderately impaired cognition. The MDS documented she was independent with transfers and walking 10 feet. The MDS documented she required supervision or touching assistance for walking 50 feet with two turns. The MDS documented she had diagnoses to include arthritis, dementia, multiple fractures of ribs and syncope and collapse. The Care Plan dated 1/2/24 documented the following fall focus for Resident #6: The resident has had an actual fall (prior to admit) with fracture to right arm R/T Poor balance, Dementia. 10/3/24 fall in room without injury. 10/5/24 fall in room when carrying items while pushing walker. 10/15/24 fall in room with 3 left rib fractures. 12/28/24 fall from obstacle in room. 2/3/25 fall in room when lost balance. 4/11/25 fall in dining room when slipped on floor. Date Initiated: 1/2/2024 Revision on: 4/14/2025 The Care Plan lacked documentation of the fall that occurred on 1/2/25 and any new interventions. The Progress Notes for the resident documented the following: On 1/2/25 at 7:05 PM Late Entry: As leaving room across the hall from resident room (her door was open) heard her yell at her radio, which was on the floor and watched her walk up to it and kick it. She went to kick it again and fell to her buttocks. She did not hit her head. Asked her to wait a minute while got someone to help get her up, she kicked at me, said it was all my fault and I wasn't to touch her. When CNA arrived, we attempted to help her up and she fought us scratching, pulling our clothes and refused to stand. On 1/2/25 at 7:05 PM Late Entry: She refused vitals (VS). When we thought she might be calmer (720pm) we were able to help her to bed, she continued to yell at us both and told us to take her to the huskow (slang for jail?). As we were leaving she put her hands above her head in the air and purposely slid easily to her floor, yelling leave me alone for good, I don't need any help from you and your people. Eventually we were able to get her up in the Hoyer without difficulty and transferred her to bed. No VS were able to be obtained. The Progress Notes lacked any other documentation regarding the fall on 1/2/25. On 4/16/25 at 11:50 AM the DON stated the facility does not have an incident report for the fall on 1/2/25. She stated the nurse at the time missed it. She stated it was crazy at the time of the fall, the resident was uncooperative and that affected their ability to assess her. Review of the clinical record and the chart lacked a Falls Tool assessment for the fall on 1/2/25. During an interview on 4/16/25 at 12:09 PM the DON stated they don't do a drill down to find the root cause at the time of the fall. She stated they discuss them the next morning at daily huddle with all staff and if there are reasons for the fall with recommendations that come out of that meeting then the MDS Coordinator will update the care plan and put those interventions in place. Upon asking, the DON provided the Falls Scene Huddle Worksheet for all of Resident #6's falls except she did not provide one for the fall that occurred on 1/2/25. The facility policy with the revised date 4/8/25 titled Fall Prevention and Management documented the following: Purpose: -To promote resident well-being by developing and implementing a fall prevention and management program. -To identify risk factors and implement interventions before a fall occurs. -To give prompt treatment after a fall occurs. -To provide guidance for documentation. Policy for fallen resident: 6. A nurse must observe the resident and perform a full body exam to determine if there may be suspected injury and direct whether to move the resident. f. Complete Fall Scene Huddle Worksheet. 8. If the resident is stable, call available employees to the scene of the fall and begin the investigation using the Fall Scene Huddle Worksheet. 9. After the initial documentation of the incident in the SAFE Event Reporting application (Incident Report), if there is a need for additional documentation, this will be done in the Progress Notes. 11. Complete the Falls Tool if not done in the post fall huddle. 16. Review and update the Care Plan with any changes/new interventions. 18. Continue to monitor condition and the effectiveness of the interventions.

Based on observation, staff interviews, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals. The facility reported a census of 43 residents. Findings include: Continuous observation on 4/16/25 at 11:19 AM to 11:40 AM revealed the following: Staff A placed 10 brownies into the blender and added milk to be pureed. Staff A then added thickener to the puree. Staff then poured the pureed brownies into serving bowls without measuring the puree. Staff A then prepared 4 servings of green beans in the blender to puree. Staff A added thickener to the green beans. Staff A then placed the green bean puree into a pan and placed this onto the steam table without measuring the amount made. Staff A then prepared 10 servings of ham and beans in the blender and again placed the puree mixture into a pan and placed into the steam table without measuring the amount of puree mixture. Staff A then obtained scoops for service and placed them on the steam table. Staff A revealed that he had made extra servings for service. Interview on 4/16/25 at 12:17 PM with the Food and Nutrition Supervisor revealed Staff A didn't measure the puree items prior to service. The Food and Nutrition Supervisor further revealed her expectation would be for puree to be measured after being pureed to obtain the correct scoop size. Interview on 4/16/25 at 12:24 PM with the Administrator revealed that proper portion sizes as well as the pureeing process should be followed. Review of a facility provided policy titled, Textured-Modified Diets with a revision date of 4/23/24 revealed: a. Measure the total volume of the food after it is pureed. b. Divide the total volume of the pureed food by the original number of portions.

Based on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with safe food handling practices. The facility reported a census of 43 residents. Findings include: During continuous observation on 4/16/25 from 11:45 AM to 12:08 PM Staff A [NAME] was observed to have touched plate warmer lids, menus, handles on scoops, and the jeans Staff A was wearing. Staff A was observed to take the lids off of the food items bare handed in the warmers and then scoop out the food and place the food onto a plate. Staff A was then observed to place the lids back on the food in the steam stable and place the scoop on top of the lids on the steam table. Staff A was observed touching multiple items between serving the food from the steam table. Interview on 4/16/25 at 12:17 PM with the Food and Nutrition Supervisor revealed that Staff A should have not placed the scoop on top of the lids of the warmer pans after use. Interview on 4/16/25 at 12:24 PM with the Administrator revealed an expectation that proper hand sanitizing should be completed at the appropriate times in the kitchen while serving. Review of a facility provided policy titled, Hand Hygiene with a revision date of 3/29/22 revealed: a. All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices.

Base on observations, staff interviews and record review the facility failed to use infection control practices for 3 of 13 records reviewed. Resident #39 had an open pressure ulcer on his coccyx that was exposed to pathogens as it came into contact with the mechanical lift sling. Staff failed to use adequate hand hygiene while caring for Resident #3, and Resident #33 was found to have his catheter bag resting on the floor. The facility reported a census of 43 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE], for Resident #39, showed that he was admitted to the facility on [DATE] and he had a Brief Interview of Mental Status (BIMS) score of 13 (moderate cognitive deficit.) The resident was always incontinent of urine and frequently incontinent of bowel. His diagnoses include: malnutrition, Chronic Obstructive Pulmonary Disease (COPD) and a Stage 4 pressure ulcer of the sacral region. The Care Plan dated 3/3/25, showed that Resident #39 had self-care performance deficits related to malnutrition and weakness. He was bedfast most of the time and non-ambulatory. Resident #39 was dependent for all bed mobility, dependent for toilet use and hygiene. He was incontinent of bowel and bladder and he required 2 staff assistance for transfers with a mechanical lift. He had the potential for pressure ulcer development. Staff were to notify the nurse immediately of any new areas of skin breakdown: redness, blisters or discoloration. Assess and monitor wound healing and report improvements and/or decline. The resident required Enhanced Barrier Precautions (EBP) related to stage 4 pressure injury to sacrum. On 4/16/25 at 10:14 AM, Staff C Certified Nurse Aide (CNA) and Staff D, CNA, prepared to transfer Resident #39 to the shower chair for a shower. The resident was in bed on his back, his legs supported with a pillow at the knees and he was wearing heel protectors. The resident had a scabbed wound on the back of his left calf and the right calf had a dark spot in the area of where the legs had been resting on the pillow. Further up on the left thigh here were two separate open areas. When asked if those skin issues were documented, Staff D responded that those were old spots that had been there for a while. Staff C and Staff D turned the resident onto his left side. He had a dressing patch on his coccyx that was not dated and was soiled. With gloved hands, Staff C pealed the dressing off and pulled the packing out of the wound and threw it away. The wound had a large opening that immediately started to bleed and dripped down his side onto the bed. Staff D then got a netted shower sling for the mechanical lift and laid it on the bed. The CNA's assisted him to roll back to his right side, then Staff D tucked the rolled-up sling under his right side. The CNA's told the resident that there would be a bump that he needed to roll over, and they assisted him to roll over the rolled-up sling, back onto his left side, pulled the sling under him and got him into position to transfer him with the mechanical lift. The wound continued to bleed throughout the process and when they transferred him to the shower chair, the netted sling was soiled with blood from the wound and Staff D pushed him to the shower room. On 4/16/25 at 10:52 AM, Staff D pushed that resident back to his room after his shower. The wound was left open through the shower and the lift sling was still soiled with blood on the back. The resident was transferred back to the bed for the wound treatment. Staff G, Treatment Nurse, provided the wound treatment including measurements and packing. Staff G removed her gloves before leaving the room but failed to wash her hands or use sanitizer before walking down the hallway. On 4/17/25 at 7:04 AM, the Director of Nursing (DON) expressed concern that the CNA removed the resident's dressing and packing. She agreed that having the open ulcer in contact with the sling and open throughout the shower was an infection control issue. On 4/17/25 at 10:11 AM the Physician said he would be more concerned with the wound having been exposed to the Hoyer sling then being open in the shower. He stated it is probably not best practice to have put him on the sling. 47673 2. The MDS for Resident #3, dated 3/11/2025 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented utilization of an enteral feeding tube for medication administration. On 4/16/25 at 9:18 AM Staff N, Registered Nurse (RN) completed hand hygiene, applied a gown and applied gloves. Staff N administered medication and water via an enteral tube. Staff N removed the old split sponge, applied a new split sponge, removed gloves and applied tape to the split sponge without gloves on. Staff N removed the gown, and completed hand hygiene. Staff N left the room and shut the door. On 4/16/25 at 10:11 AM the Director of Nursing (DON) acknowledged gloves should be utilized during any cares performed with any interaction with Resident #3's enteral tube. 3. The MDS for Resident #33, dated 1/28/2025 documented a BIMS of 14 indicating no cognitive impairment. The MDS documented placement of a suprapubic catheter. On 4/16/25 at 6:52 AM Staff O, Certified Nursing Assistant (CNA) and Staff P, CNA applied gowns and gloves. Staff O separated catheter tubing, catheter cleansed with an alcohol wipe. Staff P opened the tip of the catheter tubing, emptied the bed catheter bag into the toilet and replaced the tip of the catheter tubing. The catheter tip was not cleansed prior to replacement. The catheter bag was placed in a plastic bag. Staff O applied Resident #33's catheter leg bag. Staff P changed gloves, completed hand hygiene and applied new gloves. Resident #33 shoes were applied by Staff P. Staff O obtained peri wipes and laid the peri wipes on the bed. Staff O cleansed supra pubic stoma site with wet wipe and tubing down about 6 inches. Staff O then took Resident #33's shoes, took pant leg off, applied brief, put pant leg back on and shoe back on, pulled up pants, tore the sides of brief, obtained wipes, cleansed groin on left and right side, and cleansed the outside of Resident #33's penis. Staff O did not retract Resident #33's foreskin. Staff O asked Resident #33 to turn over. Staff O cleansed buttocks, removed gloves and reapplied gloves without hand hygiene. Staff O pulled Resident #33's brief and pants the rest of the way up. Staff O then removed gloves, completed hand hygiene and applied new gloves. Staff P assisted Resident #33 to apply a shirt, applied a gait belt, utilized the gait belt for transfer. Staff O turned water on and moistened a wash cloth. Staff P removed his gloves, gathered bedding and put them in a plastic bag. Staff O gave the warm cloth to Resident #33 to clean his face. Staff P removed his gown. Staff O removed her gloves and gown. Staff P left the room and did not complete hand hygiene. Staff O removed the gown and completed hand hygiene. Staff P went to the next resident's room and started care. On 4/16/25 at 2:26 PM the DON stated the facility's expectation was that hand hygiene would be completed between all glove changes and when moving from one area of the body to another. Review of the policy revised 3/29/22 titled, Infection Prevention Hand Hygiene documented all employees in patient care areas will adhere to the 4 moments of hand hygiene and 2 zones of hand hygiene: entering room, before clean task, after bodily fluid/glove removal, exiting room, and 2 zones patient zone and health-care zone. Hand sanitizer or soap will be utilized after removing gloves regardless of the task, application of dressings, when exiting the patient room, and when moving from contaminated body site to a clean body site during patient care.

