Every finding on record at Haven of Lakeside

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure that a pressure ulcer was assessed and treated timely and according to physician orders for one resident (#10). The deficient practice could lead to deterioration of a resident's medical condition.-Findings include:Resident #10 was admitted to the facility December 25, 2025, with diagnoses of dementia, other acute osteomyelitis of right ankle and foot, sepsis, pressure-induced deep tissue damage of right heel, non-pressure chronic ulcer of skin of other sites, type 2 diabetes mellitus with foot ulcer, Alzheimer's disease, and acquired absence of left great toe.A physician order dated December 25, 2025, included to complete a skin check weekly.A Weekly Skin check and Wound assessment dated [DATE], revealed the resident had the following skin impairments:nephrostomy tube on the right iliac crestskin impairment on the back of the right handsignificant diabetic foot ulcer on the right heel that was incised and debrided in acute carediabetic foot ulcer on the left heelleft great toe former amputation site, and remaining hallux that was an infected wound with osteomyelitis, and wound vac in place.diabetic ulcer on left toe(s)pressure injury on sacrum, with no evidence of further details or measurementsAn Audit Report of the Weekly Skin check and Wound assessment dated [DATE], revealed that a Licensed Practical Nurse (LPN / Staff #30) initially had entered pressure injury on coccyx on December 25, 2025, that was later edited on December 26, 2025, by a registered nurse / Assistant Director of Nursing (RN / ADON / Staff #45) to reveal pressure injury on sacrum.A care plan focus initiated December 25, 2025, revealed Resident #10 had a skin impairment of pressure ulcer to coccyx. Interventions included to administer treatments as ordered and monitor for effectiveness, to have a pressure-relieving mattress, a weekly skin assessment completed by licensed staff, and to monitor / document / report to physician changes in skin status as needed.A Braden Scale assessment dated [DATE], revealed Resident #10 was low risk for development of pressure ulcers.A handwritten paper Treatment Plan and Evaluation of Care document, dated December 26, 2025, and signed by Staff #45, revealed to cleanse with wound cleanser, apply Santyl (prescription enzymatic medication), cover with oil emulsion (adaptic), apply skin prep to periwound and cover with sacral dressing, and if patient refuses full treatment, please apply zinc oxide and cover dressing, to be completed daily. Despite the resident having just admitted to the facility on e day prior, the document also revealed patient has refused daily changes, seems confused, please continue to offer daily wound care. Review of the electronic medical record on January 27, 2026, revealed no evidence that the document was part of the resident's medical record.A paper document titled Formal Wound Assessment, with handwritten log entries, revealed that on December 26, 2025, the resident did not refuse the assessment, and there was no evidence that the resident refused any wound care treatment, and that the treatment objectives included enzymatic debridement and sacral foam cushion protection. The assessment did not include any evidence whether any wound care treatment was completed or not on December 26, 2025. The documentation revealed that on December 27 and 28, 2025, the resident refused a wound assessment, and refused treatment objectives. The documentation revealed that on December 29, 2025, that the wound was not measured, and that the treatment objectives included enzymatic debridement and sacral foam cushion protection, however also included that the resident refused santyl; educated. The document included no evidence of what wound care treatment was provided, if any. Review of the electronic medical record on January 27, 2026, revealed no evidence that the document was part of the resident's medical record.Physician orders dated December 26, 2025, included:- Wound care (Wound Vac): check every 4 hours for proper placement, functioning, and wound vac is upright.- Wound care (Wound Vac): if malfunctions please remove and place hydrogel-soaked gauze and cover area with ABD pad secured with tape, every shift, and notify charge nurse/Director of Nursing (DON)/ Assistant Director of Nursing (ADON).-There was no evidence of physician orders for wound care treatment for the pressure ulcer on the resident's coccyx / sacrum.A Pressure Ulcer Documentation assessment dated [DATE], however created on January 5, 2026 and signed January 6, 2026 by Staff #45, revealed Resident #10 had 1 unstageable pressure ulcer on the sacrum. Measurements were: 4.3 cm x 5.2 cm and depth unable to determine (UTD). The documentation details included Resident #10 was seen for initial assessment of pressure injury to sacral region. Additionally, the resident had diabetic foot ulcers (DFUs) to bilateral lower extremities, and that the sacral pressure wound was obscured thickness with moderate exudate which was serosanguinous in color and non-odorous, and wound bed was 90% slough and 10% granulation tissue, and peri-wound had peeling edges but was otherwise appropriate color for race. The resident experienced 2/10 pain during wound care, and declined daily Santyl (prescription enzymatic medication) at this time, and will continue education.Despite the documentation that the resident declined daily Santyl treatment, there was no evidence in the clinical record of a physician order for Santyl for the sacrum/coccyx wound.Physician orders dated December 27, 2025, included:- Wound care to left foot: cleanse with wound cleanser, pat dry, apply collagen and honey to wound bed followed by oil emulsion dressing. Apply skin prep and cover peri-wound with transparent dressing. Apply green foam followed by more skin prep and transparent dressing. Turn on unit to ensure dressing is on properly. Ensure Vac pressure at 125 mm Hg. Notify DON/ ADON of any changes.- Wound care to right heel: cleanse with wound cleanser, pat dry, paint with iodine. Apply collagen and honey to wound bed and cover with bordered gauze. May frame gauze if needed due to contour of wound area. Notify DON/ ADON of any changes.-There was no evidence of physician orders for wound care treatment to the pressure ulcer on the resident's coccyx / sacrum.A Late Entry History & Physical progress note dated December 26, 2025, however created January 15, 2026, revealed Resident #10 had a pressure ulcer of sacral region, unspecified stage.A Late Entry Wound progress note dated December 26, 2025, however created January 6, 2026, by Staff #45, revealed Resident #10 had a pressure injury to the sacral region which will be charted in the Pressure Ulcer Assessment.A Late Entry Daily Skilled Evaluation dated December 27, 2025, but created December 28, 2025, revealed Resident #10 refused wound care, but did not specify which wound care treatment was refused, or whether all wound care treatment was refused.A Late Entry Daily Skilled Evaluation dated December 28, 2025, but created December 31, 2025, revealed Resident #10 refused wound care, but did not specify which wound care treatment was refused, or whether all wound care treatment was refused.A Late Entry Daily Skilled Evaluation dated December 29, 2025, but created December 31, 2025, revealed Resident #10 refused wound care, but did not specify which wound care treatment was refused, or whether all wound care treatment was refused.A Late Entry Physician Progress Note dated December 29, 2025, but created January 2, 2026, revealed a list of Resident #10's medical diagnoses, however the list did not include a diagnosis of pressure ulcer of sacrum.A Late Entry Daily Skilled Evaluation dated December 30, 2025, but created December 31, 2025, revealed Resident #10 refused wound care, but did not specify which wound care treatment was refused, or whether all wound care treatment was refused.Despite the documentation of Resident #10 refusing wound care treatment on December 27, 28, 29, and 30, 2025, there was no evidence in the clinical record of education provided to the resident, or that multiple attempts were made, or that the provider was notified that the resident was refusing treatment.An admission minimum data set (MDS) assessment, dated December 31, 2025, revealed Resident #10 had a brief interview for mental status (BIMS) assessment score of 13, indicating intact cognition. Section M - Skin Conditions revealed the resident had no unhealed pressure ulcers/injuries, no venous and arterial ulcers, and no other open lesions other than ulcers, rashes, and cuts. The assessment revealed the resident did have an infection of the foot, a diabetic foot ulcer, and a surgical wound. Regarding treatments, the assessment revealed that Resident #10 did have surgical wound care and application of dressings to feet. However, the documentation revealed the resident did not have pressure ulcer/injury care or applications of non-surgical dressings or ointments/medications other than to feet.A Weekly Skin check and Wound assessment dated [DATE], but created on January 6, 2026 by Staff #45, revealed that Resident #10 had the following skin impairments:nephrostomy tube on the right iliac crestskin impairment on the back of the right handsignificant diabetic foot ulcer on the right heel that was incised and debrided in acute carediabetic foot ulcer on the left heelleft great toe former amputation site, and remaining hallux now infected wound with osteomyelitis, and wound vac in place.diabetic ulcer on left toe(s)pressure injury on sacrum, with no evidence of further details or measurements A Late Entry Wound progress note dated January 2, 2026, but created on January 6, 2026, by Staff #45, revealed documentation for the resident's left foot and right heel wounds. The note also included that the resident also had a pressure injury to the sacrum which would be charted in the Pressure Ulcer Assessment.A Pressure Ulcer Documentation assessment dated [DATE], but created on January 6, 2026, by Staff #45, revealed Resident #10 had 1 unstageable pressure ulcer on the sacrum. Measurements were: 4.3 cm x 5.2 cm and depth unable to determine (UTD). The documentation details included Resident #10 was seen for initial assessment of pressure injury to sacral region. Additionally, the resident had diabetic foot ulcers (DFUs) to bilateral lower extremities, and that the sacral pressure wound was obscured thickness with moderate exudate which was serosanguinous in color and non-odorous, and wound bed was 80% slough and 20% granulation tissue with zinc and sacral foam dressings. Additionally, peri-wound had peeling edges but was otherwise appropriate color for race. The documentation included that the floor nurse spoke with the resident and placed new orders for daily Santyl treatments.The clinical record was reviewed and revealed no evidence of a physician order for zinc for the sacral wound, and additionally no evidence of treatment orders specifying the type and frequency of wound dressing changes for the resident's sacral wound. Despite the documentation that new orders were placed for daily Santyl treatments, there was no evidence in the clinical record that a physician order was placed on January 2, 2026.Review of the resident's medical diagnoses list in the electronic medical record (EMR) revealed a diagnosis of pressure ulcer of sacral region, unspecified stage, was created on January 6, 2026, by Staff #45. There was no evidence of a medical diagnosis for pressure ulcer on the sacrum or coccyx created prior to January 6, 2026.A Late Entry Daily Skilled Evaluation progress note dated January 3, 2026, however created by an LPN (Staff #71) on January 4, 2026, revealed wound care completed today using aseptic technique and prescription medication to wound bed and to see TAR (treatment administration record) and wound notes for details, and that the resident tolerated wound care well. The note did not specify what site of the resident's body the wound care was provided to or which prescription medication was applied to where.A Daily Skilled Evaluation note dated January 4, 2026, revealed the resident tolerated wound care well, but did not specify what wound care treatment or to which body site.Review of the clinical record revealed no evidence of any physician order for wound care treatment to the resident's coccyx or sacrum from when the resident admitted on [DATE] until January 6, 2026.A physician order dated January 6, 2026, with a start date of January 7, 2026, included for wound care to coccyx: cleanse with wound cleanser, pat dry, apply Santyl to wound bed, followed by oil emulsion dressing, apply skin prep and cover with sacral foam dressing, and to notify DON/ADON of any changes.Review of the Medication Administration Record and Treatment Administration Record (MAR / TAR) for December 2025 revealed no evidence of any wound care treatment provided to the resident's coccyx or sacrum. Review of the MAR / TAR for January 2026 revealed treatment to the resident's coccyx started on January 7, 2026.An interview was conducted with a licensed practical nurse (LPN / Staff #19) on January 27, 2026, at 12:25 p.m. who stated that as a floor nurse, she completes an admission assessment on a new resident that admits to the unit. Staff #19 stated that additionally, a skin assessment and Braden Scale assessment are completed for a resident upon admission and documented in the electronic medical record (EMR), and that all wounds and skin impairments are documented on the skin assessment form. Staff #19 stated that the floor nurses are not supposed to take any measurements of the wounds, and that the wound nurse (Staff #45) is the staff responsible for taking wound measurements.A telephonic interview was conducted with an LPN (Staff #71) on January 27, 2026, at 12:32 p.m., who stated that for a new admission resident, nurses complete a head to toe skin assessment that is documented on the weekly skin assessment form in the EMR. If a resident had a pressure ulcer, then Staff #71 stated a nurse would inform the wound nurse (Staff #45) in order for her to complete further assessment. Regarding Resident #10, Staff #71 stated that he had been the nurse for Resident #10, and that the resident had wounds on his feet, but that he did not believe the resident had any wounds on his sacrum region.A telephonic interview was conducted with an MDS coordinator registered nurse (RN / Staff #90) on January 27, 2026, at 2:09 p.m. who stated that she completes resident assessments that are relevant to the MDS, and that she also reviews data from the EMR in order to complete the MDS assessments for residents. Staff #90 stated that she reviews admission skin assessments from the resident's EMR in order to complete the MDS assessment accurately, and if she has any further questions, she would contact the wound nurse (Staff #45). Staff #90 stated that if the MDS assessment were not completed accurately, then aspects of the resident's care plan or treatment may be missed. The admission MDS assessment for Resident #10 was reviewed, and Staff #90 stated that the assessment included that the resident had osteomyelitis, a diabetic foot ulcer, and a surgical wound, and that the resident did not have any pressure ulcers. The care plan for Resident #10 was reviewed, and Staff #90 stated that a care plan dated December 25, 2025, included that the resident had a pressure ulcer to the coccyx. Staff #90 stated that it looked like the admission MDS assessment had not been completed accurately, and that it looked like the pressure ulcer on the coccyx was missed. Staff #90 reviewed the Resident #10's physician orders, and stated that wound care treatments for the resident's coccyx / sacrum started on January 7, 2026.An interview was conducted with the ADON / RN (Staff #45) on January 27, 2026, at approximately 2:30 p.m. who stated that she performs wound assessments for residents on admission if she is notified via record review or by nursing staff that a resident has a wound that requires assessment, and that she performs weekly wound assessments, and oversees the wound program. Regarding Resident #10, Staff #45 reviewed the clinical record and stated that he had an unstageable pressure ulcer on his sacrum on admission, and that it measured 4.3 x 5.2 centimeters (cm). Staff #45 stated that initially, Resident #10 was ordered daily Santyl wound treatments for his sacrum, and that the resident was refusing the wound care. Then, Staff #45 stated over the course of the resident's admission, he became more compliant. Regarding, the Pressure Ulcer Documentation assessment dated [DATE], however created January 5, 2026, Staff #45 stated that it was entered in the medical record late because she got behind in her paperwork. Staff #45 stated that she keeps her own records of the wound assessments that she performs, and that herself and the DON have access to them.An interview was conducted with the Director of Nursing (DON / Staff #66) on January 27, 2026, at approximately 3:00 p.m. who stated that his expectation for floor nurses to assess new admission residents was that multiple types of assessments are completed, and are often dependent on the resident's diagnoses. The DON stated that all new admission residents should have a head to toe skin assessment completed, and recorded in the medical record. Additionally, the DON stated that if a resident had wounds, depending on the type of wound, further assessment and measurements would be completed. The DON stated that a risk to a resident if something was missed on initial assessment would be potentially something could be missed, such as a treatment. Regarding Resident #10, the DON stated that he was not very familiar with the resident, but that he was aware that the resident had wounds. The clinical record was reviewed, and the DON stated that the resident had a pressure ulcer on the coccyx, and feet, and that the resident had a wound vac but could not state where the wound vac was located based on his review of the medical record. The DON also stated that depending on a resident's anatomy, the word coccyx and sacrum could be at times used interchangeably because the regions are so close together on the body. The DON deferred further detailed questions regarding Resident #10's wounds to the ADON / wound nurse (Staff #45).A follow-up interview was conducted with the ADON (Staff #45) on January 27, 2026, at approximately 3:15 p.m. who then provided paper handwritten documentation, including the Treatment Plan and Evaluation of Care document, dated December 26, 2025, and signed by Staff #45, to which she stated was her treatment plan that she recommended for Resident #10. Staff #45 also provided the paper document titled Formal Wound Assessment, which she stated showed that the wound treatment was offered and provided. Staff #45 stated that there was not a physician signature on her treatment plan, and she believed she had told the physician about her treatment recommendation.Another interview was conducted with the DON (Staff #66) on January 27, 2026, at approximately 3:20 p.m. who provided a paper copy of the facility's Standing Wound Orders and Instructions, and stated that the standing wound orders covered both dressing change and debridement, so no other physician order was needed for Resident #10's wound care treatment.Review of the facility's Standing Orders and Instructions for All Patients, signed by a provider, and dated February 27, 2025, included that these wound care treatment plan instructions must be followed by nursing staff to ensure optimal wound healing. Minor modifications or clarifications to treatment plan orders may be made, such as specifying dressing brands, or adjusting dressing change days to align with the facility's dressing supply, staff scheduling, or patient preference. However, unless specified otherwise, the type of dressings used may not be changed in the treatment plan order without provider authorization.Standard Wound Preparation and Cleaning: Unless indicated or instructed otherwise, standard care protocol for ALL wounds includes the following: When possible, schedule dressing changes around shower days. Unless specified otherwise, dressings may be removed, and wounds cleaned in the shower. Nurse may apply lidocaine spray/cream before cleaning/debriding wound for patient comfort. Clean wounds, peri-wounds, and peripheral skin with Hibiclens or similar antiseptic soap, then irrigate with an antimicrobial wound cleanser (e.g., Vashe, Dakins 0.0125%, commercial wound wash, etc.). Paint peri-wound immediately around the wound with iodine or other antiseptic before dressing placement. Use skin prep solution (e.g., benzoin, Mastisol, skin prep, etc.) when applying bordered adhesive dressings. All bordered dressings may be window-paned with Tegaderm-type adhesive to enhance adhesion. Moisturize surrounding skin after every dressing change using fragrance-free cream for normal/dry skin or A&D ointment, Eucerin cream, or similar for very dry/cracked skin. Use Calmoseptine or other barrier cream for peri-wound rash caused by moisture or exudate.Wound Debridement: All wounds may be lightly to moderately scrubbed (debrided) with moist gauze and/or cotton applicator to remove exudate and revitalize wound bed. However, sharp debridement can only be done by provider or certified wound care specialist. The document revealed no evidence of a standing order for Santyl (enzymatic debridement).Review of the manufacturer's website for Santyl ointment revealed the drug is a prescription medication used to remove damaged tissue from chronic skin ulcers and severely burned areas. Do not use if you have shown hypersensitivity to collagenase. Occasional slight redness may occur if Santyl ointment is placed outside the wound area. Precautions should be taken to avoid detergents or cleansing solutions that are acidic or basic in nature, as raising or lowering of the ointment's pH can lower the effectiveness. Caregivers to debilitated patients should closely monitor the application site to ensure that the area is not becoming infected. (https://santyl.com/)Review of online database Quick Confirm License Verification revealed that Staff #45 was a registered nurse, and did not have prescriptive authority. (https://www.nursys.com/)Review of the facility policy titled Skin/Wound Management: Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated January 1, 2024, revealed the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; Current treatments, including support surfaces; and all active diagnoses. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. Review of the facility policy titled Skin/Wound Management: Wound Care, dated January 1, 2024, revealed to verify that there is a physician's order for the procedure, and to review the resident's care plan to assess for any special needs of the resident. For example, the resident may have as needed (PRN) orders for pain medication to be administered prior to would care. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc., with alcohol pledget before opening, as necessary. (Note: This may be performed at the treatment cart.) The following information should be recorded in the resident's medical record:1. The type of wound care given.2. The date and time the wound care was given.3. The position in which the resident was placed.4. The name and title of the individual performing the wound care.5. Any change in the resident's condition.6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting thewound. Review of the facility policy titled Orders / Receiving / Transcribing: Medication and Treatment Orders, dated January 1, 2024, revealed medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The signing of orders shall be by signature or a personal computer key. Signature stamps may not be used. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. Verbal orders must be signed by the prescriber at his or her next visit. Orders for medications must include:a. name and strength of the drug;b. number of doses, start and stop date, and/or specific duration of therapy;c. dosage and frequency of administration;d. route of administration;e. clinical condition or symptoms for which the medication is prescribed; andf. any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.).

