Every finding on record at Good Samaritan Society - Inver Grove Heights

Based on observation, interview, and document review, the facility failed to ensure a resident's advance directives were accurately and consistently documented in the resident's electronic health record (EHR) banner, Provider Order for Life-Sustaining Treatment (POLST), and physician orders to ensure the resident's wishes would be followed in the event of a cardiac arrest for 3 of 35 residents (R8, R36, R40) reviewed for code status.Findings include:R8R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 had severely impaired cognition and was receiving hospice care. The MDS indicated R8 was admitted to the facility on [DATE] and was diagnosed with a stroke, a seizure disorder, and respiratory failure. R8's POLST dated [DATE], indicated attempt resuscitation/full treatment and was signed by family member (FM)-B, prepared on [DATE], and signed by the provider on [DATE]. This POLST was found in the orange Resident Advance Directives binder at the nursing station on [DATE] at 11:14 a.m. along with an additional undated POLST for R8. This additional POLST indicated to attempt resuscitation/full treatment, was signed by a provider, and indicated a verbal discussion was had with the FM-B. R8's progress note dated:-[DATE] at 2:54 p.m., indicated R8 had signed onto hospice with the assistance of FM-B as of this date. -[DATE] at 3:43 p.m., indicated R8's Advance Directive was resuscitation (CPR) and had been admitted to hospice care due to a persistent decline in health status.R8's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated [DATE], indicated R8's code status was a full code and could be found on the POLST.R8's order summary dated [DATE], included an advanced directive do not resuscitate (DNR) order that was dated [DATE].R8's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated [DATE], indicated R8's code status was a full code and could be found on the POLST.R8's POLST signed by a provider on [DATE], and prepared [DATE], indicated DNR/allow natural death with comfort-focused treatment and was signed by FM-B.R8's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated [DATE] and [DATE], indicated R8's code status was DNR with comfort measures only and could be found on the POLST.R8's progress note dated [DATE] at 12:05 p.m., indicated R8's DNR code status remained accurate.R8's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated [DATE], indicated R8's code status was DNR with comfort measures only and could be found on the POLST.R8's progress note dated [DATE] at 11:47 a.m., indicated FM-B had attended the care conference. The note indicated a POLST as not on file, so the social work department would follow up with the hospice team regarding the POLST. The note did not include a preferred code status. R8's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated [DATE], [DATE], [DATE], and [DATE], indicated R8's code status was DNR with comfort measures only and could be found on the POLST.R8's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated [DATE], indicated the hospice start of care date was [DATE]. The plan of care indicated R8's code status was DNR with comfort measures only and could be found on the POLST. The note indicated R8 had terminal decline at the facility due to a stroke. The report indicated R8 was dependent for all needs and decisions and had a prognosis of six months or less to live. -R8's progress notes dated [DATE] to [DATE] were reviewed with no further code status wishes noted.R8's EHR banner, printed on [DATE], indicated R8's code status was DNR. R8's care plan dated [DATE], indicated code status as ordered. The care plan indicated R8 was receiving hospice services for a terminal prognosis related to a stroke. R36R36's quarterly MDS assessments dated [DATE] and [DATE], indicated R36 had intact cognition and was admitted to the facility on [DATE].R36's POLST dated [DATE], indicated DNR/allow natural death with selective treatment with a verbal consent from FM-C, prepared on [DATE], and signed by a provider on [DATE]. This POLST was found during a surveyor audit of the orange Resident Advance Directives binder from the nursing station on [DATE] at 2:46 p.m.R36's care plan dated [DATE], indicated R36 was forgetful/confused at times and had a difficult time making decisions related to disease process. The care plan indicated R36 required assistance from his daughter with all decision-making. The care plan did not reference code status. R36's Medical Diagnosis report dated [DATE], indicated R36 had a history of a stroke, a heart attack, end-stage kidney disease dependent on dialysis (a machine filters wastes, salts, and fluid from the blood when the kidneys are no longer healthy enough to do so), diabetes, and heart disease.R36's progress note dated:-[DATE] at 3:36 p.m., indicated facility staff received a call from the R36's daughter, indicating she and R36 wanted R36's code status to be full code. -[DATE] at 4:12 p.m., indicated facility staff discussed code status with R36 and R36 affirmed that what his daughter said was correct and R36 wished to be full code. The note indicated a message was sent to the provider to obtain an order to change the code status. R36's POLST dated [DATE], indicated attempt resuscitation/CPR with full treatment such as intubation and signed by R36 and indicated patient has capacity. This POLST was signed by a provider on [DATE], and the section indicating who prepared the document and when was left blank. -[DATE] at 9:32 a.m., indicated code status had been discussed with R36, and code status remained accurate as CPR. -[DATE] at 12:33 p.m., indicated a care conference was held, but did not indicate if the resident had attended the care conference or if code status was discussed.-R36's progress notes dated [DATE] to [DATE] were reviewed with no further code status wishes noted.R36's Order Summary Report dated [DATE], included an order for MN POLST (A): an advance directive order to attempt resuscitation/CPR dated [DATE]. An additional order dated [DATE], MN POLST (B) dated [DATE], indicated R36 wanted selective treatment that included no intubation, advanced airway interventions, or mechanical ventilation. R36's EHR banner, printed on [DATE], indicated R36's code status was to attempt resuscitation/CPR and, if not in cardiopulmonary arrest, to follow orders in POLST part B.R40R40's comprehensive MDS dated [DATE], indicated R40 was admitted to the facility on [DATE] and had moderate cognitive impairment. The MDS indicated R40 was receiving hospice services. The MDS indicated R40 was diagnosed with heart failure, kidney disease, and respiratory failure.R40's POLST dated [DATE], indicated attempt resuscitation/full treatment and was signed by R40, prepared on [DATE], and signed by the provider on [DATE]. This POLST was found during a surveyor audit of the orange Resident Advance Directives binder from the nursing station on [DATE] at 2:46 p.m.R40's POLST dated [DATE], indicated attempt resuscitation and was signed by R40, and signed by the provider on [DATE]. The POLST did not indicate who prepared the POLST or when it was completed. R40's Order Summary Report dated [DATE], included an advanced directive do not resuscitate (DNR) order that was dated [DATE].R40's progress note dated: -[DATE] at 1:32 p.m., indicated R40 had returned from the hospital and wanted to elect hospice services and not pursue therapy. The note indicated R40 wanted DNR status with comfort-focused care. -[DATE] at 8:59 p.m., indicated a care conference was held for R40, and her DNR status was confirmed. The note indicated the facility needed an updated POLST, so social work would complete this with the resident. This POLST was requested and not received. --R40's progress notes dated [DATE] to [DATE] were reviewed with no further code status wishes noted.R40's care plan dated [DATE], indicated R40 had impaired cognitive function or impaired thought processes related to a terminal illness. The care plan dated [DATE] indicated code status as ordered.R40's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated-[DATE], indicated R40 was eligible for hospice admission related to respiratory failure with comorbidities such as heart failure, obstructive sleep apnea, and insomnia contributing to terminal decline. The plan of care indicated R40's code status was DNR with comfort measures only and could be found on the POLST. -[DATE], indicated the hospice start of care date was [DATE]. The plan of care indicated R40's code status was DNR with comfort measures only and could be found on the POLST. During an interview and observation on [DATE] at 11:17 a.m., registered nurse (RN)-A confirmed that he was the only RN working during this shift and was the nurse assigned to R8. RN-A stated that to determine if he needed to start CPR on a resident found not breathing and without a pulse, he would look at the POLST. RN-A stated his process was to look in the advanced directive binder at the nursing station at the POLST to determine if the resident was to be resuscitated. RN-A was observed to grab an orange binder titled Resident Advanced Directives POLST that was observed with other various binders on the nursing station counter. The orange binder was reviewed with approximately 100 POLSTs dated [DATE] to [DATE]. A report of all residents' advance directives was not found in the binder. RN-A was observed to find R8's POLST, indicating attempt resuscitation/full treatment, and stated that he would perform CPR on R8 as this was what the POLST indicated. When asked if this was the code status source he would review if R8 or any resident was found with no pulse and not breathing, RN-A confirmed that it was and then stated that although he knew R8 was on hospice, the family must still want him resuscitated, so after looking at the POLST in the binder, he would start CPR. RN-A confirmed that R8 was unable to make his own decisions due to his cognition, so the family assisted with this. During a follow-up interview on [DATE] at 11:35 a.m., RN-A confirmed he worked at the facility full-time. During an interview on [DATE] at 11:22 a.m., licensed practical nurse (LPN)-A stated she was pool staff and did not work at the facility full-time. LPN-A stated that if a resident was found not breathing and with no pulse, she would reference the EHR banner because this was the easiest place to find the code status in an emergency. During an interview on [DATE] at 11:36 a.m., the director of nursing (DON) stated that if a resident were to be found not breathing and without a pulse, she would expect staff to look at the resident's banner in the EHR, as this was the fastest way to find the resident's most up-to-date code status. The DON stated that the banner pulled the code status from the order summary, so these two sources always matched. When the DON was asked about the orange advanced directive binder at the nurse's station, she stated she did not realize the binder was at the nurse's station and was unable to provide a date for when it was last updated. The DON stated she thought the health information manager (HIM) may have accidentally placed the binder at the nurse's station. The DON stated she would have expected staff to look at R8's order to not be resuscitated on the banner in the EHR and not perform CPR for R8.During an interview on [DATE] at 11:37 a.m., FM-B confirmed he was the primary decision maker for R8. FM-B stated that at a care conference a couple of months ago, he had a discussion with facility staff about code status, and he had decided to switch R8's code status from a full code to DNR at that time. FM-B stated this DNR code status remained accurate for his wishes for R8. During an interview on [DATE] at 12:24 p.m., the HIM stated that on resident admission, she assisted with putting code status orders in the EHR, but she did not assist past that with entering or updating the resident's code status. The HIM stated she was unaware there was a POLST binder at the nurse's station and was unsure how it got there or who updated it. During an interview on [DATE] at 12:30 p.m., the social services director (SSD) stated that she assisted with resident care conferences. The SSD stated code statuses were reviewed at care conferences, and this should be documented in a progress note. The SSD stated that after reviewing the medical record, it appeared she needed to reach back out to hospice to get R8's most up-to-date POLST. The SSD stated she had reached out to the hospice company in January, but it did not appear they had received the updated POLST yet. The SSD confirmed she was unable to find the code status that FM-B preferred in the care conference notes, although the latest note mentioned the POLST. The SSD stated she was unsure when R8's code status changed from full code to DNR.During an interview on [DATE] at 2:17 p.m. with the DON and administrator, the DON stated code status was reviewed on admission, at care conferences, and with any resident or family requests. The DON stated she would expect this to be documented in the progress notes. The DON stated it was not always their process to use a POLST, so if a resident wanted a code status change, the nurse or social worker would call the provider, get a verbal order to change the code status, and update the order in the order summary. The DON stated this was why it was important that facility staff referenced the EHR order summary and not the POLST to determine the most up-to-date code status for the residents, as a new POLST was not always completed. The DON stated she believed hospice had the conversation with R8 regarding code status and was waiting for an updated POLST from them regarding his DNR code status.During an interview on [DATE] at 3:34 p.m., family member (FM)-A stated R40 was started on hospice at the end of [DATE] due to heart failure. FM-A stated R40 has continued to decline and has not gotten out of bed since she came back from the hospital in December of 2025. FM-A stated that R40 does not wish to have CPR performed if she stops breathing or her heart stops beating, as they have been told by doctors that the trauma from CPR would be damaging to her heart. FM-A stated that resuscitation would be detrimental for R40 and would not follow her wishes.During an interview on [DATE] at 3:44 p.m., when asked about his wishes if his heart stopped beating and he stopped breathing, R36 stated he wanted staff to perform full resuscitate measures.During an interview on [DATE] at 4:35 p.m., RN-C, R8's hospice nurse, stated hospice would review the resident's code status with the resident and family at the start of care and as needed. RN-C stated she expected the facility to review the code status with the resident and family at care conferences, and, if any changes were requested. RN-C stated a different nurse had previously been assigned to work with R8, so would have to review R8's hospice notes and plan of care to determine when his code status changed from a full code TO DNR. RN-C stated that if R8 was resuscitated, this would lead to a sad outcome for him and sounded like the facility should be completing audits to ensure code statuses matched across sources. During an interview on [DATE] at 8:47 a.m., the administrator stated staff were supposed to be running a daily advanced directive report per their policy and then using that to audit the POLSTs in the advanced directive binder. The administrator stated this was not occurring before the state agency issued an immediate jeopardy on [DATE]. During an interview on [DATE] at 10:48 a.m., the medical director (MD) stated that he felt that a mismatch between code status sources that facility staff could reference during an emergency was concerning and he expected facility staff to follow their policy to ensure these sources were updated as changes occur. The MD stated it was important that these sources matched to ensure the resident's code status wishes were honored.The facility's Advanced Directive, including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) policy dated [DATE], indicated the purpose of the policy was to provide the resident with the opportunity to make decisions about their medical care and define a process to make the resident's decisions known. The policy indicated that if a resident's wishes differed from the resident's orders, the staff member was to immediately document the resident's wishes in the medical record and contact the provider to obtain an order via a fax communication form. The policy indicated CPR should be initiated unless the resident had a valid DNR order on file or a valid advanced directive on file. The policy indicated that social services (or a designated staff member) would meet with the resident/decision maker on admission and readmission to determine if the resident had an advanced directive and/or if this was something they wished to develop or amend. The policy indicated that each day, nursing staff would print a report of all advanced directive orders and keep them in a three-ring binder easily accessible to nursing staff, along with advanced directive forms. The policy indicated this was important to complete to ensure important information was available if there was a power outage or other disruption in access to the EHR. The policy indicated that at care conferences, advance directive orders were to be reviewed with the resident/decision maker to ensure no changes are needed, and this discussion is to be documented in the progress note.

Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to 2 of 3 residents (R14 and R38) reviewed whose Medicare Part A coverage ended and then remained in the facility. The facility further failed to ensure an appropriate 48-hour notice was given for 1 of 3 residents (R51) who discharged from the facility. Findings include:R14R14's admission Minimum Data Set (MDS), dated [DATE], indicated R14 was admitted to the care facility on 12/5/25.R14's Notice of Medicare Non-Coverage (NOMNC; CMS 10123), signed on 1/26/26, indicated R14's Medicare A coverage ended on 1/29/26 and they would assume cost for their care at the care facility.R14's electronic medical record (EMR) lacked evidence R14 and/or their representative had received a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) despite the fact he remained in the facility when his Medicare A coverage ended.R38R38's admission MDS, dated [DATE], indicated R38 was admitted to the care facility on 1/12/26.R38's EMR lacked evidence R38 and/or their representative had received a SNFABN; CMS-10055 despite Medicare A coverage ending on 2/11/26 and R38 remaining in the facility and assuming cost for their care at the care facility.R51R51's admission MDS, dated [DATE], indicated R51 was admitted to the care facility on 12/12/25.R51's NOMNC; CMS 10123, signed 1/22/26, indicated R51's Medicare A coverage ended 1/23/26, failing to provide R51 and/or their representative a 48-hour notice.During an interview on 2/18/26 at 11:40 a.m., director of social services (DSS) stated R38 transitioned to hospice on 2/11/26, within hours of their Medicare A coverage ending and did not have time to complete a SNFABN; CMS-10055. The DSS further stated R14 transitioned to hospice services within days of their Medicare A services ending and had Medicaid pending for his stay at the care facility. During a follow up interview on 2/19/26 at 10:15 a.m., the DSS confirmed R51 was not given an appropriate 48-hour notice for the NOMNC; CMS 10123 prior to his discharge from Medicare A and the care facility. The DSS also confirmed if a resident is remaining in the care facility, a SNFABN; CMS-10055 is always needed. The DSS stated the process is for her to stay in contact with the therapy department and issue the appropriate notices (i.e., a SNFABN; CMS-10055 and a NOMNC; CMS 10123) as soon as she is made aware Medicare A coverage is ending.A policy on beneficiary notices was requested and not received.

Based on observation, interview and document review the facility failed to monitor for resident specific target behaviors related to psychotropic medications use for 1 of 5 residents (R50) and failed to ensure appropriate medication side effect monitoring for potential daytime sleepiness/drowsiness was completed for 1 of 5 residents (R4) reviewed for unnecessary medication use. Findings include: R18's admission Minimum Data Set (MDS) assessment, dated 2/1/26, identified R18 had moderately impaired cognition with no hallucinations, delusions, behaviors or rejections of cares with an admission of 1/26/26. Diagnoses included: anxiety, depression, periprosthetic fracture around internal prosthetic right hip joint (a break in the thigh bone adjacent to the artificial hip stem), hypertension (high blood pressure) and diabetes (body can't manage blood sugars properly). R50's Order Summary Report, printed 2/19/26, included the following orders: -bupropion HCL ER (antidepressant medication) 150 milligram (mg) tablet: give 150 mg by mouth in the morning for DM2 starting 1/27/26 -escitalopram oxalate (antidepressant medication) 10 mg tablet: give 10 mg by mouth one time a day for major depressive disorder starting 1/27/26 The Physician Order Report lacked documentation of any direction to monitor target behaviors or identification of target behaviors. R50's care plan, printed 2/17/26, identified R50 was on medications with FDA Boxed warning related to major depressive disorder and included the following interventions: -WARNINGS #1 : Refer to boxed warnings in eMAR for use of escitalopram and LPN notify provider if side effects/adverse reactions are observed. - WARNINGS #2: Refer to boxed warnings in eMAR for use of bupropion and notify provider if side effects/adverse reactions are observed. - Monitor resident condition based on clinical practice guidelines or clinical standards RN of practice r/t use of escitalopram, bupropion, oxycodone. The care plan lacked documentation of any direction to monitor target behaviors or identification of target behaviors. R50's Medications Administration Record (MAR/TAR) for February was reviewed. The document indicated R50 received bupropion and escitalopram as ordered. The document lacked evidence of target behavior monitoring. During an interview on 2/19/26 at 12:15p.m., registered nurse (RN)-B stated any psychotropic medication has target behavior monitoring. RN-B stated when a resident admits to the facility, nursing put the orders in along with side effect monitoring. During an interview on 2/19/26 at 12:25 p.m., RN-A reports target behaviors are identified on the care plan and documented under treatments. RN-A verified R50 did not have any target behavior monitoring in place. During an interview on 2/19/26 at 1:35 p.m., director of nursing (DON) stated target behaviors are documented on the MAR. DON stated the expectation was all psychotropic medications have target behavior monitoring to help ensure the medication is appropriate for the residents. DON verified R50 did not have any target behavior monitoring in place. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had moderately impaired cognition and was dependent on staff for completing toileting hygiene, lower body dressing, and transferring. R4's Medical Diagnosis list dated 6/11/25, indicated R4 had a diagnosis of dementia, paranoid personality disorder, depression, and kidney failure. R4's care plan dated 11/18/25, indicated R4 was taking quetiapine and staff were to refer to the boxed warnings in the orders, eMAR, or medication reference of choice. The care plan indicated R4 was on hypnotic therapy related to sleepiness, an antipsychotic related to agitation and paranoia, and an antidepressant related to depression. The care plan indicated the resident's condition would be monitored based on clinical practice guidelines or standards. The care plan indicated R4 received hemodialysis (use of a machine that filters wastes, salts, and fluid from the blood when the kidneys are no longer healthy enough to do so) on Mondays and Fridays. R4's Order Summary dated 1/30/26, included an order:-dated 6/11/25, for six milligrams (mg) of melatonin (a supplement used for sleep with possible side effects of daytime drowsiness, headache, etc.) daily at bedtime. -dated 6/11/25, for 7.5 mg of Mirtazapine (an antidepressant with a possible side effect of drowsiness) daily at bedtime.-dated 11/13/25, for 25 milligrams of quetiapine (an antipsychotic with a common side effect of drowsiness) twice a day.-dated 1/30/26, for 25 milligrams of quetiapine once a day. R4's Medication Administration Record dated 2/1/26 to 2/17/26, included an order for:-antidepressant side effect monitoring, including sleep problems, -antipsychotic side effect monitoring, including sedation,-hypnotic side effect monitoring, including daytime drowsiness, -an order to document hours of sleep every shift. The orders had a space for check marks that were checked as completed, but did not include whether sleep problems, sedation, or daytime drowsiness were observed. The MAR also did not include documented hours that R4 slept every shift; instead, it included check marks. R4's quarterly review progress note dated 2/4/26 at 6:13 a.m., indicated R4 was often out of the facility at dialysis appointments and was often tired when he was at the facility. R4's progress notes dated 2/1/26 to 2/17/26 were reviewed with no further assessment of R4's drowsiness/fatigue found. R4's nutrition progress note dated 2/5/26 at 9:36 a.m., indicated R4 appears fatigued most often. During an observation on 2/17/26 at 9:06 a.m., R4 was observed lying in bed with the lights on. R4 was addressed and responded by saying hi, and then started snoring. During an observation on 2/18/26 at 12:16 p.m., R4 was observed lying in bed with the lights on, snoring. During an observation on 2/18/26 at 12:38 p.m., R4 was observed lying in bed with the lights on, snoring. During an observation and interview on 2/18/26 at 12:42 p.m., R4 was observed lying in bed with the lights on, snoring. Nursing assistant (NA)-B confirmed she was R4's aide today. NA-B stated she had worked with R4 in the past and thought he normally sleeps a lot. NA-B stated she had attempted to assist him with getting ready for the day and getting out of bed, but he was too drowsy, so she would attempt again later. During an interview on 2/18/26 (a Wednesday) at 12:43 p.m., NA-C stated she had worked with R4 often and noticed that R4 was often tired the day he got dialysis and would sleep longer. NA-C stated she had noticed that R4 had been really sleepy lately, but still sometimes got up to go to activities. During an interview on 2/19/26 at 11:25 a.m., registered nurse (RN)-A stated R4 had a history of intermittent sleepiness and thought it was possible he was awake more at nighttime. RN-A stated he thought facility staff were supposed to track hours that R4 slept to see if there were any changes in his status, but this was not something he was completing. RN-A stated that when R4 got back from dialysis, he was very tired, but his melatonin or antipsychotic could also be causing this drowsiness. During an interview on 2/19/26 at 11:30 a.m., the director of nursing (DON) stated R4 had a history of delusional behaviors and paranoia and thought the resident was awake at night but was not aware how often. The DON stated she would have to review R4's medical record to see if sleep monitoring was being tracked but would expect this to be completed if medications were used to assist with sleep. At 12:09 p.m., the DON confirmed she had reviewed R4's medical record and stated that the order for sleep monitoring had been entered incorrectly, so the hours R4 was sleeping were not being monitored. The DON stated she had updated the order and would complete an audit to ensure no other residents had this problem. A policy regarding medication side effect monitoring was requested but not received. A facility policy on psychotropic medication related to target behaviors was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure proper cleaning and maintenance of a non-invasive ventilation machine to reduce the risk of complications (i.e., respiratory infection) for 1 of 1 resident (R1) observed for a continuous positive airway pressure (CPAP) machine.Findings include:The [NAME] Dream Station 2 User Manual dated 2021, indicated cleaning the CPAP machine daily. The manual indicated to use a lint-free cloth dampened with a liquid soap solution to clean the exterior of the machine, heater plate and the air inlet/outlet seal. The manual indicated daily hand wash of the humidifier water tank with warm water and mild soap. Furthermore, the manual indicated the humidifier water tank should be disinfected once a week with 70% isopropyl alcohol, and the tube should be washed once a week with warm water and mild soap. The filter and tube should be replaced once a month. The American Thoracic Society information series dated 2020 indicated the CPAP mask should be cleaned every day with a damp cloth and mild detergent to remove any body oil, sweat, or debris that may have built up while wearing the mask. R1's quarterly Minimum Date Set dated 1/23/26, indicated R1 had severe cognitive impairment, needed maximal assistance with bathing, upper body dressing, and needed moderate assistance with personal hygiene. MDS indicated diagnoses of Parkinson's disease and depression.R1's medication administration record (MAR) dated 2/2026, indicated a diagnosis of obstructive sleep apnea. The MAR included an order dated 1/15/25, for CPAP EO6010 machine for home use at pressure 7-20. Use home settings at bedtime.R1's care plan did not include a respiratory care plan related to his CPAP machine. R1's electronic medical record (EMR) lacked documentation about cleaning and maintaining R1's CPAP machine. During observation on 2/17/26 at 12:05 p.m. a [NAME] Dream Station 2, CPAP machine was observed on R1's nightstand. The tube was connected to the CPAP, and the mask was attached to the tube. The mask was placed on top of the CPAP machine with the cushion down. During observation on 2/18/26 at 11:56 a.m., the CPAP's mask was on top of the machine, and the tube was attached to the mask and machine. During interview on 2/18/26 at 3:11 p.m., registered nurse (RN)-A stated this morning he removed R1's CPAP mask, checked oxygen level and R1's skin. RN-A stated he did not wash the mask, he placed the mask down on the CPAP Machine. RN-A was not sure when the mask was cleaned. RN-A stated the overnight nurse changed the CPAP's tube on Saturday or Sunday and washed the machine using vinegar. During interview on 2/18/26 at 3:37 p.m., family member (FM)-D stated R1's machine was about 2 years old. FM-D used to take care of the CPAP machine when R1 lived at home. FM-D stated the nursing staff never asked her about what kind of supplies were needed to maintain the CPAP machine. FM-D stated she had supplies at home including masks, mask straps, tubing and filters. FM-D stated she visited R1 three times a week. Every time she visited, she cleaned the mask and wiped the machine. Once a week she washed the tubing, and changed the mask as needed. Since R1's admission to the facility, FM-D had taken the CPAP to the sleep clinic once to have the machine checked.During interview on 2/19/26 at 1:09 p.m., director of nursing (DON) stated a resident admitted with a CPAP machine needed orders including the settings, which were preprogramed. The order also needed to indicate when to put it on and when to remove it. DON stated on Fridays the overnight nurse washed the machine water reservoir, changed the tubing, filter and mask. This nurse also ordered supplies as needed. DON stated the facility obtained orders about cleaning and maintenance of the CPAP machine. DON verified R1's orders, MAR and treatment administration record (TAR) did not include orders to clean the mask every morning, change the filter, wash the water reservoir, or wash and change the tubing. DON stated she expected the staff to clarify the orders and clarify on the care plan what FM-D role on the maintenance of the CPAP machine, supplies and mask was. DON stated the facility needed to make sure R1's CPAP machine was properly taken care of as there will be a risk of a less than desirable outcome. The facility's policy titled Non-Invasive Respiratory Support dated 10/31/25 indicated the policy provided guidance to location staff members when caring for residents using non-invasive respiratory support technology. The policy directed staff to follow the manufacturer's recommendations for cleaning and maintaining the equipment.