Based on CDC and CMS recommendations, clinical record review, staff interviews, and policy review, the facility failed to implement infection control practices in order to control and mitigate the spread of COVID-19 infection amongst residents and staff. On 1/15/22, a staff member reported feeling ill yet continued to report to work and provide care for residents throughout the building on 1/15/22, 1/16/22, and the morning of 1/17/22. Facility records showed the staff member worked with signs/symptoms consistent with COVID-19 infection and she provided care for residents who later tested positive. On 1/17/22, the staff member tested positive for COVID-19 infection. The facility reported an outbreak of COVID-19 infection with a total of 11 of 40 residents (Resident #6, #7, #9, #13, #18, #23, #25, #27, #34, #36, #91) and 8 staff members testing positive during the outbreak from 1/17/22 through 1/24/22. This failure resulted in an immediate jeopardy (IJ) to resident health and safety. The facility also failed to complete proper hand hygiene while performing glucometer testing and catheter cares for 3 of 3 Residents (Resident #15, #23, #41) and failed to change oxygen tubing as directed in the Treatment Administration Record (TAR) for 1 of 3 Residents (Resident #15). The facility reported a census of 40 residents. Findings included: According to the CDC website https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revised 9/10/21, which would be in effect on 1/15/22, the following recommendations were listed: Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed: 1) a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2, 2) symptoms of COVID-19, or 3)who meets criteria for quarantine or exclusion from work Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. According to the CMS QSO-20-39-NH memo revised 11/12/21, all healthcare workers must be permitted to come into the facility as long as they are not subject to a work exclusion or showing signs or symptoms of COVID-19. 1. A serious adverse outcome occurred when a staff member reported to work ill and continued to work despite reporting signs and symptoms of illness consistent with COVID-19 infection. Prior to 1/17/22, no COVID-19 infections identified in the facility since 12/15/21. According to Staff D, Certified Nurse Aide (CNA), Time Card Summary Report, she worked on 1/15/22 from 5:56 AM to 2:02 PM, worked on 1/16/22 from 5:57 AM to 2:02 PM, and worked on 1/17/22 from 5:53 AM to- 8:21 AM, she worked with fatigue and muscle aches. On 1/17/22 Staff D tested positive for COVID-19 prompting testing of all resident and staff members; 4 residents (Resident # #6, #27 #36 and #91) and 5 staff returned positive, On 1/21/22, 7 residents (#7, #9, #13, #18, #23, #25 and #34) and 1 staff member tested positive, On 1/24/22, 2 more staff tested positive. In total 10 residents and 8 staff members tested positive during the outbreak. The COVID-19 Employee Screening, Testing, Reporting, and Return to Work policy dated 7/6/21 included the following: To outline the process for employees to conduct appropriate screening for COVID-19 symptom's, completing COVID-19 testing. Reporting of COVID-19 positive tests, and to provide guidelines for work restrictions in accordance with OSHA's COVID-19 Emergency Temporary Standard (ETS). Policy/Procedure: Health Screening a.Employees will perform COVID -19 symptoms screen before each work day Employees Notification to Employer of COVID-19 Illness or Symptoms a.Employees will promptly notify supervisor or administrator when they have tested positive for COVID-19 or have been diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] >100.4 degrees F) and new unexplained cough associates with shortness of breath. b.Employees will notify supervisor or administrator if they are experiencing COVID-19 symptoms while at work or home. Testing a.Employee routine, outbreak, and symptomatic COVID-19 testing is preformed per CMS guidelines. There is no cost to the employee for the testing. An undated COVID Positive Residents sheet included the following: a. Resident #6 positive 1/17/22. b. Resident #27 positive 1/17/22. c. Resident # 36 positive 1/17/22. d. Resident #7 positive 1/21/22. e. Resident #9 positive 1/21/22. f. Resident #13 positive 1/21/22. g. Resident #18 positive 1/21/22. h. Resident #23 positive 1/21/22. i. Resident #25 positive 1/21/22. j. Resident # 34 positive 1/21/22. Resident #91, not listed on the COVID-19 positive Resident list provide by facility, tested positive on 1/17/22 along with the other 3 residents listed on the form. Resident #91 Progress Note dated 1/17/22 noted he had tested positive for COVID-19. Provider notified. Facility document dated 4/25/22 titled Screening History 1/10/22-1/25/22 included the following: Staff D CNA screened 1/15/22 at 6:24 AM no fever temperature 97.3, no symptoms, no chronic, no close contact, N/A test, ok to work yes screened by Staff E RN. Staff D, CNA, screened 1/16/22 at 6:14 AM no fever temperature 96.9, no symptoms, no chronic, no close contact, N/A test, ok to work yes screened by Staff E, RN. Staff D, CNA, screened 1/17/22 at 5:56 AM no fever temperature 99.0, no symptoms, no chronic, no close contact, no test, ok to work yes screened by Staff A, LPN. Staff D, CNA, timecard showed she punched in at 5:56 AM and worked till 2:02 PM on 1/15/22. Staff D, CNA, timecard showed she punched in at 5:57 AM and worked till 2:02 PM on 1/16/22. Staff D, CNA, timecard showed she punched in at 5:53 AM and worked till 8:21AM on 1/17/22. During an interview on 4/21/22 at 7:56 AM Staff D, Certified Nurse Aide (CNA), explained when she tested positive for COVID-19. Staff D acknowledged she had screened in of course. She explained the facility only concerned if you have a temp. Staff D reported on 1/15/22, 1/16/22 and 1/17/22 she did not have a temp but had body aches and just did not fill good. She explained she let the nurse know (Staff E Registered Nurse (RN)). Staff E stated to Staff D you do not have a fever you're okay. Staff D explained, so I worked all weekend and came in on Monday. Staff D did not have a fever but felt really bad. So I knew the guy in Housekeeping did not get vaccinated so he had to test twice a week so just followed him down and got tested it was about 8 am. Staff D explained she had been working on the floor before that. After the positive test they sent me to the breakroom until The Director of Nursing (DON) got here and sent me home for 5 days. Staff D acknowledged she had been vaccinated and did not get as sick as before being vaccinated. The DON asked if I only worked on the west hall to test the residents there. Let her know had worked the whole building over the weekend. Staff D stated she had been tested 2 times a week, and educated on signs and symptoms. She explained she works at a different facility. They always ask if I have any body aches diarrhea loss of taste or smell. This place only is concerned about fever. During an interview on 4/21/22 at 7:59 AM Staff C, CNA, stated she remembered Staff D CNA, working since they both work the same weekend and they were the only CNA's working. Staff C explained the both of them worked with everyone in the building. Staff C verified Staff D had told the nurse she did not feel well you also could just tell she wasn't up to par. During an interview on 4/21/22 at 11:55 AM Staff F, Housekeeper, explained the process for exemption. Staff F acknowledged he did get tested twice a week until he became positive for COVID in Jan. and will not be tested until later in April. When tested positive for COVID he had tested negative on a Monday, Tuesday had lost of energy and did not work that day, Wednesday felt fine, Thursday he tested positive. Staff F explained he felt fine the 5 days when off work. Staff F explained the process for Screening. He stated we have a thermometer to take are temp and we report that to my supervisor or the nurse if on the weekend. When asked about question he stated we did not have to answer any questions just report the temp. During a sequential interview on 4/25/22 at 2:07, PM Staff D explained the screening process we only take are temp in the breakroom and tell the nurse. She stated of course I let them know when I don't feel good. Staff D acknowledge she had never answered screening questions before work. During an interview on 4/25/22 at 2:33 PM, the DON explained about the extra mitigation for staff not vaccinated. DON stated they were testing twice a week but now since in the blue they still test but only one a week. During an observation and interview on 4/25/22 at 2:17 PM, when Staff C, CNA, and Staff D, CNA, the screening question they both stated they had never been asked the questions. The undated facility document titled Screening Entry included the following questions: a.Fever 100.0 or greater b.Do you have a new onset of symptoms including chills, shortness of breath, difficulty breathing, new or change in cough, sore throat or new loss of taste or smell, new sputum production, congestion, runny nose(rhinorrhea) or fatigue, muscle or body aches headache, nausea or vomiting, or diarrhea? c.In the last 14 days, have you had and exposure (6 feet and greater then 15 minutes) without PPE to a person positive with COVID-19 diagnosis? d.If you have had a high risk exposure identifies in question above, do you have a negative COVID-19 test on file following that exposure? e.Have you had a positive COVID-19 test in the last 5 days? f.Ok to work? During a sequential interview on 4/26/22 at 7:27, AM Staff F acknowledged he had not been asked screening question this morning before working. Staff F explained during the first year of the COVID-19 pandemic they would always ask. But now we just kept saying the same thing so they don't ask they just put it in the computer. During an interview on 4/26/22 at 9:19 AM, Staff Q, when asked about screening in before work she explained they take her temperature and she washed her hands and went to the floor. During an interview on 4/26/22 at 11:44 AM Staff B, RN, acknowledged there is screening log on the computer, I believe any nurse as access to the screening log. You would take temperature and ask a few questions, if fever or not feeling well and enter that into the computer. During an interview on 4/26/22 at 11:45 AM Staff Q, CNA, explained Staff A, License Practical Nurse, took her temperature but did not ask any questions. During an interview on 4/26/22 at 11:47 AM Staff A, LPN, stated she comes in about 10 min to 6 AM and takes her temperature she does not record it she keeps it until Staff R Health information Technician (HIT) gets here and records mine. If staff have a temp I go through the questions of signs or symptoms. During an interview and observation on 4/26/22 at 11:53 AM, Staff R, Health Information Tech, explained the screening process she stated she had her computer open and then took temp and writes it down. She showed a paper with names and temps on it and scratched off. Staff R them asked staff if they have anything new. If so them goes through the questions. During an interview on 4/26/22 at 11:55 AM Staff G, CNA, stated Staff A, LPN, took her temperature today. Staff G explained Staff A had the computer open and put my temperature in. Staff A did ask if felt ok since sick on Sunday. During an interview on 4/26/22 at 12:59 PM Staff E, RN, explained about the screening process staff take their temperature and give it to me. She acknowledged in the brake room there is a thermometer on the wall. Staff E would go to the computer and search for staff name and enter the temperature and then answer questions. Staff E stated the questions are [NAME] observations. Staff E replied I don't ask staff the questions. Staff E stated if staff had signs or symptoms she would send them home and get a hold of the DON. Staff E stated she could test staff. She explained she would have them wait in the break room, and if staff not feeling well during a shift she stated she would test them. During an interview on 4/27/22 at 10:05 AM Staff D, CNA, explained she had told Staff E, RN, she had not been feeling well the weekend of 1/15/22 and 1/16/22. Staff D acknowledged not sure about if wearing eye protection wore gloves and mask for sure. Staff D explained today when arrived to work they just took her temperature. I feel they trust us to let them know if we had any signs or symptoms of COVID-19. The facility did give staff education on signs and symptoms and proper PPE. During an interview on 4/27/22 at 10:14 AM, the Infection Preventionist (IP) explained about mitigation after the outbreak stated staff would be sent home if they had signs or symptoms. The Resident were placed in isolation when they tested positive for COVID-19. She stated she did not do an investigation, the DON may have. During an interview on 4/27/22 at 10:20 AM, the DON explained about the PPE staff wore at the time of the outbreak. She stated the facility in the red so mask and eye protection were to be worn. The DON stated outbreak started with a staff. The only staff that called in and stated they did not feel well would have been Staff S CNA, so she was tested out in the parking lot. The DON explained after the first staff tested positive we started outbreak testing and tested all the staff and residents. DON acknowledged they had conversations with everyone making sure they get tested right away if showing signs and or symptoms. Observation on 4/27/22 at 10:35, noted no signs or instructions about COVID-19 posted in the breakroom, is the only sign included the information to get Vaccinated. During an interview on 4/27/22 at 10:35 AM, Staff R, Health Information Tech, walk through the screening process. They have a thermometer on the wall in the breakroom. Staff take their temp and report to the screener and they enter the temperature and answer the question. Asked what they would do if someone had a temp of 99.8 and let them know they did not feel well. Staff R stated she would have them test we have test right here. Asked if staff had a fever and no one in the breakroom how they would notify a charge nurse. Staff R did not know since no phone in breakroom. When Staff R asked if they ever had a sign for the door listing the signs and symptoms if had any not to enter. Staff R explained it had been over two years I think we all know what the signs and symptoms are and not to come to work. During an interview on 4/27/22 at 10:57 AM, Staff E, RN, when asked it Staff D, CNA, had reported to her she felt bad on the weekend of January 15 and 16th Staff E stated no then changed to she did not remember that was too long ago. During an interview on 4/27/22 at 11:32 AM, Staff D, CNA, acknowledged she had talked to her sister before going to work the weekend of January 15 &16th, she is also a CNA and stated to just go in and tell them you did not feel well. Staff D explained that is what she did. She stated again I don't call in, these Residents depend on us. Staff D stated she upset when she tested positive for COVID-19 Resident #91 had been in the dining room over the weekend he had a cough and did not wear a mask, he had always been going out in the community and did not wear a mask. Resident # 91 also tested positive on the 17th of January. Resident #91 not listed on the COVID-19 positive Resident list provide by facility. He had been a resident during that time and tested positive on 1/17/22 along with the other 3 residents listed on the form. Resident #91 Progress Note dated 1/17/22 noted he had tested positive for COVID-19. Provider notified. The facility was notified of the immediate jeopardy on 4/27/22. The noncompliance started on 1/15/22 and ended on 4/27/22. The facility removed the immediate jeopardy on 4/27/22 by implementing the following: a. All staff will be reeducated on 4/27/2022 by Director of Nursing and/or designees regarding screening process. A competency quiz will be provided after education to ensure understanding of process. b. No staff member will work after 4/27/2022 if they have not been properly re-educated and competency completed. c. Electronic screening completions are monitored daily by the internal electronic system with an email sent to DNS and Admin of any symptoms entered. In addition the screener will monitor for any symptoms at the time of screening. If any symptoms are noted our testing policy will be followed. d. No staff member will work after 4/27/2022 if they have not been properly re-educated and competency completed. e. Electronic screening completions are monitored daily by the internal electronic system with an email sent to DNS and Admin of any symptoms entered. In addition the screener will monitor for any symptoms at the time of screening. If any symptoms are noted our testing policy will be followed. The scope lowered from K to E at the time of the survey after ensuring the facility implemented staff education. 2. The admission Minimum Data Set (MDS) dated [DATE] documented Resident #15 had Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition for daily decision making. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's Care Plan lacked information related to the use of oxygen. Resident #15's TAR for March included to change oxygen tubing every 2 weeks, mark with initials and date ever night shift with a start date of 3/3/22. The TAR lacked documentation the oxygen tubing had been changed. Resident #15's TAR for April included to change the oxygen tubing every 2 weeks, mark with initials and date ever night shift with a start date of 3/3/22. The TAR lacked documentation the oxygen tubing had been changed. Resident #15's Order Summary Report dated 4/1/22 included the following: a. Order for oxygen at 2 liters per nasal canula via oxygen concentrator and/or tank every shift for supplemental oxygen with a start date of 2/3/22. The Facility policy titled Oxygen Administration, Safety, Mask Types dated 5/19/21 included the following: Purpose a. To administer and store oxygen in a safe manner. [NAME] keep oxygen equipment clean and maintained in good condition. [NAME] administer various levels of oxygen concentration and or humidity in a safe manner. Policy Oxygen administration is carried out only with a medical provider order. A licensed nurse or other employee trained according to state regulations in the use of oxygen will be on duty and is responsible for the proper administration of oxygen to the resident. An observation on 4/18/22 at 1:11 PM Resident #15's oxygen concentrator had a date on the machine or 2/6/20, and no date on the oxygen tubing. An observation on 4/25/22 at 1:38 PM Resident #15's oxygen tubing not dated, when asked the resident she stated she had no idea when the tubing last changed. During an interview on 4/27/22 at 9:00 AM the DON explained she would expect staff to mark off in the MAR/TAR if the nurse completed a medication or task. She also stated she would expect staff to mark on the oxygen tubing with the date changed and to mark it off on the TAR. The DON also acknowledged if not documented not done. 3. The admission MDS dated [DATE] documented Resident #15 had Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition for daily decision making. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's Care Plan lacked specific information related to the type of catheter and frequency of catheter care. Resident #15's TAR for March included Catheter 16 french with 15 cc balloon to dependent drainage with a start date of 3/1/22. Resident #15's TAR for April included Catheter 16 french with 15 cc balloon to dependent drainage with a start date of 3/1/22. Resident #15's Order Summary Report dated 4/1/22 included the following: a.Catheter 16 french with 15 cc balloon to dependent drainage with a start date of 3/1/22. The facility policy tiled Hand Hygiene and Handwashing dated 4/6/21 included the following: Purpose To ensure appropriate hand hygiene technique for clinical use. Background Regular handwashing with soap and warm water not hot water is one of the best ways to remove germs. Avoid getting sick and prevent the spread of germs to others. During an observation on 4/20/22 at 1:04 PM Staff C, Certified Nurse Aide (CNA), and Staff G, CNA, preformed catheter cares with the same gloved hands. Staff G emptied the urine from the graduate into the toilet. With same gloves turned on the facet obtained water and into graduate and emptied into toilet placed graduate into plastic bag. Staff G stated she should have changed her gloves before turning on the facet. Staff G doffed gloves washed hands. 4.The Minimum Data Set (MDS) assessment tool dated 4/17/22 documented Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 of 15 possible on the Brief Interview for Mental Status Test (BIMS), which meant the resident demonstrated no impaired cognitive abilities. Orders dated 3/30/22 for Resident #41 documented sliding scale insulin before meals which required accu checks to be performed prior to medication administration. Observation on 04/19/22 at 11:24 AM Staff E performed an accu check on Resident #41. Staff E failed to perform hand hygiene prior to task. Staff E placed the accu check machine on a disinfectant wet wipe as a barrier on top of the medication cart. After the completion of the accu check Staff E failed to remove gloves after the completion of the accu check and proceeded to multiple surfaces with contaminated gloves including the keyboard, medication cart drawers, medications, resident door and resident with contaminated gloves. Observation on 04/20/22 at 08:13 AM, Staff B failed to perform hand hygiene prior to medication administration for Resident #41. Staff B failed to perform hand hygiene at the end of medication administration for Resident #41. The Minimum Data Set (MDS) assessment tool dated 2/23/22 documented Resident FH #23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 of 15 possible on the Brief Interview for Mental Status Test (BIMS), which meant the resident demonstrated no impaired cognitive abilities. Orders dated 5/19/21 for Resident #23 showed blood sugar checks once daily in the morning. Observation on 04/20/22 at 08:45 AM, Staff B performed a bedside accu check for Resident #23. Staff B began by placing the glucose monitor on the medication cart without a barrier. Staff B then failed to perform hand hygiene after the removal of gloves upon the completion of the accu check. An Interview on 4/20/22 at 11:43 AM with DON that her expectation is to use a barrier for the accu checks machine when placing them outside of their protected container. She also stated it was her expectation for staff and to wash hands before and after each med pass between residents, as well as performing hand hygiene upon the removal of gloves. She said she would not expect to see staff use contaminated gloves to obtain supplies or document on the computers. Policy titled Blood Glucose Monitoring dated 9/13/21 documented under the Procedure, Performing the Test section Page 2 of 7) the following: 2. Place the glucometer on a non permeable (water proof) barrier Documented under the Blood Glucose Monitoring Clinical Checklist (page 5 of 7) the following: 1. Wash hands 2. Place glucometer on non permeable (water proof) barrier 4. Put on gloves 12. Remove gloves. Perform hand hygiene. Document.