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure that the medical record was complete, accurate, and readily accessible for one resident (#10). The deficient practice could lead to care team members not being aware of a resident's status.-Findings include:Resident #10 was admitted to the facility December 25, 2025, with diagnoses of dementia, other acute osteomyelitis of right ankle and foot, sepsis, pressure-induced deep tissue damage of right heel, non-pressure chronic ulcer of skin of other sites, type 2 diabetes mellitus with foot ulcer, Alzheimer's disease, and acquired absence of left great toe.A physician order dated December 25, 2025, included to complete a skin check weekly.A Weekly Skin check and Wound assessment dated [DATE], revealed the resident had the following skin impairments:nephrostomy tube on the right iliac crestskin impairment on the back of the right handsignificant diabetic foot ulcer on the right heel that was incised and debrided in acute carediabetic foot ulcer on the left heelleft great toe former amputation site, and remaining hallux that was an infected wound with osteomyelitis, and wound vac in place.diabetic ulcer on left toe(s)pressure injury on sacrum, with no evidence of further details or measurementsA care plan focus initiated December 25, 2025, revealed Resident #10 had a skin impairment of pressure ulcer to coccyx. Interventions included to administer treatments as ordered and monitor for effectiveness, to have a pressure-relieving mattress, a weekly skin assessment completed by licensed staff, and to monitor / document / report to physician changes in skin status as needed.A handwritten paper Treatment Plan and Evaluation of Care document, dated December 26, 2025, and signed by Staff #45, revealed to cleanse with wound cleanser, apply Santyl (prescription enzymatic medication), cover with oil emulsion (adaptic), apply skin prep to periwound and cover with sacral dressing, and if patient refuses full treatment, please apply zinc oxide and cover dressing, to be completed daily. Despite the resident having just admitted to the facility on e day prior, the document also revealed patient has refused daily changes, seems confused, please continue to offer daily wound care. Review of the electronic medical record on January 27, 2026, revealed no evidence that the document was part of the resident's medical record.A paper document titled Formal Wound Assessment, with handwritten log entries, revealed that on December 26, 2025, the resident did not refuse the assessment, and there was no evidence that the resident refused any wound care treatment, and that the treatment objectives included enzymatic debridement and sacral foam cushion protection. The assessment did not include any evidence whether any wound care treatment was completed or not on December 26, 2025. The documentation revealed that on December 27 and 28, 2025, the resident refused a wound assessment, and refused treatment objectives. The documentation revealed that on December 29, 2025, that the wound was not measured, and that the treatment objectives included enzymatic debridement and sacral foam cushion protection, however also included that the resident refused santyl; educated. The document included no evidence of what wound care treatment was provided, if any. Review of the electronic medical record on January 27, 2026, revealed no evidence that the document was part of the resident's medical record.Physician orders dated December 26, 2025, included:- Wound care (Wound Vac): check every 4 hours for proper placement, functioning, and wound vac is upright. There was no evidence specifying to what site.- Wound care (Wound Vac): if malfunctions please remove and place hydrogel-soaked gauze and cover area with ABD pad secured with tape, every shift, and notify charge nurse/Director of Nursing (DON)/ Assistant Director of Nursing (ADON). There was no evidence specifying to what site.-There was no evidence of physician orders for wound care treatment for the pressure ulcer on the resident's coccyx / sacrum.A Pressure Ulcer Documentation assessment dated [DATE], however created on January 5, 2026 and signed January 6, 2026 by a registered nurse / Assistant Director of Nursing (RN / ADON / Staff #45), revealed Resident #10 had 1 unstageable pressure ulcer on the sacrum. Measurements were: 4.3 cm x 5.2 cm and depth unable to determine (UTD). The documentation details included Resident #10 was seen for initial assessment of pressure injury to sacral region. Additionally, the resident had diabetic foot ulcers (DFUs) to bilateral lower extremities, and that the sacral pressure wound was obscured thickness with moderate exudate which was serosanguinous in color and non-odorous, and wound bed was 90% slough and 10% granulation tissue, and peri-wound had peeling edges but was otherwise appropriate color for race. The resident experienced 2/10 pain during wound care, and declined daily Santyl (prescription enzymatic medication) at this time, and will continue education.Despite the documentation that the resident declined daily Santyl treatment, there was no evidence in the clinical record of a physician order for Santyl for the sacrum/coccyx wound.Physician orders dated December 27, 2025, included:- Wound care to left foot: cleanse with wound cleanser, pat dry, apply collagen and honey to wound bed followed by oil emulsion dressing. Apply skin prep and cover peri-wound with transparent dressing. Apply green foam followed by more skin prep and transparent dressing. Turn on unit to ensure dressing is on properly. Ensure Vac pressure at 125 mm Hg. Notify DON/ ADON of any changes.- Wound care to right heel: cleanse with wound cleanser, pat dry, paint with iodine. Apply collagen and honey to wound bed and cover with bordered gauze. May frame gauze if needed due to contour of wound area. Notify DON/ ADON of any changes.-There was no evidence of physician orders for wound care treatment to the pressure ulcer on the resident's coccyx / sacrum.A Late Entry History & Physical progress note dated December 26, 2025, however created January 15, 2026, revealed Resident #10 had a pressure ulcer of sacral region, unspecified stage.A Late Entry Wound progress note dated December 26, 2025, however created January 6, 2026, by Staff #45, revealed Resident #10 had a pressure injury to the sacral region which will be charted in the Pressure Ulcer Assessment.A Late Entry Daily Skilled Evaluation dated December 27, 2025, but created December 28, 2025, revealed Resident #10 refused wound care, but did not specify which wound care treatment was refused, or whether all wound care treatment was refused.A Late Entry Daily Skilled Evaluation dated December 28, 2025, but created December 31, 2025, revealed Resident #10 refused wound care, but did not specify which wound care treatment was refused, or whether all wound care treatment was refused.A Late Entry Daily Skilled Evaluation dated December 29, 2025, but created December 31, 2025, revealed Resident #10 refused wound care, but did not specify which wound care treatment was refused, or whether all wound care treatment was refused.A Late Entry Physician Progress Note dated December 29, 2025, but created January 2, 2026, revealed a list of Resident #10's medical diagnoses, however the list did not include a diagnosis of pressure ulcer of sacrum.A Late Entry Daily Skilled Evaluation dated December 30, 2025, but created December 31, 2025, revealed Resident #10 refused wound care, but did not specify which wound care treatment was refused, or whether all wound care treatment was refused.Despite the documentation of Resident #10 refusing wound care treatment on December 27, 28, 29, and 30, 2025, there was no evidence in the clinical record of education provided to the resident, or that multiple attempts were made, or that the provider was notified that the resident was refusing treatment.An admission minimum data set (MDS) assessment, dated December 31, 2025, revealed Resident #10 had a brief interview for mental status (BIMS) assessment score of 13, indicating intact cognition. Section M - Skin Conditions revealed the resident had no unhealed pressure ulcers/injuries, no venous and arterial ulcers, and no other open lesions other than ulcers, rashes, and cuts. The assessment revealed the resident did have an infection of the foot, a diabetic foot ulcer, and a surgical wound. Regarding treatments, the assessment revealed that Resident #10 did have surgical wound care and application of dressings to feet. However, the documentation revealed the resident did not have pressure ulcer/injury care or applications of non-surgical dressings or ointments/medications other than to feet.A Weekly Skin check and Wound assessment dated [DATE], but created on January 6, 2026 by Staff #45, revealed that Resident #10 had the following skin impairments:nephrostomy tube on the right iliac crestskin impairment on the back of the right handsignificant diabetic foot ulcer on the right heel that was incised and debrided in acute carediabetic foot ulcer on the left heelleft great toe former amputation site, and remaining hallux now infected wound with osteomyelitis, and wound vac in place.diabetic ulcer on left toe(s)pressure injury on sacrum, with no evidence of further details or measurementsA Late Entry Wound progress note dated January 2, 2026, but created on January 6, 2026, by Staff #45, revealed documentation for the resident's left foot and right heel wounds. The note also included that the resident also had a pressure injury to the sacrum which would be charted in the Pressure Ulcer Assessment.A Pressure Ulcer Documentation assessment dated [DATE], but created on January 6, 2026, by Staff #45, revealed Resident #10 had 1 unstageable pressure ulcer on the sacrum. Measurements were: 4.3 cm x 5.2 cm and depth unable to determine (UTD). The documentation details included Resident #10 was seen for initial assessment of pressure injury to sacral region. Additionally, the resident had diabetic foot ulcers (DFUs) to bilateral lower extremities, and that the sacral pressure wound was obscured thickness with moderate exudate which was serosanguinous in color and non-odorous, and wound bed was 80% slough and 20% granulation tissue with zinc and sacral foam dressings. Additionally, peri-wound had peeling edges but was otherwise appropriate color for race. The documentation included that the floor nurse spoke with the resident and placed new orders for daily Santyl treatments.The clinical record was reviewed and revealed no evidence of a physician order for zinc for the sacral wound, and additionally no evidence of treatment orders specifying the type and frequency of wound dressing changes for the resident's sacral wound. Despite the documentation that new orders were placed for daily Santyl treatments, there was no evidence in the clinical record that a physician order was placed on January 2, 2026.Review of the resident's medical diagnoses list in the electronic medical record (EMR) revealed a diagnosis of pressure ulcer of sacral region, unspecified stage, was created on January 6, 2026, by Staff #45. There was no evidence of a medical diagnosis for pressure ulcer on the sacrum or coccyx created prior to January 6, 2026.A Late Entry Daily Skilled Evaluation progress note dated January 3, 2026, however created by an LPN (Staff #71) on January 4, 2026, revealed wound care completed today using aseptic technique and prescription medication to wound bed and to see TAR (treatment administration record) and wound notes for details, and that the resident tolerated wound care well. The note did not specify what site of the resident's body the wound care was provided to or which prescription medication was applied to where.A Daily Skilled Evaluation note dated January 4, 2026, revealed the resident tolerated wound care well, but did not specify what wound care treatment or to which body site.Review of the clinical record revealed no evidence of any physician order for wound care treatment to the resident's coccyx or sacrum from when the resident admitted on [DATE] until January 6, 2026.A physician order dated January 6, 2026, with a start date of January 7, 2026, included for wound care to coccyx: cleanse with wound cleanser, pat dry, apply Santyl to wound bed, followed by oil emulsion dressing, apply skin prep and cover with sacral foam dressing, and to notify DON/ADON of any changes.Review of the Medication Administration Record and Treatment Administration Record (MAR / TAR) for December 2025 revealed no evidence of any wound care treatment provided to the resident's coccyx or sacrum. Review of the MAR / TAR for January 2026 revealed treatment to the resident's coccyx started on January 7, 2026.A telephonic interview was conducted with an LPN (Staff #71) on January 27, 2026, at 12:32 p.m., who stated that for a new admission resident, nurses complete a head to toe skin assessment that is documented on the weekly skin assessment form in the EMR. If a resident had a pressure ulcer, then Staff #71 stated a nurse would inform the wound nurse (Staff #45) in order for her to complete further assessment. Regarding Resident #10, Staff #71 stated that he had been the nurse for Resident #10, and that the resident had wounds on his feet, but that he did not believe the resident had any wounds on his sacrum region.A telephonic interview was conducted with an MDS coordinator registered nurse (RN / Staff #90) on January 27, 2026, at 2:09 p.m. who stated that she completes resident assessments that are relevant to the MDS, and that she also reviews data from the EMR in order to complete the MDS assessments for residents. Staff #90 stated that she reviews admission skin assessments from the resident's EMR in order to complete the MDS assessment accurately, and if she has any further questions, she would contact the wound nurse (Staff #45). Staff #90 stated that if the MDS assessment were not completed accurately, then aspects of the resident's care plan or treatment may be missed. The admission MDS assessment for Resident #10 was reviewed, and Staff #90 stated that the assessment included that the resident had osteomyelitis, a diabetic foot ulcer, and a surgical wound, and that the resident did not have any pressure ulcers. The care plan for Resident #10 was reviewed, and Staff #90 stated that a care plan dated December 25, 2025, included that the resident had a pressure ulcer to the coccyx. Staff #90 stated that it looked like the admission MDS assessment had not been completed accurately, and that it looked like the pressure ulcer on the coccyx was missed. Staff #90 reviewed the Resident #10's physician orders, and stated that wound care treatments for the resident's coccyx / sacrum started on January 7, 2026.An interview was conducted with the ADON / RN (Staff #45) on January 27, 2026, at approximately 2:30 p.m. who stated that she performs wound assessments for residents on admission if she is notified via record review or by nursing staff that a resident has a wound that requires assessment, and that she performs weekly wound assessments, and oversees the wound program. Regarding Resident #10, Staff #45 reviewed the clinical record and stated that he had an unstageable pressure ulcer on his sacrum on admission, and that it measured 4.3 x 5.2 centimeters (cm). Staff #45 stated that initially, Resident #10 was ordered daily Santyl wound treatments for his sacrum, and that the resident was refusing the wound care. Then, Staff #45 stated over the course of the resident's admission, he became more compliant. Regarding, the Pressure Ulcer Documentation assessment dated [DATE], however created January 5, 2026, Staff #45 stated that it was entered in the medical record late because she got behind in her paperwork. Staff #45 stated that she keeps her own records of the wound assessments that she performs, and that herself and the DON have access to them.An interview was conducted with the Director of Nursing (DON / Staff #66) on January 27, 2026, at approximately 3:00 p.m. who stated that his expectation for floor nurses to assess new admission residents was that multiple types of assessments are completed, and are often dependent on the resident's diagnoses. The DON stated that all new admission residents should have a head to toe skin assessment completed, and recorded in the medical record. Additionally, the DON stated that if a resident had wounds, depending on the type of wound, further assessment and measurements would be completed. The DON stated that a risk to a resident if something was missed on initial assessment would be potentially something could be missed, such as a treatment. Regarding Resident #10, the DON stated that he was not very familiar with the resident, but that he was aware that the resident had wounds. The clinical record was reviewed, and the DON stated that the resident had a pressure ulcer on the coccyx, and feet, and that the resident had a wound vac but could not state where the wound vac was located based on his review of the medical record.A follow-up interview was conducted with the ADON (Staff #45) on January 27, 2026, at approximately 3:15 p.m. who then provided paper handwritten documentation, including the Treatment Plan and Evaluation of Care document, dated December 26, 2025, and signed by Staff #45, to which she stated was her treatment plan that she recommended for Resident #10. Staff #45 also provided the paper document titled Formal Wound Assessment, which she stated showed that the wound treatment was offered and provided. Staff #45 stated that there was not a physician signature on her treatment plan, and she believed she had told the physician about her treatment recommendation.Review of the facility policy titled Charting and Documentation, dated January 1, 2024, revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Information documented in the resident's clinical record is confidential and may only be released in accordance with state law, the Health Insurance Portability and Accountability Act (HIPAA) and facility policy. Refer all requests for information to the director of nursing services, nurse supervisor/charge nurse or to the business office. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting. Review of the facility policy titled Skin/Wound Management: Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated January 1, 2024, revealed the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; Current treatments, including support surfaces; and all active diagnoses. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. Review of the facility policy titled Skin/Wound Management: Wound Care, dated January 1, 2024, revealed to verify that there is a physician's order for the procedure, and to review the resident's care plan to assess for any special needs of the resident. For example, the resident may have as needed (PRN) orders for pain medication to be administered prior to would care. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc., with alcohol before opening, as necessary. (Note: This may be performed at the treatment cart.) The following information should be recorded in the resident's medical record:1. The type of wound care given.2. The date and time the wound care was given.3. The position in which the resident was placed.4. The name and title of the individual performing the wound care.5. Any change in the resident's condition.6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting thewound. Review of the facility policy titled Orders / Receiving / Transcribing: Medication and Treatment Orders, dated January 1, 2024, revealed medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The signing of orders shall be by signature or a personal computer key. Signature stamps may not be used. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. Verbal orders must be signed by the prescriber at his or her next visit. Orders for medications must include:a. name and strength of the drug;b. number of doses, start and stop date, and/or specific duration of therapy;c. dosage and frequency of administration;d. route of administration;e. clinical condition or symptoms for which the medication is prescribed; andf. any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.)

Based on clinical record review, interviews, and facility documentation, the facility failed to implement their policy on abuse regarding reporting and investigation of an allegation of abuse for one of 3 sampled resident (#51). The deficient practice could result in residents not protected from further abuse. Findings include:-Resident #17 (alleged perpetrator) was readmitted to the facility on [DATE], with diagnoses of dementia, history of traumatic brain injury, anxiety disorder, major depressive disorder, history of transient ischemic attack, and cerebral infarction.A care plan revised on August 12, 2025 revealed the resident had behavior problems consisting of eating other resident's food, wandering, refusing care, and being sexually inappropriate. Interventions included administering medications as ordered, removing from situations and explaining why the behavior is inappropriate/unacceptable. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident had no cognitive impairment. A late entry Nurse Practitioner (NP/staff #500) note dated January 10, 2026 included staff reported that resident #17 exhibited sexual inappropriate behaviors with another resident. The note included a staff member saw the hands of resident #17 inside the back of the pants of the other resident (#51); and that, both residents were kissing each other. The documentation included that resident #17 was a registered s** o*******; and that, there was an incident where resident #17 was talking loudly on his portable phone in the lounge area, making sexually explicit comments, including asking about breast size and making sexual remarks. It also included that when staff attempted to redirect resident #17, the resident becomes upset and continues the behavior. Per the documentation, the facility was notified of the staff report and staff were instructed to continue monitoring the situation closely. The late entry behavior note dated January 15, 2026 revealed that at approximately 10:15 a.m. the resident walked by a female peer and pretended to touch the female resident's cheek. Per the documentation, the CNA (certified nursing assistant reminded resident #17 not to touch peers and the resident walked away. A NP note dated January 21, 2026 included that upon review of the camera footage by the Director of Nursing, it was determined that the staff's initial report was inaccurate. Per the documentation, the hands of resident #17 was not inside the pants of another resident (#51); but rather, both residents were holding hands. The documentation also included that on one occasion, resident #17 placed his hand on the thigh of resident #51. -Resident #51 (alleged victim) was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer's disease. A care plan revised on August 12, 202, revealed the resident had a communication problem related to impaired cognition and a hearing deficient, had an alteration in neurological status related to a diagnosis of neurocognitive disorder, and, had impaired cognitive function/dementia or impaired thought processes related to dementia and Alzheimer's disease. Interventions included anticipating and meeting needs, and encouragement to continue stating thoughts even if there is difficulty, administering medications as ordered and monitoring for side effects and interventions, and, to face the resident when speaking, make eye contact with the resident, reduce distractions, keep routine consistent and try to provide consistent care givers to decrease confusion.The MDS assessment dated [DATE], revealed the resident had a BIMS score of 00, which indicated resident had severe cognitive impairment. Review of the clinical record revealed no documentation of an incident between resident #51 and another resident (#17) on January 10, 2026. Despite documentation, there was no evidence found in the clinical record and facility documentation that the incident between resident #17 and #51 were reported to the State Agency (SA), Ombudsman and law enforcement.There was also no evidence that the incident was thoroughly investigated and the results of the investigation was reported to the SA within 5 working days of the incident. On January 21, 2026, at 10:10 a.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #230) who stated that she was aware of the report that someone saw resident #17 put his hands down the pants of a female resident (#51); however, the ADON stated that she was not aware of who saw this incident. The ADON said that the incident was reported to the Director of Nursing (DON/staff #200) and the Administrator (staff #250); and that, she heard the camera footage was reviewed and she was told that the residents were just holding hands. The ADON further stated that she did not review the camera footage herself. In an interview conducted with the DON (staff #200) and the Administrator (staff #250) on January 21, 2026 at 1:50 p.m., the DON stated that he was made aware by a staff that resident #17 placed his hands down a female resident's pants; however, he was unable to recall which staff member reported the incident. He stated the allegation was discussed in the facility's IDT (interdisciplinary team) meeting; and that, the video camera footage was reviewed by himself and the Administrator (staff #250). The DON stated the video footage showed that both residents were sitting, the hand of the female resident was on the thigh of resident #17; and that, the hand of resident #17 was on the back of the female resident. The DON stated the incident was investigated and was unsubstantiated because resident #17 has a behavior of being sexually inappropriate; and, this incident was a behavior and not abuse. Further, the DON said that this was also the reason why the incident was not reported to the SA. Regarding their investigation, he and the Administrator determined that investigation was not needed because the incident happened in the behavior unit. The Administrator stated the video footage of the incident was no longer available for review because their system auto deletes in 72 hours. Despite admitting to reviewing the video footage of the incident, both the Administrator and the DON stated that they do not know who the female resident that was involved with this incident. The Administrator stated that the intent to cause harm would constitute abuse. The DON stated that it would only be considered abuse if the psychiatric provider says that it is. He also said that there was no preventive measures in place for resident #17 because being sexually inappropriate was a behavior of resident #17. An interview was conducted with a Certified Medical Assistant (CMA/staff #220) and Certified Nursing Assistant (CNA/staff #227) on January 21, 2026 at 2:46 p.m. Both staff #220 and #227 stated they heard about the incident regarding with resident #17 putting his hands down the pants of resident #51 but they did not witness the incident.A telephone interview was conducted with the Nurse Practitioner (NP/staff #500), on January 21, 2026 at 3:18 p.m. The NP stated that he wrote the note on January 10, 2026 because staff reported to him that resident #17 had his hands down a female resident's pants; however, he did not witness the incident. The NP stated that he did not review the video footage of the incident but the DON called and told him what the DON saw on the footage; and that, he had to write another note in case anything went to court. The NP stated that this was the reason why he wrote the NP note on January 21, 2026. Review of the facility's policy on Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated January 1, 2024, included that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility; local/state ombudsman; adult protective services (where state law provides jurisdiction in long-term care); and law enforcement officials. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. All allegations are thoroughly investigated. The administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. The individual conducting the investigation as a minimum:a. Reviews the documentation and evidence;b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident;c. Observes the alleged victim, including his or her interactions with staff and other residents;d. Interviews the person(s) reporting the incident;e. Interviews any witnesses to the incident;f. Interviews the resident (as medically appropriate) or the resident's representative;g. Interviews the resident's attending physician as needed to determine the resident's condition;h. Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;i. Interviews the resident's roommate, family members, and visitors;j. Interviews other residents to whom the accused employee provides care or services;k. Reviews all events leading up to the alleged incident; andl. Documents the investigation completely and thoroughly.

Based on clinical record review, interviews, and facility documentation, the facility failed to ensure that an allegation of abuse for one of 3 sampled residents (#51) was reported to the State Agency, Ombudsman and law enforcement and failed to report the results of the investigation to the State Agency within 5 working days of the incident as required. The deficient practice could result in abuse not being reported and residents not protected from further abuse.Findings include: -Resident #17 (alleged perpetrator) was readmitted to the facility on [DATE], with diagnoses of dementia, history of traumatic brain injury, anxiety disorder, major depressive disorder, history of transient ischemic attack, and cerebral infarction.A care plan revised on August 12, 2025 revealed the resident had behavior problems consisting of eating other resident's food, wandering, refusing care, and being sexually inappropriate. Interventions included administering medications as ordered, removing from situations and explaining why the behavior is inappropriate/unacceptable. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident had no cognitive impairment. A late entry Nurse Practitioner (NP/staff #500) note dated January 10, 2026 included staff reported that resident #17 exhibited sexual inappropriate behaviors with another resident. The note included a staff member saw the hands of resident #17 inside the back of the pants of the other resident (#51); and that, both residents were kissing each other. The documentation included that resident #17 was a registered s** o*******; and that, there was an incident where resident #17 was talking loudly on his portable phone in the lounge area, making sexually explicit comments, including asking about breast size and making sexual remarks. It also included that when staff attempted to redirect resident #17, the resident becomes upset and continues the behavior. Per the documentation, the facility was notified of the staff report and staff were instructed to continue monitoring the situation closely. The late entry behavior note dated January 15, 2026 revealed that at approximately 10:15 a.m. the resident walked by a female peer and pretended to touch the female resident's cheek. Per the documentation, the CNA (certified nursing assistant reminded resident #17 not to touch peers and the resident walked away. A NP note dated January 21, 2026 included that upon review of the camera footage by the Director of Nursing, it was determined that the staff's initial report was inaccurate. Per the documentation, the hands of resident #17 was not inside the pants of another resident (#51); but rather, both residents were holding hands. The documentation also included that on one occasion, resident #17 placed his hand on the thigh of resident #51. -Resident #51 (alleged victim) was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer's disease. A care plan revised on August 12, 202, revealed the resident had a communication problem related to impaired cognition and a hearing deficient, had an alteration in neurological status related to a diagnosis of neurocognitive disorder, and, had impaired cognitive function/dementia or impaired thought processes related to dementia and Alzheimer's disease. Interventions included anticipating and meeting needs, and encouragement to continue stating thoughts even if there is difficulty, administering medications as ordered and monitoring for side effects and interventions, and, to face the resident when speaking, make eye contact with the resident, reduce distractions, keep routine consistent and try to provide consistent care givers to decrease confusion.The MDS assessment dated [DATE], revealed the resident had a BIMS score of 00, which indicated resident had severe cognitive impairment. Review of the clinical record revealed no documentation of an incident between resident #51 and another resident (#17) on January 10, 2026. Despite documentation, there was no evidence found in the clinical record and facility documentation that the incident between resident #17 and #51 were reported to the State Agency (SA), Ombudsman and law enforcement.There was also no evidence that the results of the investigation was reported to the State Agency within 5 working days of the incident.On January 21, 2026, at 10:10 a.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #230) who stated that she was aware of the report that someone saw resident #17 put his hands down the pants of a female resident (#51); however, the ADON stated that she was not aware of who saw this incident. The ADON said that the incident was reported to the Director of Nursing (DON/staff #200) and the Administrator (staff #250); and that, she heard the camera footage was reviewed and she was told that the residents were just holding hands. The ADON further stated that she did not review the camera footage herself. In an interview conducted with the DON (staff #200) and the Administrator (staff #250) on January 21, 2026 at 1:50 p.m., the DON stated that he was made aware by a staff that resident #17 placed his hands down a female resident's pants; however, he was unable to recall which staff member reported the incident. He stated the allegation was discussed in the facility's IDT (interdisciplinary team) meeting; and that, the video camera footage was reviewed by himself and the Administrator (staff #250). The DON stated the video footage showed that both residents were sitting, the hand of the female resident was on the thigh of resident #17; and that, the hand of resident #17 was on the back of the female resident. The DON stated the incident was investigated and was unsubstantiated because resident #17 has a behavior of being sexually inappropriate; and, this incident was a behavior and not abuse. Further, the DON said that this was also the reason why the incident was not reported to the SA. Regarding their investigation, he and the Administrator determined that investigation was not needed because the incident happened in the behavior unit. The Administrator stated the video footage of the incident was no longer available for review because their system auto deletes in 72 hours. Despite admitting to reviewing the video footage of the incident, both the Administrator and the DON stated that they do not know who the female resident that was involved with this incident. The Administrator stated that the intent to cause harm would constitute abuse. The DON stated that it would only be considered abuse if the psychiatric provider says that it is. He also said that there was no preventive measures in place for resident #17 because being sexually inappropriate was a behavior of resident #17. An interview was conducted with a Certified Medical Assistant (CMA/staff #220) and Certified Nursing Assistant (CNA/staff #227) on January 21, 2026 at 2:46 p.m. Both staff #220 and #227 stated they heard about the incident regarding with resident #17 putting his hands down the pants of resident #51 but they did not witness the incident.A telephone interview was conducted with the Nurse Practitioner (NP/staff #500), on January 21, 2026 at 3:18 p.m. The NP stated that he wrote the note on January 10, 2026 because staff reported to him that resident #17 had his hands down a female resident's pants; however, he did not witness the incident. The NP stated that he did not review the video footage of the incident but the DON called and told him what the DON saw on the footage; and that, he had to write another note in case anything went to court. The NP stated that this was the reason why he wrote the NP note on January 21, 2026. Review of the facility's policy on Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated January 1, 2024, included that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility; local/state ombudsman; adult protective services (where state law provides jurisdiction in long-term care); and law enforcement officials. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The follow-up investigation report will provide as much information as possible at the time ofsubmission of the report. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation.