Based on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complications (i.e., missed orders, insufficient preparation for treatment) for 1 of 1 residents (R4) reviewed for dialysis care. Findings include: R4's quarterly Minimum Data Set (MDS), dated [DATE], identified that R4 had moderate cognitive impairment along with several medical conditions, including anemia, diabetes, and kidney failure. R4's order summary dated 10/31/25, included an order for staff to send a dialysis communication sheet with R4, and it was to be checked upon return for new orders.R4's care plan dated 11/18/25, indicated R4 received hemodialysis (use of a machine that filters wastes, salts, and fluid from the blood when the kidneys are no longer healthy enough to do so) on Mondays and Fridays. The care plan included information such as monitoring related to dialysis, contact information for the dialysis center and transportation, as well as instructions related to the dialysis access port. R4's progress notes dated 1/22/26 through 2/19/26 were reviewed and included:-dated 1/30/26 at 11:10 p.m., indicated R4 did not bring any paper from dialysis but did not indicate if the facility had followed up with the dialysis center when communication was not received on the resident's return. -dated 2/13/26 at 11:54 p.m., indicated R4 had returned from dialysis at 6:40 p.m., and R4 did not bring any paper from dialysis. The note did not indicate if the facility had followed up with the dialysis center when communication was not received on the resident's return. -No further progress notes were found regarding communication with the dialysis center during this time period. Dialysis communication forms from 1/22/26 through 2/19/26 were requested, with this period containing eight dialysis appointments.R4's Dialysis Communication/Referral dated 2/6/26, included information such as a resident assessment of vital signs, status, and dialysis access site completed by the facility. The form had a space at the bottom titled Dialysis to Complete the Following Section that was not completed. R4's Dialysis Communication/Referral dated 2/9/26, included information such as a resident assessment of vital signs, status, and dialysis access site completed by the facility. The form had a space at the bottom titled Dialysis to Complete the Following Section that was not completed. A Dialysis Communication/Referral dated 2/16/26 and included information such as a resident assessment of vital signs, status, and dialysis access site completed by the facility. A Hemodialysis Patient Communication Sheet dated 2/16/26 included information such as vital signs, resident weight before and after treatment, medications given, and a space for recommendations to the long-term care facility that stated no complications. No further dialysis communication forms were received. During an interview on 2/19/26 at 11:04 a.m., the health information manager (HIM) stated she had reviewed R4's medical record and could only find the above-mentioned dialysis communication forms. During an interview on 2/19/26 at 11:23 a.m., registered nurse (RN)-A stated he was not normally working when the resident returned from dialysis, so he was unsure if facility staff was having a problem receiving communication back from the dialysis center after R4's appointments. RN-A stated that he would expect staff to call dialysis to ask them to fax the dialysis form if R4 was not coming back from his appointment with the communication form filled out. RN-A stated he would then expect nursing staff to enter a progress note that this had been completed. RN-A stated it was important that this was completed to ensure that if R4 had any changes in dialysis or if there was anything they needed to follow up on, facility staff were aware of it. During an interview on 2/19/26 at 11:29 a.m., the director of nursing (DON) stated that if nursing staff were not receiving the dialysis forms back from dialysis, she would expect the facility to call dialysis and request an update and document that this was completed in the progress notes. During an interview on 2/19/26 at 12:05 p.m., registered nurse (RN)-E, the charge nurse from the dialysis center, stated their practice was to fill out their own post-dialysis form that included an assessment, medications given, any recommendations, etc., that they send with the resident after dialysis. RN-E stated that if the facility was not receiving them, the facility could request a copy, and they could fax it to them.A policy regarding dialysis was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) pain medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., constipation, sedation) for 1 of 5 residents (R50) reviewed for unnecessary medication use. Findings include:R18's admission Minimum Data Set (MDS) assessment, dated 2/1/26, identified R18 had moderately impaired cognition with no hallucinations, delusions, behaviors or rejections of cares with an admission of 1/26/26. Diagnoses included: periprosthetic fracture around internal prosthetic right hip joint (a break in the thigh bone adjacent to the artificial hip stem), hypertension (high blood pressure) and diabetes (body can't manage blood sugars properly). In addition, the MDS outlined R50 did not receive scheduled pain medication but did receive PRN pain medication during the review along with non-medication interventions for pain. R50 indicated she frequently experienced pain which frequently made it hard to sleep at night, limited participation in rehabilitation therapies and limited day to day activities. Further, R50 indicated they had occasional pain which they rated at six (6) out of 10 (10 being the worst possible). R18's care plan, printed 2/17/26, identified R50 had acute pain related to right hip fracture. The care plan listed interventions to help R50 meet this goal which included, Attempt non-pharmacological intervention (SPECIFY), and provide resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods i.e. position, relation therapy, progressive relaxation, bathing, heath and cold application, muscle stimulation, ultra-sound, etc.R50's February Medication Administration Record (MAR) included the following:-acetaminophen (pain medication) 325 milligrams (mg) tablet-give 650 mg by mouth every 6 hours as needed for pain, must chart effectiveness started 1/26/26 which had been administered five (5) times. Four of five (4 of 5) administration documented with an e indicating effective along with a pain scale prior to administration with one (1) administration being documented with a u indicating unknown. There was no documentation on the MAR of nonpharmacological interventions offered, administered or declined prior to administration. -oxycodone (narcotic pain medication) 5 mg tablet- give 1 tablet by mouth every four hours as needed for pain 3-7, must chart effectiveness started 1/26/26 which had been administered ten (10) times. Eight of ten (8 of 10) administration documented with an e along with a pain scale prior to administration with two (2) documented with an u. There was no documentation on the MAR of nonpharmacological interventions offered, administered or declined prior to administration.-oxycodone 5 mg tablet-give two (2) tablet by mouth every four (4) hours as needed for4 pain 8-10, must chart effectiveness started 1/26/26 which had been administered three (3) times. Administration had been documented with e along with a pain scale prior to administration. There was no documentation on the MAR of nonpharmacological intervention offered, administered or declined prior to administration.The MAR lacked any documentation of any nonpharmacological interventions offered, administered or declined to R50. R50's progress notes, dated 1/26/26 to 2/19/26, reviewed and lacked evidence of nonpharmacological interventions offered or attempted prior to administrations of PRN pain medications.R1's medical record was reviewed and lacked evidence of what, if any, non-pharmacological interventions were offered or attempted prior to the administration of the PRN narcotic medication all the administered doses from 2/1/26 to 2/19/26.During an interview on 2/19/26 at 12:07 p.m., registered nurse (RN)-B stated if a resident reports pain, they would assess the resident to determine and have the resident rate the pain if they are able or use the nonverbal pain scale. RN-B stated they would determine the next steps after their assessment. RN-B stated if a nonpharmacological intervention was offered for pain, it would be documented in the progress notes.During an interview on 2/19/26 at 12:22 p.m., RN-A stated they would offer nonpharmacological interventions for pain prior to administering as needed pain medications for pain. RN-A stated they would document any nonpharmacological interventions offered in the progress notes. RN-A stated any nonpharmacological interventions offered whether accepted, helpful or declined, they would document in the progress notes. During an interview on 2/19/26 at 12:33 p.m., R50 stated she has not been offered any alternatives to pain medications. R50 stated would like to be offered ice for her pain as she previously used ice on her back when it was sore and it felt very nice.During an interview on 2/19/26 at 1:30 p.m., director of nursing (DON) stated the expectation would be that prior to administration to PRN medications, nonpharmacological interventions are offered. DON stated nonpharmacological interventions are used in conjunction with pain medication to address pain appropriately. DON stated nonpharmacological interventions would be documented on the MAR/TAR or in a progress note. DON requested to follow up to look further into if nonpharmacological interventions were provided as upon review could not identify they were being completed. No additional information was provided.A policy on nonpharmacological interventions for pain management was requested and not received.