Based on clinical record review, observation, and staff interview, the facility failed to initiate a dietician recommendation for dietary supplement for two residents with a weight loss of greater than 9 % in one month (Residents #44 and #46) out of three residents reviewed for nutrition. The facility reported a census of 53 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #44 identified a Brief Interview for Mental Status (BIMS) score of 3 without signs/symptoms of [MEDICAL CONDITION]. A score of 03 indicated severe cognitive impairment. The MDS revealed the resident independent with no setup help needed from staff for eating. The MDS documented [DIAGNOSES REDACTED]. The MDS recorded a weight of 105.0 lbs (pounds). The assessment documented she entered the facility on 12/31/18. The care plan focus area dated 12/31/18 identified an ADL (Activities of Daily Living) self care deficit related to dementia and cast to right arm. The care plan informed staff Resident #44 could hold a cup, feed herself, and eat finger foods independently. The care plan focus area revised 1/2/19 identified a potential nutritional problem related to a decline in cognitive ability. The care plan focus area revised 1/8/19 identified impaired cognitive function related to dementia evidenced by forgetfulness and need for cues or reminders. The Progress Notes dated 1/16/19 at 11:45 a.m. documented a care conference held that included discussion of the resident's eating habits and her current weight with the resident's family. The Progress Notes dated 1/17/19 at 11:11 a.m. documented a Nutritional Status Dietician Assessment. The assessment recorded the resident ate 50% of meals independently with no chewing or swallowing problems. The assessment documented the resident's current body weight measured 97.0 lbs, her ideal body weight would be 100 lbs, and an admission weight 105 lbs. The Dietician wrote Resident #44 was at risk for impaired nutritional status related to dementia. The assessment documented interventions to maintain her weight or gain, maintain skin integrity, improve the resident's oral intake to greater than 50% of all meals and continue diet as ordered. The Dietician recommended that staff start a house supplement 90 ml (milliliters) TID (3 times a day), weigh as ordered, and report weight/appetite changes to RD (Registered Dietician). The Progress Notes dated 1/17/19 at 12:30 p.m. documented a weight warning of a 7.6% weight loss and to see the RD assessment dated [DATE]. The Weights and Vitals Summary dated 1/30/19 recorded the following weight measurements for Resident #44: 12/31/18 - 105.0 lbs; 1/11/19 - 97.0 lbs; 1/18/19 - 96.0 lbs; 1/25/19 - 95.5 lbs. Comparison of the starting weight of 105.0 lbs with the ending 95.5 lbs showed a weight loss of 9.05% in one month. The clinical record lacked documentation that staff provided the resident's house supplement 90 mls TID. Observation on 1/29/19 at 4:43 p.m. revealed the resident walked independently into the dining room following her husband to the table, greeting others and socializing. At the time of the observation, the Director of Nursing (DON) reported the resident as very social and on the go since she arrived to the facility. In an interview on 1/30/19 at 2:25 p.m., the DON acknowledged she expected the nursing staff to document the administration and consumption of house supplements on the EMAR (Electronic Medication Administration Record). Review of the EMAR revealed no administration of supplements. At 4:15 p.m., the DON stated the dietician's recommendations from the 1/17/19 assessment were not passed on to anyone and therefore the recommendations got missed. The DON reported Resident #44 did not receive the house supplement 90 mls TID as recommended. 2. The admission MDS assessment dated [DATE] for Resident #46 identified a BIMS score of 02 with continuous signs of disorganized thinking. A score of 02 indicated severe cognitive impairment. The MDS revealed the resident independent with no setup help needed from staff for eating. The MDS documented [DIAGNOSES REDACTED]. The MDS recorded a weight of 122.0 lbs . The care plan focus area revised 1/3/19 identified an ADL self care performance deficit related to dementia and right [MEDICAL CONDITION]/post-op right hip hemiarthroplasty (surgical hip joint replacement). The care plan informed staff the resident could hold a cup, feed himself, and eat finger foods independently. The care plan focus area dated 1/3/19 identified a nutritional problem or potential problem related to poor nutrition evidenced by weight loss. The care plan intervention dated 1/11/19 informed staff Resident #46 had an order for [REDACTED]. The Progress Notes dated 1/17/19 at 11:28 a.m. documented a Nutritional Status Dietician Assessment. The assessment recorded Resident #46 ate 50% of meals independently with no chewing or swallowing problems. The assessment documented his current body weight measured 105.0 lbs, a usual body weight of 117 lbs, and an admission weight of 122 lbs. The Dietician wrote the resident underweight status as evidenced by a BMI (Body Mass Index) of 16. The assessment documented interventions included to gain weight, improve his oral intake to greater than 75% of meals, improve skin integrity and continue diet and nutritional supplements. The Dietician recommended that staff administer Ensure pudding TID with meals, weigh as ordered, and report weight/appetite changes to RD. The Progress Notes dated 1/17/19 at 12:29 p.m. documented a weight warning of a 14% weight loss and to see the RD assessment dated [DATE]. The Weights and Vitals Summary dated 1/31/19 recorded the following weight measurements for Resident #44: 1/2/18 - 122.1 lbs; 1/11/19 - 105.0 lbs; 1/18/19 - 106.0 lbs; 1/25/19 - 110.0 lbs. Comparison of the starting weight of 122.1 lbs with the ending 110.0 lbs showed a weight loss of 9.91% in less than one month. The clinical record lacked documentation that staff provided the resident's Ensure pudding TID following the dietician's assessment and recommendation on 1/7/19. Observation on 1/28/19 at 1:02 p.m. revealed Resident #46 appeared very thin with the outline of his rib cage visible as he laid in bed. Observation on 1/29/19 at 4:38 p.m. revealed Resident #46 self propelled into the dining room for supper and conversed with his wife to tell her where they sat and to prepare for supper. At the time of the observation the DON stated she thought the resident's admission weight was an error as the resident looked no different that day than the day he came; very thin. The DON said the resident had been eating 50% or more of meals and doing pretty good. The DON thought Resident #46 had started on a supplement. The DON reported he just snacked throughout the day for meals at home and since being in the facility had been very active and social, on the move. The DON said the resident had snacks in his room as well. In an interview on 1/30/19 at 4:15 p.m., the DON confirmed the dietician's recommendations from the 1/17/19 assessment did not get passed on to anyone and therefore the recommendations got missed. The DON reported the resident did not receive the ensure pudding TID with meals as recommended.

Based on observation, record review and interviews with staff, physician and therapist, the facility failed to provide Resident #4 with adequate supervision while eating in his room alone. Resident #4 had difficulties swallowing, at risk for choking and placed in an immediate jeopardy situation which resulted in choking and death. Although staff found the resident unresponsive and blue in color, they attempted techniques (suctioning, back blows and [MEDICATION NAME] maneuver), the resident did not respond. The sample consisted of 2 additional residents with swallowing difficulties (Resident #2, Resident #3). The facility reported a census of 53 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview of Mental Status) score of 5. A score of 5 identified severe cognitive impairment. The MDS indicated Resident required supervision and 1 person assistance when eating (a mechanically altered and therapeutic diet). The Care Plan, initiated on [DATE], identified a potential nutritional problem related to the [DIAGNOSES REDACTED]. The interventions included and directed staff to provide supervision/observation at meals. Another Care Plan intervention, initiated [DATE] identified the resident able to eat independently but spills foods and liquids at times so needed partial assistance when spilling, utilized a Flo-Trol cup for all liquids and served a reduced sodium Level 3-advanced diet with nectar thick liquids. An addendum to this intervention dated [DATE], directed the staff to monitor the resident's chewing and swallowing ability during mealtime and the resident would be moved to a table closer to the nurse's work area. The ST (speech therapy) Therapist Progress & Discharge Summary dated [DATE] documented the resident received speech therapy treatment ,[DATE]-[DATE] for the [DIAGNOSES REDACTED]. The report documented the resident exhibited increased tendency to overfill his mouth with mild residual remaining in the left [MEDICATION NAME] cavity and the tongue after swallowing. The resident displayed a delayed reflexive cough on a regular textures/liquids and large quantities and identified the resident at high risk of aspiration due to reduced awareness, tendency to be compulsive and history of dysphagia. The resident discharged from speech therapy on [DATE] after the therapist printed and distributed compensatory feeding strategies and Safe Swallow Precautions for the resident to the resident as well as the nursing staff. A document titled Safe Swallow Precautions for the resident dated [DATE] directed the following: 1. Always eat and drink while sitting up as close to 90 degrees as possible. 2. Remain sitting up for at least 30 minutes after eating, drinking or taking meds. 3. Swallow everything before taking another bite or drink. 4. Small bites and 1 drink at a time. 5. Alternate a bite then a drink. Review of the resident's Care Plan identified these directives not incorporated on the resident's current Care Plan. On [DATE] at 3:26 PM the speech therapist was interviewed and stated she treated Resident #4 from ,[DATE]/-[DATE] and staff needed to follow the recommendations she provided. The speech therapist stated she had educated the staff to the fact the resident required supervision with eating as the resident being at high risk for aspiration or choking because of his swallowing problem, impulsivity and cognitive deficits. The therapist also stated she would expect her recommendations be followed and placed on the resident's Care Plan unless the resident was re-evaluated and the recommendations she made were no longer appropriate. The therapist stated supervision should be provided with snacks and trays served to residents in their rooms. Review of the resident's record revealed no other speech therapy evaluation or treatment after [DATE]. The Progress Notes entry, completed by Staff A, registered nurse (RN) on [DATE] at 1:40 p.m. indicated she was summoned to the resident's room by the far west hall charge nurse at 1:26 PM. Staff A identified the resident as non-responsive and blue in color. The far west hall charge nurse was present and performed the [MEDICATION NAME] maneuver without success so back blows were done. The treatment nurse in the room did a finger sweep of the resident's mouth to remove the visible food and also performed the [MEDICATION NAME] maneuver without success. The charge nurse suctioned the resident's mouth with no success. The resident had no palpable pulse. The emergency responders pronounced the resident deceased at 1:40 p.m. as the resident had no pulse, respirations or measurable blood pressure. On [DATE] at 8:46 AM Staff D, certified nursing assistant (CNA), was interviewed and stated she was assigned to the hallway where Resident #4 resided and the only CNA assigned to that hallway due to a staff call-in. She assisted residents with transportation to and from the dining room for breakfast and lunch and then remained in the dining room for both meals. Staff D stated Staff A told her she passed out (served) the resident room trays for her hall. Staff D stated Resident #4 normally sat at a table at the back of the dining room in front of where the nurses keep their medication carts, but the resident had been experiencing loose stools so he remained in his room for breakfast and lunch. Staff D stated she picked up resident room trays after lunch. She had a conversation with the resident's roommate. She looked over and saw the resident's whole body as blue in color. Staff D stated she asked the resident if he was okay; she got no response so she went to the nursing desk right around the corner from the resident's room and alerted Staff C, licensed practical nurse (LPN) who went immediately to the resident's room. Staff D stated Staff C attempted to do the [MEDICATION NAME] maneuver on the resident but Staff C is small in stature and could not get her arms around him as the resident sat in a recliner. Staff C performed back blows on the resident and then Staff B, LPN (licensed practical nurse), also came into the room. Staff D stated the resident was observed eating cookies all day and had crumbs on his shirt and all the cookies were gone. Staff D stated she would assume the resident needed to be supervised while eating in his room because the resident normally sat in the supervised area of the dining room. On [DATE] at 5:11 PM, Staff C (licensed practical nurse) was interviewed and stated she was summoned to the resident's room by Staff D. Staff C stated she observed the resident sitting in the recliner and she observed his skin color to be blue. Staff C stated she attempted to do the [MEDICATION NAME] Maneuver with the resident seated in the recliner but unsuccessful because she is short in stature. She performed back blows. Staff C stated she left to get the suction machine and did a finger sweep of the resident's mouth as the chewed food and liquids were coming from the resident's mouth. Staff C stated she suctioned the resident without success and the resident had no carotid or apical pulse at this time. The staff previously checked and the determined the resident had requested no DNR (do not resuscitate). On [DATE] at 8:03 AM Staff B (licensed practical nurse) was interviewed and stated the Dietary Services Manager (DSM) called for her to come to the resident's room. Staff B stated she observed the resident as blue in color. Staff C was already in the room and Staff A was also coming down the hall from the opposite direction. The resident sat slightly forward in the recliner with food and fluid coming out from his mouth. Someone in the room said He is choking. Staff B stated the staff lowered the resident to the floor. Staff B stated she could not get her arms around the resident so she performed the [MEDICATION NAME] without response. The resident had no pulse by palpation and auscultation (listening with stethoscope). Staff B stated she was the only staff member to perform the [MEDICATION NAME] maneuver. Staff C did a finger sweep of the resident's mouth because there was food in the resident's mouth. Staff C also suctioned the resident without success. EMS (Emergency Medical Services) responded and placed the resident on a monitor (to record heart rhythm) and pronounced the resident deceased . Staff B stated the resident normally sat in the dining room in the assisted area. A nurse supervises the dining room and the other charge nurses assists in the dining room. Staff B stated she also will assist in the dining room. Staff B stated if a resident's Care Plan directed a resident to be supervised when eating and the resident required a room tray, then the staff needed to sit with the resident while they are eating, even if the resident fed themselves. On [DATE] at 4:40 PM Staff A (registered nurse) was interviewed and stated the overnight nurse had reported the resident had loose stools so she made decision to keep the resident in his room for breakfast and believed he had ate in his room the day before too. She stated she observed the resident eating cookies without difficulty when she administered his/her medications scheduled for 8:00 AM. Staff A stated she delivered the resident's room tray at lunch which consisted of regular toast, Jell-O and broth and other liquids. She stated the resident was seated upright in a recliner. Staff A stated around 12:55 PM Staff C called for her to come to the resident's room. Staff B was also present in the room. The resident was unresponsive. Staff B and C attempted to perform the [MEDICATION NAME] after staff lowered the resident to the floor in order to get behind the resident. Staff A stated the resident had beige-colored food in the oral cavity and Staff C removed it with a finger sweep. Staff A called 911 and the EMS responders verified the resident had no pulse, respirations or blood pressure. Staff A stated the staff supervised the resident from the hallway while he ate in his room. Staff A stated only 1 CNA assigned to that hall. Review of the surveillance camera footage of the resident's hallway showed Staff A delivered room trays to the resident and his roommate at 1:01 PM and 1:02 PM and no other staff present in the hallway. Staff A stated she called the resident's physician's nurse to inform her of the resident's death but did not explain the circumstances surrounding the resident's death. On [DATE] at 10:27 AM, the resident's physician was interviewed and stated he called the facility for additional information regarding the resident's death after the surveyor left him a message on [DATE]. The physician stated the facility had not informed him of the circumstances surrounding the resident's death until he requested the facility send him the resident's progress notes for review. The physician stated he had already completed the resident's death certificate prior to his knowledge of the incident but could say that it is highly suspected the resident expired because of choking and considered the death to be unexpected. The physician asked if the resident should have been supervised while eating. The resident's Care Plan and speech therapist documentation was discussed at this time. The physician stated that all recommendations and documentation from all licensed therapists is sent to him and is reviewed and he does sign them so it would have technically been a physician order [REDACTED]. The physician stated he is also the facility's medical director and the issue has been addressed with the facility management staff. Note: At the time of the complaint investigation, the complaint was coded at a J immediate and serious jeopardy. By [DATE], the facility had adequately addressed the jeopardy and the grid placement was lowered to the D level. The staff were educated to monitor and supervise for swallowing difficulties and aspiration at meals in the dining room and and a staff member must be with resident the entire time if they remain in their room for meals. The Director of Nursing reviewed all of the resident's Care Plans on [DATE] and identified all residents with aspiration or swallowing concerns that required staff observation while eating. A list of residents requiring supervision was developed and placed in the nursing communication binders on [DATE]. The Director of Nursing would do audits and results reported to the quality assurance committee. As of the [DATE] exit conference, the facility continued to need to: · Finish in-service employees of the need to monitor and supevise residents with swallowing difficulties and potential for aspiration when eating meals in their rooms (staff to stay with resident) and staff present in the dining room to ensure supervision of residents with swallowing difficulties. · Continue to monitor to ensure the staff are with residents when eating in their rooms. 2. Resident #2 had a MDS with a reference date of [DATE]. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident could feed self after set up. The Care Plan identified the resident could feed self independently and required a dysphagia Level II diet. The Speech Therapy Daily Treatment Note dated [DATE] documented the resident swallowing as safe but usually required moderate cues to use compensatory strategies. The note directed nursing staff to monitor the resident closely for pneumonia because of at high risk for aspiration. On [DATE] at 9:40 AM the speech therapist was interviewed and stated Resident #2 had significant cognitive deficits, declined thickened liquids and a modified diet, and should not eat unsupervised. 3. Resident #3 had a MDS with a reference date of [DATE]. The MDS identified [DIAGNOSES REDACTED].#3. The MDS indicated the resident required set-up and supervision with eating. The Care Plan identified a potential nutritional problem on [DATE] related to oropharyngeal dysphagia and directed the staff members to monitor the resident for chewing and swallowing difficulties. The Care Plan contained the nursing rehab plan, initiated on [DATE]. On [DATE] the plan directed the staff to ensure the resident swallowed twice with every bite (a dry swallow after the first swallow), alternate solids and liquids (a drink after a couple of bites) and for the resident to remain alert during meals (eyes open). The Speech Therapy Treatment Note dated [DATE] documented the resident aspirates across all diet consistencies due to Zenker's diverticulum. The document titled Nursing's Shift-to-Shift Huddle Care Plan Updates and Need to Knows, dated [DATE], listed 10 residents, which included Residents #2 and #3, with swallowing difficulties/aspiration. The listed residents required supervision at meals whether in the dining room or in their rooms. Observation on [DATE] at 12:55 PM identified no nursing staff in the dining room and Residents #2 and # 3 and 9 other residents still eating lunch. Observation revealed Staff E, dietary aide, in the dining room recording resident meal consumptions. Staff E stated she had received [MEDICATION NAME] maneuver training during employee orientation but would not feel comfortable in responding to a choking resident. She stated if a resident choked she would leave the area and summon a nurse. Staff E stated there is a list of residents who require supervision while eating and she thinks that Resident #2 and #3 required supervision and acknowledged they are still eating at this time. Review of the POS [REDACTED] All staff will be trained or re-trained in the [MEDICATION NAME] by [DATE] (18). If you observe a resident that appears to be choking and need to alert another staff member, page overhead for assistance STAT (immediately-No delay). A licensed nurse should be in the dining room to observe and monitor for a choking incident and to monitor residents for change in chew/swallow ability. If this is not possible, a system will be in place to alert the licensed nurse to concerns and provide a person in the dining room who is knowledgeable in performing the [MEDICATION NAME] maneuver.