Based on clinical record review, interviews, and facility policy review the facility failed to ensure an allegation of abuse for one of 3 sampled residents (#51) was thoroughly investigated. The deficient practice could result in appropriate corrective action not taken to protect residents from further abuse.Findings include: -Resident #17 (alleged perpetrator) was readmitted to the facility on [DATE], with diagnoses of dementia, history of traumatic brain injury, anxiety disorder, major depressive disorder, history of transient ischemic attack, and cerebral infarction.A care plan revised on August 12, 2025 revealed the resident had behavior problems consisting of eating other resident's food, wandering, refusing care, and being sexually inappropriate. Interventions included administering medications as ordered, removing from situations and explaining why the behavior is inappropriate/unacceptable. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident had no cognitive impairment. A late entry Nurse Practitioner (NP/staff #500) note dated January 10, 2026 included staff reported that resident #17 exhibited sexual inappropriate behaviors with another resident. The note included a staff member saw the hands of resident #17 inside the back of the pants of the other resident (#51); and that, both residents were kissing each other. The documentation included that resident #17 was a registered s** o*******; and that, there was an incident where resident #17 was talking loudly on his portable phone in the lounge area, making sexually explicit comments, including asking about breast size and making sexual remarks. It also included that when staff attempted to redirect resident #17, the resident becomes upset and continues the behavior. Per the documentation, the facility was notified of the staff report and staff were instructed to continue monitoring the situation closely. The late entry behavior note dated January 15, 2026 revealed that at approximately 10:15 a.m. the resident walked by a female peer and pretended to touch the female resident's cheek. Per the documentation, the CNA (certified nursing assistant reminded resident #17 not to touch peers and the resident walked away. A NP note dated January 21, 2026 included that upon review of the camera footage by the Director of Nursing, it was determined that the staff's initial report was inaccurate. Per the documentation, the hands of resident #17 was not inside the pants of another resident (#51); but rather, both residents were holding hands. The documentation also included that on one occasion, resident #17 placed his hand on the thigh of resident #51. -Resident #51 (alleged victim) was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer's disease. A care plan revised on August 12, 202, revealed the resident had a communication problem related to impaired cognition and a hearing deficient, had an alteration in neurological status related to a diagnosis of neurocognitive disorder, and, had impaired cognitive function/dementia or impaired thought processes related to dementia and Alzheimer's disease. Interventions included anticipating and meeting needs, and encouragement to continue stating thoughts even if there is difficulty, administering medications as ordered and monitoring for side effects and interventions, and, to face the resident when speaking, make eye contact with the resident, reduce distractions, keep routine consistent and try to provide consistent care givers to decrease confusion.The MDS assessment dated [DATE], revealed the resident had a BIMS score of 00, which indicated resident had severe cognitive impairment. Review of the clinical record revealed no documentation of an incident between resident #51 and another resident (#17) on January 10, 2026. Despite documentation, there was no evidence found in the clinical record and facility documentation that the incident was thoroughly investigated and the results of the investigation was reported to the SA within 5 working days of the incident. On January 21, 2026, at 10:10 a.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #230) who stated that she was aware of the report that someone saw resident #17 put his hands down the pants of a female resident (#51); however, the ADON stated that she was not aware of who saw this incident. The ADON said that the incident was reported to the Director of Nursing (DON/staff #200) and the Administrator (staff #250); and that, she heard the camera footage was reviewed and she was told that the residents were just holding hands. The ADON further stated that she did not review the camera footage herself. In an interview conducted with the DON (staff #200) and the Administrator (staff #250) on January 21, 2026 at 1:50 p.m., the DON stated that he was made aware by a staff that resident #17 placed his hands down a female resident's pants; however, he was unable to recall which staff member reported the incident. He stated the allegation was discussed in the facility's IDT (interdisciplinary team) meeting; and that, the video camera footage was reviewed by himself and the Administrator (staff #250). The DON stated the video footage showed that both residents were sitting, the hand of the female resident was on the thigh of resident #17; and that, the hand of resident #17 was on the back of the female resident. The DON stated the incident was investigated and was unsubstantiated because resident #17 has a behavior of being sexually inappropriate; and, this incident was a behavior and not abuse. Further, the DON said that this was also the reason why the incident was not reported to the SA. Regarding their investigation, he and the Administrator determined that investigation was not needed because the incident happened in the behavior unit. The Administrator stated the video footage of the incident was no longer available for review because their system auto deletes in 72 hours. Despite admitting to reviewing the video footage of the incident, both the Administrator and the DON stated that they do not know who the female resident that was involved with this incident. The Administrator stated that the intent to cause harm would constitute abuse. The DON stated that it would only be considered abuse if the psychiatric provider says that it is. He also said that there was no preventive measures in place for resident #17 because being sexually inappropriate was a behavior of resident #17. An interview was conducted with a Certified Medical Assistant (CMA/staff #220) and Certified Nursing Assistant (CNA/staff #227) on January 21, 2026 at 2:46 p.m. Both staff #220 and #227 stated they heard about the incident regarding with resident #17 putting his hands down the pants of resident #51 but they did not witness the incident.A telephone interview was conducted with the Nurse Practitioner (NP/staff #500), on January 21, 2026 at 3:18 p.m. The NP stated that he wrote the note on January 10, 2026 because staff reported to him that resident #17 had his hands down a female resident's pants; however, he did not witness the incident. The NP stated that he did not review the video footage of the incident but the DON called and told him what the DON saw on the footage; and that, he had to write another note in case anything went to court. The NP stated that this was the reason why he wrote the NP note on January 21, 2026. Review of the facility's policy on Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated January 1, 2024, included that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. All allegations are thoroughly investigated. The administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. The individual conducting the investigation as a minimum:a. Reviews the documentation and evidence;b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident;c. Observes the alleged victim, including his or her interactions with staff and other residents;d. Interviews the person(s) reporting the incident;e. Interviews any witnesses to the incident;f. Interviews the resident (as medically appropriate) or the resident's representative;g. Interviews the resident's attending physician as needed to determine the resident's condition;h. Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;i. Interviews the resident's roommate, family members, and visitors;j. Interviews other residents to whom the accused employee provides care or services;k. Reviews all events leading up to the alleged incident; andl. Documents the investigation completely and thoroughly.

Based on record review, staff interviews, review of facility documents and policy, [NAME] Nursing Drug Handbook, and Medlineplus.gov website, the facility failed to ensure medications for four residents (#24, #64, #9, #86) were administered as ordered by the physician. The deficient practice could place residents safety at risk and could result in resident's not receiving the treatment that they need.Number of residents sampled: 20Number of residents cited: 4Findings include:-Resident #24 was admitted to the facility on [DATE] with diagnoses that included hypertension, depression and Non-Alzheimer's Dementia.The care plan dated March 17, 2023 revealed the resident was on opiate medication and was at risk for pain related to pain and history of right hip fracture and generalized discomfort. Intervention included to administer medications as ordered.Another care plan dated March 18, 2023 revealed resident use antidepressant medication related to Depression. The interventions included to give antidepressant medications as ordered by the physician and monitor/document side effects and effectiveness.A review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12.0, moderately impaired.On September 15, 2025 at 7:36 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN)/Staff #89. The following medications were dispensed: Sertraline (Antidepressant) 50 mg (milligram) one tablet, lisinopril (Antihypertensive)10 mg one tablet and lidocaine patch (topical anesthetic) 4% one patch. At 7:36 AM, Staff #89 stated there were two pills and one patch and at 7:37 AM, the medications were administered to the resident by mouth. At 7:38 AM, Staff #89 asked the Resident where would the Resident like the patch to be applied on. Staff #89 then immediately removed a white patch from the resident's left lower leg, folded it in half and discarded it; and stated that the folded white patch was just removed from the Resident's left lower leg. Staff #89 then applied the new patch to the shin area of the resident's left lower leg. Regarding Lidocaine External Patch 4%:The physician order dated September 30, 2025 revealed an order for Lidocaine External Patch 4% applied to knee topically one time a day for pain and remove per schedule. However, the order did not include a schedule when to apply and when to remove the patch.A review of Medication Administration Record (MAR) for September 2025 revealed that Lidocaine External Patch 4% was transcribed in the MAR to be applied at 8:00 AM and to be removed at 8:00 PM. The documentation in the MAR included check marks and initials on the boxes from September 1 through September 14, 2025 indicating the Lidocaine patch was applied and removed as scheduled. Further, the documentation included that the lidocaine patch was applied on September 14, 2025 at 8:00 AM and removed on September 14, 2025 at 8:00 PM.However, there was a patch that was still present on the resident's left lower leg that was removed by staff #89 only during the medication administration observation on September 15, 2025 at 7:38 AM. The clinical record revealed no evidence of any physician order regarding the schedule of application and removal time for the lidocaine patch; and that, the physician was notified.Regarding Sertraline HCl tablet 100 mg:A physician order dated September 4, 2025 revealed an order for Sertraline HCl (Hydrochloride) tablet 100 mg give one tablet by mouth one time a day for sad statements related to depression.The order for Sertraline was transcribed onto the MAR for September 2025.There was no evidence found in the clinical record that the order for Sertraline 100 mg was changed since September 4, 2025.Review of the documentation in the MAR revealed that Sertraline 100 mg was administered as ordered from September 4 through September 15, 2025.However, during the medication administration observation conducted with Staff #89 on September 15, 2025 at 7:36 AM, Staff #89 dispensed and administered one tablet of Sertraline 50 mg to Resident #24.On September 15, 2025, at 10:16 AM, an interview was conducted with Certified Medication Assistant (CMA/Staff #31) who was standing next to the medication cart. She pulled out Resident #24's new bubble pack of Sertraline HCl 100 mg and explained that the resident previously took 50 mg, but the order had been changed to 100 mg. The CMA stated the new 100 mg bubble pack must have arrived two days ago. However, she stated that she administered two 50 mg tablets to the resident the previous day because she had not seen the new 100 mg bubble pack until then.On September 16, 2025, at 10:01 AM, an interview was conducted with the Director of Nursing (DON/Staff #80) who stated that the expectation for all staff, including himself, during medication administration is to follow facility policy, review the order, and follow the physician's instructions. The DON explained that when a medication dosage is changed such as when the psychiatric provider increases the dose of a psychotropic medication, the facility policy requires a new assessment and a new consent form. He said that if the change was made during rounds, the provider was responsible for obtaining the consent; and, a new order is then placed, the pharmacy delivers the updated medication, and the new dosage is administered the following day. Regarding resident #24, the DON stated that the previous dosage for Sertraline was 50 mg, which was increased to 100 mg; and that, according to their policy, the old 50 mg medication bubble pack should be returned to the pharmacy, and a new 100 mg bubble pack should be used. He further stated that during medication administration, staff must follow the doctor's orders at all times.-Resident #64 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Anxiety Disorder and Depression.The care plan dated May 25, 2023 revealed resident was on an opiate medication and was at risk for pain related to chronic pain. Intervention included to administer analgesia medications as per orders.The physician order July 19, 2025 revealed an order for Lidocaine External Patch 4% apply to ankle topically one time a day for pain. The order did not include a schedule when to apply and when to remove the patch.The order for Lidocaine patch was transcribed to be applied in AM onto the MAR for September 2025. However, it did not include a transcribed schedule on when to remove the patch. Review of the MAR for September 2025 revealed that lidocaine patch was documented as administered to the resident. During a medication administration observation conducted with staff #89 on September 15, 2025 at 7:43 AM, staff #89 prepared the lidocaine 4% one patch (topical anesthetic) to be administered to resident #64. At 7:49 Am, staff #89 removed a patch from the resident's right ankle then placed a new Lidocaine patch on the same site.-Resident #9 was admitted to the facility on [DATE] with diagnoses of hypertension and urinary tract infection (UTI).A physician order dated August 15, 2025 revealed an order for Lidocaine External Patch 4% apply to right shoulder topically in the morning for pain. The order did not include a schedule for when to remove the patch.The lidocaine patch order was transcribed onto the MAR for September 2025. However, it did not include a transcribed schedule on when to remove the patch. Review of the MAR for September 2025 revealed that lidocaine patch was documented as administered to the resident. On September 15, 2025 at 8:06 AM, a medication administration observation was conducted with Registered Nurse (RN/Staff #54). The RN dispensed one lidocaine patch 4% one patch and at 8:08 AM, Staff #54 removed a patch from Resident #9's right shoulder and then applied the new Lidocaine patch below the right shoulder.-Resident #86 was admitted to the facility on [DATE] with diagnoses of hypertension, depression, Post Traumatic Stress Disorder (PTSD), and morbid obesity.The care plan dated April 15, 2025 revealed resident was on diuretic therapy related to edema. Interventions included to administer medication as ordered; observe for possible side effects every shift which may cause dizziness, postural hypotension, fatigue, and an increased risk for falls; monitor dose which may require modification in order to achieve desired effects while minimizing adverse consequences especially when multiple antihypertensives are prescribed simultaneously; when discontinuing, gradual tapering may be required to avoid adverse consequences caused by abrupt cessation; and report pertinent lab results to the provider.The provider progress notes dated June 2, 2025 revealed that the resident continued to take Lasix for edema and was complaining about legs still edematous and weeping. Per the documentation, the provider planned to consult a lymphedema clinic and increase the Lasix (diuretic and brand name for Furosemide) to 20 mg twice a day.A review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15.0 indicating the resident had intact cognition. The physician order summary revealed an order for Furosemide (diuretic) tablet 20 mg give 1 tablet by mouth two times a day related to edema (order date of May 28, 2025) with no scheduled times for administration.Review of the MAR for September 2025 revealed a transcribed order for for Furosemide tablet 20 mg give 1 tablet by mouth two times a day related to edema scheduled to be administered at 8:00 AM and 12:00 PM (approximately 4 hours apart).However, there was no evidence found in the clinical record of any physician order that indicated Furosemide were to be administered at 8:00 AM and 12:00 PM (approximately 4 hours apart). Continued review of the MAR for September 2025 revealed that Furosemide was administered on September 15, 2025 at 8:00 AM.There was also no evidence found that the order for Furosemide was clarified with the physician until September 16, 2025. A review of progress note dated September 16, 2025 at 1:21 PM revealed that the DON communicated with the physician regarding the furosemide order to be administered at 0800 and 1200. The physician clarified stating that for this resident it is clinically appropriate medication administration schedule. There have been no concerns noted in the pharmacy review additionally.On September 15, 2025 at 11:26 AM, a medication administration observation was conducted with LPN/Staff #47 who dispensed Furosemide 20 mg and administered the medication to the resident at 11:28 AM (approximately 3 1/2 hours from the last administration)An interview was conducted on September 15, 2025 at 2:41 PM with a Registered Nurse (RN/ Staff #54) who when a diuretic such as Furosemide is ordered once daily, it is usually given around 7:00 or 8:00 AM; and, if it is ordered for twice daily, it is usually administered at 8:00 AM and 4:00 PM to avoid the resident being up all night urinating. The RN said that giving Furosemide at 8:00 AM and again at 12:00 PM could cause excessive urination and increase the risk of dehydration. Further, she stated she was not aware of any residents receiving Furosemide on an 8:00 AM and 12:00 PM schedule. On September 16, 2025, at 8:40 AM, a phone interview was conducted with the provider (Staff #450) who stated that lidocaine patches are ordered either once daily or as needed, and the pharmacy label includes instructions for application. The provider said that there was no specific order to remove the patch because it was considered common sense that it should not be left on for days. Further, the provider said that the expectation was that staff would remove it appropriately; and that, the facility follows standard protocol for lidocaine patch use as directed by the pharmacy. Regarding Furosemide, the provider stated that the standard of practice for a twice daily order of Furosemide was that the drug is administered at 8:00 AM and evening, i.e., one dose in the morning and the another dose in the evening. Further, the provider said that he does not advice Furosemide to be taken in the morning and at noon.A phone interview was conducted with the pharmacist (Staff #480) on September 16, 2025 at 9:20 AM. The pharmacist stated that the lidocaine 4% patch was a facility/house stock so the pharmacy do not deliver Lidocaine 4% patch to the facility. Regarding Furosemide, the pharmacist stated that the administration times for Furosemide was dependent on the facility. She stated that the pharmacy does not enter administration times unless provider specifies this in their order. The pharmacist said that Furosemide was usually administered 6 to 8 hours apart and not less than 6 to 8 hours; and that, each resident reaction to furosemide was different such as it might cause a blood pressure drop, dizziness or frequent urination. Further, the pharmacist said that if administered too often or continuously, it can cause dehydration.On September 16, 2025, at 9:41 AM, an interview was conducted with an LPN orientee (Staff #503) and an LPN (Staff #47). Staff #47 stated that diuretics like Lasix (Furosemide) remove excess water from the body through the kidneys. She stated that she administers the medication according to the physician's schedule which is sometimes in the morning or afternoon. Staff #47 said that if Lasix was ordered for twice daily, the second dose was usually given at 4:00 PM; and, this timing allows residents to sleep through the night without frequent urination. Staff #47 stated that Resident #86 had a physician's order for Furosemide 20 mg twice a day, scheduled at 8:00 AM and 12:00 PM. She said that this schedule was based on the provider's instructions and it might have been requested by the resident. Staff #47 said that although she would typically question a twice-daily Furosemide order set for 8:00 AM and 12:00 PM, she had been administering it that way to Resident #86 since the order was written in May 2025. She also stated the provider had previously informed her that the resident preferred the medication be given at those times.In an interview conducted on September 16, 2025, at 10:01 AM, the Director of Nursing (DON/Staff #80) who stated that the expectation during medication administration for all staff, including himself, was to follow facility policy, review the order, and follow the physician's instructions. Regarding Furosemide, the DON stated that Furosemide is given as ordered by the physician. The DON said that if Furosemide was ordered for twice a day, without specific times, the expectation was for staff to follow the doctor's order; and that, the schedule for administration for medications was set in their electronic record. The DON stated that if Furosemide was ordered for twice a day, it will be given in the morning and late afternoon between 3:00 PM and 6:00 PM to facilitate restful sleep. However, he stated that his nursing judgement was not the policy. The DON stated that the expectation was for staff to follow their policy and the doctor's order to give furosemide twice a day; and in the case of Resident #86, to give the second dose of Furosemide 4 hours later. Regarding the lidocaine patch, the DON said that staff were expected to follow the doctor's order; and, failure to do so could result in the resident not receiving a needed medication. He stated that the lidocaine patch is a topical pain reliever applied by either a nurse or a Certified Medication Assistant (CMA) to the area specified in the physician's order; and that, if the physician orders removal of the patch, staff are expected to follow that order. However, the DON said that if no removal instructions were provided, the nurse may use their clinical judgment or follow the manufacturer's guidelines.During an observation at the nurses' station conducted with the DON on September 16, 2025 at 10:23 AM, the DON pulled out an unopened lidocaine patch in its original package from the medication cart. On the front side of the 4% Lidocaine Patch Pain Relief package revealed the following written information:For Single-UseEasy to Apply and RemoveStay-Put Flexible PatchNo-Mess ApplicationLasts Up to 12 HoursAnd, on the back side of the 4% Lidocaine Patch package, the direction revealed the following information:Apply sticky side of patch to affected areaUse one patch for up to 12 hoursDiscard patch after single useIn a later interview with the DON conducted on September 16, 2025 at 1:03 PM, the DON sated that the Furosemide order for Resident #86 was entered by the provider and all orders for resident #86 were reviewed by their pharmacy. The DON provided a copy of a progress note dated June 2, 2025 from the clinical record of Resident #86 and stated that the provider will increase Resident's Furosemide to 20 mg twice a day; however, the documentation of the order in the progress note did not indicate a specific instruction for Furosemide to be administered at 8:00 AM and at 12:00 PM. The DON stated that he clarified with the provider today, September 16, 2025 the Furosemide order and documented this in the clinical record. According to [NAME] Nursing Drug Handbook, Furosemide is used for the treatment associated with heart failure and renal/hepatic disease; and acute pulmonary edema. The pharmacokinetics (study of how the body interacts with administered substances for the entire duration of exposure) of the drug when taken by mouth are: the onset of the drug when taken orally is 30 to 60 minutes, the drug peaks in 1 to 2 hours, and the duration is 6 to 8 hours. It also included a half-life of 30-90 minutes. Black Box Alert included that large doses can lead to profound diuresis with water and electrolyte depletion. Expected side effects included increased urinary frequency/volume, electrolyte imbalance, dizziness, light-headedness, blurred vision, diaphoresis and blurred vision.The medlineplus.gov website last revised on June 15, 2021 included that nonprescription lidocaine transdermal comes as a 4% patch to apply to the skin. It is applied up to 3 times daily and for no more than 8 hours per application. Use nonprescription lidocaine patches exactly as directed. Do not use more or less of it or use it more often or for a longer period of time than directed by the package instructions. The doctor will tell you how many lidocaine patches or topical systems you may use at one time and the length of time you may wear the patches. Applying too many patches or topical systems or leaving them on for too long may cause serious side effects.Review of facility policy on Medication and Treatment Orders, effective January 1, 2024 revealed that orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribed such medications in this state. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis.Review of facility policy titled, F014-Medications: Medication Administration Schedule, effective January 1, 2024 revealed medication are administered according to established scheduled and following routine schedule. For ordered times of BID (two times a day), policy did not indicate what time in a.m. and in p.m. should the medication be given. Per the policy, scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified. A physician's order for specific times supersedes any routine schedule. Residents may request alternate medication schedules. Such times must be documented on the resident's medication administration record and care plan.