During observation, interview, and record review the facility failed to ensure a safe, sanitary, and comfortable environment for 1 of 1 residents (R40) observed whose headboard and footboard of their bed was not maintained in good repair and whose personal fan was not clean.Findings include: R40R40's Significant change in status assessment (SCSA) Minimum Data Set (MDS) dated [DATE] identified R40 had impaired cognition, required assistance of two for all personal cares and transfers, was on oxygen and hospice, and had diagnoses of heart failure, kidney disease, hip fracture, respiratory failure, obesity and lymphedema (swelling caused by accumulation of protein-rich fluid in the body's tissues).During observation and interview on 2/17/26 at 8:18 a.m., R40 was lying in bed on her back with cracked, splintered particle board running along top of the footboard and headboard of her bed. The edge banding on top of them was not adhered. In addition, her personal fan with visible matter attached to the front of the fan and blades was operating on high speed, blowing air across R40's head while R40 was using Oxygen on 2 liters via nasal canula. The nightstand the fan was on also had visible dust on all surfaces. R40 stated she recalled the footboard and headboard were in disrepair as long as I have been here and it does not look good. R40 also stated she could not recall if her personal fan or nightstand had ever been wiped down or cleaned when housekeeping came into her room.During observation and interview with R40's primary emergency contact and significant other (SO) on 2/17/26 at 9:38 a.m., SO stated he visited R40 daily and, fan is usually on all the time. No one has cleaned it. Looks dirty. In addition, SO stated R40's footboard and headboard, had been broke since last September and indicated facility staff were aware but did nothing about it. SO stated he was concerned with the fan blowing dirty air across R40s face while she was on oxygen. SO stated he had never seen housekeeping or other facility staff clean or wipe down R40s fan.During observation and interview with R40 and SO on 2/18/26 at 9:52 a.m., R40's personal fan with visible matter attached to the front of the fan and the blades was operating on high blowing air across R40's head while they were using Oxygen on 2 liters via nasal canula. R40 looked at the chipped and broken particle board of the footboard of her bed and stated, it does not look good to me. It is something I have gotten used to. Looks like it is falling apart.During observation and interview with nursing assistant (NA)-A on 2/18/26 at 10:01 a.m., NA-A stated R40's fan looks very dirty. It should not be blowing across her face due to respiratory concerns. NA-A stated he was unaware of who was responsible for managing and cleaning personal fans. NA-A observed R40's headboard and footboard and stated expectation of staff to notify maintenance through an email portal or verbally of any repairs that were identified, including the footboard and headboard of R40. NA-A stated he was unaware of any staff member submitting a maintenance request. NA-A stated he had not notified maintenance of the issue either. NA-A stated it was important for safety to get it fixed and indicated he would hate to have his bed frame look like that.During observation and interview with registered nurse (RN)-A on 2/19/26 at 10:27 a.m., RN-A looked at R40's personal fan and stated, it needs to be cleaned. RN-A stated aide should clean it because it could be causing issues with her breathing due to her respiratory status. RN-A stated they didn't know when personal fans should be cleaned and wiped down, but it was dirty and could cause infection, however indicated the aide should wipe the nightstands and tables daily. RN-A stated R40's footboard was not in good repair and needed to be fixed, and they would not like it in their home. RN-A stated maintenance should be notified through online portal, however she was unaware of any requests for maintenance for repair or replacement of R40s headboard and footboard. RN-A stated she did not notify maintenance of any repairs needed for R40's room.During interview with RN-B on 2/18/26 at 10:35 a.m., RN-B stated expectations of all staff to notify maintenance of any repair request to use the online portalDuring interview with maintenance director (MNC) on 2/18/26 at 10:40 a.m., MNC stated expectation of staff to use online portal to request repairs. MNC verified there were no requests to repair or replace R40's headboard and footboard. MNC agreed that R40's headboard and footboard needed to be replaced.During observation and interview with director of nursing (DON) on 2/18/26 at 10:54 a.m., DON looked at R40's personal fan and stated, I appreciate it being cleaned. DON stated housekeeping staff were responsible for cleaning the personal fans and did not know how often the surfaces were wiped down. DON verified R40's fan had visible dust and matter on them while it was blowing air across R40's face.During interview with interim administrator on 2/18/26 at 11:24 a.m., interim administrator stated expectation of staff to utilize the online portal to document and submit work order requests. The staff have been trained but they are not consistent with doing that.During observation and interview with housekeeper (HK)-A on 2/18/26 at 11:24 a.m., HK-A stated expectation of housekeeping is to pick up garbage, clean toilets, and mop the floors in each resident room daily. HK-A observed the dust on R40's nightstands and personal fan and stated, I have never been told to wipe down the personal fans. HK-A verified, it looks like it has not been done in over a week. HK-A also stated expectation of staff to submit an online maintenance request for repairs of facility equipment including headboards and footboards. HK-A observed R40's headboard and footboard and stated they had not noticed that before and stated it did not look good and maintenance should fix it or replace it.During interview with infection control preventionist (IP) on 2/18/26 at 1:25 p.m., IP stated they did not know who was responsible for cleaning the personal fans. IP stated it is a potential issue with dirty fan blades blowing air across [R40] in her bed. She is vulnerable respiratory wise and cardiac wise.During interview with MNC on 2/19/26 at 7:15 a.m., MNC stated facility did not have a schedule to clean personal fans, but indicated dirty fans are not appealing and should be clean with no visible dirt or matter on them.Policies on maintaining facility equipment and personal fans was requested and not received.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 2 of 3 residents (R1, R2) reviewed for dignity. Findings include: R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and was dependent upon staff for all activities of daily living (ADLs). Identified R1 had diagnoses that included traumatic spinal cord dysfunction and quadriplegia. R1's care plan dated 8/26/24, indicated R1 had a self-care performance deficit related to quadriplegia and further indicated due to paralysis and contractures, R1 needed assistance with personal hygiene. On 4/1/25 at 1:44 p.m., during an interview and observation, R1 stated her nails were trimmed very occasionally and thought it had been weeks since they had been cut. R1 stated she preferred them short. R1's left hand was not covered by the blanket and her fingernails were very long. R1 stated she felt like staff did not want to help her or take care of her. On 4/2/25 at 11:48 a.m., during an observation and interview, the director of nursing (DON) observed R1's fingernails and stated the nails were too long, and should have been cut during R1's bath. The DON stated residents did not feel great when they did not get their care. R2 R2's significant change MDS dated [DATE], indicated R2 was cognitively intact, had an indwelling catheter, and diagnosis of an unspecified neurological condition. R2's diagnoses list printed 4/2/25, indicated epilepsy, a bladder disorder, and cystitis (an inflammation of the bladder). R2's care plan dated 12/5/24, indicated R2 had a self-care performance deficit and required one staff for bathing and preferred baths/showers twice a week. R2's care plan lacked preferences for hair care and beard care. On 4/1/25 at 5:07 p.m., during an interview, nursing assistant (NA)-B stated she was not able to find documentation of R2 receiving baths in the electronic health record (EHR) in the past few weeks. NA-B stated R2 would want his showers, liked to look good, and all the residents liked to look good. On 4/2/25 at 9:48 a.m., during an observation and interview, R2 was sitting in the dining room with his hair uncombed and long over his ears, and a beard that appeared long and un-groomed. R2 stated it had been a couple of weeks since he had shower and had one beard trim and hair cut in the seven months he had been in the facility. R2's fingernails were long and jagged. R2 stated he needed them cut, but the activity staff who normally cut them had been gone, and no one else had cut them. R2's catheter was uncovered and in view of other residents and visitors in the dining room. R2 stated he did not look like he did when he lived at home and wanted to go home to look better again, and wished his catheter bag was covered. On 4/2/25 at 10:48 a.m., a message was left for R2's family member (FM)-A to return a call to the surveyor. FM-A returned the call on 4/2/25 at 5:28 p.m. During an interview, FM-A stated R2 liked his hair short, beard trimmed, and R2 paid attention to his appearance before he was admitted to the facility. FM-A stated R2 liked his nails trimmed short and if they were long, R2 would have felt unkept. FM-A stated R2 spent his life going to work in a suit every day and looked professional. Additionally, FM-A stated R2 would be embarrassed if his catheter was showing and if it was noticeable by others. FM-A stated R2 would not like it. On 4/2/25 at 11:31 a.m., during a follow-up interview, DON stated residents felt better when they received their scheduled showers and care, and without scheduled care, the residents would experience a loss of dignity. The DON further stated R2 would not like his catheter showing and would want staff to cover it. The Resident Dignity policy dated 12/11/24, indicated the interdisciplinary team would assist in maintaining the dignity of all residents by grooming residents as they wished to be groomed (hair combed and styled, beards shaved/trimmed, nails clean and clipped). The policy further indicated staff would refrain from keeping urinary bags uncovered. The Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen policy dated 7/30/24 indicated every effort is made to keep a resident's catheter covered or out of sight. Catheter bags should be covered when up in a chair and out in public or visible from door/hall. Catheter tubing is secured to the resident's leg, coiled on bed with no kinks, obstructions and the rest of the tubing should be in a straight line into urinary drainage bag.

Based on observation, interview and document review, the facility failed to ensure nail care was provided for 2 of 3 residents (R1, R2) and bathing/shower assistance was provided for 2 of 3 residents (R2, R3) reviewed for activities of daily living (ADLs). Findings include: R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and was dependent upon staff for all ADLs. Identified R1 had diagnoses that included traumatic spinal cord dysfunction and quadriplegia. R1's care plan dated 8/26/24, indicated R1 had a self-care performance deficit related to quadriplegia and further indicated due to paralysis and contractures, R1 needs assistance with personal hygiene. On 4/1/25 at 1:44 p.m., during an interview and observation, R1 stated her nails were trimmed very occasionally and thought it had been weeks since they had been cut. R1 stated she preferred them short. R1's left hand was not covered by the blanket and her fingernails were very long. On 4/2/25 at 10:37 a.m., during an interview nursing assistant (NA)-C stated she was unsure who was supposed to cut R1's nails and was unsure if the nursing assistants were supposed to and acknowledged she had not cut R1's nails. On 4/2/25 at 10:58 a.m., during an interview, family member (FM)-A stated R1's nails were long and needed to be cut. R2 R2's significant change MDS dated [DATE], indicated R2 admitted to the facility 9/5/24, was cognitively intact, had an indwelling catheter, and diagnosis of an unspecified neurological condition. R2's diagnoses list printed 4/2/25, indicated epilepsy, a bladder disorder, and cystitis (an inflammation of the bladder). R2's care plan dated 12/5/24, indicated R2 had a self-care performance deficit and required one staff for bathing and preferred baths/showers twice a week. The care plan lacked preferences for hair care and beard care. R2's bath task log printed 4/2/25, indicated baths on Monday and Friday evening, adjusted on 4/2/25, for showers on Saturday evenings only and indicated the following bath data: 3/3/25 shower 3/7/225 NA [not applicable] 3/10/25 shower 3/14/25 NA 3/17/25 non facility staff provided care 100% of the time [for residents on hospice - R2 was not on hospice]. 3/21/25 NA 3/24/25 did not occur On 4/1/25 at 4:59 p.m., during an interview registered nurse (RN)-C acknowledged R2 had two baths in the past 30 days and stated the bath schedule did not match the printed schedule which may be why the baths were not completed. On 4/1/25 at 5:07 p.m., during an interview NA-B stated she could not find baths recorded for R2 in the electronic health record (EHR) in the past few weeks. NA-B stated the facility had enough staff to provide baths for residents, and the schedule was printed and posted on the nursing cart. On 4/2/25 at 9:48 a.m., during an observation and interview, R2 was sitting in the dining room with his hair uncombed and long over his ears, with a beard that appeared long and un-groomed. R2 stated it had been a couple of weeks since he had shower and had one beard trim and hair cut in the seven months he had been in the facility. R2's fingernails were long and jagged. R2 stated he needed them cut, but the activity staff who normally cut them had been gone, and no one else had cut them. The director of nursing (DON) approached R2 and inquired about his hair and beard preferences. R2 told the DON he preferred a monthly trim, and had only had one beard trim since he arrived. DON stated to R2 she would add his preferences to his care plan. On 4/2/25 at 10:15 a.m., during an interview, NA-A stated R2 had not had a shower he was aware of, but thought he was scheduled for evening showers. NA-A stated the chart indicated R2 showered on Monday and Friday evening, but was supposed to get showers on Saturday evenings. NA-A stated the data in the EHR did not match the schedule, and may be why the showers were not completed. NA-A further stated R2 needed his nails cut but the nursing assistants could not do it because R2 was diabetic. On 4/2/25 at 10:39 a.m., during an interview ,NA-D stated there was enough staff to provide baths and did not know why R2 was not getting showers weekly. NA-D acknowledged R2 did not refuse showers. On 4/2/25 at 10:24 a.m., during an observation, the DON observed R2's nails, acknowledged R2's nails should have been cut and asked a nurse to cut R2's nails. On 4/2/25 at 10:48 a.m., a message was left for R2's family member to return a call to the surveyor. FM-A returned the call on 4/2/25 at 5:28 p.m. During an interview, FM-B stated R2 liked his hair short and beard trimmed and he paid attention to his appearance before he was admitted to the facility. R3 R3's Medicare 5-Day MDS dated [DATE], indicated R3 was unable to participate in the cognitive assessment but had a memory problem. Identified R3 was dependent in all ADLs and had diagnoses that included Multiple Sclerosis (MS). R3's care plan dated 10/17/23, indicated R3 had a self-care performance deficit related to MS and required assistance of staff for bathing. The care plan indicated R3 did not like showers but was updated on 4/2/25, to indicate R3 could use the tilt in space shower chair to take a shower. R3's bath task data printed 4/2/25, indicated R3 had baths on Monday evenings, Wednesday and Saturday mornings, and indicated the following bath data: 3/15/25 bed bath 3/17/25 sponge bath 3/19/25 NA 3/22/25 NA 3/24/25 NA 3/31/25 bed bath On 4/1/25 at 4:50 p.m., during an observation, R3 was lying in bed, her hair appeared greasy. On 4/2/25 at 10:39 a.m., during an interview ,NA-D stated there was enough staff to provide baths, did not know why R3 was not getting showers weekly and acknowledged R3 did not refuse showers. On 4/1/25 at 5:07 p.m., during an interview, NA-B stated R3 did not have her scheduled bath on 3/22/25, did not know why, and acknowledged R3 did not refuse baths. NA-B stated the NAs were supposed to tell the nurses when residents refused baths, and further acknowledged there was no documentation to indicate R3 refused any baths. On 4/2/25 at 11:31 a.m., during an observation and interview, the DON observed R1's fingernails and stated they were too long and would have staff cut them. The DON stated the facility had a performance improvement plan (PIP) for baths, and she had changed the bath schedules that morning (4/2/25) to be performed once weekly. The DON stated residents could request an extra bath, but they were no longer scheduled more than once weekly. The DON stated resident nail care was supposed to occur on bath days. Further, the DON acknowledged R2 and R3 did not receive weekly baths and did not know why. DON stated the facility had enough staff to provide weekly baths. In addition, the DON acknowledged R2's last documented shower was 3/10/25, and R3 missed three baths in March that were charted as NA and did not know why. The DON stated residents felt better when they received their scheduled showers and cares. On 4/2/25 at 4:15 p.m., an email sent by the administrator indicated the facility implemented a performance improvement plan (PIP) on 3/19/25, to ensure residents were showered/ bathed weekly. The email indicated there was some improvement however, acknowledged R2 and R3 were identified as not having scheduled baths on 3/29/25, and did not provide baths/showers for either resident until 4/2/25. On 4/3/25 at 2:20 p.m., an email sent by the administrator included documentation R2 was offered a shower and face trim after survey exit and declined. The Activities of Daily Living policy dated 12/4/23, indicated any resident who was unable to carry out activities of daily living would receive necessary services to maintain good grooming, personal care, and oral hygiene. The policy stipulated ADLs, were those necessary tasks conducted in the normal course of a resident's daily life. Included in these tasks were care of hair, hands, face, shaving, nails, and oral care.