Based on observation, staff interviews, review of records and the facility policy and procedures, the facility failed to prevent an avoidable suspected deep tissue injury wound on the heel (Resident #4). The sample consisted of 2 residents and the facility reported a census of 51 residents. Findings include: 1. Resident #4 had a quarterly Minimum Data Set (MDS) assessment with a reference date of 5/3/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS). A score of 1 identified the resident had a severe cognitive impairment. The MDS indicated the resident required extensive assistance of 2 staff members for bed mobility, and depended upon 2 staff members for transfers and toilet use. The MDS identified the resident at risk for pressure ulcers and had no pressure ulcers. The MDS indicated the resident used a pressure reducing device on the chair and bed. The MDS indicated the resident weighed 97 pounds. The Care Plan identified a focus area with activities of daily living (ADL) self-care performance deficit related to a [MEDICAL CONDITION] manifested by the resident required total care dated 7/31/14. The Care Plan indicated the resident's ADL preferences dated 6/30/17 included to be put back in bed after meals and (for staff) to turn (the resident) every 2 hours. The intervention on 8/10/17 identified the resident as totally dependent on staff to provide repositioning and turn in bed. The resident is totally dependent on staff for toilet use and is incontinent of bowel. The resident had a bladder indwelling catheter. The Care Plan intervention revision date of 5/26/15 indicated the resident required weight bearing support of 2 staff members with a full body lift. The Care Plan identified a focus area with the potential for pressure ulcer development related to immobility dated 8/28/14. The Care plan directed the staff to turn/reposition the resident at least every 2 hours while in bed, use pillows to ensure proper body alignment, and reposition with 2 people and lifter, and initiated on 6/30/17. Another intervention initiated on 4/13/15 and revised on 8/9/17 directed a pressure relieving/reducing device air mattress on bed and cushion in wheelchair and recliner. The intervention for heel protectors were initiated on 8/9/17. The intervention initiated on 4/13/15 and revised on 6/30/17 and 8/9/17 directed staff to return the resident to bed after meals and turn every 2 hours. The Braden Scale for Predicting Pressure Sore Risk dated 4/26/17 revealed a score of seventeen indicating the resident at risk for skin break down. The Braden Scale for Predicting Pressure Sore Risk dated 7/26/17 revealed a score of seventeen indicating the resident at risk for skin break down. A Progress Note dated 7/20/17 revealed staff noted a 1.5 centimeter (cm) x 1 cm purple area on the left lateral heel. No open areas noted on heels. No [DIAGNOSES REDACTED] noted on periwound (around the wound) skin. Heel protectors applied to bilateral heels to off load heels off bed. Air mattress on bed. A document titled fax communication to physician dated 7/20/17, noted a 1.5 centimeter (cm) x 1 cm purple area on the left medial heel. No open area noted on heel or [DIAGNOSES REDACTED]. Air mattress on bed, heel protects bilateral heels to off load heels, may we apply skin prep to area twice a day (BID) and [MEDICATION NAME] 1 package by mouth BID. The physician responded yes to the above order request on 7/20/17. A document titled Wound Data Collection identified the following measurements: On 7/20/17, revealed a suspected deep tissue injury (SDTI) to the left lateral heel that measured 1.5 cm x 1 cm. On 7/25/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm and 1 cm redness around purple area. On 7/27/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm, unable to determine depth. 1 cm x 1 cm purple area with 1 cm x 1 cm light redness around purple. On 7/28/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm, soft purple area in center with 1 cm x 1 cm redness around wound. On 8/3/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm. 1 cm x 1 cm purple area with 1 cm x 1 cm purple/red area around center. 8/8/17 revealed a SDTI to the left heel that measured 1 cm x 1 cm. 1 cm x 1 cm dark purple area on left heel with 1 cm x 1 cm purple/red around the center. On 8/13/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm. On 8/15/17, revealed a SDTI to the left heel, area now calloused and measured 2 cm x 2 cm and area dark brown in color and 100 % eschar (dark and leathery, consisting of dead cells). On 8/18/17, a SDTI to the left heel measured 2 cm x 2 cm and area now a soft, partially calloused area. On 8/21/17, revealed a SDTI to the left heel and the area now calloused and measured 2 cm x 2 cm with 100% eschar. On 8/25/17, revealed a SDTI to the left heel that measured 2 cm x 2 cm with 100% eschar. On 8/29/17, revealed a SDTI to the left heel that measured 2 cm x 2 cm with 100% eschar. On 9/2/17, revealed a left heel intact with eschar and no measurements documented. On 9/5/17, revealed a SDTI to the left heel, area now calloused and measured 1.3 cm x 1.3 cm with a 100% eschar. On 9/8/17, revealed a SDTI to the left heel that measured 1.2 cm x 1.2 cm with 100% eschar. On 9/13/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm calloused area. On 9/15/17, identified a SDTI to the left heel that measured 1 cm x 1 cm calloused and stable with 100% eschar. On 9/17/17, the left heel has half black eschar and half red healing. On 9/18/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm calloused area with 100% eschar. On 9/23/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm calloused area with 100% eschar. On 9/28/17, revealed a SDTI to the left heel that measured 1 cm x 1 cm stable callous. On 10/4/17, revealed a SDTI to the left heel, area light brown , stable callous that measured 0.5 cm x 0.5 cm. On 10/9/17, revealed a SDTI to the left heel which measured 0.5 cm x 0.5 cm calloused area. On 10/10/17 at 6:45 a.m., observation identified the resident had an approximate 1 cm (centimeters) x (by)1 cm callous on the left heel. The treatment record dated 7/1/17-7/31/17 directed staff to apply skin prep to the left medial heel BID with a start date of 7/21/17. The treatment record dated 8/1/17-8/31/17 directed staff to apply heel protects to bilateral heels, off load heels while in bed every shift with a start date on 8/8/17. On 10/12/17 at 8:13 a.m., the Director of Nursing (DON) was interviewed and stated Resident #4 was a full body lift prior to the suspect deep tissue heel injury. The resident was dependent on staff for transfers and repositioning. The DON doesn't recall any injury that caused the suspected deep tissue injury and feels it was developed by not suspending the heels and due to pressure. An interview on 10/12/17 at 9:30 a.m., Staff C licensed practical nurse (LPN), stated the resident has been a full body lift and dependent on staff prior to the injury and feels the suspected deep tissue injury was caused due to pressure. On 10/12/17 at 10:00 a.m., Staff D LPN/Wound Care Nurse, was interviewed and stated the resident had navy blue heel protectors on and had worn those for a long time. The navy blue heel protectors are a preventative and placed per nursing judgement. An order was obtained for a different heel boot that suspended the heels after the SDTI developed. Staff D stated the resident was a full body lift and depended on staff for bed mobility. The policy and procedures titled Pressure Ulcers, revised January 17, directed the staff that based on the resident's comprehensive assessment, the location will use prevention and assessment interventions to ensure that a resident entering the location without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable.

Based on record review, interviews with staff, physician and hospital wound nurse and review of policy and procedures, the facility failed to provide [MEDICAL CONDITION] care services in order to meet the needs of the resident (Resident #3). Resident #3 had a new [MEDICAL CONDITION] and admitted to the facility for education and care for the ostomy. The facility failed to perform adequate and appropriate care to the stoma and intestinal drainage caused the skin to deteriorate and painful. The resident required hospitalization for care of the ostomy. The sample consisted of 4 residents and the facility reported a census of 50 residents. Findings include: 1. Resident #3 had an admission MDS (Minimum Data Set) assessment with a reference date of 4/12/17. The resident came to the facility from the hospital. The MDS identified the resident had no cognitive problems or behaviors. The MDS indicated the resident required supervision with bed mobility, ambulation, dressing and personal hygiene. The resident required limited assistance with toileting. The Care Plan dated 4/7/17 indicated the resident had a new [MEDICAL CONDITION] (a stoma (surgical opening) constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin and to the surgical procedure which creates this opening. Intestinal waste passes out of the [MEDICAL CONDITION] and is collected in an artificial external pouching system which is adhered to the skin. The interventions directed the staff to provide education to the resident/family about managing the [MEDICAL CONDITION], provide stoma care per the physician's orders [REDACTED]. The complications included fever, abdominal pain, guarding, tenderness, altered mental status, drainage or odor from the stoma site, etc. The interventions indicated the nursing staff are to perform the following cares: empty bag, report to nurse if dressing/skin barrier becomes soiled, keep skin clean and dry around site. Review of the hospital transfer/discharge orders dated 4/7/17, indicated the resident discharged from the hospital and transferred to a rehabilitation facility with a [DIAGNOSES REDACTED]. A hospital wound assessment, completed 4/7/17, at 11:10 a.m. indicated the [MEDICAL CONDITION] wafers had been holding for longer periods. Previous wafer held for 40 plus hours. The hospital wound care nurse spoke to the facility nurse about the resident's wounds and current treatments. A follow-up appointment with the general surgeon and the hospital wound care nurse planned for 4/12/17 in the outpatient clinic. A review of the hospital discharge orders did not include treatment parameters for [MEDICAL CONDITION] care. A form titled, Nursing Admit Re-Admit Data Collection, dated 4/7/17 at 11:45 a.m. identified the resident had an [MEDICAL CONDITION]. The assessment had no other information related to the [MEDICAL CONDITION]. Note: The assessment incorrectly identified the ostomy as a [MEDICAL CONDITION] and bowel sounds diminished. The ileum is a portion of the small intestine and not the large intestine-colon so is an [MEDICAL CONDITION]. The form titled Skin Observation, dated 4/7/17 Indicated the abdomen as beefy red, raw skin around stoma and unable to have the [MEDICAL CONDITION] appliance (wafer to skin with bag to collect intestinal waste) adhere to the skin. A skin assessment completed 4/10/17 documented denuded (loss of the epidermis (layer of skin), caused by exposure to urine, feces, body fluids, wound exudate or friction). The denuded area measured 6 centimeters (cm) by 9 cm in size. The area appeared beefy red and the wafer around the stoma, wound not adhere. The treatment consisted of a stoma paste and stoma powder mixed together before wafer attached. The Progress Notes dated 4/7/17 at 11:45 a.m. documented the resident admitted to the facility post strangulated hernia repair with [MEDICAL CONDITION], Foley catheter and wound care on coccyx. [MEDICAL CONDITIONS] bag intact and the skin excoriated around the wound. Notes dated 4/7/17 at 7:09 p.m. documented the [MEDICAL CONDITION] in the right upper quadrant (RUQ) leaking periodically with the bag replaced three (3) times. The skin around the stoma very excoriated. Notes dated 4/8/17 at 10:23 a.m. indicated the [MEDICAL CONDITION] bag leaking and the bag and bed sheets changed. The Progress Notes dated 4/8/17 at 12:45 p.m. documented the [MEDICAL CONDITION] bag changed twice and the skin around the stoma slightly irritated. Notes dated 4/9/17 at 2:09 a.m. documented the [MEDICAL CONDITION] bag changed and the skin under the bag and around the stoma as very red, irritated and slightly tender to touch. The Progress Notes dated 4/9/17 at 2:56 a.m. documented the [MEDICAL CONDITION] bag leaking. Staff changed the bag again and used powder and paste mixed together to help hold bag in place over stoma and didn't use the ostomy ring per resident suggestion. Notes dated 4/9/17 at 9:53 a.m. identified the [MEDICAL CONDITION] bag slightly leaking and noted not enough paste available. Staff notified the wound nurse who reported she had to get supplies and would come to the resident's room. Staff placed a pad over the area to absorb the leaking contents. The Progress Notes dated 4/9/17 at 10:41 p.m. noted the [MEDICAL CONDITION] stoma site red and irritated. Staff noted they would inform the physician of the resident's status. Notes dated 4/10/17 at 1:49 a.m. documented [MEDICATION NAME] 5 mg/[MEDICATION NAME] ([MEDICATION NAME]) 325 mg given as the resident complained of abdominal skin pain. Notes dated 4/19/17 at 3:50 a.m. documented the [MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg given earlier had been effective in reducing the resident's pain. Notes dated 4/10/17 at 8:08 a.m. documented [MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg given as the resident cried in pain from the [MEDICAL CONDITION] site. Notes dated 4/10/17 at 10:22 a.m. revealed the pain medication effective in reducing the resident's pain. The Progress Notes dated 4/10/17 at 2:01 p.m. documented the resident upset and crying about the [MEDICAL CONDITION] appliance not sticking. The wound nurse attempted everything to get the dressing to stay. [MEDICATION NAME]/[MEDICATION NAME] given for pain with relief. Notes dated 4/11/17 at 8:28 a.m. revealed [MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg given as the resident complained of [MEDICAL CONDITION] pain. Notes dated 4/11/17 at 11:33 a.m. revealed pain medication effective. Notes dated 4/11/17 at 7:10 p.m. documented [MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg given as the resident complained of [MEDICAL CONDITION] pain. The Progress Notes dated 4/11/17 at 10:13 a.m. documented the [MEDICAL CONDITION] bag has leaked and caused a red raised area on the abdomen causing discomfort. Notes dated 4/12/17 at 10:00 a .m. documented [MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg given as the resident complained of [MEDICAL CONDITION] trouble. The Progress Notes dated 4/12/17 at 10:15 a.m. documented the resident left the facility for a scheduled appointment with the general surgeon. The facility received a phone call from the local hospital reporting the physician admitted the resident for [MEDICAL CONDITION] care. The Progress Notes dated 4/12/17 at 12:37 p.m. documented the hospital wound nurse called and reported the resident admitted to the hospital due to the condition of the stoma site. The area around the stoma was so reddened and the feces leaking out around the wafer of the [MEDICAL CONDITION]. Staff A, a licensed practical nurse (LPN) and wound nurse told the hospital wound nurse the resident had been admitted to the facility with raw skin around the stoma and the [MEDICAL CONDITION] appliance would not adhere to the skin. The hospital wound nurse asked why she hadn't received a call from the facility so she could tell you what we were doing here. Staff A reported she did exactly what she (the hospital wound nurse) did while hospitalized by mixing the powder and paste together so the wafer would adhere to the skin. Facility staff had worked with the stoma site multiple times to get the wafer to adhere the skin. A review of Treatment Administration Records (TARs) for 4/7/17-4/12/17 revealed no documentation of an entry for [MEDICAL CONDITION] care. During a phone interview dated 4/24/17 at 3:55 p.m., the hospital wound nurse reported she would complete a written statement of the events that took place during the resident's hospitalization and collaboration with the facility's wound nurse. The written statement dated 4/24/17 reads as follows: The resident had been hospitalized due to difficulty with her [MEDICAL CONDITION] appliances not adhering. Hospital staff tried several different styles of appliances, skin preps and adherence techniques. Prior to discharge, an appliance was on for 2 days then the last one on for approximately 12 hours. The hospital wound nurse stated she had talked with Staff A, the facility wound nurse on 4/5/17, explaining the difficulties with the ostomy appliance adhering and what we had discovered worked best at the time. She gave Staff A her cell phone number and encouraged her to call if any problems, even over the weekend. The hospital wound nurse stated she returned a call to Staff B on 4/5/17 in the late afternoon regarding what type of appliance wafers/bags we had used as well as how many so that she could order supplies for the patient. The resident returned to the hospital on [DATE] at 10:15 a.m. for a follow up appointment with Wound Care and the physician. On arrival, an ostomy appliance was over the stoma, but not adhered. Patient's skin distal to stoma was red, excoriated and weeping in an area of 30.0 by 20.0 cm. Excoriation also extended anterior to the stoma, but not measured. Area identified as extremely painful even without touching. The resident readmitted to the hospital. The appliance was removed, skin flushed and gently cleansed. A thick layer of [MEDICATION NAME] ointment was applied to entire area to protect skin. A roll of fluffed Kerlix gauze was placed over stoma to absorb stool. Staff repeated this procedure approximately every 30 to 60 minutes as needed to absorb stool, protect skin to allow healing. She did not write specific orders regarding the [MEDICAL CONDITION] care on discharge due to the extended conversations she had with Staff A. Since ensuring that the nursing home had my cell number, I was expecting them to call me if problems occurred. No calls were received. During the resident's admission to the hospital (4/12/17), the resident reported nursing home staff had not cut the ostomy wafers to fit the stoma, but had applied the round factory cut over the oval stoma, repeatedly. The resident reported he/she could feel it pop right off. The resident reported the nursing home had run out of supplies and had placed incontinence briefs over area to absorb stool, but no skin barrier was utilized. During an interview dated 4/24/17 at 3:55 p.m. Staff A reported she completed an admission assessment which included a skin assessment which noted the resident had an [MEDICAL CONDITION]. She reported she had received a phone call from the hospital wound nurse the day before the resident had been admitted (4/7/17) and discussed the problems hospital staff had with the resident's care of the [MEDICAL CONDITION]. The hospital wound nurse reported the stoma wafer would not adhere to the skin. The hospital wound nurse described the procedure for the placement of the wafer and the stoma care the facility was to follow. She reported she had written down the procedure but she had misplaced the notes and couldn't find them. She reported she hadn't placed the [MEDICAL CONDITION] care on the TARs and the treatment for [REDACTED]. Staff A reported she had been aware of the problems facility staff had in caring for the resident's [MEDICAL CONDITION] care. She voiced her concerns and felt uncomfortable with the situation. She reported she didn't call the resident's physician or the hospital wound nurse with the resident's change in status and the worsening excoriation of surrounding skin and difficulty with placement of the wafer and appliance. Staff A reported the facility wasn't prepared to care for the resident. During an interview dated 4/25/17 at 9:00 a.m. Staff B, health information management (HIM) officer reported she had spoken to the hospital wound nurse on 4/5/17 regarding what ostomy supplies to order prior to the resident's admission. The hospital wound nurse reported hospital staff had difficulty getting the ostomy pouch/wafer to adhere to the resident's abdomen. Staff B reported she discussed with the hospital wound nurse supplies used previously on another resident specifically for [MEDICAL CONDITION]. Both agreed and Staff B ordered the supplies and they arrived the morning of 4/7/17 prior to the admission of the resident. During an interview dated 4/25/17 at 2:50 p.m. Staff C, a registered nurse (RN) reported she had completed [MEDICAL CONDITION] care for the resident at the request of another nurse who had difficulty successfully placing the wafer and appliance to the [MEDICAL CONDITION]. She reported the skin around the [MEDICAL CONDITION] had denuded and she had difficulty with placement of the wafer and appliance. She reported she had not documented the treatment on the TAR, as it hadn't occurred to her to do so. During an interview dated 4/25/17 at 3:10 p.m., Staff D, LPN, reported he remembered two episodes of the resident's [MEDICAL CONDITION] leaking. He had completed [MEDICAL CONDITION] care on 4 separate occasions and followed the suggestions made by the resident in the process of cleansing the skin around the area of the stoma, the application of the barrier wipes in order to for a sticky surface for placement of the wafer around the stoma. He reported he didn't document the treatments because the software program on the computer didn't prompt him to do so. He reported he had documented the resident's status on the facility's 24-hour report sheet but those reports were not available as the facility destroys them. During an interview dated 4/24/17 at 3:12 p.m., the resident's general surgeon (also referenced as the resident's physician) reported the hospital wound nurse gave specific instructions for [MEDICAL CONDITION] care. The surgeon stated he expected facility staff to contact him of any change in the resident's [MEDICAL CONDITION] status. The Policy and Procedure titled [MEDICAL CONDITION]/[MEDICAL CONDITION] Stoma Care, with a revised date of 5/16 directed staff to observe condition of the ostomy and prevent complications such as skin irritation or infection, to prevent odor or leakage of intestinal material and monitor throughout the shift and report to the nurse if little or no contents noted in the bag. Staff are to document routine stoma care on the TAR (Treatment Administrative Record) and note color, consistency and amount of stool in ostomy appliance. During an interview dated 4/25/17 at 7:50 a.m. the Director of Nursing (DON) stated prior to admission, Staff A received a phone call from the hospital wound nurse on 4/6/17. The hospital wound nurse provided instructions for the [MEDICAL CONDITION] care the resident had received when hospitalized . The DON stated she didn't know exactly what had been discussed. The DON acknowledged the hospital discharge orders didn't include orders for treatment of [REDACTED]. and ask for any new orders. Treatments performed by staff needed to be documented in the TARs along with a description of what treatment and the date and time performed.