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents. Findings include: A review of the personnel file for the Activities Director (staff #24) revealed staff #24 was hired on October 18, 2024. Review of staff #24's job description revealed that as the Activity Manager she directs the development, implementation, supervision, and ongoing evaluation of the activities program. This includes the completion of the activities component of the comprehensive assessment along with the comprehensive care plan goals and approaches. The job description indicated that the Activity Manager oversees the direction of the activity program to include scheduling of activities, both individual and groups, and the implementation of such programs. The Activity Manager directs the monitoring of the residents' responses as well as the evaluation of responses to the programs to determine if the activities meet the assessed needs. Further review of the job description revealed that the facility's minimum requirement for the Activities Director listed the following:- background check- fingerprint clearance card- TB (tuberculosis) clearance- employee health screening post hire- speak and understand English Additionally, the facility's job description did not reflect the requirements indicated in the State Operations Manual for the Activity Director position. Review of staff #24's resume revealed that she held the position of Senior Research Associate/Administrative Director from 2018 until her employment at the facility. The resume also indicated that her educational background are as follows:- Master in Education- Bachelors in Arts (Music Therapy/Music Education/Psychology) Further review of staff #24's resume did not indicate that her education, background, and experience met the requirements indicated in the State Operations Manual for the Activity Director position. Staff #24's personnel file revealed she submitted an application to initiate Activity Director Certification on June 11, 2025. A copy of the email dated July 11, 2025 accompanying the application verification for Activity Director Certification had a handwritten note dated September 15, 2025 stated that an essay was submitted and is under review for her certification application. An interview with Human Resource (HR/staff #70) was conducted on September 16, 2025 at 9:47 a.m. Staff # 70 stated that the Activity Director (staff #24) has an extensive background which included a BA (Bachelor in Arts) in Music Therapy, Music Education, and Psychology. Additionally, staff #24 held the position of Senior Research Associate from 2018-2024. Per HR, staff #24 applied for Activity Director Certification on June 11, 2025. Staff #70 said that to his knowledge staff #24 has not held an activities position prior to her current position as the Activity Director. HR stated that staff #24's position requires her to oversee activities for their residents. On September 16, 2025 at approximately 4:20 p.m., an interview with staff #24 was attempted. However, the receptionist was unable to help the survey team locate the staff member. A follow-up interview with HR (staff #70) was conducted on September 17, 2025 at 8:02 a.m. Staff #70 stated that during the hiring process they use the job description to determine the qualifications needed for the position. HR stated that they try to stay within the parameters, ensure that the candidate has experience, and have the appropriate license/credentials required, and history in employment and education. Staff #70 stated that this is important to ensure that the member can function in the position, do the job correctly, are responsible to do the duties, and ensure resident safety/care/good quality of life. HR said that the possible impact of a staff not having the appropriate requirements for the position is that it can potentially lead to poor quality of services, and not meet the criteria for the position. An interview with the Director of Nursing (DON/staff #80) was conducted on September 17, 2025 at 8:35 a.m. Staff #80 stated that candidates are vetted during hiring and interview process to determine if they are a fit and qualified for the position. The DON also noted that the facility has 90-days after hire to evaluate the member's abilities to perform the job. Staff #80 stated that his expectation with regards to hiring is that they follow the policy with the assumption that it follows state and federal regulations. The DON noted that this is important because not doing so could lead them to get shut down. Additionally, the potential impact of hiring individuals not qualified for a position is that the facility would be out of compliance with federal regulations. The facility did not provide the requested Hiring policy as there was not a hiring policy in place.

Based on observation, staff interviews, facility documents and policy review, the facility failed to ensure current nurse staffing information was accurate for actual hours worked by licensed and unlicensed direct care nursing staff and that the census was updated daily to reflect the actual number of residents. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information and census. Findings include: The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing the last two quarters in 2024 and the first three quarters of 2025. Per the report, submitted weekend data was excessively low. A weekend date was picked from each of the quarters that triggered for excessively low weekend for review. -Regarding June 30, 2024 Review of the June 30, 2024 Staff Posting indicated the following:-5 CNAs (Certified Nursing Assistant) scheduled for the 6:00 p.m. - 6:00 a.m. shift-Total hours worked by CNAs on the 6:00 p.m. - 6:00 a.m. shift = 60 hours However, review of the signed Staffing Sheet (daily staffing assignment) for June 30, 2024 revealed that:-only 4 CNAs reported to work for the NOC (nocturnal = night) shift (6:00 p.m. - 6 a.m.) - 1 scheduled CNA called off Additionally, review of the punch details for June 30, 2025 revealed:-4 CNAs worked the 6:00 p.m. - 6 a.m. shift-Total of actual hours worked by the CNAs for that shift = 50.23 hours. -Regarding September 21, 2024 Review of the September 30, 2024 Staff Posting indicated the following:-No Valets for the 6:00 a.m. - 6:00 p.m. shift -1 RN (Registered Nurse) for the 6:00 p.m. - 6:00 a.m. shift-Total hours worked by RN on 6:00 p.m. - 6:00 a.m. shift = 12 hours-2 LPNs (Licensed Practical Nurse) for the 6:00 p.m. - 6:00 a.m. shift-Total hours worked by LPN on 6:00 p.m. - 6:00 a.m. shift = 24 hours-5 CNAs for the 6:00 p.m. - 6:00 a.m. shift-Total hours worked by CNAs on 6:00 p.m. - 6:00 a.m. shift = 48 hours However, review of the signed Staffing Sheet for September 21, 2024 licensed nurse listed for the 6:00 p.m. - 6:00 a.m. shift, compared to the punch details revealed that the three individuals were all LPNs. Furthermore, review of the punch details for September 21, 2024 revealed the following:-2 valets on 6:00 a.m. - 6:00 p.m. shift-Total of actual hours worked for Valets on 6:00 a.m. - 6:00 p.m. shift = 6.69 hours-No RN on shift for the 6:00 p.m. - 6:00 a.m. shift-3 LPNs on shift for the 6:00 p.m. - 6:00 a.m. shift-Total of actual hours worked by LPNs on 6:00 p.m. - 6:00 a.m. shift = 37.74 hours-4 CNAs on shift for the 6:00 p.m. - 6:00 a.m. shift-Total of actual hours worked by CNAs on 6:00 p.m. - 6:00 a.m. shift = 49.49 hours -Regarding December 29, 2024 Review of the December 30, 2024 Staff Posting indicated the following:-2LPNs for the 6:00 a.m. - 6:00 p.m. shift -Total hours worked by LPN on 6:00 a.m. - 6:00 p.m. shift = 24 hours-5 CNAs for the 6:00 p.m. - 6:00 a.m. shift-Total hours worked by CNAs on 6:00 p.m. - 6:00 a.m. shift = 60 hours However, review of the signed assignment sheet for December 29, 2024 revealed:-1 LPN called off for the 6:00 a.m. - 6:00 p.m. shift -An RN was erroneously annotated as an LPN-1 CNA called off for the 6:00 p.m. - 6:00 a.m. shift Furthermore, review of the punch details for December 29, 2024 revealed:-1 LPN for the 6:00 a.m. - 6:00 p.m. shift -Total of actual hours worked by LPN on 6:00 a.m. - 6:00 p.m. shift = 12.40 hours-4 CNAs for the 6:00 p.m. - 6:00 a.m. shift-Total of actual hours worked by CNAs on 6:00 p.m. - 6:00 a.m. shift = 41 hours -Regarding March 8, 2025 Review of the March 8, 2025 Staff Posting indicated the following:-9 CNAs for the 6:00 a.m. - 6:00 p.m. shift -Total hours worked by CNAs on 6:00 a.m. - 6:00 p.m. shift = 108 hours-5 Valets for 6:00 a.m. - 6:00 p.m. shift -Total hours worked by valets on 6:00 a.m. - 6:00 p.m. shift = 60 hours-6 CNAs for the 6:00 p.m. - 6:00 a.m. shift-Total hours worked by CNAs on 6:00 p.m. - 6:00 a.m. shift = 72 hours However, review of the signed assignment sheet for March 8, 2025 revealed:-7 CNAs scheduled for the 6:00 a.m. - 6:00 p.m. shift -1 [NAME] called off for the 6:00 a.m. - 6:00 p.m. shift -1 CNA called off for the 6:00 p.m. - 6:00 a.m. shift Furthermore, review of the punch details for the March 8, 2025 revealed:-8 CNAs for the 6:00 a.m. - 6:00 p.m. shift -Total of actual hours worked by CNAs on 6:00 a.m. - 6:00 p.m. shift = 95.39 hours-4 valets for the 6:00 a.m. - 6:00 p.m. shift -Total of actual hours worked by [NAME] on 6:00 a.m. - 6:00 p.m. shift = 42.61 hours-1 CNA scheduled for the 6:00 p.m. - 6:00 a.m. shift, worked the 6:00 a.m. - 6:00 p.m. shift instead-4 CNAs for the 6:00 p.m. - 6:00 a.m. shift -Total of actual hours worked by CNAs on 6:00 p.m. - 6:00 a.m. shift = 48.76 hours -Regarding May 4, 2025 Review of the May 4, 2025 Staff Posting indicated the following:-Total hours worked by CMAs on 6:00 a.m. - 6:00 p.m. shift = 24 hours- 9 CNAs for the 6:00 a.m. - 6:00 p.m. shift-Total hours worked by CNAs on 6:00 a.m. - 6:00 p.m. shift = 108 hours However, review of the signed assignment sheet for May 4, 2025 revealed:- 2 CNAs called off for the 6:00 a.m. - 6:00 p.m. shift Furthermore, review of the punch details for the May 4, 2025 revealed:-Total of actual hours worked by CMAs on 6:00 a.m. - 6:00 p.m. shift = 22.80 hours-8 CNAs for 6:00 a.m. - 6:00 p.m. shift-Total of actual hours worked by CNAs on 6:00 a.m. - 6:00 p.m. shift = 91.86 hours-Total of actual hours worked by [NAME] on 6:00 a.m. - 6:00 p.m. shift = 11.47 hours The facility assessment updated August 15, 2025 revealed that the facility was licensed to care for 112 residents, had an average daily census of 90 with 15-35 of the census being from short term stays and an average admission and discharges of 1-8 over the weekend. Staffing plan included the following: - full time Director of Nursing- Up to 5 nurses/CMA (Certified Medical Assistant) on day shift (6:00 a.m. - 6:00 p.m.)- Up to 5 nurses/CMA on night shift (6:00 p.m. - 6:00 a.m.)- Up to 12 direct care staff for day shift (6:00 a.m. - 6:00 p.m.)- Up to 8 direct care staff for night shift (6:00 p.m. - 6:00 a.m.) During the entrance conference conducted on September 14, 2025 at 11:06 a.m., it was observed that the Daily Staff Posting located at the reception desk did not contain the census. Additionally, during the entrance conference conducted on September 14, 2025 at 11:06 a.m., the Charge Nurse (staff #14) was unable to state the current census. During an interaction with the Executive Director (ED/staff #411) on September 14, 2025 at approximately 1:15 p.m., staff #411, stated that the census was 89. However, review of the facility completed CMS-671 form dated September 14, 2025 revealed that the census was 86. During clarification with the ED (staff #411) on September 14, 2025 at approximately 3:30 p.m., staff #411 confirmed that the census was 86. The ED stated that the correct census was provided by their Business Office Manager. An observation of the Daily Staff Posting located at the reception desk was conducted on September 15, 2025 at 8:14 a.m. Although, the Staff Posting posted was for that day. The posting did not contain the census. A follow-up observation of the Daily Staff Posting conducted on September 15, 2025 at 9:15 a.m. revealed that the posting was updated with the census indicating that it was 85. A telephonic interview with the Staffing Coordinator (staff #7) was conducted on September 17, 2025 at 7:38 a.m. According to staff #7 the Daily Staff Posting is updated by either the Business Office Manager or the Receptionist. The Staffing Coordinator said that she staffs the facility based on the yearly review of the Director of Nursing (DON) and acuity. Staff #7 indicated that manning the facility accurately is important in order to meet the needs of the residents and not have long wait times. An interview with Human Resource (HR/staff #70) was conducted on September 17, 2025 at 8:02 a.m. Staff #70 stated that the receptionist updates the provided staffing sheets with the accurate information based on the actual numbers of staff that shows up for shift. According to HR, it is important for the Daily Staff Posting to be accurately posted so that the public can know how many people are caring for their family (residents). Additionally, accurate posting is important for compliance. Staff #70 said that the impact of not having accurate Daily Staff Posting is that the facility would be out of compliance. Furthermore, HR stated that inaccurate Daily Staff Posting could give the public a perception of dishonesty. The Director of Nursing (DON/staff #80) was interviewed on September 17, 2025 at 8:34 a.m. According to staff #80 the Daily Staff Posting is posted at the front to indicate how many staff are working the floor and the census. The DON stated that accurately posted Daily Staff Posting is important in order to be compliant with policies. Staff #80 said that the impact of inaccurate/incomplete Daily Staff Posting is that it would impact the facility's compliance with policies.

Based on observations, record review, staff interviews, review of facility documentation and policy, [NAME] Nursing Drug Handbook and Medlineplus.gov website, the facility failed to ensure that medication error rates were not five percent or greater. The deficient practice could place residents safety at risk.Findings include:-Resident #24 was admitted to the facility on [DATE] with diagnoses that included hypertension, depression and Non-Alzheimer's Dementia.The care plan dated March 17, 2023 revealed the resident was on opiate medication and was at risk for pain related to pain and history of right hip fracture and generalized discomfort. Intervention included to administer medications as ordered.Another care plan dated March 18, 2023 revealed resident use antidepressant medication related to Depression. The interventions included to give antidepressant medications as ordered by the physician and monitor/document side effects and effectiveness.On September 15, 2025 at 7:36 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN)/Staff #89. The following medications were dispensed: Sertraline (Antidepressant) 50 mg (milligram) one tablet, lisinopril (Antihypertensive)10 mg one tablet and lidocaine patch (topical anesthetic) 4% one patch. At 7:36 AM, Staff #89 stated there were two pills and one patch and at 7:37 AM, the medications were administered to the resident by mouth. At 7:38 AM, Staff #89 asked the Resident where would the Resident like the patch to be applied on. Staff #89 then immediately removed a white patch from the resident's left lower leg, folded it in half and discarded it; and stated that the folded white patch was just removed from the Resident's left lower leg. Staff #89 then applied the new patch to the shin area of the resident's left lower leg.Regarding Lidocaine External Patch 4 %:The physician order dated September 30, 2025 revealed an order for Lidocaine External Patch 4% applied to knee topically one time a day for pain and remove per schedule. However, the order did not include a schedule when to apply and when to remove the patch.A review of Medication Administration Record (MAR) for September 2025 revealed that Lidocaine External Patch 4% was transcribed in the MAR to be applied at 8:00 AM and to be removed at 8:00 PM. The documentation in the MAR included check marks and initials on the boxes from September 1 through September 14, 2025 indicating the Lidocaine patch was applied and removed as scheduled. Further, the documentation included that the lidocaine patch was applied on September 14, 2025 at 8:00 AM and removed on September 14, 2025 at 8:00 PM.However, there was a patch that was still present on the resident's left lower leg that was removed by staff #89 only during the medication administration observation on September 15, 2025 at 7:38 AM. Regarding Sertraline HCl tablet 100 mg:A physician order dated September 4, 2025 revealed an order for Sertraline HCl (Hydrochloride) tablet 100 mg give one tablet by mouth one time a day for sad statements related to depression.The order for Sertraline was transcribed onto the MAR for September 2025.There was no evidence found in the clinical record that the order for Sertraline 100 mg was changed since September 4, 2025.Review of the documentation in the MAR revealed that Sertraline 100 mg was administered as ordered from September 4 through September 15, 2025.However, during the medication administration observation conducted with Staff #89 on September 15, 2025 at 7:36 AM, Staff #89 dispensed and administered one tablet of Sertraline 50 mg to Resident #24.On September 15, 2025, at 10:16 AM, an interview was conducted with Certified Medication Assistant (CMA/Staff #31) who was standing next to the medication cart. She pulled out Resident #24's new bubble pack of Sertraline HCl 100 mg and explained that the resident previously took 50 mg, but the order had been changed to 100 mg. The CMA stated the new 100 mg bubble pack must have arrived two days ago. However, she stated that she administered two 50 mg tablets to the resident the previous day because she had not seen the new 100 mg bubble pack until then.On September 16, 2025, at 10:01 AM, an interview was conducted with the Director of Nursing (DON/Staff #80) who stated that the expectation for all staff, including himself, during medication administration is to follow facility policy, review the order, and follow the physician's instructions. The DON explained that when a medication dosage is changed such as when the psychiatric provider increases the dose of a psychotropic medication, the facility policy requires a new assessment and a new consent form. He said that if the change was made during rounds, the provider was responsible for obtaining the consent; and, a new order is then placed, the pharmacy delivers the updated medication, and the new dosage is administered the following day. Regarding resident #24, the DON stated that the previous dosage for Sertraline was 50 mg, which was increased to 100 mg; and that, according to their policy, the old 50 mg medication bubble pack should be returned to the pharmacy, and a new 100 mg bubble pack should be used. He further stated that during medication administration, staff must follow the doctor's orders at all times.-Resident #64 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Anxiety Disorder and Depression.The care plan dated May 25, 2023 revealed resident was on an opiate medication and was at risk for pain related to chronic pain. Intervention included to administer analgesia medications as per orders.The physician order July 19, 2025 revealed an order for Lidocaine External Patch 4% apply to ankle topically one time a day for pain. The order did not include a schedule when to apply and when to remove the patch.The order for Lidocaine patch was transcribed to be applied in AM onto the MAR for September 2025. However, it did not include a transcribed schedule on when to remove the patch. During a medication administration observation conducted with staff #89 on September 15, 2025 at 7:43 AM, staff #89 prepared the lidocaine 4% one patch (topical anesthetic) to be administered to resident #64. At 7:49 Am, staff #89 removed a patch from the resident's right ankle then placed a new Lidocaine patch on the same site.-Resident #9 was admitted to the facility on [DATE] with diagnoses of hypertension and urinary tract infection (UTI).A physician order dated August 15, 2025 revealed an order for Lidocaine External Patch 4% apply to right shoulder topically in the morning for pain. The order did not include a schedule for when to remove the patch.The lidocaine patch order was transcribed onto the MAR for September 2025. However, it did not include a transcribed schedule on when to remove the patch. On September 15, 2025 at 8:06 AM, a medication administration observation was conducted with Registered Nurse (RN/Staff #54). The RN dispensed one lidocaine patch 4% one patch and at 8:08 AM, Staff #54 removed a patch from Resident #9's right shoulder and then applied the new Lidocaine patch below the right shoulder. -Resident #86 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Depression, Post Traumatic Stress Disorder (PTSD), and Morbid Obesity.The care plan dated April 15, 2025 revealed resident was on diuretic therapy related to edema. Interventions included to administer medication as ordered; observe for possible side effects every shift which may cause dizziness, postural hypotension, fatigue, and an increased risk for falls; monitor dose which may require modification in order to achieve desired effects while minimizing adverse consequences especially when multiple antihypertensives are prescribed simultaneously; when discontinuing, gradual tapering may be required to avoid adverse consequences caused by abrupt cessation; and report pertinent lab results to the provider.The provider progress notes dated June 2, 2025 revealed that the resident continued to take Lasix for edema and was complaining about legs still edematous and weeping. Per the documentation, the provider planned to consult a lymphedema clinic and increase the Lasix (diuretic and brand name for Furosemide) to 20 mg twice a day.The physician order summary revealed an order for Furosemide (diuretic) tablet 20 mg give 1 tablet by mouth two times a day related to edema (order date of May 28, 2025) with no scheduled times for administration.Review of the MAR for September 2025 revealed a transcribed order for Furosemide tablet 20 mg give 1 tablet by mouth two times a day related to edema scheduled to be administered at 8:00 AM and 12:00 PM (approximately 4 hours apart).However, there was no evidence found in the clinical record of any physician order that indicated Furosemide were to be administered at 8:00 AM and 12:00 PM (approximately 4 hours apart). Continued review of the MAR for September 2025 revealed that Furosemide was administered on September 15, 2025 at 8:00 AM.On September 15, 2025 at 11:26 AM, a medication administration observation was conducted with LPN/Staff #47 who dispensed Furosemide 20 mg and administered the medication to the resident at 11:28 AM (approximately 3 1/2 hours from the last administration)An interview was conducted on September 15, 2025 at 2:41 PM with a Registered Nurse (RN/ Staff #54) who when a diuretic such as Furosemide is ordered once daily, it is usually given around 7:00 or 8:00 AM; and, if it is ordered for twice daily, it is usually administered at 8:00 AM and 4:00 PM to avoid the resident being up all night urinating. The RN said that giving Furosemide at 8:00 AM and again at 12:00 PM could cause excessive urination and increase the risk of dehydration. Further, she stated she was not aware of any residents receiving Furosemide on an 8:00 AM and 12:00 PM schedule. On September 16, 2025, at 8:40 AM, a phone interview was conducted with the provider (Staff #450) who stated that lidocaine patches are ordered either once daily or as needed, and the pharmacy label includes instructions for application. The provider said that there was no specific order to remove the patch because it was considered common sense that it should not be left on for days. Further, the provider said that the expectation was that staff would remove it appropriately; and that, the facility follows standard protocol for lidocaine patch use as directed by the pharmacy. Regarding Furosemide, the provider stated that the standard of practice for a twice daily order of Furosemide was that the drug is administered at 8:00 AM and evening, i.e., one dose in the morning and the another dose in the evening. Further, the provider said that he does not advice Furosemide to be taken in the morning and at noon.A phone interview was conducted with the pharmacist (Staff #480) on September 16, 2025 at 9:20 AM. The pharmacist stated that the lidocaine 4% patch was a facility/house stock so the pharmacy do not deliver Lidocaine 4% patch to the facility. Regarding Furosemide, the pharmacist stated that the administration times for Furosemide was dependent on the facility. She stated that the pharmacy does not enter administration times unless provider specifies this in their order. The pharmacist said that Furosemide was usually administered 6 to 8 hours apart and not less than 6 to 8 hours; and that, each resident reaction to furosemide was different such as it might cause a blood pressure drop, dizziness or frequent urination. Further, the pharmacist said that if administered too often or continuously, it can cause dehydration.An interview was conducted on September 16, 2025 at 9:41 AM with Staff #47 and present during the interview was Staff #503 at the nursing station. Staff #47 stated that regarding diuretic medication, she stated that a diuretic medication draws water out of the body from the kidneys, the diuretics mostly given at the facility is Lasix/furosemide. Staff #47 stated that she administers the medication when doctor schedules it, sometimes in the morning or sometimes in the afternoon, and usually the second dose is given at 4:00 PM. Staff #47 stated that if one dose is given in the morning, the second dose is given at 4:00 PM so resident can go to sleep and not urinate all night. Staff #47 stated that the Furosemide order for Resident #86 was furosemide 20 mg twice a day which is scheduled to be administered at 8:00 AM and at noon time. Staff #47 stated that the administration times, 8:00 AM and at noon time, for the Furosemide was how the provider/Staff #600 had it scheduled and was based on the doctor's order. Staff #47 suggested that the surveyor should ask the resident why it was ordered that way. In addition, Staff #47 stated that the resident might have asked the doctor to order it that way. However, Staff #47 stated that if she sees an order for Furosemide twice a day scheduled for 8:00 AM and at 12:00 PM, she would question the order. Staff #47 stated that she has been giving the Furosemide at 8:00 AM and at 12:00 PM to the resident for quit sometimes because the order was written in May 2025. Staff #47 stated that the excuse the doctor gave to her last time was the resident want that scheduled at 8:00 and at 12:00 PM.On September 16, 2025, at 9:41 AM, an interview was conducted with an LPN orientee (Staff #503) and an LPN (Staff #47). Staff #47 stated that diuretics like Lasix (Furosemide) remove excess water from the body through the kidneys. She stated that she administers the medication according to the physician's schedule which is sometimes in the morning or afternoon. Staff #47 said that if Lasix was ordered for twice daily, the second dose was usually given at 4:00 PM; and, this timing allows residents to sleep through the night without frequent urination. Staff #47 stated that Resident #86 had a physician's order for Furosemide 20 mg twice a day, scheduled at 8:00 AM and 12:00 PM. She said that this schedule was based on the provider's instructions and it might have been requested by the resident. Staff #47 said that although she would typically question a twice-daily Furosemide order set for 8:00 AM and 12:00 PM, she had been administering it that way to Resident #86 since the order was written in May 2025. She also stated the provider had previously informed her that the resident preferred the medication be given at those times.In an interview conducted on September 16, 2025, at 10:01 AM, the Director of Nursing (DON/Staff #80) who stated that the expectation during medication administration for all staff, including himself, was to follow facility policy, review the order, and follow the physician's instructions. Regarding Furosemide, the DON stated that Furosemide is given as ordered by the physician. The DON said that if Furosemide was ordered for twice a day, without specific times, the expectation was for staff to follow the doctor's order; and that, the schedule for administration for medications was set in their electronic record. The DON stated that if Furosemide was ordered for twice a day, it will be given in the morning and late afternoon between 3:00 PM and 6:00 PM to facilitate restful sleep. However, he stated that his nursing judgement was not the policy. The DON stated that the expectation was for staff to follow their policy and the doctor's order to give furosemide twice a day; and in the case of Resident #86, to give the second dose of Furosemide 4 hours later. Regarding the lidocaine patch, the DON said that staff were expected to follow the doctor's order; and, failure to do so could result in the resident not receiving a needed medication. He stated that the lidocaine patch is a topical pain reliever applied by either a nurse or a Certified Medication Assistant (CMA) to the area specified in the physician's order; and that, if the physician orders removal of the patch, staff are expected to follow that order. However, the DON said that if no removal instructions were provided, the nurse may use their clinical judgment or follow the manufacturer's guidelines.During an observation at the nurses' station conducted with the DON on September 16, 2025 at 10:23 AM, the DON pulled out an unopened lidocaine patch in its original package from the medication cart. On the front side of the 4% Lidocaine Patch Pain Relief package revealed the following written information:For Single-UseEasy to Apply and RemoveStay-Put Flexible PatchNo-Mess ApplicationLasts Up to 12 HoursAnd, on the back side of the 4% Lidocaine Patch package, the direction revealed the following information:Apply sticky side of patch to affected areaUse one patch for up to 12 hoursDiscard patch after single useIn a later interview with the DON conducted on September 16, 2025 at 1:03 PM, the DON sated that the Furosemide order for Resident #86 was entered by the provider and all orders for resident #86 were reviewed by their pharmacy. The DON provided a copy of a progress note dated June 2, 2025 from the clinical record of Resident #86 and stated that the provider will increase Resident's Furosemide to 20 mg twice a day; however, the documentation of the order in the progress note did not indicate a specific instruction for Furosemide to be administered at 8:00 AM and at 12:00 PM. The DON stated that he clarified with the provider today, September 16, 2025 the Furosemide order and documented this in the clinical record. According to [NAME] Nursing Drug Handbook, Furosemide is used for the treatment associated with heart failure and renal/hepatic disease; and acute pulmonary edema. The pharmacokinetics (study of how the body interacts with administered substances for the entire duration of exposure) of the drug when taken by mouth are: the onset of the drug when taken orally is 30 to 60 minutes, the drug peaks in 1 to 2 hours, and the duration is 6 to 8 hours. It also included a half-life of 30-90 minutes. Black Box Alert included that large doses can lead to profound diuresis with water and electrolyte depletion. Expected side effects included increased urinary frequency/volume, electrolyte imbalance, dizziness, light-headedness, blurred vision, diaphoresis and blurred vision.The medlineplus.gov website last revised on June 15, 2021 included that nonprescription lidocaine transdermal comes as a 4% patch to apply to the skin. It is applied up to 3 times daily and for no more than 8 hours per application. Use nonprescription lidocaine patches exactly as directed. Do not use more or less of it or use it more often or for a longer period of time than directed by the package instructions. The doctor will tell you how many lidocaine patches or topical systems you may use at one time and the length of time you may wear the patches. Applying too many patches or topical systems or leaving them on for too long may cause serious side effects.Review of facility policy on Medication and Treatment Orders, effective January 1, 2024 revealed that orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribed such medications in this state. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis.Review of facility policy titled, F014-Medications: Medication Administration Schedule, effective January 1, 2024 revealed medication are administered according to established scheduled and following routine schedule. For ordered times of BID (two times a day), policy did not indicate what time in a.m. and in p.m. should the medication be given. Per the policy, scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified. A physician's order for specific times supersedes any routine schedule. Residents may request alternate medication schedules. Such times must be documented on the resident's medication administration record and care plan.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that four staff members (#21, #58, #1, & 55) received Disaster training. The deficient practice could result in staff not being familiar with the procedures to follow in the event of an emergency and/or disaster.Findings include:On September 15, 2025 at 9:11 a.m., a written request for personnel files which included staffs #21, #58, #24, #16, #1, & 55) was submitted specifically asking for proof of Disaster training. -Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed August 4, 2025. However, it did not indicate what training were covered under this orientation. Further review of the personnel file provided by the facility did not reveal any evidence that staff #21 completed Disaster training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #21 completed Disaster training. Furthermore, during a sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that Disaster training was not assigned or completed by staff #21. HR noted that he would have to call the training system resource to add courses. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Disaster was a topic covered. The training included a typed roster with a list of the staff and a training complete section. The roster included staff #21's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #21 and the other staff on the roster actually completed the training. -Regarding Staff #58Review of the personnel record for a Licensed Practical Nurse (LPN/staff #58) revealed a hire date of September 20, 2016. The personnel file provided by the facility did not reveal any evidence that staff #58 completed Disaster training. Additionally, the personnel file revealed a signed job description dated September 20, 2016 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. An interview with Human Resource (HR/staff #70) conducted on September 15, 2025 at 2:04 p.m. Staff #70 stated that the training system itself is the one that assigns the courses. However, based on the personnel records that was reviewed together with the surveyor, he would need to find out why courses are not being assigned. According to HR the expectation is that assigned training is completed a month from when it is assigned. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #58 completed Disaster training. During a sit down with HR to conduct personnel record review specific to training, conducted on September 16, 2025 at 9:47 a.m., staff #70 stated that review of their training system revealed that the Disaster training was an assigned training indicated in the system for staff #58. However, it has not been completed by the member. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Elder Justice Act was among the topics covered. The training included a typed roster with a list of the staff and a training complete section. The roster included staff #58's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #58 and the other staff on the roster actually completed the training-Regarding Staff #1Review of the personnel record for a Certified Nursing Assistant (CNA/staff #1) revealed a hire date of February 28, 2025. The file also included a New Employee Orientation Acknowledgement signed February 28,2025. However, it did not indicate what training were covered under this orientation. Additionally, the personnel file revealed a signed job description signed on April 4, 2025 that outlined roles and responsibilities which stated that staff will participate in all required meetings, trainings and events. Further review of the personnel file provided by the facility did not reveal any evidence that staff #1 completed Disaster training. During the review of the training system with staff #70 for staff #1's training completion conducted on September 15, 2025 at 2:04 p.m., he noted that there is no documentation of Disaster training on either the training system or orientation. An interview with Human Resource (HR/staff #70) conducted on September 15, 2025 at 2:04 p.m. Staff #70 stated that the training system itself is the one that assigns the courses. However, based on the personnel records that was reviewed together with the surveyor, he would need to find out why courses are not being assigned. According to HR the expectation is that assigned training is completed a month from when it is assigned. Staff #70 recommended to check Inservice training log/binder to determine if staff # 1 completed Disaster training since it was not on the training system or the orientation training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #1 completed Disaster training. Furthermore, during a sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #1 had no documented Disaster training. HR noted that he would have to call the training system resource to add courses. Review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #1's name/was prior to hire date- In-Service roster dated May 20, 2025 = did not include staff #1's name- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training -Regarding Staff #55Review of the staff list for a Licensed Practical Nurse (LPN/staff #55) revealed a hire date of February 5, 2019. Additionally, the personnel file revealed a signed job description dated February 12, 2025 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed February 12, 2025. However, it did not indicate what training were covered under this orientation. Review of the personnel file provided by the facility did not reveal any evidence that staff #55 completed Disaster training. Furthermore, during a sit down with the Human Resource (HR/staff #70) to conduct personnel record review specific to training, conducted on September 15, 2025 at 2:04 p.m., staff #70 stated that staff #55 does not have documentation on either the training system or orientation for Disaster training. HR recommended to check the Inservice binder to determine if staff #55 had completed the training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m., did not reveal any evidence that staff #55 had completed Disaster training. Furthermore, during a follow-up sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #55 had no documented Disaster training. HR noted that he would have to call the training system resource to add courses/get training loaded. However, review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #55's name- In-Service roster dated May 20, 2025 = did not include staff #55's name- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training An interview with a Licensed Practical Nurse (LPN/staff #43) was conducted on September 16, 2025 at 5:18 p.m. Staff #43 stated that staff members are provider training via monthly in-service and yearly computer-based training. According to the LPN training is important for topics such as Disaster so that staff would know what to do in that situation, how to take care of the resident, and know how to act/think in that situation. The impact of not getting the appropriate training is that staff would not know what to do if a situation arises. During an interview with a Certified Nursing Assistant (CNA/staff #60) conducted on September 17, 2025 at approximately 8:30 a.m., staff #60 noted being a relatively new employee at the facility. According to the CNA, although on-the-job training was provided, no other training had been provided. Additionally, staff #60 was told that there would be a series of online training that would need to be completed within 2-months. Staff #60 said that training is important for everyone's safety. The CNA noted that if staff is not provided appropriate training then they would not know how to react and would have to rely on common sense. An interview with the Director of Nursing (DON/staff #80) was conducted on September 17, 2025 at 8:34 p.m. Staff #80 stated that his expectation is that staff follow the facility policy with regards to training. This means completing the onboarding process for general orientation which covers the general education to start the job and do education periodically throughout the year. According to the DON it is important to have Disaster training in order for staff to be trained on how to evacuate/respond in the situation and be prepared to protect the residents. Staff #80 said that not having training could lead to a knowledge deficit which could lead to delayed responses and impact care. The facility policy titled Staff Development Program version 0123 stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes. The policy noted that Emergency Preparedness was a state agency mandatory topic. Review of the Facility Assessment updated September 15, 2025 indicated that the facility's staff/training/education and competencies included Fire, Disaster, Emergency Preparedness training. According to the facility assessment competencies are started during orientation and had to be completed during the first few weeks of hire and then annually.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that two staff members (#21 and #58) are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. The deficient practice could result in staff not being familiar with residents' rights. Findings include:On September 15, 2025 at 9:11 a.m., a written request for personnel files which included staffs #21 and #58 was submitted specifically asking for proof of training for Resident Rights. -Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. However, review of the personnel file provided by the facility did not reveal any evidence that staff #21 completed Resident Rights training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #21 completed Resident Rights training. Furthermore, during a sit down with Human Resource (HR/staff #70) to conduct personnel record review specific to training, conducted on September 16, 2025 at 9:47 a.m., staff #70 stated that review of their training system revealed that the Resident Rights training was not assigned and have not been completed by staff #21. HR noted that he would have to call the training system resource to add courses/loaded. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all 10 staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Resident Rights was one of the topics covered. The training included a typed roster with a list of the staff and a training complete section. The roster was included staff #21's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #21 and the other staff on the roster actually completed the training. -Regarding Staff #58Review of the personnel record for a Licensed Practical Nurse (LPN/staff #58) revealed a hire date of September 20, 2016. A Resident's Rights Summary listing the resident's rights in long-term care facilities was signed by staff #58 on September 20, 2016. However, there was no evidence that staff #58 had current Resident Rights training. Additionally, the personnel file revealed a signed job description dated September 20, 2016 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. An interview with Human Resource (HR/staff #70) conducted on September 15, 2025 at 2:04 p.m. Staff #70 stated that the training system itself is the one that assigns the courses. However, based on the personnel records that was reviewed together with the surveyor, he would need to find out why courses are not being assigned. According to HR the expectation is that assigned training is completed a month from when it is assigned. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #58 completed Resident Rights training. During a sit down with HR to conduct personnel record review specific to training, conducted on September 16, 2025 at 9:47 a.m., staff #70 stated that review of their training system revealed that the Resident Rights training was assigned but not completed by staff #58. The HR noted that the training system point of contact has to be called to add courses due to the discovery from yesterday's sit down with the survey team in which required courses were not assigned/loaded standardized for all staff. An interview with a Licensed Practical Nurse (LPN/staff #43) was conducted on September 16, 2025 at 5:18 p.m. Staff #43 stated that staff members are provider training via monthly in-service and yearly computer-based training. According to the LPN training is important for topics such as Resident Rights so that staff can determine if there is something going on that should not be happening. The impact of not getting the appropriate training is that staff would not know what to do if a situation arises. During an interview with a Certified Nursing Assistant (CNA/staff #60) conducted on September 17, 2025 at approximately 8:30 a.m., staff #60 noted being a relatively new employee at the facility. According to the CNA, although on-the-job training was provided, training on Resident Rights was not provided. Additionally, staff #60 was told that there would be a series of online training that would need to be completed within 2-months. The CNA indicated starting some Resident Rights training online. Staff #60 said that training is important for everyone's safety. The CNA noted that if staff is not provided appropriate training then they would not know how to react and would have to rely on common sense. An interview with the Director of Nursing (DON/staff #80) was conducted on September 17, 2025 at 8:34 p.m. Staff #80 stated that his expectation is that staff follow the facility policy with regards to training. This means completing the onboarding process for general orientation which covers the general education to start the job and do education periodically throughout the year. According to the DON it is important to have Resident Rights training in order for staff to be educated on residents' rights and protect the residents. Staff #80 said that not having training could lead to a knowledge deficit which could lead to delayed responses and impact care. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all 10 staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Resident Rights was one of the topics covered. The training included a typed roster with a list of the staff and a training complete section. The roster was included staff #58's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #58 and the other staff on the roster actually completed the training. The facility policy titled Staff Development Program version 0123 stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes. The policy noted that Resident's Rights was a state agency mandatory topic. Review of the Facility Assessment updated September 15, 2025 indicated that the facility's staff/training/education and competencies included Resident Rights and facility responsibilities to properly care for its residents. According to the facility assessment competencies are started during orientation and had to be completed during the first few weeks of hire and then annually.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that one staff member (#21) was educated on abuse, and that seven staff members (#21, #58, #24, #1, #12, #55 & #11) and one nursing aide (NA) student (staff #255) received Elder Justice Act training. The deficient practice could result in staff not being familiar with the detection, prevention and reporting of abuse, neglect, and exploitation of property.Findings include:On September 15, 2025 at 9:11 a.m., a written request for personnel files which included staffs #21, #58, #24, #1, #12, #55 & #11) was submitted specifically asking for proof of training for Abuse and Elder Justice Act. Additionally, a written request for personnel file for staff #255 specifically asking for proof of training for Abuse and Elder Justice Act was submitted on September 15, 2025 at 10:16 a.m. -Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed August 4, 2025. However, it did not indicate what training were covered under this orientation. Further review of the personnel file provided by the facility did not reveal any evidence that staff #21 completed Abuse and/or Elder Justice Act training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #21 completed Abuse and/or Elder Justice Act training. Furthermore, during a sit down with Human Resource (HR/staff #70) to conduct personnel record review specific to training, conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that Abuse and Elder Justice Act training were not assigned or completed by staff #21. HR noted that he would have to call the training system resource to add courses/loaded. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Abuse and Elder Justice Act were topics covered. The training included a typed roster with a list of the staff and a training complete section. The roster included staff #21's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #21 and the other staff on the roster actually completed the training. -Regarding Staff #58Review of the personnel record for a Licensed Practical Nurse (LPN/staff #58) revealed a hire date of September 20, 2016. Additionally, the personnel file included a Preventing and Reporting Resident Abuse: Clinical Practices and the Elder Justice Act form signed September 20, 2016. However, there was no evidence that staff #58 had current Elder Justice Act training. Furthermore, the personnel file revealed a signed job description dated September 20, 2016 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. An interview with Human Resource (HR/staff #70) conducted on September 15, 2025 at 2:04 p.m. Staff #70 stated that the training system itself is the one that assigns the courses. However, based on the personnel records that was reviewed together with the surveyor, he would need to find out why courses are not being assigned. According to HR the expectation is that assigned training is completed a month from when it is assigned. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #58 completed Elder Justice Act training. During a sit down with HR to conduct personnel record review specific to training, conducted on September 16, 2025 at 9:47 a.m., staff #70 stated that review of their training system revealed that the Elder Justice Act training was not a training indicated in the system for staff #58. The HR noted that the training system point of contact has to be called to add courses due to the discovery from yesterday's sit down with the survey team in which required courses were not assigned/loaded standardized for all staff. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Elder Justice Act was among the topics covered. The training included a typed roster with a list of the staff and a training complete section. The roster included staff #58's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #58 and the other staff on the roster actually completed the training. -Regarding Staff #24Review of the personnel record for the Activity Director (staff #24) revealed a hire date of October 18, 2024. Additionally, the personnel file revealed a signed job description dated October 18, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed October 18, 2024. However, it did not indicate what training were covered under this orientation. Further review of the personnel file provided by the facility did not reveal any evidence that staff #58 completed Elder Justice Act training. An interview with Human Resource (HR/staff #70) conducted on September 15, 2025 at 2:04 p.m. Staff #70 stated that the training system itself is the one that assigns the courses. However, based on the personnel records that was reviewed together with the surveyor, he would need to find out why courses are not being assigned. According to HR the expectation is that assigned training is completed a month from when it is assigned. During the review of the training system with staff #70 for staff #24's training completion, he noted that there is no documentation of Elder Justice Act completion and said that staff #24 might have done an Inservice training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #24 completed Elder Justice Act training. Furthermore, during a sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #24 had no documented Elder Justice Act training. HR noted that he would have to call the training system resource to add courses/loaded. Review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:-In-Service roster dated September 26, 2024 = did not include staff #24's name/was prior to hire date- In-Service roster dated May 20, 2025 = training topics did not include Elder Justice Act- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = did not include staff #24's name -Regarding Staff #1Review of the personnel record for a Certified Nursing Assistant (staff #1) revealed a hire date of February 28, 2025. The file also included a New Employee Orientation Acknowledgement signed February 28,2025. However, it did not indicate what training were covered under this orientation. Additionally, the personnel file revealed a signed job description signed on April 4, 2025 that outlined roles and responsibilities which stated that staff will participate in all required meetings, trainings and events. Further review of the personnel file provided by the facility did not reveal any evidence that staff #1 completed Elder Justice Act training. During the review of the training system with staff #70 for staff #1's training completion conducted on September 15, 2025 at 2:04 p.m., he noted that there is no documentation of Elder Justice Act on either the training system or orientation. An interview with Human Resource (HR/staff #70) conducted on September 15, 2025 at 2:04 p.m. Staff #70 stated that the training system itself is the one that assigns the courses. However, based on the personnel records that was reviewed together with the surveyor, he would need to find out why courses are not being assigned. According to HR the expectation is that assigned training is completed a month from when it is assigned. Staff #70 recommended to check Inservice training log/binder to determine if staff # 1 completed Elder Justice Act since it was not on the training system or the orientation training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #1 completed Elder Justice Act training. Furthermore, during a sit down with Human Resource (HR/staff #70) to conduct personnel record review specific to training, conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #1 had no documented Elder Justice Act training. HR noted that he would have to call the training system resource to add courses/loaded. Review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #1's name/was prior to hire date- In-Service roster dated May 20, 2025 = training topics did not include Elder Justice Act- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training -Regarding Staff #12Review of the personnel record for a Certified Nursing Assistant (CNA/staff #12) revealed a hire date of June 19, 2025. Additionally, the personnel file revealed a signed job description dated June 19, 2025 that outlined role and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed June 19, 2025. However, it did not indicate what training were covered under this orientation. During a sit down with Human Resource (HR/staff #70) to conduct personnel record review specific t training, conducted on September 15, 2025 at 2:04 p.m., staff #70 stated that review of their training system revealed that staff #12 does not have Elder Justice Act on either the orientation or training system. HR recommended to check the Inservice log to determine if staff #12 had completed the training. Review of the Inservice training log/binder conducted o September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #12 completed Elder Justice Act training. Furthermore, during a follow-up sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #12 had no documented Elder Justice Act training. HR noted that he would have to call the training system resource to add courses/loaded. Review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #12's name/was prior to hire date- In-Service roster dated May 20, 2025 = did not include staff #12's name/was prior to hire date- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training -Regarding Staff #55Review of the staff list for a Licensed Practical Nurse (LPN/staff #55) revealed a hire date of February 5, 2019. Additionally, the personnel file revealed a signed job description dated February 12, 2025 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed February 12, 2025. However, it did not indicate what training were covered under this orientation. Review of the personnel file provided by the facility did not reveal any evidence that staff #55 completed Elder Justice Act training. Furthermore, during a sit down with the Human Resource (HR/staff #70) to conduct personnel record review specific to training, conducted on September 15, 2025 at 2:04 p.m., staff #70 stated that staff #55 does not have documented training on either the training system or orientation for Elder Justice Act. HR recommended to check the Inservice binder to determine if staff #55 had completed the training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m., did not reveal any evidence that staff #55 had completed Elder Justice Act training. Furthermore, during a follow-up sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #55 had no documented Elder Justice Act training. HR noted that he would have to call the training system resource to add courses/ get training loaded. However, review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #55's name- In-Service roster dated May 20, 2025 = training topics does not include Elder Justice Act- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training -Regarding Staff #11Review of the personnel record for a Registered Nurse (RN/staff #11) revealed a hire date of February 17, 2025. Additionally, the personnel file revealed a signed job description dated February 18, 2025 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed February 18, 2025. However, it did not indicate what training were covered under this orientation. Review of the personnel file provided by the facility did not reveal any evidence that staff #11 completed Elder Justice Act training. Furthermore, during a sit down with the Human Resource (HR/staff #70) to conduct personnel record review specific to training, conducted on September 15, 2025 at 2:04 p.m., staff #70 stated that staff #11 does not have documented training on either the training system or orientation for Elder Justice Act. HR recommended to check the Inservice binder to determine if staff #11 had completed the training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m., did not reveal any evidence that staff #11 had completed Elder Justice Act training. During a follow-up sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #11 had no documented Elder Justice Act training. HR noted that he would have to call the training system resource to add courses/ get training loaded. However, review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #11's name/was prior to hire date- In-Service roster dated May 20, 2025 = training topics does not include Elder Justice Act- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training -Regarding Staff #255Review of the Nursing Assistant Class roster for September 2025 revealed a class start date of August 25, 2025. The roster listed staff #255 as one of the participants of the program. A written request for personnel record for Nursing Assistant student (staff #255) was submitted to the facility on September 15, 2025 at 10:16 a.m. The request included proof of completion for Elder Justice Act Training. An email response was received from the facility on September 15, 2025 at 10:50 a.m. which stated that the staff #255 was not an employee but a participant in the Certified Nursing Assistant (CNA) class. The email noted that due to staff #255's status, all they have on file is a Tuberculosis test. Furthermore, per the email the items listed as part of the personnel record request were not required to obtain for non-employees participating in the free CNA class. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #21 completed Resident Rights training. Additionally, attachments from the email received from the facility on September 15, 2025 at 4:18 p.m. did not include proof of fingerprint clearance card (FPCC) for staff #255. Review of an undated Application for Employment |Recruiter Added FREE CNA Training Program Lakeside revealed that staff #255 submitted the form for consideration for CNA training. The Consent/Acknowledgement section of the form indicated that staff #255 acknowledge and certify:-Equal Employment Opportunity-Employment-At-Will Although, the facility provided a sheet that outlined the General Orientation Topics, review of the email attachments from the facility dated September 15, 2025 did not reveal any documentation of training completion for Elder Justice Act. An interview with a Licensed Practical Nurse (LPN/staff #43) was conducted on September 16, 2025 at 5:18 p.m. Staff #43 stated that staff members are provider training via monthly in-service and yearly computer-based training. According to the LPN training is important for topics such as Abuse so that staff can determine if there is something going on that should not be happening. The impact of not getting the appropriate training is that staff would not know what to do if a situation arises. During an interview with a Certified Nursing Assistant (CNA/staff #60) conducted on September 17, 2025 at approximately 8:30 a.m., staff #60 noted being a relatively new employee at the facility. According to the CNA, although on-the-job training was provided, training on Abuse and Elder Justice Act were not provided. Additionally, staff #60 was told that there would be a series of online training that would need to be completed within 2-months. Staff #60 said that training is important for everyone's safety. The CNA noted that if staff is not provided appropriate training then they would not know how to react and would have to rely on common sense. An interview with the Director of Nursing (DON/staff #80) was conducted on September 17, 2025 at 8:34 p.m. Staff #80 stated that his expectation is that staff follow the facility policy with regards to training. This means completing the onboarding process for general orientation which covers the general education to start the job and do education periodically throughout the year. According to the DON it is important to have Abuse training in order for staff to be trained on how to identify and report appropriately so allegations can be investigated by the facility. Additionally, it is important for staff to be trained on Elder Justice Act so know the resident's rights and how to treat them. Staff #80 said that not having training could lead to a knowledge deficit which could lead to delayed responses and impact care. The facility policy titled Staff Development Program version 0123 stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes. The policy noted that Abuse was a state agency mandatory topic. The policy did not mention anything regarding Elder Justice Act training. Review of the Facility Assessment updated September 15, 2025 indicated that the facility's staff/training/education and competencies included Abuse, Neglect, and Exploitation. According to the facility assessment competencies are started during orientation and had to be completed during the first few weeks of hire and then annually. There was no specific mention regarding Elder Justice Act training. The facility policy titled Abuse Policy version 0622 indicated that all employees receive education on the Elder Justice Act as well as contact and reporting information. The policy noted that education will be provided regarding abuse prevention, recognition, and reporting procedures during new hire orientation, annual in-service, and as needed.