Based on interview and document review, the facility failed to ensure a provider order for a TSH (thyroid-stimulating hormone - a protein produced in the brain that regulates the thyroid gland's production of thyroid hormones) blood draw was performed as ordered for 1 of 3 residents (R3) reviewed for services performed as ordered. Findings include: R3's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated R3 was unable to complete the cognitive assessment, but had a memory problem. Identified a diagnosis that included a thyroid disorder. R3's diagnoses list printed 4/2/25, included hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). R3's progress notes dated 3/19/25, at 3:28 p.m. indicated the TSH (thyroid-stimulating hormone) lab level was not drawn because the order was missing the resident's room number, and the lab would be redrawn 3/21/25. The medical record lacked indication an order was placed to redraw the lab on 3/21/25, nor that it had been performed. R3's provider orders printed 4/1/25, lacked an order for a TSH level to be re-drawn 3/21/25, as indicated in the progress note. On 4/2/25 at 11:30 a.m., during an interview, registered nurse (RN)-A stated she was new and not aware of the lab order for R3, nor the lab process, and requested the director of nursing (DON) assist with answering the questions. On 4/2/25 at 11:31 a.m., during an interview the DON stated the nurses were responsible to enter the lab orders, a lab technician came the facility on Wednesdays and Fridays to draw labs, and the nurses followed up with the ordering provider after lab results were reported to the facility. The DON stated she was unsure how the TSH order got missed. On 4/2/25 at 12:46 p.m., during an interview the nurse practitioner (NP)-A stated she ordered the TSH level, and it should have been obtained. NP-A stated R3's levothyroxine (medication used to treat hypothyroidism) dose was decreased from 124 micrograms (mcg) to 112 mcg on 2/24/25, because R3's TSH level was 10.2 [mIU/L - milli-international units per liter] on 2/21/25, with a normal range of 0.3 to 4.2 [mIU/L]. NP-A acknowledged R3's TSH was not performed as ordered but was ordered because when the previous TSH result was too high, the levothyroxine dose was adjusted. The TSH level was required to determine if further medication adjustment was required. NP-A stated if R3's TSH level was too high, R3 could experience weight loss, loss of appetite, or feel cold. NP-A indicated R3's health was already declining and NP-A did not want to see a decline related to an elevated TSH level. The Processing and Auditing Laboratory and Diagnostic Orders policy dated 4/16/24, indicated the facility staff would enter provider orders into the clinical record, and there would be a process in place to track when labs were due.

Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed for 1 of 3 residents (R1). Additionally, the facility failed to secure a leg bath for a catheter off the floor for 1 of 1 resident (R2) reviewed for infection control. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had an indwelling catheter, an ostomy (a surgically created opening in the abdomen that allows waste to exit the body), a feeding tube, and was dependent upon staff for all activities of daily living (ADLs). Identified R1 had diagnoses that included traumatic spinal cord dysfunction, a neurogenic bladder (loss of bladder function due to a nerve problem), and quadriplegia. R1's care plan dated 8/26/24, indicated R1 had an indwelling foley catheter, a feeding tube, and indicated enhanced barrier precautions (EBP) (measures intended to prevent the spread of multi-drug-resistant organisms) was in place related to wounds and an indwelling catheter. On 4/1/25 at 1:25 p.m., during an observation R1's door had two signs posted to indicate the following: Enhanced Barrier Precautions (EBP) Sign 1: Families and Visitors, please follow enhanced barrier precautions. If you have questions, please see nurse. Everyone must clean their hands before entering room and when leaving the room. Providers and Sign 2: Providers and Staff: Wear gloves and a gown for the following high-contact resident care activities: Bathing/ showering, transferring residents from one position to another, changing bed linens, providing hygiene (only during high contact activities such as peri-care), changing briefs or assisting with toileting, caring for assisting with an indwelling medical device (for example central venous catheter, urinary catheter, feeding tube care, tracheostomy/ventilator care) and performing wound care. On 4/1/25 at 2:03 p.m., during an observation, registered nurse (RN)-B entered R1's room with medications wearing gloves. While performing cares, RN-B doffed his gloves and donned clean gloves to move a graduated cylinder off R1's tray table without performing hand hygiene between glove changes. R1 asked RN-B to scratch the back of her head. RN-B doffed gloves and re-donned gloves, without performing hand hygiene between. On 4/1/25 at 2:24 p.m., during an interview, RN-B acknowledged he had not performed hand hygiene between gloves changes and stated he had not because he was only in the room to give medications. RN-B acknowledged he touched many items in the room and should have performed hand hygiene according to EBP. On 4/2/25 at 9:32 a.m., during an observation, RN-A entered R1's room to view R1's tube feeding (TF) pump. RN-A donned a gown and gloves and entered R1's room without performing hand hygiene. RN-A stated the TF pump was not working, and RN-A doffed her gloves and gown, and left the room without performing hand hygiene. RN-A returned to the room with new tubing for the TF, donned gown and gloves and entered the room without performing hand hygiene. On 4/2/25 at 9:41 a.m., during an interview, RN-A acknowledged she had not performed hand hygiene during her interactions with R1 but should have when she entered and exited the room. RN-A stated she was in a rush and just did not do it. RN-A stated R1 was on contact precautions, and R1 could get an infection from staff if the precautions were not followed. RN-A looked at the precaution signs on R1's door and stated, No, she is on Enhanced Barrier Precautions. It's the same, I think. R2 R2's significant change MDS dated [DATE], indicated R2 was cognitively intact, had an indwelling catheter, and diagnosis of an unspecified neurological condition. R2's diagnoses list printed 4/2/25, indicated a bladder disorder, and cystitis (an inflammation of the bladder). R2's care plan dated 9/5/24, indicated R2 had a Foley catheter, and on 9/6/24, was on EBP. On 4/1/25 at 4:48 p.m., during an observation, R2 had EBP signs on his door. On 4/2/25 at 9:48 a.m., during an observation and interview, R2 was sitting in the dining room, his catheter leg bag was full and sitting on the floor between R2's feet, and the strap to secure the bag was also resting on the floor. R2 stated he wished the bag was strapped to his leg and further stated he did not want an infection from the bag being on the ground as he had many urinary infections before. On 4/2/25 at 10:15 a.m., during an interview, nursing assistant (NA)-A acknowledged R2's catheter bag was full, sitting on the floor, and the outlet tube was touching the floor. NA-A stated the floor was not a clean place for the catheter bag, and R2 could get an infection from the catheter bag and outlet sitting on the ground. NA-A secured the catheter bag to R2's leg. On 4/2/25 at 10:24 a.m., during an interview, the director of nursing (DON) stated R2's catheter bag should not rest on the floor to prevent infection. During a follow-up interview on 4/2/25 at 11:31 a.m., the DON stated staff were expected to perform hand hygiene prior to entering /exiting a room and in between glove changes. The Hand Hygiene policy dated 3/29/22, indicated hand hygiene should be performed before entering a room, before a clean task, after glove removal, and after exiting a room. The Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen policy dated 7/30/24, indicated catheter tubing should never be allowed to touch the floor.

Based on observation, interview, and document review, the facility failed to ensure final cooking temperatures were checked or obtained in a manner to reduce the risk of cross-contamination between food items prepared in the main production kitchen. This had potential to affect all 36 residents who were served the meal. Findings include: On [DATE] at 11:36 a.m., food production in the main kitchen was observed with cook (CK)-A present. CK-A placed a metallic tray filled with breadsticks into the oven and pulled out a pan which had two, foil pans on top with lasagna in them. CK-A used a spike-style thermometer to pierce the seal over the lasagna and obtain a temperature which read, 182 [F]. CK-A then turned and stated aloud to the food and nutrition service manager (FNM) they were looking for a wipe to clean the probe of the thermometer. FNM left the kitchen and returned with a white-colored box labeled, Ecolab Probe Wipes, and placed them on the elevated counter. The counter space contained another box of these wipes hidden amongst some spices and paper, along with several loose ones in a hard-plastic tray seated on the same counter surface. CK-A removed a wipe from the obtained box and used it to clean the thermometer spike before re-sheathing it and placing it back on the counter for future use. The box of wipes FNM obtained, along with the other wipes present, were reviewed. The boxes and individual wipes both contained the following items printed on them, [LOT] 08302020, and, [Hour-glass symbol] 08292023. At 11:50 a.m., CK-A removed the breadsticks from the oven. CK-A then picked up another spike-style thermometer and cleaned the probe using the same wipes available before replacing the sheath of the probe. CK-A was not observed spiking any food using this thermometer despite cleaning it using the wipes. CK-A then placed the thermometer back on the counter before moving to the opposite side and working on shredded carrots which were in another metallic pan. At 11:59 a.m., CK-A loaded the prepared lasagna, carrots and breadsticks onto a mobile cart and brought them out to the dining room to place into an activated steam table. CK-A was questioned on final cooking temperatures of the items and expressed they hadn't obtained them yet. CK-A returned to the kitchen and obtained one of the spike-style thermometers observed just prior along with a torn-open Ecolab wipe. CK-A then placed the spike of the thermometers into the lasagna, removed it, and then immediately inserted it into the carrots. CK-A did not clean the spike between food items despite having the wipe in their hand. CK-A was questioned on cleaning the spike and stated it should be cleaned between each food item to prevent cross contamination of the items. CK-A verified the wipes located in the kitchen were what they obtained prior and, upon the surveyor request, checked the boxes and wipes. CK-A verified the dates on the boxes and stated they had never been told to check them for an expiration date, rather just the packaging of them should be intact if using them. CK-A then stated they had, at times, used another type of wipe to clean the thermometer spike and showed the surveyor a plastic container of wipes. These were labeled, Purell Hand Sanitizing Wipes, and CK-A reiterated using them on the spike, too, adding aloud, Yea, sometimes. CK-A stated they were unsure if the Purell wipes' were safe for food items or, as a result, potential human consumption of the residue. CK-A then began to plate and serve the prepared meal to the residents' seated within the dining room. The following day, on [DATE] at 1:19 p.m., FNM was interviewed. FNM stated the Ecolab wipes were expired and they had just ordered more adding, I didn't notice that [expired]. FNM stated other products could be used in the meantime which were food safe to sanitize the thermometer spike. FNM stated they were unaware CK-A had been using Purell hand sanitizing wipes to clean the spike and expressed they had corrected him right away to not use them further. FNM verified wipes used to clean the thermometer spike should be current adding, You always want to use things that are not expired. FNM stated doing such was, A huge thing for food service. FNM stated checking the wipes being used for expiration was not on a formal kitchen audit list but expressed aloud, We should be checking [them]. When interviewed on [DATE] at 10:22 a.m., registered dietician (RD)-A stated they were currently helping to cover the care center' campus describing their help as PRN as they need me. RD-A stated they had not been physically onsite to the campus since sometime last year, but expressed thermometer probe wipes, such as the Ecolab ones observed, were used at their campus too, however, they were unsure if they were the same brand or not. RD-A stated they couldn't recall what the printed dates meant on the packaging of the wipes adding they would have to consult with the food service manager about it as they dealt more with food safety. However, RD-A stated from their understanding the wipes would likely be less effective after that date [expiration] and you shouldn't use them. Further, RD-A verified the thermometer spike should be cleaned between food items adding such was important so there's no cross contamination or allergen spreading. On [DATE] at 10:24 a.m., the Ecolab representative (ERP) was contacted. A return call was received on [DATE] at 11:12 a.m., and ERP was interviewed. ERP verified they were the assigned representative for the care center and expressed they had last visited with FNM last week about other items. ERP stated they were unsure the exact meaning of the symbols on the packaging adding aloud, I would have to look into that. ERP stated the care center was their only account which used them and expressed they had just told FNM a better work around would likely be using a food-safe contact cleaning solution which they already had on-hand. ERP explained the wipes were developed by another division of the company and reiterated he was unsure of the symbol or dates' meaning but expressed with an hour-glass present next to the a date it was probably true they had expired. ERP stated their 'general guidance' was their products were expired or shouldn't be used after a year adding again such was a general guideline. A facility' provided Food Temperature Monitoring policy, dated ,d+[DATE], identified a procedure to check final cooking temperatures of prepared items. This included inserting the thermometer into the center, thickest part of the food for at least 15 seconds and, The thermometer is cleaned and sanitized after testing each food item (See Food Thermometers). A provided Food Thermometers policy, dated ,d+[DATE], identified the tool was a critical device to effective monitoring of food temperature adding, Thermometer probes are cleaned and sanitized on a regular basis to limit contamination and prevent foodborne illness. The policy continued with a section labeled, Sanitizing Thermometers, which directed they should be sanitized according to manufacturer guidelines and after, Between taking temperatures of different foods/fluids. Further, the policy directed either an alcohol swab or food contact approved sanitizing solution should be used according to the manufacturer's directions.