Based on record review, staff interviews and review of policy/procedures, the facility failed to assess and or intervene with severe bruising found on 1 of 4 residents reviewed (Resident #1). The facility identified a census of 58 current residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 8/22/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The same assessment indicated the resident had moderately impaired decision making skills and depended upon staff for activities of daily living. Review of the Care Plan for Resident #1 revealed [DIAGNOSES REDACTED]. The policy and procedures titled Skin Assessment, and last reviewed on 4/16 directed staff to monitor bruises weekly and monitor for any changes and or progress toward healing and document. On 9/15/16 at 4:00 PM, observation identified Resident #1 in bed, wearing a hospital gown, sleeping, disheveled with hair growth on face, dark black to yellow bruising noted on left shoulder (color indicated they were older than 3 days old). Review of the Good Samaritan Society form used by bath aides dated 9/6/16 (Tuesday) documented bruising found on bilateral (both) shoulders that had not been there on Saturday or Sunday (9/3, 9/4). Review of the Progress Notes dated 9/5/16 at 2:55 a.m. and again on 9/6/16 at 0220 (2:20 AM), the same nurse documented the resident grimacing and moaning. The nurse asked the resident if in pain. The resident shook his/her head to indicate yes. The nurse did not assess where the pain was or the cause of the pain. The same day, the bruises on the resident's left shoulder were documented on a hand written note and left for the Director of Nursing (DON). Review of the Progress Notes dated 9/6/16 at 1000 (10 AM) and 1352 (1:52 PM), documented by Staff B, Licensed Practical Nurse LPN revealed no assessment or intervention completed regarding the bruising on left shoulder. Review of the Progress Notes dated 9/6/16 at 1519 (3:19 PM), documented by Staff C, LPN revealed no assessment or intervention completed regarding the bruising on the left shoulder. Review of the Progress Notes dated 9/7/16 at 0638 (6:38 AM), documented by Staff G, Registered Nurse, (RN) identified no assessment or intervention completed regarding the bruising on left shoulder, no injuries noted at that time. Review of the Progress Notes dated 9/7/16 at 0905 (9:05 AM), documented by Staff H, LPN indicated no assessment or intervention completed regarding the bruising on left shoulder. During an interview on 9/15/16 at approximately 4:30 PM, Staff E, Certified Medication Aide (CMA) stated Resident #1 had fallen about a week prior and as soon as she saw the bruising she reported it to, Staff C, LPN, and charge nurse at the time. She stated the nurse did little for the resident. She stated she can't remember which day it was though. Resident #1 had been in bed for the past few days. The hospice nurse had been coming in to assist with his/her cares. Some of the staff had been concerned about the resident. During interview on 9/20/16 at 2:10 PM, Staff A, LPN stated when signs of injury are found, such as bruising, they are expected to measure the area, document it and notify the physician for orders and notify the family. She further stated she then would let the DON know, then DON and the department head's would begin an investigation. During an interview on 9/15/16 at approximately 5:00 PM, the Administrator stated the DON had been at the Corporate Office all week and he had been in charge for the week. He stated he didn't think Resident #1 had fallen and he had not been made aware of bruising. He further stated an x-ray had not been done. During an interview on 9/20/16 at 4:15 PM, Staff F, Certified Nursing Assistant (CNA) stated when she first saw the bruises, she and the medication aide reported it to the DON. She and Staff E completed a bath sheet and drew out where the bruising had been seen. She stated they both reported the bruising to the charge nurse, Staff C and she didn't think an assessment or x-rays had been done. She stated she and other staff had been very concerned for the resident and did not feel anything had been done. During an interview on 9/21/16 at 10:15 AM, the DON stated she did not see the bruising, when she received the report from Staff E and F, she spoke to the charge nurse, heard the bruising showed signs of healing so she did not do anymore about it. She further stated the charge nurse is responsible for completing an incident report and a full assessment whenever there is an injury of unknown origin. During an interview on 9/20/16 at 8:35 AM, Staff D, LPN stated whenever they have an injury of unknown cause, they are to do a complete assessment and fill out an incident report. Staff D stated she felt they all assumed the bruising was from one of many falls and they did not follow through to determine that. During an interview on 9/21/16 at 10:30 AM, Staff B, LPN stated she remembered seeing some bruising but since it showed healing, she did not think at that time she should have assessed it more and verified that the resident's physician had been notified. On 9/22/16 at 11:20 a.m., the Hospice nurse was interviewed and stated the last 2 weeks she had seen the resident more lethargic, not eating, periods of being up to the table or sleeping in a recliner. The last week the resident remained in bed all of the time. The nurse stated Resident #1 had fallen out of bed onto the floor mat a few times and she did see an ecchymotic (bruise) area on the upper left shoulder. The nurse stated she examined the resident and when she palpated the area, the resident had no grimacing or moaning and used the left arm without signs of pain.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision in order to prevent resident to resident negetive interactions (Resident #4,#6, #10, #16). which resulted in injury to Resident #4 and Resident#10. The sample consisted of 17 residents and the facility reported a census of 63 residents. Findings include: 1. Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 7/8/15. The MDS identified the resident had [DIAGNOSES REDACTED]. A BIMS (brief interview for mental status) reflected the resident scored 5. A score of 5 identified the resident as severely cognitively impaired. The MDS reflected the resident needed limited assistance and supervision with transfers and ambulation and extensive assistance with dressing and toileting, however, the resident demonstrated resistance with cares. The MDS documented the resident demonstrated physical and verbal behaviors toward others and wandering. The Care Plan identified the resident displayed dementia behavior symptoms on 3/9/15. The resident showed aggression towards staff and called people names. The interventions directed the staff to intervene when necessary to protect others, minimize potential for disruptive behaviors, inappropriate comments and aggression toward staff and provide interaction for positive interaction and attention. The Progress Notes beginning 7/7/15 at 3:50 p.m. documented Resident #4 yelling and cursing at residents. The resident received Ativan (anti-anxiety medication) 0.5 milligrams tablet. The Progress Notes dated 7/12/15 at 3:08 p.m. documented the resident yelling and using profanity at another resident's family member. The nurse administered Ativan 0.5 milligrams. The same notes continued and documented the resident intrusive and unpredictable. Notes dated 7/13/15 at 5:18 p.m. documented the resident unpredictable this day, making intimidating gestures, telling residents and staff what to do. When staff attempted to take another resident to the bathroom the resident shoved a chair across the room, cursed and pushed and grabbed staff's hand and mumbling not to get close to him/her. The notes dated 7/16/15 at 4:00 p.m. documented the resident yelling and hitting other residents. Notes dated 8/22/15 at 1:00 p.m. documented the resident picked up a water glass and threw the glass on the table, upsetting two other residents sitting at the table. The Progress Notes dated 8/25/15 at 7:12 p.m. documented staff attempted to redirect Resident #4 and the resident threw the glass of water on staff. The resident threatened to knock her block off. Notes dated 9/7/15 at 4:10 p.m. documented the resident being rude to other residents and treating to hit staff. Notes dated 9/15/15 at 1:42 p.m. documented another resident kept going into Resident #4's room and Resident #4 yelling at the other resident to get out. Notes dated 9/17/15 at 9:40 p.m. documented the resident began yelling at another resident who had been yelling. Resident #4 started to walk toward the other resident and raised his/her fist. Staff redirected Resident #4 away from the other resident. Notes dated 9/22/15 at 9:54 p.m. documented the resident became very rude and calling a resident names and telling the other resident to shut up. Staff attempted to redirect and on the 4th attempt the resident went to his/her room but on the way there elbowed staff in the stomach. Later, in the same note, staff noted the resident yelling at another resident who had entered his/her room and saw the resident had the other resident's shirt sleeve and pulling the resident off balance. Notes dated 9/25/15 at 3:48 p.m. and again at 9:48 p.m. documented Resident #4 yelling at another resident who tried to enter h/her room, shoving the other resident out of the room. Notes dated 9/29/15 at 4:15 p.m. documented the resident slapping staff's hands and yelling at staff and other residents and wanting to hit another resident. Notes dated 10/2/15 at 2:17 p.m. documented staff attempted to assist the resident with cares when the resident kicked the staff in her stomach. Notes dated 10/3/15 at 5:56 p.m. documented staff reported the resident threw cranberry juice and another resident's face and called the resident a (expletive) and a (expletive) whore. Staff removed the other resident from the area. An incident report dated 10/4/15 at 11:53 p.m. documented Resident #4 pushed another resident out of his/her room causing both residents to fall with Resident #4 falling on top of Resident #16. Resident #4 complained of left arm pain and having trouble moving the arm and squeezing the hand. An observation on 10/5/15 at 2:20 p.m. revealed Resident #4 sitting in the dining room wearing an arm sling on the left arm. At 2:45 p.m. Resident #4 complained of pain to the left shoulder/arm. The Progress Notes dated 10/5/15 at 2:23 p.m. documented Resident #4 left the facility at 7:00 a.m. for the local hospital emergency room for evaluation of the resident's left arm and possible fracture. The resident returned at 9:45 a.m. and hospital records dated 10/5/15 at 9:36 a.m. documented a non-displaced fracture of the left proximal humerus (upper arm). During an observation on 10/6/15 at 2:00 p.m. Resident #4 saw Resident #16 and told the resident to stay out of his/her room. Resident #16 didn't respond and continued to wander throughout the unit. 2. Resident #16 had a MDS with a reference date of 9/10/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident had severe cognitive impairment, disorganized thinking, altered level of consciousness and physical behavioral symptoms directed toward others and wandering daily. The resident needed extensive assistance with bed mobility, transfer and needed supervision of one staff with ambulation. A Care Plan with a print date of 10/5/15 reflected the resident had an impaired cognitive function and inability to communicate needs of staff, aggressive behavior toward others. The interventions directed the staff to intervene as necessary to protect the rights and safety of others, divert attention and remove the resident from a situation and take to an alternate location and prefer diversional activities: walking up and down the halls, wanders into other resident rooms and redirect as necessary. The Progress Notes dated 9/5/15 at 6:50 a.m. documented Resident #16 hit staff with cares. The notes dated 9/9/15 at 10:24 a.m. documented the resident hit, pinched and tried to bite staff when personal cares were done. The resident's behaviors escalated and the resident scratched, attempted to bite and slapped staff members. The notes dated 9/9/15 at 11:47 a.m. documented while the nurse was at lunch, Resident #16 went into another resident's room and took the resident's clothes which caused the other resident to come out of his/her room and yank the clothes from Resident #16's hands. Staff interceded by positioning themselves between both residents. The notes dated 9/10/15 at 2:14 p.m. documented the resident hit staff when staff attempted to change their wet clothes. The notes dated 9/12/15 at 2:05 p.m. documented the resident walked up and down the hall and went into another resident's room. The notes dated 9/20/15 at 8:25 p.m. documented the resident bothered some of the other residents in their rooms, turned lights on and picked stuff from other resident's belongings. The notes dated 9/21/15 at 10:58 a.m. documented the resident roamed around the unit and carried things around with him/her. Progress notes dated 10/5/15 at 12:00 a.m. documented Resident #16 going into another resident's room. The other resident pushed Resident #16 out of h/her room causing Resident #16 to fall to the floor with the other resident falling on top of Resident #16. An incident dated 10/4/15 at 11:56 p.m. confirmed the events documented in the above progress notes. A continuous observation on 10/5/15 beginning at 2:20 p.m. and concluding at 3:15 p.m. revealed the following: a. Resident #16 walked down the hall from the dining room and into Resident #4's room and then exited with a pillow. Staff members were not present when this incident occurred. At 2:21 p.m. Resident #16 wandered throughout the memory unit without any redirection from staff. At 2:30 p.m. Resident #16 wandered throughout the unit and went into Resident #4's room and returned to the dining room with a hooded sweatshirt. At 2:45 p.m. Resident #16 walked into Resident #4's room and was in the room for several minutes. No staff were present during this observation. At 2:53 p.m. Resident #16 walked into Resident #4's room, remained there for three minutes and walked back to the dining room. Staff C, a registered nurse (RN) and Staff D, a certified medication aide (CMA) were at the nurse's station and dining room and observed Resident #16 wandering and going into Resident #4's room. Staff C and Staff D did not redirect the resident. At 3:00 p.m. Resident #16 walked into Resident #4's room and remained there for two minutes. Resident #16 came out of Resident #4's room and passed Staff B, a licensed practical nurse (LPN) as h/she walked by. Staff B did not redirect or engage the resident during this incident. At 3:12 p.m. Staff #16 went into Resident #4's room, came out holding a sweater and returned to the dining room. Staff E and Staff D were in the dining room and watched Resident #16 walk down the hall from Resident #4's room holding a sweater but neither staff redirected or engaged the resident. At 3:15 p.m. Resident #16 walked down the hall toward Resident #4's room, entered the resident's room and remained there for five minutes. Staff D was in the hallway as Resident #16 came out of Resident #4's room and Staff D did not redirect or engage the resident. An observation on 10/7/15 at 11:00 a.m. revealed Resident #16 wandered throughout the unit. The resident walked down the hall, entered Resident #4's room and closed the door. One and 1/2 minutes passed and Resident #16 came out of Resident #4's room accompanied by Staff B. Staff B told Resident #16 not to enter Resident #4's room, showed the resident the stop sign and told the resident to remember the stop sign means not to come into Resident #4's room. Staff B then accompanied Resident #16 down the hall and assisted the resident to a chair by the nurse's station. At 11:15 a.m. Resident #16 wandered down the hall and again entered Resident #4's room. The resident closed the door, exited a few seconds later and as the resident came out of the room he/she passed by Staff B. Staff B did not redirect or engage Resident #16. During an interview on 10/6/15 at 1:50 p.m. Staff B (Licensed Practical Nurse) stated there were no new interventions related to Resident #16 wandering into Resident #4's room. She stated there had been some discussion to possibly place a stop sign on Resident #4's door, but no other interventions in place. During an interview on 10/6/15 at 2:40 p.m. the Director of Nursing stated only one intervention had been added related to Resident #16 going into Resident #4's room. A stop sign on Resident #4's room door had been placed to keep Resident #16 out of Resident #4's room. During an interview on 10/7/15 at 2:41 p.m. Staff G, registered nurse, stated on 10/4/15 at 11:00 p.m. she was off the unit but heard screaming in a high pitch. She entered the unit and found Resident #16 in Resident #4's room. Each resident had their hands locked together and Resident #16 had freed a hand and tried to swing his/her arm toward Resident #4, but both lost their balance and fell with Resident #4 falling on top of Resident #16. Staff G stated both Resident #4 and #16 have a history of verbal aggression toward each other. Staff G stated Resident #16 wandered from the very beginning and continues to go into Resident #4's room. It's automatic for the nurse to attempt to redirect residents who wander into other resident's rooms. Residents are allowed to wander throughout the unit and if a resident is found in another resident's room, staff are to redirect the resident. Staff cannot keep an eye on every resident. There are two staff that work evenings and staff are often giving or assisting with bathing. Staff G stated there are no other staff available to assist when additional staff are needed. During an interview dated 10/7/15 at 3:00 p.m., Staff F, a certified nursing assistant (CNA) stated Resident #4 and #16 are physically combative toward each other and both residents are combative with cares. Resident #16 continually walks into Resident #4's room, taking clothes and other items from Resident #4's room. The incident reports (Resident #6 and #10) dated 9/12/15 at 8:00 p.m. documented Resident #6 had been walking in the hallway and grabbed Resident #10's left forearm, causing a 2 centimeter (cm) by 3 cm skin tear to the left forearm. Resident #10 had been sitting in his/her wheelchair in the hallway. Both incident reports indicated a resident to resident incident occurred with physical contact. 3. The MDS assessment dated [DATE] indicated Resident #6 had [DIAGNOSES REDACTED]. A staff assessment for mental status identified a severe cognitive impairment. The MDS identified verbal and physical aggression toward others and refused cares and wandered. A Care Plan with a revision date of 2/5/15 included a focus area of impaired cognition with wandering into other resident's rooms. Interventions included for staff to provide diversionary activities, redirect and reassure as needed. A focus area dated 7/30/15 of behaviors of hitting and kicking staff directed staff to intervene as necessary to protect the rights and safety of others, remove the resident from the situation and provide an alternate location. Resident #6's progress notes dated 9/3/15 at 2:55 a.m. - 9/10/15 at 10:15 a.m. documented a history of pacing in the hallway, being aggressive toward other residents, wandering all over the unit and combative; pinching, biting and kicking with cares. No other documentation other than the incident report dated 9/12/15 at 8:00 p.m. had been found in the resident's clinical record. 4. Resident #10 had a MDS assessment with a reference date of 8/26/15. The MDS reflected the resident had [DIAGNOSES REDACTED]. A BIMS score of 6 identified the resident as severely cognitively impaired. The resident needed extensive assistance of one staff for transfers and limited assistance of one staff with ambulation. The resident used a wheelchair and walker and had a history of [REDACTED]. A Care Plan identified on 2/16/15, a focus area included the resident had deficits with activities of daily living self -care performance. The resident had limited mobility, impaired balance and needed assistance with activities of daily living and transfers. On 3/5/15, the resident could independently toilet due to refusing help from the family or staff. The facility provided briefs. The Care Plan reflected the resident was independent with transfers due to refusing any help. A revision dated 8/23/15 identified a focus area of a risk for falls and established interventions for staff to provide diversions and distraction by allowing the resident to wander in his/her wheel chair. The intervention directed staff to remind the resident to ask for assistance with toileting and transfers. The Progress Notes dated 8/30/15 at 8:58 a.m. to 9/8/15 at 10:08 a.m. documented Resident #10 had made multiple attempts to exit the dementia unit, yelled at staff and refused cares and medications. During an interview on 10/5/15 at 11:30 a.m., the Director of Nursing confirmed she had been made aware of the incident. An incident report had been completed but an investigation of the incident had not been done. During an interview on 10/7/15 at 3:00 p.m., Staff F, stated Resident #6 and #10 have a history of having arguments leading to confrontations between each other and often leading to physical aggression. During an interview on 10/7/15 at 8:55 a.m. Staff A, RN stated he had been present when the incident occurred between Resident #6 and Resident #10. He stated both residents wander throughout the facility and have a history of verbal and physical aggression toward others. Staff A reported the evening of the Resident #6 had grabbed Resident #10. Resident #10 pulled away which caused the skin tear. He stated he tried to take care of Resident #10's wound but the resident refused treatment.