The facility failed to ensure that the advance directive was consistent and correct for one Resident.(#7)Number of residents sampled: 20Number of residents cited: 1 Based on clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure that the advance directives were consistent throughout one (#7) of twenty sampled resident's clinical records. The deficient practice could result in residents receiving services that are not in accordance with their wishes. Findings include: Resident #7 was admitted to the facility on [DATE],.2025 with diagnoses that included Chronic Obstructive Pulmonary Disorder, Atrial Fibrillation and Vascular Dementia. The resident was admitted to Hospice on August 18,2025. A Prehospital Medical Care directive signed by the resident's representative on August 18,2025 provided by the Hospice, revealed the resident chose the code status of DNR. (Do not resuscitate). The advance directive form signed by the resident on August 22, 2025 found in the clinical record, revealed that no selection was made in relation to the choices of Full Code or DNR code status. No selection was made on the signed form. There was no evidence that the residents code status was reflected in the care plan or the physician's orders for resident #7.An interview was conducted on September 15,2025 at 2:35 p.m. with the Clinical Resource Staff # 888 She stated that the Advance Directive on file for resident #7was not adequate as the resident's choice was unclear, as no choice was clearly selected on the form in the clinical record of the resident. She further stated that this may cause confusion as to the residents wishes.An interview was conducted on September 15, 2025 at 2:42 p.m. with Registered Nurse/ staff # 54. She stated that during an emergent code situation, to determine the residents code status, staff would look at the banner on the resident's electronic chart and the then check the hard chart book that is kept at the nurse's station. She stated that in the case of resident # 7, the banner indicated that the resident was a DNR and the paperwork in the hard chart indicated that the resident had not selected a code status on the signed form Staff #54 stated that by default, this lack of a choice on the signed document made the resident a full code. Looking further into the hard chart book, a signed DNR can be found however, the RN stated that the lack of consistency throughout the resident's clinical record could lead to confusion on the part of the staff and therefore, the resident's wishes may not be followed. The facility policy Advance Directives (4/2013) revealed that changes or revocations of the residents advance directive must be in writing to the administrator and changes should be reflected in the resident's MDS (minimum data set) and care plan. It further revealed that the Director of Nursing or designee would notify the Attending Physician of the advance directives of the resident so that appropriate orders can be reflected in the resident's medical record and plan of care.

Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure one resident (#14) was referred for Level II Pre-admission Screening and Resident Review (PASRR). The deficient practice could result in residents not receiving appropriate services to meet their needs.Number of residents sampled: 20Number of residents cited: 1Findings include:Resident #14 was initially admitted on [DATE] and was readmitted to the facility on [DATE] with a diagnosis that included myocardial infarction, depression, anxiety disorder, bipolar disorder, and schizoaffective disorder.A review of care plan dated January 3, 2024 revealed resident use antipsychotic and antidepressant medications related to schizoaffective disorder. Interventions included to administer medications as ordered, monitor side effects of the antipsychotic medication and report side effects and adverse reactions of medication to provider; and consult with pharmacy and provider to consider gradual dosage reduction (GDR) when clinically appropriate.A care plan dated January 15, 2024 revealed resident had a psychosocial well-being problem potential related to anxiety, depression, psychosis, substance abuse, schizoaffective disorder, and bipolar disorder. The interventions included to allow resident to answer questions and to verbalize feelings, perceptions, and fears; and to initiate referrals as needed or increase social relationships.Review of the Level I PASRR (Pre-admission Screening and Resident Review) document dated March 8, 2024 revealed resident did not have Serious Mental Illness (SMI) such as Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Major Depression or Paranoid Disorder; and, resident had anxiety disorder and depression as mental disorders. Further, the documentation included that no referral necessary for any Level II.A review of Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.0 indicating the resident was cognitively intact. Active diagnoses included anxiety disorder, depression and bipolar disorder. The assessment also included that the resident was on antianxiety and antidepressant medications.Despite documentation that the resident had diagnoses of anxiety, depression, psychosis, schizoaffective disorder, and bipolar disorder and a care plan intervention initiate referrals as needed, there was no evidence found that a referral for level two PASRR was completed for resident #14.A provider progress notes dated May 19, 2025 revealed assessments which included psychotic disorder with hallucinations, active auditory hallucinations, Bipolar disorder, depression, anxiety disorder, and insomnia.The MDs assessment dated [DATE] revealed resident had an onset of mental status change and had behavior of inattention and disorganized thinking that were continuously present. Active diagnoses included anxiety disorder, depression, bipolar disorder, psychotic disorder and Schizophrenia. The assessment also included that the resident was receiving on antipsychotic and antidepressant medications. A provider progress note dated September 8, 2025 revealed medical diagnoses that included Schizoaffective Disorder, Psychotic Disorder with Hallucinations Due to Known Physiological Condition, Bipolar Disorder, Current Episode Hypomanic, Depression, Anxiety Disorder, and Insomnia.A document signed by the administrator (staff #411) and dated September 16, 2025 revealed a handwritten note stating that the facility does not have PASARR Level II referral for resident #14. An interview was conducted on September 16, 2025 at 4:23 PM with a case manager (Staff #15) who stated that she primarily deals with the skilled side of the facility; and her responsibilities included conducting a UDA (User Define Assessment) and MDS in 3 days, advocating for the residents when they arrived at the facility, meeting weekly with IDT (Interdisciplinary Team) team for discharge plans, ordering DME (Durable Medical equipment), hospice, and handling complaint and grievances. The case manager stated that she was not trained and does not do PASRR screening but the resident relation manager (Staff #44) does. On September 16, 2025, at 4:29 PM, an interview was conducted with the Resident Relations Manager (CNA/Staff #44) who stated that a PASRR (Preadmission Screening and Resident Review) is completed upon admission, and she ensures that residents coming from the hospital have a PASRR in place. She stated that a 30-day PASRR is completed for residents who remain in the facility for more than 30 days, and a Level II PASRR is completed when indicated-such as when a resident exhibits behaviors or is prescribed psychiatric medications. Staff #44 reported that she conducts the pre-screening portion of the PASRR process and then contacts the appropriate person to complete the Level II evaluation if needed. According to her, the evaluating psychiatrist will determine whether a resident requires a Level I or Level II PASRR and will contact her if a Level II is needed. During the interview, a review of Resident #14's clinical record was conducted with Staff #44 who said that the PASRR screening dated January 1, 2024, was completed by the transferring hospital; and, a second PASRR, dated January 29, 2024, was also completed by the hospital. She stated that both were Level I screenings. Further, she said that Resident #14 was readmitted to the facility on [DATE], and another Level I PASRR was completed on March 3, 2024, because the resident had remained in the facility for more than 30 days. Staff #44 noted that while the screening documented diagnoses of anxiety and depression, nothing was marked under Serious Mental Illness in Section B. However, Resident #14's clinical record includes diagnoses of schizoaffective disorder, bipolar disorder, and psychotic hallucinations. She stated that no Level II PASRR referral was made and said she could not explain why, as she was not in the position to handle PASRR screenings at that time. She stated that Resident #14 should have been assessed and referred for a Level II PASRR and confirmed that no additional PASRR screenings have been completed since March 3, 2024.Review of facility's policy titled, Pre-admission Screening and Resident Review (PASRR), revealed that if the resident is positive for potential MI (Mental Illness), a Level II PASRR referral must be submitted. It is the responsibility of the facility to make referrals for a Level II PASRR, or in some cases, to ensure the referral is made by the ALTCs case manager, if a Level II PASRR is determined to be necessary.

Based on observations, clinical record review, resident and staff interviews, and facility policy and procedure, the facility failed to coordinate with hospice to ensure quality care and services for one resident (#29). The deficient practice could result in residents not receiving the appropriate interventions for their comfort and end of life services.Findings include: A hospital record dated June 12, 2025 documented resident's plan of care included full liquid diet and continue supportive care. The plan indicated that the resident is to remain on full liquid diet indefinitely. Resident # 29 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of the pancreas, atherosclerotic heart disease, type 2 diabetes mellitus, and anxiety disorder. Review of the hospice respite care document dated August 29, 2025 revealed a diagnosis of malignant neoplasm of the pancreas. The paperwork indicated the resident's diet as as tolerated. A care plan revised on August 29, 2025 revealed that the resident was on hospice for terminal diagnosis of pancreatic cancer. Interventions included nutrition/hydration to maintain comfort. Review of the Order Summary Report revealed a physician order dated August 29 2025 which prescribed a regular diet with diabetic preference. The order indicated regular texture and thin liquids consistency. The 30-day (August 31, 2025 thru September 16, 2025) look back of the CNA (Certified Nursing Assistant) task log for eating revealed that during that timeframe, there were 15 instances of resident refusal, 10 instances in which resident only consumed 0-25% of his meal, 7 instances in which resident consumed 26-50% of his meal, 6 instances which resident consumed 51-75% of his meal, and only 2 instances that the resident consumed 76-100% of his meal. However, review of the 30-day look back of the CNA task log for snack offered revealed documentation for only 9 days out of the 30 days. The documentation indicated the following:- August 29, 2025: taken- August 30, 2025: taken- September 4, 2025: not applicable- September 5, 2025: not applicable- September 6, 2025: resident refused- September 11, 2025: taken- September 12, 2025: taken- September 13, 2025: taken- September 15, 2025 - two encounters: both marked as taken A Dietary Communication form dated September 1, 2025 revealed that the resident's diet was regular. The texture was marked as regular. Fluid was marked as thin. The hospice section was marked as tolerated. A revised care plan dated September 3, 2025 indicated that the resident was at risk for decreased/variable intakes. The goal was for the resident not to experience unsatisfied hunger or thirst. Interventions noted that resident prefers a pureed diet, liquified per resident preference, provide with food preferences, and encourage intake of food/fluids. However, review of the admission Nutrition Data Collection and Assessment dated September 3, 2025 revealed that the Food & Fluid Preference/Likes section documented see tray ticket. Additionally, the Nutritional Monitoring and Evaluation section indicated continue to monitor nutrition related concerns and give comfort care. Although, resident's intake was monitored via the CNA task log for eating and snacks offered, review of the clinical record did not reveal any indication that the issue with regards to poor intake or refusal to eat was relayed to hospice or that comfort care was provided in response to this issue. An admission Minimum Data Set (MDS) assessment date September 4, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The assessment documented that the resident did not have dental or oral issues. Additionally, the MDS noted that the resident was receiving hospice care. A progress note dated September 4, 2025 documented that resident had nausea, abdominal pain, very poor appetite, and complained of difficulty or pain when swallowing mechanically altered diet. However, review of the resident's clinical record did not reveal any indication that hospice was notified of the situation or that the facility's provider was informed of the issues. A progress note dated September 6, 2025 documented that the resident did not consume anything that day other than water. According to the note, the resident preferred to sleep. The note also indicated that the resident complained of difficulty or pain when swallowing mechanically altered diet. Additionally, there was no evidence that the issues/concerns were addressed. However, review of the resident's clinical record did not reveal any indication that hospice was notified of the situation or that the facility's provider was informed. Additionally, there was no evidence that the issues/concerns were addressed. Furthermore, there was no evidence that the resident was on mechanically altered diet. Another progress note also dated September 6, 2025 documented that resident #29 had to be woken up several times throughout the date to ensure he was okay. According to the note the resident refused any meals and medications. However, further review of the resident's clinical record did not indicate any documentation that hospice was notified or that the facility's provider was informed of the situation. Additionally, there was no evidence that the issues/concerns were addressed. Review of the facility's Incident Report dated September 7, 2025 revealed that resident #29 sustained a fall resulting in a dime sized abrasion to the back of his head/top of scalp. The report did not indicate what time the incident took place. Per the report, the nursing staff witnessed the resident walking behind his wheelchair when he lost his balance and fell backwards hitting the top of his head. According to the Incident Report, hospice was notified regarding the fall on September 7, 2025 at 11:49 p.m. However, a progress note dated September 8, 2025 noted that resident #29 stated that the resident sustained a fall on September 7, 2025 at 10:40 p.m. The note indicated that the Director of Nursing (DON) was notified and that facility protocol was followed. The note did not specify if hospice was notified of the incident. Additionally, review of the IDT (Interdisciplinary Team) Fall Review document dated September 8, 2025 documented that notifications were made to providers and family and did not specify that hospice was included in the notification. A progress note pertaining to the IDT Fall Review dated September 8, 2025 documented that the resident sustained a fall with minor injury on September 7, 2025 at 11:00 p.m. The note indicated that Notifications were made to providers and family. But the note did not specify whether hospice was notified. A progress note dated September 12, 2025 documented that resident had very poor appetite and difficulty or pain when swallowing mechanically altered diet. However, further review of the resident's clinical record did not indicate any interventions to address the issue. Additionally, there was no evidence that the resident's poor appetite and difficulty/pain when swallowing was relayed to hospice. Furthermore, there was no evidence that the issues/concerns were addressed. An interview with a Licensed Practical Nurse (LPN/staff #43) was conducted on September 16, 2025 at 6:58 a.m. Staff #43 stated that resident #29 does not normally eat breakfast and has to be coached a lot. Per the LPN, the resident noted that he is often nauseated and had to be given his prescribed medication for nausea. Staff #43 said that breakfast is normally the only meal with issues. During an interview with staff #28 conducted on September 16, 2025 at 7:05 a.m., staff #28 said that resident #29 normally refuses food. According to staff #28 the resident refuses food because he does not like the food. Staff #28 relayed that resident #29 asked his case manager about getting food from a delivery service since he cannot eat the food. When the resident does eat, he consumes between 25-50% of his meals. Staff #28 said that yesterday, the resident asked for soup since he could not eat his food. An interview with resident #29 was conducted on September 16, 2025 at 7:09 a.m. Resident #29 stated that he does not eat the food because it is not consistent with his needs. According to resident #29 he has pancreatic cancer and needs soft food. However, most of the meals he receives is not soft. Resident #29 said that when he askes for something else, he is told that it would take hours. He said that sometimes he is able to get alternate meals but other times he just goes hungry. An observation of resident #29's breakfast tray was conducted on September 16, 2025 at 7:30 a.m. Resident #29's breakfast consisted of apple juice, a piece of toast sliced in half, 2 pieces of really crispy bacon, and scrambled eggs. In a follow-up interview with resident #29 conducted on September 16, 2025 at 7:32 a.m., the resident stated that this breakfast is too tough for him with his cancer. Resident #29's meal ticket for breakfast on September 16, 2025 was reviewed with staff #28 and revealed the following:- Regular diet, regular texture, thin liquid consistency; low carbohydrates preference- Dislikes section was left blank- Likes section was left blank- Beverage preference was left blank- Tray instructions was left blank- Assist instructions indicated to send applesauce and pudding During the post-breakfast meal observation of resident #29's meal tray with staff #28 conducted on September 16, 2025 at 7:53 a.m., staff #28 stated that the resident consumed 15-20% of his meal. The resident appears to have eaten 1 of the 2 pieces of back, almost half of the toast, and some of the scrambled eggs. Review of resident #29's lunch meal ticket for September 16, 2025 revealed an alternate meal request of chicken soup or vegetable soup and hot dog with ketchup. During an interview with the Dietary Manager (staff #90) conducted on September 16, 2025 at 11:29 a.m., staff #90 stated that he has not heard about any issues with resident #29. The Dietary Manager said that there are no listed preferences for this resident and that his is on a regular/regular diet. According to staff #90, resident #29 has cancer so sometimes he does not eat but wants soup. The Dietary Manager stated that over time resident #29 has gotten sicker so they make him whatever he wants. In a follow-up interview with resident #29 conducted on September 16, 2025 at 12:54 p.m., he stated that the meal was not acceptable as it was hard to eat. Resident #29 noted that since he has cancer, he is only able to have liquids. During an observation of resident #29's lunch tray on September 16, 2025, a bag of chips was observed open and it appeared that the resident took a bite out of the hotdog. The resident was eating his soup. A telephonic interview with the hospice's Director of Clinical Services (DCS/staff #500) was conducted on September 16, 2025 at 2:03 p.m. Staff #500 stated that resident #29 originally admitted to the facility for respite care on August 29, 2025 and was supposed to discharge on [DATE]. However, the resident remained in the facility since he felt unsafe at home by himself. According to the DCS, the resident is deciding whether he would remain at the facility for long term care or discharge home. Staff #500 said that the resident is visited by a hospice nurse twice a week and as needed and a hospice aide, once a week or as needed. The last hospice visit was yesterday. Per the DCS, her expectation is that hospice is notified if a resident sustains a fall or has a change in condition or has issues/concerns. Staff #500 said that it is important that facility informs hospice of any changes so they can determine if the resident is experiencing further decline. Additionally, changes should be relayed to hospice so that hospice can determine if there are adjustments that can be made to address the decline/developing symptoms. The DCS noted that from a hospice standpoint information is used to ensure the residents are provided comfort and control symptoms. Staff #500 stated that to her knowledge and review of the resident # 29's hospice record in conjunction with this interview, the facility did not notify hospice that the resident sustained a fall or that the resident was having food intake issues. She indicated that those are information that should have been relayed to hospice. Review of the Order Summary Report revealed a physician order dated September 16, 2025 which prescribed regular with diabetic preferences. The order indicated pureed texture, thin liquids consistency and that per resident's request may liquify to resident preference. An interview with an LPN (staff #43) was conducted on September 16, 2025 at 5:18 p.m. Staff #43 stated that if a hospice resident sustained a fall, hospice would be contacted as part of the notification. This is also the case if a hospice resident's eating pattern changes or if the resident is having issues eating. According to the LPN, it is important to notify hospice so that everyone is aware of what is going on and determine the right treatment/intervention. Staff #43 stated that in the case of a hospice resident's change in eating habits, not addressing the issue could result in the resident feeling d and not depressed. The LPN noted that resident #29 had reported being nauseated but had not been informed of him experiencing hunger. During an interview with the Director of Nursing (DON/staff #80) conducted on September 17, 2025 at 8:34 a.m., staff #80 stated that his expectation with regards to falls is that staff follow the facility policy. This meant that resident is assessed and based on assessment that interventions are put in place. According to the DON the family and provider should be notified of the incident. Staff #80 noted that in the case of hospice residents, hospice should be notified rather than or along with the facility's provider. The DON stated that this is important so that appropriate interventions can be given for that resident's needs. Per staff #80 the potential impact of not notifying hospice depends. He explained that if the facility provider was notified then it would not impact the care. The DON said that if there was no attempt to contact the hospice then the impact would be situational. Although, staff #80 agreed that care for hospice residents is a collaboration between the facility and hospice, if there was no documentation on both sides that the issue was relayed to hospice, then the facility should look at what could have been done since it would be an individual problem. According to the DON although hospice is responsible for end of life care, the overall care is not affected if there is a facility provider that can provide appropriate interventions. With regards to nutrition/food intake issues, staff #80 said that his expectation is that staff members follow the facility policy which entails notifying the provider overseeing the care so that the resident can receive interventions. In the case of hospice residents, his expectation is that the resident's issue is still addressed the same way. However, per the DON it is not necessary for hospice to be involved as long as they receive direction from the facility physician. Staff #80 said that it is important to communicate/address nutrition/food intake issues so that they can collaborate to solve it and have interventions in place from provider. The DON noted that the impact can vary on nursing interventions. Review of the facility's hospice agreement revealed that the facility's responsibilities regarding notification indicated that the facility immediately notify hospice when: a significant change in the resident's physical, mental, social or emotional status occurs, clinical complications have appeared that suggest a need to alter the plan of care, a life-threatening condition appears, a need to transfer the resident from the facility arises, and if the resident dies. Further review of the facility's hospice agreement noted the joint responsibilities of both the facility and hospice included Development and Implementation of Care Plan noted that hospice shall retain overall professional management responsibility for directing the implementation of each resident's plan of care. Additionally, the Modification of Plan of Care portion of the agreement indicated that hospice and facility shall jointly coordinate and participate in periodic review and modification of the resident's plan of care, taking account any changes in the resident's conditions. Furthermore, the agreement directed that hospice and facility shall document the review and modification, and shall immediately notify the other party of any change in condition of a resident that requires a change in the resident's plan of care. Review of the facility policy titled End of Life Care: Hospice Program version 051123 and in effect January 1, 2024 indicated that it is the responsibility of the hospice to manage the resident's care as it related to the terminal illness and related conditions. Per the policy this includes changing the level of services provided when it is deemed appropriate and providing medical direction, nursing, and clinical management of the terminal illness. Additionally, the policy noted that it is the facility's responsibility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the resident's needs. Per the policy this includes notifying the hospice about significant change in the resident's physical, mental, social, or emotional status. Furthermore, the facility is responsible for communicating with the hospice provider and documenting such communication to ensure that the needs of the resident are addressed and met 24 hours per day. The facility policy titled Resident Nutrition Services version 2.1, revised November 2015 stated that significant variations from usual eating or intake patterns must be recorded in the resident's medical record. The Nurse Supervisor and/or Unit Manager shall evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian. The policy noted that nursing personnel will evaluate food and fluid intake in residents with, or at risk for, significant nutritional problems. The policy indicated that nursing staff will assess and document the amounts eaten as indicated for individuals with, or at risk for, impaired nutrition. The policy stated that each resident shall receive meals, with preferences accommodated, prompt meal service and appropriate feeding assistance. Review of the facility policy titled Resident Safety: Accidents and Incidents - Investigating and Reporting version 051123 and in effect January 1, 2024 stated that the following data shall be included in the Report of Incident/Accident form the time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions. The facility policy titled Documentation: Charting and Documentation version 051123 and in effect January 1, 2024 noted that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observations, clinical record review, staff interviews and review of facility policies and procedure, the facility failed to ensure appropriate treatment and services was provided to 1 of 3 sampled residents (#22) with limited ROM.Findings include: Resident #22 was admitted on [DATE] with diagnoses of dementia, hemiplegia/hemiparesis following cerebral infarction, cerebral atherosclerosis, dysphagia, and dysarthria. The OT (occupational therapy) evaluation dated November 1, 2021 included that resident required skilled OT services to improve rehab potential, increase functional activity tolerance, increase independence with ADLs (activities of daily living) and increase safety awareness. Per the documentation, the resident presented with deficits in ADL performance, strength, functional mobility and cognition; and that, skilled OT services was required to maximize functional performance, address deficits and promote safe discharge. Musculoskeletal assessment included that ROM (range of motion) of both upper extremities were within normal limits. The PT (physical therapy) evaluation