Based on interview, and document review, the facility failed to provide the opportunity for 4 of 4 residents (R22, R31, R1, R15) reviewed to participate in care planning and care conferences. Findings include: R22 R22's significant change Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition. R22's medical record was reviewed from 2/10/24 to 12/11/24 and lacked evidence that R22's representative was invited or attended a care conference held during this period. During an interview on 12/10/24 at 2:30 p.m., R22's resident representative (FM)-A stated she was the one who would attend R22's care conferences but she had not been invited to one since 10/23. FM-A stated she would have wanted to participate in a care conference, but none had been offered since last year. R31 R31's quarterly MDS dated [DATE], indicated R31 had intact cognition. R31's medical record was reviewed from 6/10/24 to 12/11/24 and lacked evidence that R31 or her representative was invited or attended a care conference held during this period. During an interview on 12/10/24, R31 stated she did not remember being invited or attending a care conference in the last few months but would have wanted to. During an interview on 12/11/24 at 9:55 a.m., licensed social worker (LSW)-A stated that she oversaw inviting the family, guardians, and/or residents to the care conferences. LSW-A stated care conferences were supposed to be held within three weeks after the assessment reference date (ARD) of the MDS to include residents/resident representatives in the care planning process. LSW-A stated she had reviewed both R22's and R31's medical records and they were both due for care conferences but had not had them yet. During an interview on 12/12/24 at 9:35 a.m., the director of nursing (DON) stated LSW-A oversaw care conferences and would be the best resource for questions regarding this. 49339 R1 R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 had moderately impaired cognition with no hallucinations or delusions present with an admitted [DATE]. Diagnoses included: dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing foods or liquids), diabetes (disease that results in too much sugar in the blood), depression, anxiety, and osteoporosis (condition that causes the bones to become brittle and fragile). R1's progress notes, dated 5/1/23 to 12/11/24, were reviewed and identified the following: -10/27/23: Care Conference Note: [R1] and family were invited, but they could not come today. There is another care conference with [R1] and family scheduled for next. -10/30/23: Care Conference Note: identified family, dietary manager, activities manger, and social services attended care conference. The progress notes lacked evidence having a care conference in 2024. Furthermore, lacked documentation of planning of a care conference. On 12/10/24 at 1:35 p.m., family member (FM)-A indicated they are involved with their mother's care. They indicated they have had only had a couple care conferences in the past year and cannot recall the last one. FM-A indicated they feel as though details about their mom and her likes/dislikes can get lost between staff. On 12/11/24 at 11:16 a.m., licensed social worker (LSW)-A verified the last care conference for R1 was October 2023 and added I know we have met since then. LSW-A stated she is responsible for care conference and documenting they occurred. LSW-A indicated R1 family visits often and will bring issues to her attention. LSW-A stated, I do know the importance of having the care conferences and she would have been due at the latest October 31st. R15 R15's quarterly Minimum Data Set (MDS) assessment, dated 11/20/24, indicated R15 had intact cognition with no hallucinations or delusions with an admitted [DATE]. Diagnosis included: quadriplegia (condition that causes partial or total loss of movement in all four limbs and the torso), epilepsy (abnormal electrical brain activity that causes seizures), depression, dysphagia, and chronic pulmonary embolism (condition when a blood clot in the lung doesn't go away). R15's progress notes, dated 7/18/24 to 12/11/24, reviewed and identified the following: -7/18/24: Care Conference Note: in attendance R15, family, friend, DON [director of nursing] and social services for weekly care conferences and planning for surgery. The progress notes lacked evidence having a care conference since 7/18/24, after returning to the facility. Furthermore, lacked documentation of planning of a care conference. On 12/10/24 at 10:21 a.m., R15 stated they have lived here for quite a few years. R15 indicated that they previously had care conferences, and this was something that they liked as they felt more involved. R15 stated they have not had one in several months and would like to be having care conferences. On 12/11/24 at 11:10 a.m., LSW-A verified the last care conference R15 had was in July, right before R15 went to the hospital. LSW-A indicated R15 was considered an admission when she came back from the hospital and should have had a care conference and verified this was not completed. LSW-A verified care conferences should be done with MDS assessment schedules. LSW-A stated she has talked to the daughter and friend since R15 has returned and verified there has not been a care conference since R15 returned from the hospital. LSW-A indicated she was going to try to schedule a care conference in the next week or something and verified she has not attempted to schedule it at this time. A facility policy titled Comprehensive Care Plan and Care Conferences, revised 12/4/23, indicated residents and their representatives are to be invited to care conferences and right to request meetings.

Based on observation, interview, and record review the facility failed to ensure routine personal care (i.e., bathing, nail care) were provided for 1 of 3 residents (R11) reviewed for activities of daily living (ADL's). Findings include: R11's admission Minimum Data Set (MDS) assessment, dated 9/11/24, indicated R11 had intact cognition with no hallucinations or delusions, no behaviors or no rejection of care. MDS assessment indicated R11 required maximal staff assistance for bathing and moderate assistance with personal hygiene. Diagnoses included: diabetes (disease that results in too much sugar in the blood), Alzheimer's disease (progressive disease that affects memory and other mental functions), and epilepsy (abnormal electrical brain activity that causes seizures). R11's care plan, printed 12/12/24, identified R11 has an ADL [activity of daily living] self-care performance deficit with the following interventions: -BATHING: Resident requires 1 staff for bathing. Prefers two baths/showers per week. -ORAL CARE STRENGTH: Resident is able to brush own teeth after set up. -TOILET USE: Resident requires 1 staff assist. -DRESSING: Resident requires 1 staff with LBD [lower body dressing]. Supervision for UBD [upper body dressing]. Furthermore, R11's care plan indicated R11 has potential for impairment to skin integrity with the following intervention: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. R11's care plan lacked identification of level of assistance needed for nail care and what staff was responsible for nail care. R11's Kardex, printed 12/12/24, indicated the following: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Bathing: Monday & Friday Evening -BATHING: Resident requires 1 staff assist for bathing. Prefers two baths/showers per week. R11's Kardex lacked identification of level of assistance needed for nail care and who was responsible for nail care. R11's Point of Care (POC) questionnaire for task of bathing for type of bath that occurred by marking designated answer with a checkmark: -12/6/24: did not occur -12/2/24: shower R11's progress notes, dated 11/12/24 to 12/11/24 were reviewed. Progress notes lacked evidence of R11 refusing showers, staff assistance with ADLs or nail trimming. Furthermore, lacked documentation of staff offering an additional showers/bed bath/partial bath since last documented shower on 12/2/24 (10 days ago). During an interview on 12/10/24 at 9:54 a.m., R11 was observed seated in his wheelchair. R11's fingernails were observed to be approximately half inch long with some sharp edges with dark colored debris underneath them. R11 stated he would like assistance trimming his nails as he doesn't have a nail clipper, doesn't like his nails that long and stated no staff has offered to assist him. R11 stated that it was his preference to have 2 baths per week and I haven't had a bath in at least 4 weeks. R11 stated doesn't understand why he is not getting 2 showers or baths a week. R11 stated, my nails are really long. On 12/11/24 at 11:56 a.m., R11 was observed sitting in his room watching tv. R11 stated he has not been offered a shower or a bath and his nails continue to appear as they did yesterday. On 12/11/24 at 2:55 p.m., nursing assistant (NA)-C went and observed R11's fingernails and described them as really, really long and need to be cut. NA-C indicated staff assist resident with trimming nails. NA-C stated they do not document nail care in the electronic medical record (EMR) or on paper charts. NA-C indicated nail care should be offered with showers and when needed. On 12/12/24 at 10:01 a.m., NA-D verified that nail care should be done with showers. NA-D verified that showers/baths are documented in POC (part of the EMR). NA-D verified there is no specific area to indicate when nail care was done. NA-D stated nurses provide nail care to residents that are diabetic and typically that is done on shower days. At 10:11 a.m., NA-D observed R11's fingernails and stated, they are fairly long and chipped. While NA-D was observing R11's nail, R11 stated, they are way too long. On 12/12/24 at 10:21 a.m., registered nurse (RN)-B stated showers needed to be done at least once a week, but some residents had a preference of twice a week. RN-B stated if a resident refuses a shower, the nursing assistants will notify nursing and a progress note will be put in. RN-B verified R11 preference was twice a week and verified last documented shower was 12/2/24. RN-B verified no progress about shower refusals. RN-B verified a skin assessment was done on 12/9/24 and verified a skin assessment is completed whether a shower or not a shower is completed. RN-B stated the skin assessment does not include nail care documentation, but nursing should be providing nail care for R11 due to being diabetic. RN-B observed R11's nails and stated, they are long, longer than regular nails should be. RN-B stated they were going to trim them as R11 asked RN-B to cut them. RN-B stated they should probably assist R11 trim their nails or at least supervise them to see if they can do it. On 12/12/24 at 12:11 p.m., interim director of nursing (DON) stated R11 showers are offered twice a week and should be completed at minimum weekly unless refused. DON indicated refusals should be documented. DON verified last documented shower was 12/2/24 and that was not within needed timeline. DON verified nursing assistants should be doing nail care on bath days and as needed unless a resident diabetic then it would be done by nursing unless they are followed by podiatry. A facility policy titled Activities of Daily Living, reviewed/revised 12/4/23, indicated the purpose to provide resident with appropriate treatment and services to maintain or improve abilities in activities of daily living for the well-being of mind, body and soul. Furthermore, clarifies that ADLs are those necessary tasks conducted in the normal course of a resident's daily life, Included in these are the following: General Personal, Daily Hygiene/Grooming: Care of hair, hands, face, shaving, applying makeup, skin, nails and oral care.

Based on observation, interview, and document review, the facility failed to ensure vision needs were met for 1 of 1 residents (R31) reviewed for missing eye glasses. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31 was diagnosed with dementia and required set-up help with dressing. The MDS indicated R31 had adequate vision and used corrective lenses. R31's admission assessment dated [DATE], indicated R31 had adequate ability to see in adequate light (with glasses or other visual appliances) and utilized corrective lenses. R31's care plan dated 2/22/24, indicated R31 had impaired cognition, impaired decision making, short-term memory loss, and scored an 8/30 on the St. Louis University Status Examination (SLUMS, test to determine neurocognitive disorder/dementia) indicating dementia. R31's care plan indicated she needed the assistance of one person for dressing and grooming and had a history of falls. The care plan did not include R31's need for corrective lenses but did include a picture of R31 wearing eye glasses. R31's Kardex dated 12/10/24, was reviewed and did not include R31's need for corrective lenses. R31's medical record was reviewed and did not include information regarding R31's missing glasses or what interventions were placed regarding her missing glasses. During an interview on 12/10/24 at 10:27 a.m., R31 stated she thought she lost her glasses a couple months ago and no one had offered to help her get new ones, but she did not recall which staff member she told they were missing. During an interview on 12/10/24 at 2:15 p.m., with registered nurse (RN)-A and nursing assistant (NA)-B, NA-B stated she wasn't sure if R31 wore glasses. RN-B stated he did not think R31 wore glasses as he did not find this information in the care plan. On 12/11/24 at 11:38 a.m., a call was attempted to R31's resident representative (FM)-C, a message was left, and no return call was received. During an interview on 12/12/24 at 10:58 a.m., NA-A stated she worked with R31 frequently and the last time she saw R31 wearing her glasses was three weeks ago, but she isn't sure what happened to them. NA-A stated she had not reported the missing glasses to the nurse on duty, director of nursing (DON), or other management staff and was not sure if anyone else had. NA-A stated R31 was confused so staff had to help her keep track of her clothing and belongs. During an interview on 12/12/24 at 9:31 a.m., the director of nursing (DON) stated R31 did wear glasses, but she had not been informed they were missing. The DON stated she would have expected nursing staff to notify her when they noticed the glasses were missing so they could notify the resident representative and get her glasses replaced. At 1:33 p.m., the DON stated R31 did not have any appointment with an eye doctor set up currently and they had looked for her glasses but had not been able to find them. The facility's Eye Care policy dated 10/30/24, indicate the location would assist the resident in making appointments for vision treatment if necessary and refusals would be documented.

Based on observation, interview, and document review, the facility failed to provide timely assistance with repositioning for 1 of 1 residents (R22) with a history of pressure ulcers. Findings include: R22's significant change Minimum Data Set (MDS) dated [DATE], indicated R22 had severely impaired cognition and was diagnosed with kidney disease, diabetes, and dementia. The MDS indicated R22 was dependent on staff for bed mobility and was receiving hospice care. The MDS indicated R22 was at risk of developing pressure ulcers. R22's provider progress note dated 11/26/24, indicated R22 had a pressure injury on her right shoulder, impaired skin integrity, limited mobility, and muscle weakness. The note indicated R22 was predisposed to pressure injuries due to weakness and inability to reposition herself. The provider encouraged staff to offload and reposition [R22] as much as possible. R22's Order Summary Report dated 12/5/24, indicated nursing staff were to turn and reposition R22 every two to three hours and document all refusals in the progress notes. R22's progress notes were reviewed and lacked evidence indicating R22 refused repositioning on 12/11/24. During observation on 12/11/24 at 9:46 a.m., R22 was observed in a left-lying position in bed. During an observation and interview dated 12/11/24 at 1:48 p.m., R22 was observed in a left-lying position in bed. Registered nurse (RN)-D stated he was unsure when the last time R22 was turned as her aide, nursing assistant (NA)-C, oversaw ensuring R22 was repositioned. RN-D stated R22 was supposed to be repositioned every two hours so he would turn her now. R22 confirmed he had not assisted R22 in repositioning during the shift until this time. During an interview on 12/11/24 at 2:36 p.m., NA-C stated she oversaw assisting R22 with repositioning and it was supposed to be completed every two hours. NA-C stated the last time she had repositioned R22 was around 6:30 a.m. and confirmed that no one had assisted R22 with repositioning until RN-D had at 1:48 p.m. NA-C stated she had planned to turn R22 again after breakfast but had gotten too busy. During an interview on 12/12/24 at 9:43 a.m., the director of nursing (DON) stated it was important for staff to reposition R22 every two to three hours especially given her pressure ulcer history to prevent new injuries or worsening of the pressure injury she already had. The Facility Skin Assessment Pressure Ulcer Prevention and Documentation Requirements-Rehab/Skilled policy dated 4/26/24, indicated residents who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches.