Based on record review and physician, family and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosical well-being in accordance to the resident's change of change of condition (Resident #6,#7, #8) and failed to provide cardiopulmonary resuscitation (CPR) as requested by the Advanced Directive (Resident #8). The facility reported a census of 63 residents. The sample consisted of 16 residents. Findings include: Resident #8 verbalized severe abdominal pain for approximately 4 hours prior to his/her death. The resident had no cognitive problems and able to request pain medication based on his/her pain level. Resident #8 had an advanced directive to be resuscitated (CPR). Staff discovered the resident without pulse and respirations; however staff did not perform CPR (Cardio [MEDICAL CONDITION] Resuscitation). Resident #6 had a change in [MEDICAL CONDITION] status which included a distended abdomen. The staff did not perform an assessment when the resident had a change in condition. Upon arrival to the hospital emergency room 2,550 cc of urine was decompressed from his/her bladder. Resident #7 had a change in cognition and status change. The record reflected no assessment had been performed. The physician had the resident transferred to the hospital for an evaluation and the resident noted to be dehydrated. The clinical record lacked evidence to include an assessment of the resident's hydration status prior to or upon return from the hospital. Upon entrance to the facility on [DATE] the facility Director of Nursing stated she was not aware of a policy for nursing assessment. 1. Resident #8 had a MDS (Minimum Data Set) assessment with a reference date of [DATE] which reflected the resident had a Brief Interview of Mental Status (BIMS) score of 14. A score of 14 identified the resident had no cognitive impairments. The MDS identified the resident's admitted as [DATE]. The resident was identified as independent with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had [DIAGNOSES REDACTED]. The current Care Plan, revised on [DATE], reflected the resident had chronic pain and discomfort due to [MEDICAL CONDITION]. The interventions directed staff the resident could call for assistance when in pain, reposition self, ask for medication and able to tell how much pin he/she experienced. The resident could tell what increase or alleviates the pain. The resident ' s pain is identified as rated numerically (,[DATE]). The form titled Order Sheet, initially dated [DATE] and signed by the physician on [DATE], identified a physician's orders [REDACTED]. Do Resuscitate directs the staff that the resident requests cardiopulmonary resuscitation (CPR) be completed in the event staff discover the resident with no pulse or respirations. The Nursing Progress Notes reflected the following: On [DATE] at 12:09 p.m. the physician ordered [MEDICATION NAME] (antibiotic) for an infection. On [DATE] at 8:11 p.m. the nurse documented the resident took the antibiotic for cold symptoms and the resident ' s temperature registered 98.4. The resident had the evening meal in his/her room and ate nothing. On [DATE] at 8:51 p.m. the nurse documented the resident had complaints of cold symptoms and a head ache. On [DATE] at 9:33 a.m. the nurse documented the Director of Nursing (DON) observed Resident #8 in the hallway and very confused. The resident had poor balance and required assistance to his/her room. The clinical record lacked evidence of an assessment; however, the physician was notified. The physician ordered the staff to hold the [MEDICATION NAME] for 2 days and continue to monitor status. On [DATE] at 2:31 p.m. the resident did not voice complaints and had no reactions. The nurse document no changes noted. On [DATE] at 12:28 a.m. the nurse documented earlier in the shift, the resident cried in his/her room and complained of his/her stomach hurting. The nurse documented the resident appeared to be asleep, will continue to observe. (The note did not reflect an assessment) On [DATE] at 1:25 a.m. the nurse documented the resident complained of stomach pain and she administered Tylenol ([MEDICATION NAME]) 325 milligrams 2 tablets to the resident. (The note did not reflect an assessment performed prior to administering the [MEDICATION NAME]). The Medication Record form confirmed the Tylenol had been administered. On [DATE] at 2:24 a.m., the nurse documented the resident up and crying again stating his/her stomach hurt. Denied nausea or arm pain but stated stomach hurt " bad " . On [DATE] at 3:02 a.m. Resident #8 continued to voice complaints of abdominal pain. The resident denied nausea or arm pain. On [DATE] at 3:45 a.m. Resident #8 crying and complaining of abdominal pain in the mid gastric area. The nurse noted the resident ' s color as ashy. On [DATE] at 3:49 a.m. The nurse documented a CNA (certified nursing assistant) exited the resident's room to report Resident #8 as not breathing. The nurse documented no respirations or pulse. (The record lacked evidence to indicate the nurse completed an assessment of the resident's change in status or performed CPR). On [DATE] at 3:50 a.m., the nurse documented she notified the physician and Coroner at 3:55 a.m. On [DATE] at 10:22 a.m. Staff H, licensed practical nurse (LPN) was interviewed and stated she provided nursing care to Resident #8 on the night he/she passed away and she admitted error. Staff H stated Staff K, LPN, reported Resident #8 didn't feel well and the antibiotic was on hold. Staff H provided the following information: At approximately 11:00 to11:30 p.m. the certified nursing assistant (CNA) reported Resident #8 as crying. Staff H entered the resident's room and noted he/she was crying and complained of stomach hurting. Staff H administered Tylenol and went to supper. Staff I, CNA, reported Resident #8 as crying after the supper break. Staff H stated the resident's crying was audible from the nurse ' s station, approximately 2 doors from the station. Staff H stated she entered Resident #8's room and the resident had the same complaint of abdominal pain and denied nausea. Staff H reviewed the Medication Administration Record [REDACTED]. Staff H stated MARs include medications, diagnoses, allergies [REDACTED]. Staff H stated she thought she read Resident #8 as DNR (do not resuscitate) and she remained in the area due to concern for Resident #8. Staff H stated at 3:45 a.m. Resident #8 complained of midsternum pain, and pointed to the area just under his/her sternum. Staff H stated she worried and hoped it wasn't his/her heart. Staff H stated she left Resident #8's room to check the computer for orders. Staff H stated as an Intensive Care Unit nurse in California, she recalled use of [MEDICATION NAME] for stomach pain to rule out cardiac concerns. Staff H stated she reviewed physician orders [REDACTED].#8 was gone (expired). Staff H entered the resident's room and noted no pulse or respirations. Staff H notified the physician, Director of Nursing, and attempted to notify the resident's family. Staff H stated she retrieved the resident's belongings form and noted Resident #8's advanced directive Do Resuscitate rather than Do Not Resuscitate (DNR). She then notified the Director of Nursing and the physician. Staff H stated typically if a resident is not breathing/no pulse the Advanced Directive book is used to check code status, but at the time she was confident she saw Do Not Resuscitate (DNR) earlier in her shift. Staff H stated she auscultated the resident's lungs and bowels but did not document her assessment. Staff H then stated if the assessment is not documented it is not completed. On [DATE] at 10:54 a.m. Staff I, CNA, stated Resident #8 complained his/her stomach hurt and pointed to an area above his/her naval (belly button). Staff I stated she checked vital signs, and assisted him/her to the bathroom. Staff I stated Resident #8 usually slept all night and used the call light for bathroom assistance but that night the resident voiced complaints of stomach pain. On [DATE] at 11:05 a.m. Staff J, CNA, stated Resident #8 complained of not feeling well. Staff J stated Staff H was concerned and went to get an antacid for the resident. Staff J stated Resident #8 was incontinent and very pale. Staff J began pericare and noticed the resident did not respond to her voice. She called for Staff H. Staff H was unable to elicit a response when the resident's shoulders were rubbed. Staff J stated Staff H then left the room to notify the family and physician. Staff J stated typically Resident #8 was alert and oriented and knew he/she didn't feel right, and something was wrong. On [DATE] at 9:53 a.m. Staff K, LPN, stated if a resident is not breathing, she would check the Advance Directives book to determine the resident's code status. If the resident is a full code, start CPR and call 911. On [DATE] at 10:03 a.m. Staff L, LPN, stated if a resident is not breathing she would check the binder (Advance Directives binder) for code status then start CPR while staff calls 911 if the resident is not DNR. On [DATE] at 10:05 a.m. Staff M, registered nurse (RN), stated if a resident is not breathing she would check the Advance Directives book or computer to check the resident's code status and start CPR, if not DNR. On [DATE] at 11:14 a.m. Resident #8's physician stated with the change in status he would expect the nursing assessment to include vital signs, an assessment to include symptoms identified as well as heart, lungs and abdomen, location of discomfort as well as a detailed description of pain. The physician stated he expects to be notified of any change in resident status (condition). On [DATE] at 11:50 a.m. observation of the Advance Directives book identified a list of all residents and their code status dated [DATE]. On [DATE] at 11:53 a.m. the surveyor requested a copy of the list of residents in the Advance Directives book from [DATE]. The Director of Nursing (DON) stated she shredded the list and confirmed knowledge that CPR was performed on Resident #8. The DON confirmed Resident #8 requested CPR be initiated. The Director of Nursing Services stated the resident list is updated daily and that she didn't even think to save the list and she was not able to recreate the resident list dated [DATE]. The facility policy titled Cardiopulmonary Resuscitation (CPR) directed staff to perform CPR unless the resident has a DNR (do not resuscitate) order, has obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) or the initiation of CPR could cause injury or peril to the rescuer. Note: At the time of the complaint investigation, the complaint was coded at a " J " , immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to " G " level. The Advanced Directive binder was updated to identify the status of resuscitation. Additional training was provided to staff nurses regarding timely and appropriate assessment and intervention for residents with a change in status. The facility implemented an S Bar program to assist with assessments. As of the [DATE] exit conference, the facility needed to: · Continue to in-service the nursing staff regarding the policy/procedure titled Cardiopulmonary Resuscitation (CPR). · Monitor nursing staff to assure compliance with the policy/procedure for CPR and the updating and application of the Advanced Directive Binder. · Monitor nursing staff for timely and adequate nursing assessment and intervention for residents with a change in condition (SBar System). 2. Resident #6 had a MDS assessment with a reference date [DATE]. The MDS reflected the resident had a score of 9 on the Brief Interview of Mental Status test. A score of 9 identified the resident had mild cognitive impairment. The MDS identified the resident's admitted as [DATE]. The resident required extensive assistance from staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had [DIAGNOSES REDACTED]. The Care Plan identified a focus area with the resident being deficit with self-care performance due to weakness evidenced by the need for assistance with activities of daily living and transfers. The nurse initiated the focus area on [DATE] and revised the Care Plan on [DATE]. The Nursing Progress Notes identified the following: On [DATE] at 12:39 p.m. the nurse notified the physician that the resident had a moderate amount of red drainage from the urinary meatus and observed (the drainage) in the toilet. The resident had no complaints of discomfort. On [DATE] at 12:46 p.m. the physician responded and stated the tests identified a tumor on the resident's right kidney. The resident and family chose no treatment. The physician ordered the staff to perform daily weights and to inform if there is an increase in weight. On [DATE] at 3:18 a.m. Resident #6 continued to have blood tinged urine, 1 extra-large loose stool very black in color, and 1 extra-large loose stool with blood. On [DATE] at 8:42 a.m. reflected the resident had no discomfort this morning and no report of red drainage from penis or in bowel movements. On [DATE] at 8:46 p.m. the resident ' s family member telephoned the facility and expressed concern about the resident ' s blood tinged urine and stools. The family member questioned the use of the anticoagulation (prevents blood clotting) medication and the cause of the bleeding (in urine and stool). The nurse documented the physician would be contacted. On [DATE] at 10:10 p.m. the nurse notified the physician about the blood in the resident's urine and stools, and the family member expressed concern about the bleeding and anticoagulation medication use. The physician directed the anticoagulation medication be held (not given for now). On [DATE] at 4:44 a.m. the nurse documented the resident continued to have blood in the urine and stool and the abdomen appeared very distended. The resident expressed no complaints of pain. (The clinical record lacked evidence to indicate a nursing assessment was completed of the distended abdomen). On [DATE] at 4:30 a.m., the resident received [MEDICATION NAME] ([MEDICATION NAME]) 50 milligrams one tablet for pain. (The record did not identify an assessment of the pain). The note reflected the [MEDICATION NAME] as effective. A late entry on [DATE] at 6:45 a.m. reflected Resident #6 had a blood sugar reading of 40 (normal is ,[DATE]). The resident received orange juice and milk and 2 staff assisted the resident with a full body lift. The nurse noted the resident as very lethargic and required continuous stimuli at breakfast. The staff returned the resident to his/her room and into bed. The clinical record lacked evidence to indicate a nursing assessment was completed with the exception of the blood sugar reading. A late entry on [DATE] at 9:00 a.m. described Resident #6's abdomen as large, round and distended with bowel sounds auscultated in the upper quadrants only. The resident had foul smelling loose diarrhea, and continued to be very lethargic. The nurse notified the physician. On [DATE] at 10:50 a.m. reflected the resident's family member present at the facility. The nurse reviewed the resident's laboratory tests with the family member and the physician had not addressed the laboratory test at this time. Later the physician adjusted the insulin and ordered a stool specimen to check for [MEDICAL CONDITION] ([MEDICAL CONDITION]-a form of bacteria). The physician ordered [MEDICATION NAME] (antibiotic) 500 milligrams to be given three times a day. A late entry dated [DATE] at 12:50 p.m. reflected the resident remained in room for lunch and required much encouragement to eat and swallow. On [DATE] at 1:20 p.m. the nurse sent a stool specimen to the hospital for testing. The nursing notes noted the resident remained in bed and continued to have loose/liquid stools. (The record did not identify a nursing assessment had been completed). On [DATE] at 3:30 p.m. the facility received a facsimile from the physician. The physician informed the facility of a concern of the resident having a bowel blockage. The physician documented it did not sound like a bowel blockage but the resident can have x-rays if the family desires, if has pain or change in condition, then send to the emergency room . On [DATE] at 4:20 p.m., the nurse contacted the family member and the family member requested the resident be sent to the emergency room . On [DATE] at 4:45 p.m. Resident #6 left the facility via a stretcher and transported to the area hospital. The clinical record lacked evidence to indicate an assessment was completed when the change in status was noted. Facility output documentation identified the following: On [DATE] at 9:07 a.m. Resident #6 was incontinent a large amount of urine. On [DATE] at 9:53 p.m. Resident #6 was incontinent a large amount of urine. On [DATE] at9:54 p.m. Resident #6 was incontinent a large amount of urine. On [DATE] at 2:37 a.m. Resident #6 was incontinent a large amount of urine. On [DATE] at 5:27 a.m. Resident #6 was incontinent a large amount of urine. On [DATE] at 10:04 a.m. Resident #6 was incontinent a medium amount of urine. A transfer/discharge report dated [DATE] noted the resident's abdomen as large, round and distended and the resident experiencing liquid stools, and dribbling bloody urine. A hospital physician History and Physical document dated [DATE] reflected Resident #6 was found to be obtunded and had a markedly distended abdomen. Upon arrival to the hospital (Resident #6) was completely obtunded, unresponsive, and unable to answer any questions. A urinary catheter was placed and 2,500 cc of Coca Cola colored