dated December 17, 2021 revealed that skilled PT was required to address functional deficits and underlying impairments for maximal functional independence. Treatment approaches included therapeutic exercises/activities, neuromuscular reeducation, gait training, manual therapy techniques, group therapeutic procedure, and wheelchair management training. Clinical Impressions included that the resident had functional deficits in bed mobility, transfers, gait with impaired neuromuscular control, balance, strength and endurance. Per the documentation, the resident had no equipment prior to CVA (cerebrovascular accident). The care plan dated February 6, 2024 included that the resident was dependent on staff for activities, cognitive stimulation and social interaction. Interventions included that all staff to converse while providing care, needed assistance with ADLs as required during the activity and needed assistance/escort activity functions. The therapy services screening dated October 23, 2024 revealed the resident reportedly coughing with chopped meals. The recommendation included all ground diet, with extra gravy/moisture. The documentation did not include any limitation in the resident's ROM. The late entry NP note dated May 19, 2025 included that the resident had weakness. The documentation did not include that the resident had any limitation with ROM of the upper extremities. The NP encounter notes dated May 21 and June 4, 2025 revealed that the resident had no gross musculoskeletal angulations or deformities. The IDT (interdisciplinary team) care conference dated June 12, 2025 revealed that resident needs were being met and there were no concerns. The NP encounter notes dated July 16 and July 20, 2025 included resident was alert and oriented x 0 and had no gross musculoskeletal angulations or deformities. The quarterly nursing summary dated July 29, 2025 included that the resident was oriented x3, had bowel and bladder incontinence and had manual wheelchair. The documentation did not include that the resident had any limitation with ROM of the upper extremities. The annual MDS assessment dated [DATE] included a BIMS (brief interview for mental status) score of 99 indicating severe cognitive impairment. Active diagnoses included aphasia, non-Alzheimer's dementia, hemiplegia/hemiparesis, dysphagia and cerebral atherosclerosis. The assessment did not code for therapy and/or recreational therapy; and, there were no RNA (restorative nursing assistance) and/or use of splint/brace coded. The late entry provider progress note dated August 8, 2025 revealed that the resident lived at the facility because of dementia, was alert and oriented x 0 and had right-sided weakness. Physical exam included generalized weakness. Problem lists included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphasia/dysarthria following cerebral infarction. The documentation did not included that the resident had any limitation with ROM of the upper extremities. The late entry physician progress note dated August 25, 2025 revealed that the resident was alert and oriented x 0 and had right-sided weakness. Physical exam included generalized weakness. Problem lists included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphasia/dysarthria following cerebral infarction. The documentation did not included that the resident had any limitation with ROM of the upper extremities. The weekly assessment dated [DATE] revealed no skin issues. Further review of clinical record revealed that the resident was assessed for the extent and limitations of movement of his joints since the PT and OT evaluation in 2021. There was also no documentation the resident had previously received treatment and services for ROM and whether the resident's ROM was maintained or declined. The clinical record also revealed no documentation of a reason why ROM services was not provided to the resident; and that, the resident refused ROM services. There was also no evidence in the clinical record that the resident was a care plan was developed with interventions to address resident's limited ROM. During an observation conducted on September 14, 2025 at 12:07 p.m., resident #22 was sitting in his wheelchair and was eating his meal using his left hand. The resident's right wrist was bent in a downward direction towards the underside of the right forearm; and his right thumb and pointer finger were bent inwards towards the palm of the hand. The resident did not have any splint or brace in place on his right wrist and right hand. On September 14, 2025 at 1:40 p.m., resident #22 was using the side rails with his left hand to wheel himself from the nurse station down the hallway of the unit . His right wrist was bent in a downward direction and was in front of his abdominal area. His right thumb and pointer finger were bent inwards towards the palm of the hand; and, he does not have any any splint or brace in place on his right wrist and right hand. In another observation conducted on September 15, 2025 at 12:03 p.m., resident #22 sitting in his wheelchair in the dining room and eating his meal independently using his left hand. His right wrist was bent in a downward direction and was in front of his abdominal area. His right thumb and pointer finger were bent inwards towards the palm of the hand; and, he does not have any any splint or brace in place on his right wrist and right hand. An interview with a certified medical assistant (CMA/staff #39) was conducted on September 15, 2025 at 1:02 p.m. The CMA stated that resident #22 had a bad stroke and was admitted at the facility with weakness on the right side. She stated that resident #22 was currently not on therapy; and, the resident cannot move his right arm, cannot open/close his right hand and cannot move his fingers on the right hand. She stated that the right wrist, and fingers on the right hand were now stiff and hard. She stated that resident #22 was referred to therapy, had therapy initially but then the resident started refusing them. She stated that the resident were offered/given some splint devices in the past to help his hands open up but the resident refused to use them. She stated that resident #22 was not on any RNA program but, she attempted doing some exercise with his hands when providing cares but resident #22 would immediately take his arm from her. The CMA further stated that she was not aware that a therapy screen for further decline of ROM was completed for resident #22. During an interview with the Director or Nursing (DON/staff #80) conducted on September 17, 2025 at 8:34 a.m. the DON stated that when staff identified an issue related to resident care, the expectation was for staff assess the resident; and, based on the assessment, interventions are put in place and implemented. He also stated that his expectation was that staff members follow the facility policy which entails notifying the provider overseeing the care so that the resident can receive interventions; and, while waiting for the provider's order, nursing staff should discuss with each other if there are interventions that can be implemented in the mean time. The DON said that it was important to communicate/address issues identified so that they can collaborate to solve it and have interventions in place from provider. Further, the DON noted that the impact can vary on nursing interventions. In an interview with the director of rehabilitation conducted on September 17, 2025 at 9:00 a.m., the director stated that residents must be screened by therapists. The facility's policy on Restorative Nursing Services revealed resident w will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's care plan. Restorative goals may include, but are not limited to supporting and assisting the residents in (a) adjusting or adapting to changing abilities; (b) developing, maintaining or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence and self-esteem; and, participating in the development and implementation of his plan of care.

Based on observations, staff interviews, review of facility documentations and policy, the facility failed to ensure that medications were secured and stored properly. The deficient practice could result in unauthorized access to medications and could place resident's safety at risk.Findings include:A medication administration observation was conducted with Licensed Practical Nurse (LPN/Staff #47) on September 15, 2025 at 11:19 AM. There was a gray basin covered with a white towel located on top of the medication cart. Staff #47 pulled a bottle of lactobacillus acidophilous (probiotic) from the gray basin then took one capsule from the bottle placed it in the medication cup and administered the medication to a resident. An interview was conducted with the LPN (Staff #47) on September 15, 2025 at 11:29 AM. Staff #47 stated that the gray basin which was covered with white towel and located on the top of the medication cart contained apple sauce, acidophilous (probiotic), and ensure (supplement). She stated that she keeps the bottle of lactobacillus acidophilous in the basin to keep it cold by using ice packs. She said that does not lock the lactobacillus acidophilous in the medication cart because she has to keep it on ice and that was why it was in a basin. She further stated that the basin was covered with a towel to keep the residents away and to keep it hidden because tempted eyes likes to touch things. During an observation of the medication room conducted with another LPN (staff #89) on September 15, 2025 at 11:43 AM, the LPN (staff #89) stated that the facility has one locked medication room. This room stores IV supplies such as flushes, tubing, syringes, and individualized labeled IV medication bags (not yet mixed), as well as lab supplies. She said that the room also contains a refrigerator for specimens, another refrigerator for medications like insulin pens, a locked box inside the refrigerator for medications requiring secure storage, and a freezer for ice packs. The LPN said that medications requiring room temperature storage, such as over-the-counter (OTC) medications, were stored either in the medication room or in the medication cart; and, medications requiring refrigeration were stored in the refrigerator. The LPN stated that for medications like Lactobacillus, which need to be kept cool, an ice bucket with an ice pack was used on the medication cart; and, ice packs were changed as they melt, which was why the freezer contains a large supply of them. She further stated that Lactobacillus, which was an OTC probiotic, was sometimes stored on top of the medication cart in a covered ice bucket (covered with a towel to keep it out of residents' view), and was not kept in locked storage; and that, this had been the standard practice at the facility. The LPN said that if Lactobacillus was not kept on ice or was placed inside a drawer without proper cooling, it does not meet storage standards; and, since it is a live culture, improper temperature can reduce its medicinal effectiveness. The LPN further stated that the preferred alternative would be to store it in the refrigerator and retrieve it as needed; and that, this was something staff may not have considered carefully before, and in hindsight, should have. Additionally, she emphasized that if a medication was not locked, there is a risk a resident could access it and take it without a physician's order.On September 15, 2025 at 1:45 PM an interview was conducted with LPN (Staff #89) with a Registered Nurse (RN/Staff #14) present. The LPN removed the white towel that covered the gray basin on the medication cart and pulled a bottle of Lactobacillus from the basin. The LPN stated that the bottle of Lactobacillus included a written instruction to store unopened bottle at room temperature; and, after opening to refrigerate the bottle. The LPN said that this was why the bottle was stored in the basin with ice pack.In an interview conducted on September 16, 2025, at 10:01 AM, the Director of Nursing (DON/Staff #80) who stated that the expectation during medication administration for all staff, including himself, was to follow facility policy, review the order, and follow the physician's instructions. The DON stated that medications were stored in the medication room for bulk storage and specific medications were stored in the cart. He said that supplements such as calorie supplement protein, med pass, protein shakes were stored outside the medication cart on ice and probiotics were stored on ice according to the manufacturer's direction. The DON stated that a probiotic is a supplement used to assist with microbiome in the GI (gastrointestinal) tract; and can be ordered by the dietician but probiotic is ultimately ordered by the doctor. The DON also stated that their medication carts and medication room were both locked following regulations and policy. He stated that he would consider a probiotic such as Lactobacillus as a supplement stored according to the manufacturer's direction but can be placed in the ice box on top of the medication cart and not locked. He stated that a probiotic supplement would be stored according to manufacturer's direction i.e., stored on ice after opening. he DON stated that he does not believe that there was any risk for the other residents other than spoilage if not following manufacturer's direction.A review of facility policy titled, G001-Orders/Receiving/Transcribing: Medication and Treatment Orders, effective date January 1, 2024 revealed orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that two staff members (#21, and #58) are educated on infection control and prevention. The deficient practice could result in staff not being familiar with process and procedures for the control and prevention of infection. Findings include:-Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed August 4, 2025. However, it did not indicate what training were covered under this orientation. Further review of the personnel file provided by the facility did not reveal any evidence that staff #21 completed Infection Control training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #58 completed Infection Control training. During a sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that Infection Control training was not assigned or completed by staff #21. HR noted that he would have to call the training system resource to add courses/loaded. However, review of an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Abuse and Elder Justice Act were topics covered. The training included a typed roster with a list of the staff and a training complete section. The roster included staff #21's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #21 and the other staff on the roster actually completed the training. -Regarding Staff #58Review of the personnel record for a Licensed Practical Nurse (LPN/staff #58) revealed a hire date of September 20, 2016. Further review of the personnel file provided by the facility did not reveal any evidence that staff #58 completed Infection Control training. The personnel file revealed a signed job description dated September 20, 2016 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. During a sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that Infection Control training was not assigned or completed by staff #58. HR noted that he would have to call the training system resource to add courses/loaded. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Elder Justice Act was among the topics covered. The training included a typed roster with a list of the staff and a training complete section. The roster included staff #58's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #58 and the other staff on the roster actually completed the training. An interview with a Licensed Practical Nurse (LPN/staff #43) was conducted on September 16, 2025 at 5:18 p.m. Staff #43 stated that staff members are provider training via monthly in-service and yearly computer-based training. According to the LPN training is important for topics such as Infection Control so that staff do not spread infections and residents and other staff. The impact of not getting the appropriate training is that staff would not know what to do if a situation arises or how to take care of the resident. During an interview with a Certified Nursing Assistant (CNA/staff #60) conducted on September 17, 2025 at approximately 8:30 a.m., staff #60 noted being a relatively new employee at the facility. According to the CNA, although on-the-job training was provided, training on Infection Control was not provided. Additionally, staff #60 was told that there would be a series of online training that would need to be completed within 2-months. Staff #60 said that training is important for everyone's safety. The CNA noted that if staff is not provided appropriate training then they would not know how to react and would have to rely on common sense. An interview with the Director of Nursing (DON/staff #80) was conducted on September 17, 2025 at 8:34 p.m. Staff #80 stated that his expectation is that staff follow the facility policy with regards to training. This means completing the onboarding process for general orientation which covers the general education to start the job and do education periodically throughout the year. According to the DON it is important to have Infection Control training in order to have good resident outcomes. Staff #80 said that not having training could lead to a knowledge deficit which could lead to delayed responses and impact care. The facility policy titled Staff Development Program version 0123 stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes. The policy noted that Infection Control was a state agency mandatory topic. Review of the Facility Assessment updated September 15, 2025 indicated that the facility's staff/training/education and competencies included Infection Control. According to the facility assessment competencies are started during orientation and had to be completed during the first few weeks of hire and then annually. The facility policy titled Infection Control Program version 0214 stated that all facility staff will be educated on hand hygiene, infection control, and isolation precautions on hire and annually. The policy noted that education may also be required on an ad hoc basis as deemed appropriate by the Infection Control Coordinator.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#21, #58, #1, #55 & #11) received Dementia Care training. The deficient practice could result in staff not being familiar with process and procedures to care for residents with dementia.Findings include:On September 15, 2025 at 9:11 a.m., a written request for personnel files which included staffs #21, #58, #24, #1, #55 & #11) was submitted specifically asking for proof of training for Dementia Care. -Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed August 4, 2025. However, it did not indicate what training were covered under this orientation. Further review of the personnel file provided by the facility did not reveal any evidence that staff #21 completed Dementia Care training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #21 completed Dementia Care training. Furthermore, during a sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that Dementia Care training was not assigned or completed by staff #21. HR noted that he would have to call the training system resource to add course/get course loaded. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Dementia and Managing Behaviors to Prevent Abuse was a topic covered. The training included a typed roster with a list of the staff and a training complete section. The roster included staff #21's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #21 and the other staff on the roster actually completed the training. -Regarding Staff #58Review of the personnel record for a Licensed Practical Nurse (LPN/staff #58) revealed a hire date of September 20, 2016. Further review of the personnel file provided by the facility did not reveal any evidence that staff #58 completed Dementia Care training. Furthermore, the personnel file revealed a signed job description dated September 20, 2016 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. An interview with Human Resource (HR/staff #70) conducted on September 15, 2025 at 2:04 p.m. Staff #70 stated that the training system itself is the one that assigns the courses. However, based on the personnel records that was reviewed together with the surveyor, he would need to find out why courses are not being assigned. According to HR the expectation is that assigned training is completed a month from when it is assigned. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #58 completed Dementia Care training. During a sit down with HR conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that the Dementia Management training was assigned staff #58. However, the training had not been completed. However, an email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. An attachment marked Clinical Staff Annual Education with a handwritten start date of June 15, 2025 and finished date of July 15, 2025 indicated that Dementia and Managing Behaviors to Prevent Abuse was among the topics covered. The training included a typed roster with a list of the staff and a training complete section. The roster included staff #58's typed name and on the training complete section a handwritten check mark was annotated. There was no clear indication of when staff #58 and the other staff on the roster actually completed the training. -Regarding Staff #1Review of the personnel record for a Certified Nursing Assistant (staff #1) revealed a hire date of February 28, 2025. The file also included a New Employee Orientation Acknowledgement signed February 28,2025. However, it did not indicate what training were covered under this orientation. Additionally, the personnel file revealed a signed job description signed on April 4, 2025 that outlined roles and responsibilities which stated that staff will participate in all required meetings, trainings and events. Further review of the personnel file provided by the facility did not reveal any evidence that staff #1 completed Dementia Care training. During the review of the training system with staff #70 for staff #1's training completion conducted on September 15, 2025 at 2:04 p.m., he noted that there is no documentation of Dementia Care training on either the training system or orientation. An interview with Human Resource (HR/staff #70) conducted on September 15, 2025 at 2:04 p.m. Staff #70 stated that the training system itself is the one that assigns the courses. However, based on the personnel records that was reviewed together with the surveyor, he would need to find out why courses are not being assigned. According to HR the expectation is that assigned training is completed a month from when it is assigned. Staff #70 recommended to check Inservice training log/binder to determine if staff # 1 completed Dementia Care training since it was not on the training system or the orientation training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. did not reveal any evidence that staff #1 completed Dementia Care training. Furthermore, during a sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #1 had no documented Dementia Care training. HR noted that he would have to call the training system resource to add the course. Review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #1's name/was prior to hire date- In-Service roster dated May 20, 2025 = did not include staff #1's name- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training -Regarding Staff #55Review of the staff list for a Licensed Practical Nurse (LPN/staff #55) revealed a hire date of February 5, 2019. Additionally, the personnel file revealed a signed job description dated February 12, 2025 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed February 12, 2025. However, it did not indicate what training were covered under this orientation. Review of the personnel file provided by the facility did not reveal any evidence that staff #55 completed Dementia Care training. Furthermore, during a sit down with the Human Resource (HR/staff #70) to conduct personnel record review specific to training, conducted on September 15, 2025 at 2:04 p.m., staff #70 stated that staff #55 does not have documented training on either the training system or orientation for Dementia Care. HR recommended to check the Inservice binder to determine if staff #55 had completed the training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m., did not reveal any evidence that staff #55 had completed Dementia Care training. Furthermore, during a follow-up sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #55 had no documented Dementia Care training. HR noted that he would have to call the training system resource to add course/get training loaded. However, review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #55's name/was prior to hire date- In-Service roster dated May 20, 2025 = did not include staff #55's name- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training -Regarding Staff #11Review of the personnel record for a Registered Nurse (RN/staff #11) revealed a hire date of February 17, 2025. Additionally, the personnel file revealed a signed job description dated February 18, 2025 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed February 18, 2025. However, it did not indicate what training were covered under this orientation. Review of the personnel file provided by the facility did not reveal any evidence that staff #11 completed Dementia Care training. Furthermore, during a sit down with the Human Resource (HR/staff #70) to conduct personnel record review specific to training, conducted on September 15, 2025 at 2:04 p.m., staff #70 stated that staff #11 does not have documented training on either the training system or orientation for Dementia Care. HR recommended to check the Inservice binder to determine if staff #11 had completed the training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m., did not reveal any evidence that staff #11 had completed Dementia Care training. During a follow-up sit down with Human Resource (HR/staff #70) conducted on September 16, 2025 at 9:47 a.m., staff #70 along with the surveyor verified on the training system that staff #11 had no documented Dementia Care training. HR noted that he would have to call the training system resource to add courses/get training loaded. However, review of the email sent by the facility after the survey exit, received September 17, 2025 at 2:09 p.m. noted that all staff sampled had completed training. The following attachments were reviewed:- In-Service roster dated September 26, 2024 = did not include staff #11's name/was prior to hire date- In-Service roster dated May 20, 2025 = did not include staff #11's name- Clinical Staff Annual Education roster (June 15, 2025 - July 15, 2025) = typed name and handwritten check mark was annotated with no clear indication of when staff member actually completed the training An interview with a Licensed Practical Nurse (LPN/staff #43) was conducted on September 16, 2025 at 5:18 p.m. Staff #43 stated that staff members are provider training via monthly in-service and yearly computer-based training. According to the LPN training is important for topics such as Dementia Care so that staff would know how to handle and treat residents with dementia the right way. The impact of not getting the appropriate training is that staff would not know what to do if a situation arises. During an interview with a Certified Nursing Assistant (CNA/staff #60) conducted on September 17, 2025 at approximately 8:30 a.m., staff #60 noted being a relatively new employee at the facility. According to the CNA, although on-the-job training was provided, training on Dementia Care was not provided. Additionally, staff #60 was told that there would be a series of online training that would need to be completed within 2-months. Staff #60 said that training is important for everyone's safety. The CNA noted that if staff is not provided appropriate training then they would not know how to react and would have to rely on common sense. An interview with the Director of Nursing (DON/staff #80) was conducted on September 17, 2025 at 8:34 p.m. Staff #80 stated that his expectation is that staff follow the facility policy with regards to training. This means completing the onboarding process for general orientation which covers the general education to start the job and do education periodically throughout the year. According to the DON it is important to have Dementia Care in order for staff to be trained how to care for residents with dementia. Staff #80 said that not having training could lead to a knowledge deficit which could lead to delayed responses and impact care. The facility policy titled Staff Development Program version 0123 stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes. The policy did not mention anything regarding Dementia Care training. Review of the Facility Assessment updated September 15, 2025 indicated that the facility's staff/training/education and competencies included Dementia training. According to the facility assessment competencies are started during orientation and had to be completed during the first few weeks of hire and then annually.