Based on interview and document review, the facility failed to provide appropriate side effect monitoring of psychotropic medication consumption for 1 of 5 residents (R26) reviewed for unnecessary medication use. Findings include: R26's admission Minimum Data Set (MDS) dated [DATE], indicated R26 was cognitively intact, needed setup for oral hygiene and eating, needed moderate assistance with upper body dressing and was dependent with bathing, lower body dressing, personal hygiene, and toileting. The MDS included diagnoses of fractures and other multiple traumas, atrial fibrillation (irregular heart rhythm that can lead to blood clots in the heart) , hypertension (high blood pressure), renal insufficiency (poor function of the kidneys), hyperlipidemia (high levels of fat particles in the blood), thyroid disorder (thyroid gland dysfunction), arthritis (swelling and tenderness in one or more joints), depression, and glaucoma (a condition that damages the optic nerve that causes vision loss and blindness). R26's Clinical Orders report dated 12/10/24, identified R26 had physician orders for several psychotropic medications including the following: - trazadone HCL (medication to treat major depressive disorder) 25 milligrams (mg) tablet: take 25 mg by mouth once a day for insomnia with a start day of 9/20/24. - Cymbalta delayed release (medication to treat major depressive disorder) particles 60 mg capsules: take 2 capsules every morning for anxiety with a start date of 9/21/24. - bupropion HCL extended release (medication to treat depression) oral tablet: take 300 mg every morning for anxiety with a start date of 9/21/24. - aripiprazole (medication to treat depression) oral tablet: take 20 mg at bedtime for depression with a start date of 9/20/24. R26's clinical orders report dated 12/10/24 had boxed warnings for trazadone, bupropion, aripiprazole, and Cymbalta as follow: Warning: suicidal thoughts and behaviors. Closely monitor all antidepressant treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. R26's care plan printed on 12/11/24, indicated R26 was on antidepressant medication therapy related to depression, anxiety, and insomnia. Interventions listed included: - Monitor resident condition based on clinical practice guidelines or clinical standards of practice related to use of trazadone, duloxetine [Cymbalta], bupropion, aripiprazole. - Warnings #1: Refer to boxed warnings in the orders or eMar [electronic MAR]. R26's care plan lacked evidence of monitoring of side effects, and/or non-pharmacological interventions attempted in the past or present and effectiveness. It also lacked non-pharmacological interventions for sleep. R26's medication administration record (MAR) for November and December 2024, printed on 12/11/24, lacked evidence of monitoring side effects of psychotropic medications, non-pharmacological interventions for sleep or behaviors or indication of target behaviors. During interview on 12/11/24 at 11:48 a.m. registered nurse (RN)-D stated, residents taking antidepressant needed to be monitored for side effects (SE), document their behaviors and vital signs. During interview on 12/11/24 at 11:55 a.m. RN-A stated, when residents take psychotropic medications including antidepressants, antianxiety and antipsychotics nurses needed to monitor their mood, behaviors, refusal of cares, restlessness. RN-A indicated the monitoring was documented in the MAR. RN-A stated interventions to address behaviors, anxiety, etc. needed to be in place to properly care for their residents. During interview on 12/11/24 at 1:59 p.m. pharmacist consultant (PC) stated, usually residents taking antidepressant medications needed to be monitored for confusion, sedation, and cognitive changes. PC stated behaviors needed to be monitored using some kind of tracking form to measure the effectiveness of the medications. During interview on 12/11/24 at 2:13 p.m. director of nursing (DON) verified there was no monitoring or documentation of behaviors, interventions or side effects related to R26's antidepressants medications. DON stated, nursing needed to monitor and document behaviors and side effects. DON also stated if a resident was taking a medication for insomnia, nursing should monitor and document the resident's hours of sleep. DON stated the documentation of behaviors would assure gradual reductions of psychotropic medications would be accurately done. Facility's policy titled Psychotropic Medications-Rehab/Skilled dated 12/6/23 indicated a Psychotropic medication referred to any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: anti-psychotics; antidepressants; anti-anxiety; and hypnotics. Policy indicated throughout the administration of the psychotropic medications; the following must be completed: a. Mood and behavior documentation must continue to monitor the effect the medication has on the behavior. b. Monitor side effects of the medication. If a side effect occurs or worsening of a known side effect is noted, the nurse will make a note in Point Click Care (PCC) and notify the physician and family/legal representative of this change in condition.

Based on interview and document review, the facility failed to develop a baseline care plan for smoking for 1 of 1 residents (R189) reviewed who smoked. Findings include: During an interview on 12/10/24, at 11:57 a.m., R189 indicated he smoked cigarettes and was made aware after admission the facility was a non-smoking facility. R189 stated he has gone outside the building to smoke while being a resident. R189 indicated staff has told him a few different things about smoking which included: must go on the other side of the parking lot to smoke, can't let people see me smoking and just tell people I am going for a walk. R189 stated the staff at the front desk told him, that as long as she couldn't see me, I could go for a long walk [to smoke]. R189 indicated that over the weekend, one of the nurses sat by the front window and watched me smoke outside. R189 further indicated the head of nursing came and told me today that I can't smoke here and indicated no staff have discussed or offered any nicotine replacement therapy since admission. R189 stated he has smoked forever. R189 stated he was able to manage his own cigarettes without burning himself and has not sustained any burns. R189's facility Admission Record, printed on 12/11/24 indicated R189 was admitted to the facility on [DATE]. Diagnoses included: nicotine dependence. R189's care plan, printed 12/11/24, indicated the following: -Date initiated 12/10/24: Focus: The resident attempts to use tobacco products outside of facility E/B smoking on facility grounds with an intervention of resident education to that smoking is not allowed on facility grounds. Staff will continue to encourage resident to not smoke of facility grounds. R189's Nursing Admit Re-Admit Data Collection, dated 12/7/24, identified R189 as a current tobacco user with a radio-button question answered, yes. The data collection tool lacked evidence of any further questions about tobacco use. R189's progress notes, dated 12/7/24 to 12/12/24, were reviewed and identified the following: -12/9/24: LATE ENTRY: Writer was informed resident was going outside to smoke. Resident was educated that this is a no smoking facility and the is not allowed to smoke at the facility. Resident stated he understood the education. On 12/11/24 at 1:10 p.m., nursing assistant (NA)-C indicated that they believe they have one resident that smokes residing in the facility. NA-C indicated R189 was told to either smoke far away from the building or there is a back door with a table that R189 was allowed to sit at. NA-C indicated the facility's a tobacco free facility and residents should not be smoking. NA-C stated they have not observed R189 smoking but it is known that he goes and smokes as he goes outside and comes in and you can smell it. NA-C indicated they have not observed burn holes in R189 clothes and indicated R189 was pretty much independent. On 12/12/24 at 9:18 a.m., business office coordinator (BOC)-A stated the facility typically doesn't have residents who smoke. BOC-A stated she would tell the social worker and director of nursing (DON) if there was a resident who was smoking. On 12/12/24 at 9:27 a.m., registered nurse (RN)-A indicated the facility was a tobacco free campus. RN-A indicated if a resident smokes, their family can come and take them out to go smoke or if there was a providers order or physical therapy would write an order that they could leave the facility grounds. RN-A indicated the admission assessment asked about current tobacco use. RN-A stated it would be on the care plan if a resident was a known smoker. RN-A indicated if a resident was identified as a smoker, we let the social worker know right away for follow up. On 12/12/24 at 10:08 a.m., NA-D stated they were unsure of what the actual policy was if a resident was a smoker as when they first started residents were able to smoke in the parking lot, but they were unsure if they still could. NA-D stated R189 smokes and verified they have witnessed R189 go outside to smoke since admission. NA-D stated R189 will usually let staff know he was going outside to smoke but would go out independently. NA-D stated they have not seen any burn holes in R189's clothes or any signs on burns on his fingers. On 12/12/24 at 10:14 a.m., RN-B indicated the facility was smoke free facility. RN-B stated, we usually don't take smokers, or they are on the patch for the time being. RN-B verified R189 currently smokes. RN-B stated they were aware R189 was a smoker as when R189 would visit other residents (prior to R189's admission), R189 would go outside and smoke. RN-B stated R189 had asked about going outside to smoke and RN-B stated she referred him to talk to staff in the office. RN-B verified no additional smoking assessments had been completed for R189 and verified no smoking cessation had been ordered. On 12/12/24 at 12:18 p.m., licensed social worker (LSW)-A indicated the facility is a non-smoking facility. LSW-A stated residents can not smoke on our grounds so technically they can go outside the grounds, then we would have to go with them, so we don't allow that. LSW-A verified they knew R189 smoked prior to admitting to the facility. LSW-A stated she talked to R189 on 12/11/24 and inquired about a nicotine patch (4 days after admission) and verified no documentation of this. LSW-A verified R189's tobacco use was added to the care plan on 12/20/24 (3 days after admission) and after it was known R189 was smoking on outside on facility grounds. On 12/12/24 at 12:14 p.m., interim DON stated the facility's a non-smoking facility. DON verified additional assessment needs to be completed for identified smokers along with being care planned. DON verified she added tobacco use to R189 care plan on 12/10/24 (3 days after admission), the day she spoke with him. DON stated it would be expectation that tobacco use be identified on the care plan as soon as it was identified. On 12/12/24 at 2:40 p.m., RN-C stated the baseline care plans are the building blocks for the comprehensive care plans. RN-C verified there are not two separate care plans. RN-C verified if you pull up the care plan in the electronic medical record (EMR), the dates on the care plan are indicated and that is both the baseline and comprehensive care plan. On 12/12/24 at 2:04 p.m., administrator stated the facility's non-smoking facility and residents are told this prior to admission. Administrator indicated DON spoke with R189 about not being allowed to smoke on facility grounds. A facility policy titled Care Plan, reviewed/revised 12/2/24, indicated a baseline care plan will be developed upon admission according to federal and state regulations. A facility policy titled Smoking and Tobacco Use, reviewed/revised 11/24/24, indicated Upon admission, all residents/clients who smoke or use tobacco products will be assessed dousing the Tobacco Use Assessment. Assessments also will be administered if a resident/client has a change in cognitive ability, judgement, manual dexterity and/or mobility. Care plan will be updated as needed.