urine drained (from the resident's bladder). A CT (Computed Tomography) scan demonstrated bilateral hydro[DIAGNOSES REDACTED] (kidney becomes swollen due to the failure of normal drainage of urine from the kidney to the bladder). A chest x-ray determined the resident had bilateral mild pleural effusions (fluid around the lungs) and the CT scan identified left lower lobe pneumonia (lung infection). The physician admitted the resident into the hospital for dehydration and careful monitoring of the resident ' s blood sugar. The eighth edition of Clinical Nursing Skills (copy right 2012), page 759 reflected the following: Micturition (urination) is a reflex act that occurs in response to pressure changes within the bladder. After about 300 cubic centimeters (10 ounces), the bladder walls tighten and pressure increases. After ,[DATE] cc is in the bladder, the bladder walls will contract and the resident will sense an urgency to void. Once the volume of urine reaches about 700 cc, most individuals lose their ability to delay micturition. If an individual cannot urinate, as much as 1000 cc of urine can accumulate in the bladder. When a large volume of urine is retained, the bladder ' s lining and blood vessels can be damaged by the increased stretching and pressure. When this happens, the person will experience pain, restlessness, chilling, flushing, headache, diaphoresis and a rise in blood pressure. On [DATE] at 1:07 p.m. Resident #6's family member was interviewed and stated on [DATE] (Resident #6) complained of his/her abdominal pain. On [DATE] he/she complained of severe stomach pain and was coherent in the morning. Later in the afternoon, he/she was kind of talking and at about 3:30 p.m. he/she was out of it and his/her stomach was distended. The family member informed the nurse and social worker about their concerns and request to transfer to the hospital for evaluation. The family member stated the facility social worker informed the family she didn't feel a transfer would be in the best interest of the resident because it would be very painful to move him/her. The family member stated at the hospital, Resident #6's blood sugar was down to 30 (normal ,[DATE]) and his/her bladder had 2,550 cc of urine which was uncalled for. On [DATE] at 8:10 a.m. Resident #6's physician confirmed a urinary catheter was inserted at the hospital and approximately 2,500 cc of urine was decompressed from the bladder. The physician added the resident's [DIAGNOSES REDACTED]. The physician stated he would expect nursing assessments regarding bladder distention (determined when the clinician taps/thumps the abdomen), pain, nausea/vomiting, vital signs, etc. The physician stated he expects to be notified with any change in status. On [DATE] at 1:39 p.m. the Director of Nursing (DON) stated Resident #6's family was not happy and 2,500 cc was drained from his/her bladder at the hospital, and they felt we failed to assess the resident and get treatment. The DON stated the void record showed Resident #6 voided 3 times that morning. The DON stated the facility does have a bladder scanner but it is currently at another facility. On [DATE] at 3:34 p.m. the DON confirmed the clinical record lacked assessment of the change in condition for Resident #6, and should include a head to toe assessment with vital signs. On [DATE] at 10:15 a.m. the DON stated the facility's bladder scanner has been broken for approximately 1 month and they have not decided to purchase another because it's not regulatory. On [DATE] at 2:41 p.m. Staff B, registered nurse (RN) stated on [DATE] she spoke with one of Resident #6's family members who informed her the resident had a tumor on his/her kidney, but opted for no treatment. Staff B stated she really did not have a reason that she did not complete the assessment but thought because the resident's daughter was in the room, even though the daughter did not direct the nurse to not complete an assessment. Staff B stated had she known about the [MEDICAL CONDITION], she would have completed a bladder scan and was aware the facility had a bladder scanner but it was currently at the other facility (in Villisca). Staff B stated additional assessment documentation should include vital signs, blood sugar and pain. On [DATE] at 7:36 p.m. Staff E, LPN, stated the day Resident #6 was transferred he/she was very lethargic thru the day and would only answer at times. Staff E stated Resident #6 didn't complain of pain and could not recall if the resident winced when his/her belly was palpated. Staff E was unable to recall what assessment she completed and documented any assessment she did complete. On [DATE] at 7:25 p.m. Staff D, LPN, was unable to recall if Resident #6 had pain, however was able to recall the resident's abdomen was distend his/her and firm. Staff D stated his/her bowel sounds were hyperactive due to diarrhea. On [DATE] at 10:10 a.m. Staff F, CNA, recalled Resident #6 had a "big belly." On [DATE] at 2:32 p.m. Staff A, CNA; stated Resident #6's belly was a little protruded and Resident #6 got a lot weaker and confused at times. Staff A stated the resident became more incontinent before he/she left for the hospital and she observed blood in the urine. Staff A stated she reported this to the charge nurse. 3. Resident #7 had a MDS assessment with a reference date of [DATE]. The MDS reflected the resident had a score of 10 on the BIMS (Brief Interview of Mental Status). A score of 10 identified the resident had moderate cognitive impairment. The MDS identified the resident's admitted as [DATE]. The MDS identified the resident as independent with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had [DIAGNOSES REDACTED]. The Care Plan, dated [DATE], identified a focus area for activities of daily living and self-care performance for Resident #7 due to weakness. The interventions identified and included the resident as independent with activities of daily living such as eating, toileting and personal hygiene. The Nursing Progress Notes reflected the following: On [DATE] at 7:43 p.m. the nurse documented Resident #7 continued to not feel well and vomited a large amount of undigested food three times. The staff transferred the resident to the emergency room at 6:00 p.m. for an evaluation. The clinical record lacked evidence of a nursing assessment to include vital signs, bowel sounds and etc. prior to the transfer. On [DATE] at 9:18 p.m., the resident returned from the emergency room with an order for [REDACTED]. On [DATE] at 1:27 a.m. the resident voiced complaints of nausea but had no emesis. On [DATE] at 5:20 p.m. Resident #7 remained in his/her bedroom for meals, denied nausea or pain and didn't feel well. On [DATE] at 6:30 a.m. the documented Resident #7 as very confused and attempted to urinate in the trash. The nurse noted the resident as lethargic and unable to follow commands. The nurse assessed the resident's blood sugar and vital signs and documented will continue to monitor. The clinical record lacked evidence to indicate a nursing assessment was completed after the nurse noted a change in the resident's condition. On [DATE] at 9:15 a.m. the nurse spoke with the physician and received an order for [REDACTED]. On [DATE] at 10:23 a.m. the physician requested a blood sugar assessment. On [DATE] at 11:30 a.m. the nurse received an order to have the resident transferred to the hospital for a CT of the head per family request. The clinical record lacked evidence to indicate an assessment was completed with the change in condition and prior to the resident's transfer. On [DATE] at 4:57 p.m. Resident #7 returned to the facility and had [DIAGNOSES REDACTED]. No new orders were noted. The clinical record lacked evidence to indicate an assessment was completed upon return to the facility. On [DATE] at 1:03 a.m. the nurse documented Resident #7 resting in bed, unclear of time and not making sense. The nurse noted the resident's skin color appeared darker/ slight jaundice, had an unsteady gait, and not smiling/joking as before. The clinical record lacked evidence to indicate a nursing assessment was completed to address the resident's hydration status following the [DATE] [DIAGNOSES REDACTED]. On [DATE] at 9:12 a.m. the resident ' s family member was interviewed and stated when she arrived the resident was sick and urinating in the room and no one did anything. The family member stated she was ready to take Resident #7 to the hospital herself/himself. The family member stated when the facility sent Resident #7 to the hospital he/she was really sick. On [DATE] at 11:00 a.m. the Director of Nursing (DON) stated there was no assessment of the resident's vital signs on [DATE] and [DATE] prior to transfer. The DON stated she expected nursing staff to complete a head to toe assessment with a change in status.

Based on record review, staff interview and observation the facility failed to provide appropriate supervision and intervention for 1 of 4 residents reviewed (Resident #3). The facility identified a census of 57 current residents. Findings include: According to Resident #3 ' s MDS (minimum data set) dated 12/5/14, revealed a BIMS (Brief Interview for Mental Status) score at 14, indicated Resident #3 as cognitively intact. The MDS listed Resident #3 required extensive assistance of one staff person for bed mobility, transfers, ambulation in the room and on the unit, dressing, toilet use and personal hygiene and required total dependence of one staff person for bathing. Resident #3 required a wheelchair for mobility. Resident #3 ' s[DIAGNOSES REDACTED]. The care plan dated 12/2/14 and revised 12/23/14 revealed Resident #3 required weight bearing support with the full body lift and 2 person assist with a large sling. The ADL (Activities of daily living) self-care performance sheet dated 12/2/14 and revised 12/23/14 for Resident #3 revealed a transfer required weight bearing support with a full body lift and two person assist with a large sling. Review of the Order Summary Report dated 12/1/14 revealed the following orders: a. Aleve 220 mg (milligram) every 8 hour as needed for pain. b. Hydrocodone-acetaminophen 5/325 mg 1 tablet three times a day as needed for pain. Review of the MAR (medication administration record) dated 1/1/15 through 1/5/15 revealed the following: a. Aleve 220 mg administered 1/1/15 at 7:06 p.m. b. Hydrocodone/acetaminophen 5/235/mg administered1/3/15 at 10:20 AM and 1/5/15 at 11:29 p.m. Review of the Incident Report dated 12/1/14 at 4:05 p.m. revealed Resident #3 found sitting on the floor by his/her bed. Resident #3 stated he/she slid off of the bed trying to get up into the wheel chair. Review of the Incident Report dated 1/2/15 at 7:25 p.m. revealed Resident #3 sat on the edge of the bed and slid off the bed. Resident #3 was unable to independently transfer back to the bed. Staff members retrieved the sit stand lift to assist Resident #3 up and back on the bed. When lifting Resident #3 up, he/she was unable to hang onto the handles of the lift. Both of Resident #3 ' sarms went up over his/her head. Resident #3 ' s left leg bumped and rubbed the metal foot platform area of the lift, resulting in a skin tear and hematoma. The staff members placed Resident #3 in the wheel chair and then used the Hoyer lift to assist Resident #3 back into bed. Staff members cleansed and applied a dressing to the skin tear on the left leg of Resident #3. Predisposing situation factors identified for Resident #3 included a sit to stand mechanical lift. Review of the Emergency Department Record dated 1/5/15 at 3:48 p.m. revealed Resident #3 presented with a chief complaint of shoulder problem. Resident #3 experienced bruising to the left front of the shoulder and the back of the left shoulder and up the back of the neck. Resident #3 had limited movement of both shoulders due to arthritis and was wheel chair bound. Resident #3 rated the pain at a 10 on a 1-10 scale when just sitting in the wheel chair. The duration of the symptoms had been since onset of the fall from the bed and the transfer by staff members. Review of the Diagnostic Radiology Report dated 1/5/15 revealed Resident #3 with a mid-left clavicle fracture and severe left shoulder arthropathy. Review of the progress notes dated 12/1/14 at 4:22 p.m. revealed Resident #3 had an incident and slid off of the bed when trying to get out of bed into the wheel chair. a late entry on 12/1/14 at 4:10 p.m. revealed Resident #3 alert and oriented and admitted that his/her knee gives out and caused to slide to the floor beside the bed. Due to this the decision made to change Resident #3 to a sit to stand lift for all transfers and care plan updated. On 12/23/14 at 1:49 p.m. staff documented Resident #3 alert and oriented and continued to be noncompliant. Resident #3 was previously a sit to stand for all transfers. Resident #3 stated he/she was unable to stand with the assist of the sit to stand. Resident #3 changed to a full body lift for all transfers and educated to wait in the solarium until staff can assist with transfers and care plan updated. Review of the progress notes dated 1/3/15 at 1:51 a.m. revealed an incident occurred and Resident #3 obtained a skin tear and hematoma on the left shin when trying to transfer and keep from falling. Review of the progress notes dated 1/4/15 at 4:47 p.m. revealed Resident #3 had a bruise on the left shoulder by the neck. The area was measured. Range of motion was the same bilaterally with very limited movement in either arm. Staff members notified the Physician with order received to monitor. Review of the physician's orders [REDACTED]. Review of the Wound Data Collection document dated 1/4/15 revealed Resident #3 had a bruise to the rear left shoulder area that measured 12.5 cm (centimeters) by 2 cm by 0.1 cm. The area 100% epithelialized and intact. The medical record failed to include weekly assessments. During an interview with Staff A, CNA (Certified Nursing Assistant) on 1/21/15 at 1:30 p.m. stated she was aware Resident #3 required a Hoyer lift, to transfer. Staff A stated the morning following the incident she was notified Resident #3 complained of a lot of pain and pointed to the left shoulder and stated that it was severe. Staff A stated she reported to the nurse Staff B, Licensed Practical Nurse (LPN) that Resident 3 complained of pain and requested medication. During an interview with Staff B, LPN on 1/22/15 at 12:00 p.m. stated Resident #3 at the time of the incident required a sit to stand lift transfer from the chair to the toilet. Resident #3 required a full body lift from the bed to a chair. Resident #3 then changed to a full body lift the Saturday following the incident. During an interview with Staff B, LPN on 1/23/15 at 10:30 a.m. stated the night nurse reported to her that an incident occurred with Resident # 3 but did not report that Resident # 3 complained of shoulder pain until Sunday afternoon of 1/4/15. During an interview with Staff C, Certified Medication Assistant (CMA) on 1/22/15 at 1:50 p.m. stated she thought Resident #3 was a sit to stand at the time of the incident on 1/3/15 and changed to a full lift pad Hoyer after the accident. During an interview with Staff D, CNA on 1/22/15 at 2:40 p.m. stated Resident #3 required a full body lift to get up and could use a sit stand lift after up in the chair. During an interview with the Director of Nursing on 1/22/15 at 4:30 p.m. stated she noticed a lack of follow up completed regarding Resident #3 ' s bruising. According to the DON she expected the staff nurse to trigger follow up for the bruising on the MAR/TAR (Medication Administration Record /Treatment Administration Record) however this failed to be completed. During an interview with Staff E, RN (Registered Nurse) on 1/22/15 at 10:00 p.m. stated Resident #3 was sitting on the edge of the bed and sliding off. Staff E went to get the sit stand lift and put the sling around Resident #3 ' s back and connected it to the lift. Resident #3 tried to put his/her feet on the platform and slid more. Staff E tried to take the platform off but failed to succeed. Staff E requested Resident #3 to get up higher and Resident #3 bumped his/her leg. Staff E stated then other staff came in to assist. The strap came up on Resident #3 pretty fast and Resident #3 let go of the handles of the lift that caused Resident #3's arms to rise overhead quickly. Staff placed Resident #3 into the wheel chair. Staff E stated Resident #3 complained his/her shoulder hurt. Staff E did not see a bruise or redness and that range of motion had not changed. Staff E acknowledged she failed to document the incident. Staff E stated the sit stand lift should not have been used and the staff members should have lowered Resident #3 to the ground when the incident first occurred. During an interview with the Physician on 2/4/15 at 10:20 a.m. stated he believed the fractured clavicle occurred from slipping in the lift. Resident #3 ' s arms moved very fast upward. It was a significant fracture. Resident #3 ' s weight caused the arms to move quickly. The Physician was not aware of any other fall or anything to occur for that to have happened. Observation and interview of Resident #3 on 1/21/15 at 3:50 p.m. revealed Resident #3 in bed and stated he/she remembered the lift hit him/her and Resident #3 failed to be able to hold onto the handles. Observation of Resident #3 on 1/22/15 at 2:00 p.m. revealed him/her up in a wheelchair and staff prepared to use a four point full body lift for transfer back into bed.