Based on interview and document review, the facility failed to ensure voiced complaints of potential abuse were acted upon, and investigated to ensure an adequate protection plan was provided to ensure freedom from abuse for 1 of 3 residents (R29) reviewed for abuse and neglect. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition with no delusional behaviors or hallucinations. R29's care plan dated 7/18/24, indicated R29 had a history of paranoia, accusations against staff, only allowing certain staff to work with her, and manipulating situations and staff. The care plan included goals for R29 of not displaying symptoms such as paranoia, yelling and swearing at staff, refusing care, accusing staff, and manipulation. The care plan included interventions such as using approaches with R29 to maximize involvement in daily decision-making and activity, stopping care and returning if R29 becomes agitated, and providing care in pairs for staff and resident safety. The care plan did not indicate what accusations had been made by R29 against staff in the past and if these accusations, were allegations of abuse. During an interview on 12/10/24 at 9:43 a.m., R29 stated three staff members at the facility were nonverbally and verbally abusive, even aggressive with her. R29 stated that one of these staff members, her aide right now, was verbally abusive towards her today. R29 stated she was fearful of these people caring for her as they said mean things to her. During an interview on 12/10/24 at 9:49 a.m., the administrator was notified of R29's accusations of verbal/nonverbal abuse by three staff members, one of which was her aide today. The administrator stated R29 had a history of making allegations against staff members and this was care planned. During an interview on 12/10/24 at 1:44 p.m., nursing assistant (NA)-B stated she was the aide in charge of R29's care. NA-B stated that R29 refused to let her perform her daily living activities, but she would enter R29's room by herself to answer R29's call light, give and retrieve her food tray, etc., as she had today. During an interview on 12/11/24 at 10:11 a.m., registered nurse (RN)-A stated he knew R29 had a history of making accusations about staff who R29 did not like but did not think R29 had made accusations of staff being abusive towards her. During an interview on 12/11/24 at 10:22 a.m., the administrator stated he had discussed R29's allegations of abuse with his interdisciplinary team but was unsure if the allegation had been investigated. The administrator stated if it had been, it would have been licensed social worker (LSW)-A or the director of nursing (DON) who completed the investigation. LSW-A stated she had not been aware of the allegation of abuse R29 had made, so this is not something she had investigated. During an interview on 12/11/24 at 10:29 a.m., R29 stated no one from the facility had followed up with her regarding the allegations of abuse she had made yesterday, and NA-B had continued to be her aide for the rest of the shift, so she occasionally entered her room which made her uncomfortable. During an interview on 12/11/24 at 10:36 a.m., the DON stated she had not talked with R29 regarding her abuse allegations yesterday or further investigated it, but she would look into it. At 12:04 p.m., the DON stated R29 had a history of making these accusations but they should have gone and followed up with R29 to determine if these accusations were new and if a protection plan needed to be placed. The DON stated it was care planned that R29 made false accusations about staff in the past but acknowledged the care plan did not outline if these false allegations had been abuse allegations or when these would be reported. The DON stated she was going to update the care plan, so staff knew what to do when R29 made abuse allegations as this was not currently part of the care plan. On 12/12/24 at 9:36 a.m., the DON stated the facility handled R29's allegations differently related to the past allegations she had made against staff, so the facility had not reported R29's allegations of abuse to the state agency. The DON stated if it were a different resident, they would have suspended the aide who the allegations were made against immediately to ensure resident safety and then the incident would be reported. The facility's Abuse and Neglect policy dated 7/6/23, indicated that all alleged or suspected violations/abuse would be thoroughly investigated, and they would put interventions in place to prevent further abuse while the investigation was in progress. The policy indicated if the allegation was employee-to-resident abuse, the employee would be removed from providing direct care to residents and placed on suspension pending the results of the internal investigation.

Based on interview and document review, the facility failed to immediately report incidents of potential staff to resident abuse to the state agency (SA) within two hours, as required for 1 of 3 residents (R29) reviewed for abuse. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition with no delusional behaviors or hallucinations. R29's care plan dated 7/18/24, indicated R29 had a history of paranoia, accusations against staff, only allowing certain staff to work with her, and manipulating situations and staff. The care plan included goals for R29 of not displaying symptoms such as paranoia, yelling and swearing at staff, refusing care, accusing staff, and manipulation. The care plan included interventions such as using approaches with R29 to maximize involvement in daily decision-making and activity, stopping care and returning if R29 becomes agitated, and providing care in pairs for staff and resident safety. The care plan did not indicate what accusations had been made by R29 against staff in the past and if these accusations, were allegations of abuse. During an interview on 12/10/24 at 9:43 a.m., R29 stated three staff members at the facility were nonverbally and verbally abusive, even aggressive with her. R29 stated that one of these staff members, her aide right now, was verbally abusive towards her today. R29 stated she was fearful of these people caring for her as they said mean things to her. During an interview on 12/10/24 at 9:49 a.m., the administrator was notified of R29's accusations of verbal/nonverbal abuse by three staff members, one of which was her aide today. The administrator stated R29 had a history of making allegations against staff members and this was care planned. During an interview on 12/10/24 at 1:44 p.m., nursing assistant (NA)-B stated she was the aide in charge of R29's care. NA-B stated that R29 refused to let her perform her daily living activities, but she would enter R29's room by herself to answer R29's call light, give and retrieve her food tray, etc., as she had today. During an interview on 12/11/24 at 10:11 a.m., registered nurse (RN)-A stated he knew R29 had a history of making accusations about staff who R29 did not like but did not think R29 had made accusations of staff being abusive towards her. During an interview on 12/11/24 at 10:22 a.m., the administrator stated he had discussed R29's allegations of abuse with his interdisciplinary team but was unsure if the allegation had been investigated. The administrator stated if it had been, it would have been licensed social worker (LSW)-A or the director of nursing (DON) who completed the investigation. LSW-A stated she had not been aware of the allegation of abuse R29 had made, so this is not something she had investigated. During an interview on 12/11/24 at 10:29 a.m., R29 stated no one from the facility had followed up with her regarding the allegations of abuse she had made yesterday, and NA-B had continued to be her aide for the rest of the shift, so she occasionally entered her room which made her uncomfortable. During an interview on 12/11/24 at 12:04 p.m., the DON stated R29 had a history of making these accusations but they should have gone and followed up with R29 to determine if these accusations were new and if a protection plan needed to be placed. The DON stated it was care planned that R29 made false accusations about staff in the past but acknowledged the care plan did not outline if these false allegations had been abuse allegations or when these would be reported. The DON stated she was going to update the care plan, so staff knew what to do when R29 made abuse allegations as this was not currently part of the care plan. On 12/12/24 at 9:36 a.m., the DON stated the facility handled R29's allegations differently related to the past allegations she had made against staff, so they had not reported R29's allegations of abuse to the state agency. The DON stated if it were a different resident, they would have suspended the aide who the allegations were made against immediately to ensure resident safety and then the incident would be reported. The facility's Abuse and Neglect policy dated 7/6/23, indicated that if an abuse allegation was made, it would be reported to the state agency immediately but no later than two hours after the allegation was made.

Based on interview and document review, the facility failed to ensure 1 of 3 (R1) residents reviewed for medication errors did not have properly transcribed orders for an antibiotic for an infected pressure ulcer. This medication error resulted in actual harm to R1 when she developed sepsis and was hospitalized . The facility implemented corrective action prior to the survey, so the deficiency was issued at past non-compliance. Findings include: Pressure Ulcer staging per the National Pressure Ulcer Advisory Panel (NPUAP): Stage 2 pressure ulcer: a partial-thickness skin loss with exposed dermis, the wound bed is viable, pink, and moist. Stage 4 pressure ulcer: a full-thickness skin and tissue loss with exposed muscle, ligament, cartilage or bone. Slough and/or eschar may be visible. Rolled edges or tunneling often occur. R1's 1/8/24 quarterly Minimum Data Set (MDS) identified she was cognitively intact, and required extensive assist of one to two staff for all activities of daily living. R1 had one Stage 2 pressure ulcer and one Stage 4 pressure ulcer. R1's care plan dated 4/8/24 included diagnoses of osteomyelitis, quadriplegia, history of stroke, and atherosclerosis of native arteries of right leg with ulceration of heel and midfoot. On 3/28/24 a report to the State Agency (SA) identified nurse practitioner (NP)-A ordered an antibiotic and new wound care orders for R1 on 3/13/24 for a right heel pressure ulcer infection. The order was not transcribed by the facility until 3/28/24, when the previous director of nursing (DON) found the written order in NP-A's office while organizing paperwork. The previous DON noted the order was not in R1's active orders. The facility was unable to determine how the written order ended up back in NP-A's office. On 4/4/24 a report to the SA identified licensed practical nurse (LPN)-A received a written order from NP-A on 3/13/24 for Bactrim (antibiotic) 200 milligram (mg) per 40 milliliter (ml), give 20 ml BID (twice a day) via feeding tube for 10 days. The written order also included updated wound care orders. The report indicated LPN-A had an issue entering the medication into the electronic health record (EHR) system and asked a coworker for help. The medication was not entered into the EHR on 3/13/24. The antibiotic was delivered by the pharmacy and placed in the medication fridge but none of the nursing staff noticed it in the fridge or verified if the medication was documented in the EHR for administration. R1's Active Orders dated 3/13/24 written by NP-A directed for R1's right heel wound to discontinue old wound orders and to clean with wound cleanser, apply moist blue foam dressing and cover with border sacral foam dressing. Change dressing daily and as needed when soiled. The antibiotic order directed Bactrim 200 mg per 40 ml, give 20 ml via feeding tube twice daily for ten days. R1's Active Orders dated 3/28/24 verified the antibiotic order was not started until 3/28/24. The orders directed to clean with wound cleanser, apply moist gauze to wound bed, cover with dressing pad and wrap with Kerlix. Change twice a day. R1's Wound Care Data Collection assessments for R1's right heel indicated the following: 3/7/24: The assessment indicated there was drainage leaking around the dressing and the condition of tissue surrounding the dressing was death tissue. It indicated eschar (dead tissue that sheds off after an injury) as 99% and noted there was a strong odor. 3/12/24: The assessment identified R1's right heel as a deep tissue injury, unstageable and covered with eschar. 3/19/24: The assessment identified the dressing was present and intact, with drainage present on the dressing. Another assessment was completed on 3/19/24 which indicated R1's heel was noted as having a foul odor and discharge. 3/21/24: The assessment identified the condition of the tissue surrounding the dressing was slightly macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture). 3/23/24: The assessment identified the heel was pink, intact and macerated. 3/24/24: The assessment identified the dressing was present, intact, with drainage present on the dressing. There was no leaking around the dressing and the skin around the dressing was macerated. The assessment indicated there was not a presence of possible complications, increasing area of ulceration or soft tissue infection. The wound margins were checked off as reddened. 3/25/24: The assessment identified the condition of the tissue surrounding the dressing was macerated, white, dry and flaky, moving further from the wound bed. 3/26/24: The assessment identified the surrounding skin of the heel was macerated, denuded and reddened. 3/27/24: The assessment identified the wound exhibits purulent discharge with a foul odor. But these have decreased with current treatment: Course of antibiotic therapy and use of Vashe (a wound cleansing solution). On 3/27/24, an additional assessment was completed. The assessment indicated the condition of the tissue surrounding the dressing was pink and intact. There was not a presence of possible complications, increasing area of ulceration or soft tissue infection. In addition, the assessment identified the surrounding skin of the wound was reddened. 3/28/24: The assessment identified the wound had necrotic tissue to the area, slough was present, and there was an odor. R1's progress notes lacked right heel wound care and assessment information prior to 3/28/24. On 4/2/24 R1's Hospital Care Consultation Note indicated R1 was admitted to the hospital's intensive care unit (ICU) and had septic shock (a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism)with persistent hypotension (low blood pressure) requiring vasopressor (medication used to make blood vessels constrict or become narrow in people with low blood pressure) support. R1 was diagnosed with an infected right foot ulcer, calcaneal osteomyelitis (bone infection in the heel), and a urinary tract infection. R1 was discharged from the hospital and returned to the facility on [DATE]. On 4/8/24 at 12:01 p.m., R1's family member (FM)-A stated she was never updated R1 was on an antibiotic until the previous DON discovered it had not been administered. She was not normally updated on medication changes, but she would have liked to have known about the antibiotic at the time it was ordered. On 4/8/24 at 1:50 p.m., R1 stated she was unaware that she was prescribed an antibiotic until she was notified that it was missed for two weeks. She would liked to be updated about new medications. On 4/9/24 at 9:17 a.m. LPN-A stated he received new orders for an antibiotic and wound treatment orders for R1 from NP-A. He had issues with entering it into the EHR and put a question mark on it and passed it to the night shift nurse so she could clarify and enter it into the system. He had been provided training on how to enter in new orders before the incident. He did not follow up on the orders again. H had received training on wound care, and he provided monitoring and assessments for R1's wounds on the shifts he worked. On 4/9/24 at 9:26 a.m., LPN-B stated she worked the night shift following LPN-A on 3/13/24. She did not remember LPN-A questioning an order for R1, or passing it on to her. On 4/9/24 at 2:27 p.m., the current DON stated R1 was hospitalized for sepsis related to the right heel wound infection. She stated the issue came down to LPN-A not knowing what to do in reference to entering the order into the system. She was surprised by this, because he usually asked other nurses or the DON for assistance. On 4/9/24 at 2:50 p.m., NP-A stated she was unaware R1's antibiotic and wound care orders had not been transcribed. She would have expected the nurses to let her know. She was updated about the worsening of the heel wound on 3/28/24, and noticed it herself when she saw it that day. From her assessment on 3/28/24, she was concerned about R1 being septic due to the worsening heel pressure ulcer, and decided to have R1 sent to the hospital. The facility policy Physician/Practitioner Orders - Rehab/Skilled revised 4/1/24 directed orders should be processed and transcribed into Point Click Care (PCC) immediately upon receipt of an order. Once the order is entered into PCC, the order will populate the appropriate electronic administration documentation location within the application. The past non-compliance began on 3/13/24 and the deficient practice was found and corrected on 3/28/24. The facility provided education to all nurses for implementing new provider orders. On 3/28/24, a skilled nursing facility shift form report was implemented to aid in hand off reports about new provider orders. Expectations for the wound nurse position was clarified and education was provided to nursing staff. A standing order workflow sheet was created and provided to staff. An audit of all active antibiotic orders and new provider orders from the previous 30 days was started on 3/28/24.