Based on observation, record review, staff interviews, and facility policy reviews, the facility failed to assess and implement interventions to aid in the prevention of skin breakdown and promote healing for two (2) of five (5) residents (Resident#1 and Resident#4).The facility reported a census of 67 residents. Findings include: Resident #1's Minimum Data Set (MDS) with the assessment reference date of 5/10/12 identified he/she had [DIAGNOSES REDACTED]. The MDS identified the resident's cognitive skills as moderately impaired for daily decision making skills according to the Brief Interview for Mental Status (BIMS) test with a score of 8. The assessment identified Resident #1 required two person physical assistance for bed mobility (how the resident moves to and from lying position, turns side to side, and position body while in bed/or alternate furniture). A previous MDS with the assessment reference date of 2/23/12 documented Resident #1 had a pressure ulcer (unstageable) measuring 2.2 cm by 2.5 cm. The assessment identified Resident #1 required two person physical assistance for bed mobility (how the resident moves to and from lying position, turns side to side, and position body while in bed/or alternate furniture). Review of the Comprehensive Care Plan dated 3/1/12, indicated Resident #1's skin integrity had a potential for alteration associated with his/her [DIAGNOSES REDACTED]. The care plan directed staff to complete the following : a. Initiate a Braden Scale quarterly and for significant changes. b. Monitor (skin) for red or open areas. c. Report red or open areas to doctor. d. Remind the resident to reposition every 2-3 hours and as needed. e. Provide treatments as ordered. f. Provide a pressure reduction cushion in the wheelchair. Review of the Braden Scale for Predicting Pressure Sore Risk revealed on 5/15/12 a score of 15 (scores of 15-18 indicate a (low) risk). Review of the Wound Flow Sheet, dated 5/14/12 revealed the resident had an open area to the left hip/ buttocks and area intact. Review of the Treatment Record dated 5/1/12 revealed an order for [REDACTED]. Observations revealed: a. On 5/15/12 at 7:55 AM revealed the resident lying in bed. Staff G Certified Nursing Assistant (CNA) and Staff E CNA removed the resident's snapped brief and removed an incontinent pad. The staff turned the resident to his/her left side. Staff E did not provide perineal care prior to applying protective barrier to the buttocks. The left buttock did not have a [MEDICATION NAME] on the left hip/buttock area. There were 3 areas observed as follows: one on the left upper hip (dark purple and measured 1-2 centimeters); a second area on the lower left buttock (stage 2 measuring approximately 1-2 cm x 1 cm); and a third area on the right buttock measuring 1 cm x 2 cm. The third area observed only red in color and not opened. The staff placed the resident in the wheelchair after cares. At 8:30 AM the resident sat in a wheelchair in the dining room. The wheelchair had a cushion in the seat of the chair. At 9:00 AM the resident remained in the wheelchair with the cushion in place. At 9:30 AM the resident continued to sit in the wheelchair attending activities. At 10:00 AM the resident remained in the wheelchair. The resident leaned to the left side with added pressure to the left side and buttocks. At 10:30 AM the resident continued to sit in the wheelchair and leaning on the left side. At 11:10 AM the resident continued to sit in the wheelchair, in the dining room. The resident leaned to the left side, with the elbow on the arm of the wheelchair. The resident appeared in pain and uncomfortable. At 12:10 PM the resident continued to sit in the wheelchair and leaning on the left side. At 12:30 PM the resident continued to sit in the wheelchair by the dining room. At 12:50 PM the resident sat in the wheelchair in the room. Staff E and Staff G entered the room and transferred the resident from the wheelchair to the bed. Staff B Licensed Practical Nurse entered the room. The staff turned the resident to his/her left side and removed the resident's brief. The resident incontinent of bowel movement. Staff G cleansed the resident's rectal area and buttocks front to back, wiping over the opened areas. The left hip still did not have a [MEDICATION NAME] in place. Staff B cleansed the left hip with wound cleanse, and then placed a [MEDICATION NAME] to the hip. Staff B measured the area as 1 cm x 2 cm. Staff B did not implement a dressing or treatment to the left and right buttock area. The third area had opened up. The staff turned the resident to the left side and Staff E cleansed the buttocks, several times front to back with the soiled cloth. b. On 5/16/12 at 9:05 AM the resident laid in bed. Staff J CNA and Staff D CNA turned the resident to the left side and revealed the resident incontinent of bowel movement. Staff J cleansed the resident's buttocks front to back, up and directly over the opened wounds. Staff J verified the open area on Resident #1 buttocks and soothing cream applied to buttocks, with a clean pad and snap underwear put on. Interview with Staff B on 5/16/12 at 9:30 AM revealed she implanted the resident's heel dressing and would not change the [MEDICATION NAME] dressing. She would not do any additional treatments to the buttocks. Interview with Staff G on 5/16/12 at 2:15 PM revealed the care plan of the residents were on the palm pilots. The palm pilots did not direct the staff to reposition the residents. Communication among staff directed the staff the names of the residents needing repositioning. Staff G stated Resident #1 always complains of buttocks hurting. Staff G stated the resident needs to lay down between meals due to open areas. Interview with Staff B on 5/17/12 at 7:45 AM revealed she measured the left hip but did not have measurements for the buttock areas. Staff B stated the resident did not have any open areas at this time. Interview on 5/16/12 at 2:00 PM with Staff E CNA revealed staff are to lie Resident #1down (in bed) between meals and turned and repositioned every 2 hours because the resident had a history of [REDACTED].#1 up in the morning and lay the resident down after lunch. The review of the facility's Procedure of Pressure Ulcers: Skin Assessment and Prevention dated 1/12 revealed in section 7, that if a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The registered nurse should record the type of wound and the degree of the wound damage. The licensed practical nurse records the location of the area, the measurements and the ulcer/wound characteristics. Document the information on the Wound Flow Sheet (GSS#487). Skin tears and bruises should not be recorded on that form. 2. Resident #4's MDS dated [DATE] revealed the resident required extensive assistance of 2 person's physical assistance for bed mobility and depended on 2 person's physical assistance for transfers.The MDS assessment indicated Resident #4 was at risk for developing pressure ulcers but did not have any unhealed pressure ulcers. The review of the wound sheet (GSS #487) revealed the resident had intact skin on the rectal fold from 4/12/12 through 5/14/12. The review of the wound sheet revealed the resident had an open area on the coccyx on 5/15/12 that measured .2 centimeter (cm) by .2 cm and the staff could not measure the depth. The resident remained with an open area on the coccyx on 5/16/12 that measured. 2 cm by .2 cm superficial in depth and the granulation appeared pink in color. According to the care plan dated 3/15/12 Resident #4 had [DIAGNOSES REDACTED]. The resident's care plan also identified a concern with alteration of skin integrity due to resident's Peripheral [MEDICAL CONDITIONS]([MEDICAL CONDITION]) and decreased mobility evidence by stage II pressure area. The care plan directed staff to assist in reposition every 2-3 hours and when needed (prn). The observation of Resident #4 on 5/15/12 at 9:56 a.m. revealed the resident in the chapel area sitting in his/her wheelchair. On the same date at 10:35 a.m., Resident #4 continued sitting in the wheelchair which had been located in front of the nursing's station. The surveyor continued to observe the resident at 10:50 a.m. as the resident remained in the wheelchair in his/her room and received a breathing treatment. At 11:15 a.m. the resident had been sitting in wheelchair in the dining room drinking tea. At 11:20 a.m. staff provided assistance to the resident during lunch with his/her puree diet (resident continued to sit in wheelchair). At 12:15 p.m. revealed the resident now in his/her bed on his/her back. Staff B, licensed practical nurse, stated on 5/15/12 at 1:25 p.m. that the staff reported to her in the last several days the resident had opened up again. Staff B stated the resident's open area had been chronic, the resident's area would close and then open. The observation of the resident on 5/15/12 at 1:25 p.m. revealed the resident in bed with a 2 cm. by 2 cm. open area on the coccyx. The review of the facility's policy on Pressure Sores dated March 2007 revealed that a resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection, and prevent new pressure sores from developing.

Based on clinical record reviews and interviews, the facility failed to provide nursing provisions with timely assessment and interventions for 1 of 2 discharged residents reviewed (Resident #3). The facility failed to assess Resident #3's risk factors and intervene in response to the resident's symptoms and condition changes which resulted in hospitalization for dehydration. The facility identified a census of 61 current residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented [DIAGNOSES REDACTED]. The assessment documented a Brief Interview of Mental Status score of 14 (out of 15) which indicated Resident #3 ' s cognitive skills were intact; and he/she had clear speech, the ability to express ideas, wants and had clear comprehension of verbal communication. The assessment determined Resident #3 required extensive assistance for completion of transfer, bed mobility, toileting, hygiene and dressing. The assessment identified Resident #3 occasionally incontinent of bladder and continent of bowel, and no problems were documented related to vomiting, dehydration or any internal bleeding. Resident #3 used a wheelchair for mobility. The Comprehensive Care Plan problem dated 10/6/11, and reviewed 12/29/11, identified the resident with a potential for alteration in bowel elimination and directed staff assess all complaints of constipation and/or loose stools, encourage fluids and activity, and monitor and document bowel movements (BM) every shift. The Care Plan identified the resident with a self-care deficit and directed staff to assist the resident with transfers, toileting, hygiene and bathing. A Nutrition assessment dated [DATE] identified the resident's daily fluid needs at 1860 cc (cubic centimeters) calculated by the facility's consulting dietician and indicated the resident received 10 medications on a daily basis that could have a negative nutrition impact. A Dining Report for Resident #3 documented the following fluid intakes which were below what the resident required to maintain adequate hydration: On 1/1/12, 180 cc's (equivalent to 6.08 fluid ounces (fl oz)). On 1/2/12, 600 cc's (equivalent to 20 fl oz). On 1/3/12, 340 cc's (equivalent to 11.49 fl oz). On 1/4/12, 180 cc's (equivalent to 6.08 fl oz). On 1/5/12, 0 (zero) cc's. The Dining Report documented the resident's daily food intakes averaged only 12.5% for the period of 1/1/12 to 1/5/12. The Dining Report also documented no supplements or nourishments given between 1/1/12 to 1/5/12. The BM (bowel movement) Report for Resident #3 documented the following: On 12/30/11, 3 large/loose/liquid stools and 1 medium loose/liquid stool On 12/31/11, 1 large loose/liquid stool and 1 medium loose/liquid stool On 1/1/12, 1 medium soft On 1/2/12, nothing documented On 1/3/12, 2 large/loose/ liquid stool and 1 small hard On 1/4/12, 1 large/loose/ liquid stool On 1/5/12, nothing documented. On 12/23/11 at 11:50 the facility received a FAX back from the physician as they reported the resident ' s average intake at 50% and suggested a supplement (2 Cal three times a day). The physician indicated " no " on the supplement as the resident ' s weight had not changed and there was no reason for the supplement. The Interdisciplinary Progress Notes contained in the clinical record for Resident #3 documented the following: On 12/28/11 at 11 p.m., the nurse documented Resident #3 was not feeling well and had loose stools with bright red blood in it. On 12/29/11 at 2:15 p.m., the resident returned per facility van with new orders noted. The nurse documented the resident would have an upper gastrointestinal (UGI) test in the morning. On 12/30/11 the nurse charted the resident was now NPO (nothing by mouth) and all glasses which contained liquid had been removed from his/her room. On 12/30/11 at 11:00 a.m., the resident returned from UGI appointment with lab test request (see lab test dated 12/30/11 at 11:56 a.m., below.) On 12/30/11 3:15 p.m., the resident complained of mouth pain and stated the physician told him/her it is an infection. The note documented the resident had oral thrush and was started on [MEDICATION NAME] (an anti-fungal medication). On 12/30/11 7:00 p.m., the resident with a poor appetite and the resident expressed s/he just does not feel well. The note contained no physical assessment of the resident. On 12/31/11 at 2:00 p.m., documented the resident not feeling well and s/he complained of mouth pain and stated it hurt to swallow and it appeared the resident talked as if their tongue was swollen. The nurse assessed the resident's mouth which revealed a white round areas to the left and right side of the tongue. The note documented the resident with a poor intake at meals but drank liquids and did eat Jell-O and ice cream. On 12/31/11 5:00 p.m., the resident's family and physician contacted regarding condition of the resident. The note at 5:20 P.M., documented the physician ordered the facility try rinsing the resident's mouth with [MEDICATION NAME] mouthwash 3-4 times a day to see if it would help. On 1/1/12 at 1:00 a.m., documented the resident continued to complain of mouth being sore and had difficulty swallowing food and only drank sips of water. The note documented the mouthwash ([MEDICATION NAME]) was on back order from the pharmacy and not available. On 1/2/12 at 12:00 a.m., the resident remained in his/her room for lunch and consumed only pudding and documented the areas to the tongue less whitish and the top of the tongue not as deep red. On 1/2/12 at 7:00 a.m., the resident had supper in his/her room and took in a few sips of soup and ate strawberry ice cream. On 1/3/12 at 1200 p.m., documented the resident very weak and needing assistance for transfers on and off the toilet and refused to eat or drink anything because of the mouth sores. The nurse documented Resident #3 consumed 6 ounces of milkshake earlier in the morning and 4 ounces at the time. The noted also documented the resident incontinent of loose BM and with open areas of skin on the coccyx which looked extremely excoriated. Staff applied barrier cream, to the area. The nurse documented at 2 p.m., she FAXED a note to the physician requesting barrier cream orders and milkshake orders. On 1/4/12 at 6 a.m., the notes documented the facility received the approved orders. On 1/4/12 at 11:40 a.m., documented an entry by the facility's consulting dietician which recorded the resident had a severe weight loss of 8 % in 30 days with the resident's intake decreased to an average of 16% at meals. The note documented the physician declined to order Med Pass(a nutritional supplement) as requested on 12/23(11). Review of the clinical record failed to contain documentation of the significant weight loss determined on 1/4/12. Review of the Interdisciplinary Progress Notes continued to document the following: On 1/4/12 at 12:00 a.m., the nurse reported the resident continues to not feel well and the mouth sores still present. The resident stayed in his/her room and consumed some pancake and drank a milkshake. The note contained no physical assessment information. On 1/4/12 at 6:00 p.m., the resident not doing well and his/her family present and wanted a physician ' s appointment or have him/her sent to the emergency room tomorrow. The note documented the nurse left a note for the morning nurse tomorrow. The note contained no physical assessment information. On 1/4/12 at 7:00 p.m., the resident had an emesis after eating only a few bites of supper and the resident's skin appeared pale, the resident weak and some confusion noted. The note contained no further assessment. On 1/5/12 at 4:00 a.m., the resident weak and confused. The staff used a mechanical lift to get the resident to the bathroom and the resident had not voided that shift. The note contained no assessment of the resident. On 1/5/12 at 9:00 a.m., the resident's temperature at 97.9 degrees, a pulse of 96 and respiration of 20 and blood pressure of 124/70. The nurse reported the resident felt very weak and required the assistance of 2 staff for completion of activities of daily living. The note documented staff called the physician and received an order for [REDACTED]. The entry on 1/5/12 at 3:10 p.m., documented the resident ' s family called the facility and stated the resident had been admitted to the hospital. On 1/11/12 at 8:30 p.m., the notes documented the hospital notified the nursing home the resident had passed away. The hospital History dated 1/5/12 documented Resident #3 had been seen on the office on 12/29/11 for rectal bleeding and a sore mouth. The physician documented a vaginal and rectal exams at that time revealed no blood. The resident had oral thrush (a fungal infection of the mouth). The physician documented the facility called him today and related the resident "doing worse" and had some bleeding in the underwear and had tremendous soreness on the buttocks and diarrhea. The physician documented this is the first time diarrhea had been discussed. The resident was seen in the (physician ' s) office today and s/he had an elevated white count of 20,000 (high) and blood urea nitrogen (BUN) of 91 (high). The resident was then sent to the hospital for severe dehydration and acute confusional (confusion) state. The hospital assessment dated [DATE] documented at 3:05 p.m., Resident #3 admitted to the hospital and started on IV (intravenous) fluids at 4 p.m. The physical examination documented the resident's oral cavity was dry. The lab report dated 1/5/12 documented the resident's white blood cell count as 22.4 (normal 4.8-10.8), hemoglobin as 10.5 (normal 12.0-16.0), hematocrit as 33.0 (normal 37.0-47.0), BUN of 91 (normal 6-20) (blood urea nitrogen), creatinine 7.2 (normal 0.5-1.5), potassium at 5.5 (normal 3.5-5.0), sodium as 124 (normal 136-146). The lab report from 12/30/11 at 11:56 a.m. identified the following: the resident's BUN at 32 (normal 9-23), ceatinine 2.9 (normal 0.6-1.0), potassium at 3.9 (normal 3.5-5.1), sodium at 136 (normal 137-145). The Discharge Summary dated 1/112 documented the final [DIAGNOSES REDACTED]. During interview on 1/31/12 at 11:30 a.m., the resident's family member stated s/he had not been notified of his/her parent's significant weight loss. S/he stated his/her parent ' s roommate had told him/her about the nausea, vomiting and diarrhea, not the facility. During interview on 1/31/12 at 9:30 a.m., the nurse at Resident #3's physician office stated the physician would expect the nursing home to notify the physician of loose stools, significant weight loss, and of the resident's decreased appetite, nausea and vomiting great than 24 hours in duration. She further stated the physician would expect the facility to assess the resident's vital signs, bowel sounds, and to be notified of diarrhea and sudden decrease in the resident's food and fluid intake. During interview on 1/31/12 at 2:10 p.m., Staff B, registered nurse, stated she is in charge of physician notification of the registered dietician's recommendations; however, she is not provided with the information on significant weight losses or gains that are identified by the dietitian so physician and family notifications of those are not done by the facility. The facility's Intake and Output procedure revised 11/09 directed to measure fluid intake and/or output (I&0) on residents at risk for imbalances such as potential dehydration, [MEDICAL CONDITION], diuretic use, [MEDICAL CONDITION], nausea, vomiting, diarrhea, or blood loss in which the nurse may initiate on a case-by -case basis for a specific period of time. It also directed that I&O should be used during acute illness (fever, nausea/vomiting) that last > (greater than) 24 hours. The facility's Notification of Condition Change and Observation procedure dated 2/2005 documented the purpose as to assist in collection of pertinent data prior to providing physician notification of a change in resident status to the physician. The procedure directed: 1. staff implement The Condition Change and Observation Form (GSS #241) to collect pertinent data on the resident and his/her current condition 2. Notify the physician of the change in the resident condition 3. Notify the director of nursing, charge nurse or nurse on-call of the change in the resident's condition 4. Notify the resident's responsible party. The facility's Weight Monitoring Policy dated 2/2005 directed the following: The center will immediately inform the resident, consult with the resident's physician and, if known, the resident's legal representative when there is a significant change in the resident's weight. During interview on 1/31/12 at 2:00 p.m., the facility's Director of Nursing state the GSS#241 form suggested, but not required, for use. She would expect nurses to assess residents and notify physicians of condition changes including loose stools, diarrhea, vomiting and decreased food and fluid intake. She further stated the facility does not utilize the I &O policy but it is something she now plans to implement.