Based on interviews, review of clinical record, and facility policy, the facility failed to protect the residents' (#26, #24, #4, and #6) right to be free from physical abuse by a resident. The deficient practice could result in physical and psychosocial harm.Regarding Resident #26 and Resident #24:-Resident #26 was admitted to the facility November 6, 2023, with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance, prediabetes, type 2 diabetes mellitus, chronic kidney disease, cardiomegaly, delirium due to known physiological condition, anxiety disorder, bradycardia, and adult failure to thrive.An admission minimum data set (MDS) assessment dated [DATE], revealed a brief interview for mental status (BIMS) score of 1, indicating severe cognitive impairment. Section C revealed the resident had inattention and disorganized thinking. Section E revealed the resident had wandering behavior that occurred daily.A care plan dated November 15, 2023, revealed the Resident #26 had a behavior problem due to wandering/exit seeking, with interventions for staff to intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, and remove from situation and take to alternate location as needed.An Incident Note, dated December 10, 2023, revealed Resident #26 was in the room of Resident #24 and was standing over Resident #24. Resident #24 became extremely angry and started hitting Resident #26 in the face several times. Resident #24 hit Resident #26 on the left cheek leaving a red mark. The residents were separated by the nurse and a Certified Nursing Assistant (CNA). Resident #26 was assessed and had visible open skin on the left hand fourth finger on both sides. Basic first aid given, and 15-minute checks initiated.An additional Incident Note dated December 10, 2023, revealed Resident #26 was wandering in the hall since start of shift. No redness was noted to face, and middle finger left hand bandages are intact to fingers. Resident remained on every 15-minute checks per provider directions.Despite the documentation of open skin on Resident #26's hand, a Weekly Skin check and Wound assessment dated [DATE], revealed the resident did not have any new or ongoing skin impairments.-Resident #24 was re-admitted to the facility December 28, 2020, with diagnoses that included epilepsy, personal history of traumatic brain injury, unspecified intracranial injury with loss of consciousness of unspecified duration, hypo-osmolality and hyponatremia, anxiety disorder, other specified mental disorders due to known physiological condition, unspecified intellectual disabilities, schizoaffective disorder, and obsessive-compulsive disorder.A quarterly MDS assessment dated [DATE], revealed a BIMS assessment was not conducted for the resident.A care plan dated October 12, 2022, revealed the resident had a behavior problem due to physical behaviors, yelling at staff, pacing, urinating and defecating on bathroom floor to annoy roommates, and touching inappropriately. Interventions included for staff to intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed.An Incident Note dated December 10, 2023, revealed Resident #24 was in his room and Resident #26 was standing over Resident #24. Resident #24 became extremely angry and started hitting Resident #26 in the face several times. Resident #26 hit Resident #24 on the left cheek leaving a red mark. The residents were separated by the nurse (Staff #70) and CNAs. Basic first aid was administered. Notifications were made to the Administrator, Director of Nursing (DON), physician, and resident's family.An additional Incident Note dated December 10, 2023, revealed Resident #24 remained on 15-minute checks per the physician. No redness was noted to the resident's left cheek.A facility Reportable Event Record/Report dated December 15, 2023, revealed that on December 10, 2023, at approximately 5:45 p.m., Resident #26 was walking around the facility's behavioral unit when he walked into Resident #24's room. Staff called out to Resident #26 to redirect him and started working their way toward Resident #24's room. When staff approached the room, they found that Resident #26 and Resident #24 were in an altercation. Staff separated the residents and escorted Resident #26 out of Resident #24's room. When staff asked Resident #24 what happened, he told staff that he was resting and when he opened his eyes, Resident #26 was there at his bedside and it startled Resident #24. Resident #24 stated that he swung at Resident #26 and contacted Resident #26's left cheek. Resident #26 defended himself and contacted Resident #24's cheek. Both residents were assessed by the nurse and found to have no injuries or skin impairments. Residents were separated, made safe, and placed on 15-minute safety checks per medical provider's instructions.A telephonic interview was attempted on July 16, 2025, at 9:04 a.m., with a Licensed Practical Nurse (LPN / Staff #70), however the phone contact provided was a wrong number.An interview was conducted with a CNA (Staff #20) on July 16, 2025, at 9:15 a.m., who stated that she was working on the behavioral unit on the day of the incident between Resident #26 and Resident #24. Staff #20 stated that Resident #26 was very confused and went into Resident #24's room, and that she remembered hearing Resident #26 screaming. Staff #20 stated that then another CNA went into Resident #24's room and called for help, so Staff #20 ran into the room. Staff #20 stated when she entered the room, she saw Resident #24 grabbing Resident #26's neck and hitting Resident #26. Staff #20 stated she intervened and helped to separate the residents and calmed Resident #24 down. Staff #20 stated that she could not remember if there were any injuries to the residents. Additionally, Staff #20 stated after the incident, the residents were kept separated and were placed on 15-minute checks.An interview was conducted with the facility Administrator (Staff #39) on July 16, 2025, at 9:38 a.m. The Administrator stated that if there is an allegation of abuse, that the facility staff ensure the safety of residents, then staff notify their immediate supervisor, the DON, and Administrator. The Administrator stated an initial investigation is conducted and within 2-hours the facility determines if it is a legitimate allegation, and then if it is a legitimate allegation, the allegation is reported to mandated entities. The facility staff then complete the investigation and submit a 5-day report to the State Agency. Regarding the incident on December 10, 2023, between Resident #26 and Resident #24, the Administrator stated that he did not recall the actual incident, but that his understanding based on reading the investigation report was that Resident #26 wandered into Resident #24's room, and that startled Resident #24. The Administrator stated that Resident #24's immediate reaction was that he swung and contacted Resident #26's cheek and Resident #26 struck Resident #24, and then staff separated the residents. The Administrator stated that there were no major skin impairments on the residents. The Administrator stated that the definition of abuse is not clear, and that taken at face value, there was an altercation between the residents, and by current definitions that would be defined as abuse. However, the Administrator stated that he did not think there was ill intent of Resident #26 to go into the room and startle Resident #24. Additionally, that Resident #24 had a traumatic brain injury and given his impairments, the Administrator stated that he did not think Resident #24 had intent to harm, and that Resident #26 was defending himself.Regarding Resident #6 and Resident #4:-Resident #6 was admitted to the facility February 20, 2021, with diagnoses that included cerebral infarction due to thrombosis of left anterior cerebral artery, epilepsy, diffuse traumatic brain injury with loss of consciousness, hemiplegia affecting right dominant side, cerebral edema, atrial septal defect, tachycardia, unspecified psychosis, insomnia, anxiety disorder, schizoaffective disorder, personal history of traumatic brain injury, and major depressive disorder.An annual MDS assessment dated [DATE], revealed the resident had a BIMS score of 1, indicating severe cognitive impairment.A care plan dated March 2, 2022, revealed Resident #6 had a communication problem due to brain injury, with interventions for staff to be conscious of the resident's position when in groups, activities, and the dining room to promote proper communication with others.An additional care plan dated January 28, 2022, revealed Resident #6 had a psychosocial well-being problem due to anxiety, ineffective coping, lack of acceptance to current condition, traumatic brain injury (TBI), schizophrenia, and verbal and physical aggression. Interventions included that the resident needs assistance/supervision/support to identify precipitating factors and stressors, and when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings.A Behavior note dated July 5, 2024, revealed another resident was in a wheelchair behind Resident #6, who did not like this and stated mother fu****. The other resident was redirected back down the hallway.A Behavior note dated July 5, 2024, revealed Resident #6 drank juice out of another resident's drink, and a staff approached Resident #6 and took the juice and tried to redirect Resident #6. Resident #6 started to swing at the staff, and a CNA came and redirected the resident to the TV room.A Behavior note dated July 11, 2024, revealed Resident #6 approached the nurse when at the medication cart and became very invasive of personal space. The resident became agitated with the nurse when nurse did not shake the resident's hand, and slapped the nurse on left upper arm.A Behavior note dated July 11, 2024, revealed staff attempted to encourage resident unsuccessfully to lay in bed to rest. The resident's responses were come on mother fu****, and Resident #6 attempted to hit a CNA.A Behavior note dated July 13, 2024, revealed at 6:27 p.m., Resident #6 attempted to grab a male peer, and the nurse intervened to keep the residents separated. At 7:15 p.m., Resident #6 stated to a nurse come on mother fu****. At 8:50 p.m., Resident #6 attempted to enter another peer's room and the nurse attempted to redirect the resident, then Resident #6 attempted to hit the nurse. Another resident heard Resident #6 stating fu** you bi***, and motherfu****, and the other resident emerged from the room. A verbal altercation ensued and the nurse stood between the residents preventing a physical altercation from occurring.A Behavior note dated July 13, 2024, revealed that Resident #6 stated to another resident Mother fu**** and bast***.An Incident note dated July 15, 2024, revealed that Resident #6 was struck by another resident in the face. Per the documentation, Resident #6 was unable to state what happened, and was removed from the area and assessed for injury. The documentation revealed that first aid was initiated. There was no evidence of a skin assessment or description of any injury or details on what type of first aid was initiated and to what area of the resident's body.The clinical record was reviewed and there was no evidence of a skin assessment for Resident #6 that described any injury following a resident to resident altercation incident on July 15, 2024.-Resident #4 admitted to the facility April 17, 2024, with diagnoses that included cerebral infarction, unspecified mood disorder, type 2 diabetes mellitus, opioid dependence, post-traumatic stress disorder, epilepsy, hemiplegia and hemiparesis following cerebral infarction affecting left side, dysphagia, disorientation, and history of falling.An admission MDS assessment dated [DATE], revealed Resident #4 had a BIMS score of 15, indicating intact cognition.A care plan dated April 9, 2024, revealed Resident #4 had potential for impaired cognitive function or impaired thought process due to behaviors, with interventions to reduce any distractions: turn off TV, radio, close door etc., and to use consistent, simple, directive sentences, and to provide the resident with necessary cues, and to stop and return if the resident is agitated and as needed.An Incident note dated July 15, 2024, revealed that Resident #4 rolled alongside Resident #6 in the dining room, and Resident #4 punched Resident #6 in the face. Resident #4 refused to comment, and Resident #6 was removed from the area and assessed for injury.A Behavior note dated July 16, 2024, revealed Resident #4 went by Resident #6 as he was leaving the dining room and stated you're a useless human being.A facility Reportable Event Record/Report dated July 20, 2024, revealed that on July 15, 2024, at approximately 12:00 p.m., on the behavioral unit, Resident #4 struck Resident #6 on the lower part of Resident #6' face. Prior to the event occurring, Resident #4 was wheeling himself to the dining area for lunch, and Resident #6 looked at Resident #4 and called him a mother fu****. In response, Resident #4 wheeled over to Resident #6 and struck Resident #6 causing Resident #6's lip to swell. Staff did witness the physical altercation, and immediately intervened and separated the two residents. The nurse on duty issued an ice pack for the Resident #6's swelling but did not find any other skin impairments. Social services staff met with Resident #4 to discuss his behavior, in which Resident #4 admitted it was not the right thing to do, but that he did not appreciate being called that name. Resident #4 apologized and stated that he has calmed down and will not have any further issues.A facility investigation (undated) revealed that per a CNA (Staff #86), she was passing trays in the dining room and witnessed Resident #4 reach out and contact Resident #6's lower jaw. Staff #86 immediately separated the residents.A telephonic interview was conducted with a CNA (Staff #52) on July 15, 2025, at 3:11 p.m., who stated that she recalled that staff had informed her that there was an incident where Resident #4 struck Resident #6 in the face on July 15, 2024, but that she did not witness the incident personally.An interview was conducted with a CNA (Staff #86) on July 16, 2025, at 8:11 a.m. Staff #86 stated that if there is an allegation of abuse, then staff are expected to remove the residents to safety and notify the nurse, and try to keep the residents separated. Regarding the incident on July 15, 2024, Staff #86 stated that she witnessed Resident #4 approach Resident #6 and that Resident #4 struck Resident #6 in the face, and that it was aggressive in nature. Staff #86 stated that she then intervened and removed Resident #6 from that area and reported to the nurse. Staff #86 additionally stated that Resident #4 does not care for Resident #6.An interview was conducted with the Administrator (Staff #39) on July 16, 2025, at 9:38 a.m. The Administrator stated that his understanding of the incident on July 15, 2024, was that Resident #4 was passing by Resident #6, and Resident #6 used some language toward him (Resident #4). The Administrator stated that Resident #6 has limited words available to him and that is how he communicates. The Administrator stated that Resident #4 took offense and wheeled over to Resident #6 and made contact with Resident #4, causing Resident #4's lip to swell, and then Resident #4 received an ice pack from the nurse. The Administrator stated that the incident was a resident to resident altercation.Review of the facility policy titled Abuse Policy, dated 2022, revealed the facility strives to prevent the abuse of all their residents, and recognizes that we care for residents with the diagnosis of dementia and other mental illnesses whose behaviors are not always predictable. The facility further recognizes that due to the proximity of our residents to one another and an individual's freedom of choice, that situations may arise where it is not possible to completely prevent all incidents of abuse. By definition, abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well- being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, mental abuse including abuse facilitated or enabled through the use of technology, and misappropriation of property. Potential abusers can be residents, employees, family members, visitors, venders, or any other person who comes into the facility. None of these types or sources of abuse are condoned in the facility. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. If abuse is witnessed or suspected, or an injury of unknown origin is identified, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.Review of the facility policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated January 1, 2024, revealed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on clinical review, interviews and facility policy review, the facility failed to ensure that two residents (#75 and #10) were free from injuries from a preventable accident. The deficient practice could lead to serious injury or death to residents. Findings include: - Regarding resident #10: Resident #10 was admitted to the facility on [DATE] with diagnoses of myocardial infarction type 2, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, psychotic disorder with hallucinations due to known physiological condition, bipolar disorder current episode with hypomanic, burn of third degree of abdominal wall, burn of second degree of abdominal wall, dependence on supplemental oxygen, depression and anxiety disorder. Review of a smoking policy signed by the resident dated [DATE] revealed that the policy indicated that smoking is prohibited in any area where oxygen is being administered or stored. The policy indicated acknowledgement by the resident that the policy was reviewed and that violations may result in forfeiture of smoking privileges. A smoking care plan initiated on [DATE] indicated a goal of smoke safety at designated areas at scheduled times. Interventions included orientation to smoking procedures and areas, and smoking policy provided to resident/resident representative. Review of the smoking evaluations dated [DATE], [DATE], and [DATE] revealed that resident #10 did not have cognitive loss, no visual deficit and no dexterity problems. Frequency was 2-5 cigarettes per day and preferred to smoke mornings, afternoons, evenings and at night. He was considered a safe smoker due to he could light his own cigarette and did not require any adaptive equipment such as: a smoking apron, cigarette holder, supervision or one to one assistance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #10 had a BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment. A progress note dated [DATE] documented that at approximately 5:00 PM, resident #10 was outside smoking when he dropped his cigarette causing his oxygen tank, clothes right flank, stomach, and upper thigh to catch fire. According to the note the resident ' s wounds were cleansed, covered with Silvadene, and a border dressing was applied. Additionally, the note indicated that 911 was called and the resident was transported to the hospital for further evaluation. An emergency department (ED) note dated [DATE] revealed that resident #10 presented to the ED with burns to this right hip, thigh flank area after oxygen tubing caught fire while the resident was smoking during supplemental oxygen use. The note indicated that the resident ' s symptoms included pain. The intervention noted was bandage applied. The note cited that resident sustained 3rd degree burn in a small area on right side. The plan of care indicated was to have resident follow-up with outpatient wound clinic. It was noted that the injury did not require skin graft. Further description of the burn indicated that it was approximately a 5 x 8 cm area that may be full-thickness burn with some surrounding erythema (redness) and blistering. The resident ' s disposition was listed as home discharge. Further review of the ED noted revealed a provider which described the encounter as resident presented to ED with burns to right hip, thigh area after oxygen tubing caught on fire as he was smoking during supplemental oxygen use. The note indicated that the resident stated that he dropped his cigarette on his sweatpants and it started to smolder. The note stated that the resident could not assist himself and stated that I do not have any legs. The note documented that the resident ' s friends had to respond by using a blanket to put the fire out. An emergency room (ER) discharge instruction dated [DATE] revealed that resident #10 was diagnosed with second degree burn of flank and third degree burn of flank. The instruction indicated for the resident to follow-up with the wound clinic that week due to the likelihood that the skin will need debrided. A smoking care plan revised on [DATE] revealed resident required supervision. Interventions indicated that to ensure safety while smoking, the resident required staff supervision. - Regarding resident #75 Resident #75 was admitted to the facility on [DATE] with a diagnosis of orthostatic hypotension, chronic obstructive pulmonary disease, and cervicogenic headache. A smoking care plan initiated on [DATE] indicated a goal for the resident to smoke safely. Interventions included for facility staff to supervise resident #75 while smoking at designated times and that facility will store smoking materials between designated times. However, review of the resident's smoking evaluation dated [DATE] indicated that the resident did not require any supervision or one to one assistance. The evaluation stated that the facility did need to store the resident's lighter and cigarettes. A progress note dated [DATE] revealed that resident #75 was outside smoking when he gave another resident a cigarette and that resident caught his oxygen (O2) tubing on fire. The note documented that resident #75 turned off the other resident ' s O2 and patted the fire with his right hand to put it out. The note indicated that resident #75 sustained blisters on the tips of his 3 middle fingers and the palm of his hand. The note stated that resident #75 ' s wounds were cleansed and petroleum dressing was applied. Review of the admission MDS dated [DATE] revealed a BIMS score of 15 indicating that the resident was cognitively intact. Resident #25 admitted to the facility on [DATE] with a readmission date of [DATE] with a diagnosis of aftercare following joint replacement surgery, anxiety disorder, depression cognitive communication deficit, bipolar disorder and nicotine dependence. Review of the MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Review of the smoking evaluation dated [DATE] revealed the resident had no cognitive loss, no visual deficit and no dexterity problems. Frequency was 5-10 cigarettes per day and preferred to smoke in the morning, afternoon, evenings and at night. Resident #25 was considered a safe smoker due to she could light her own cigarette and did not require any adaptive equipment such as: a smoking apron, cigarette holder, supervision or one to one assistance. The evaluation stated she could store her own lighter and cigarettes. Review of the State Agency ' s (SA) complaint database revealed a Facility Reported Incident (FRI) submitted on [DATE]. The FRI, indicated that resident #10 was in the designated smoking area when he accidentally dropped his cigarette in his lap, setting himself on fire. An interview was conducted on [DATE] at 1:10 PM with the Executive Director, staff #100. He stated he was in his office getting ready to leave for the day when the Director of Nursing (DON), staff #300, came into his office and told him resident #10 had set himself on fire while smoking. Staff #100 and staff #300 went to resident #10's room to speak with him. Upon entrance, the resident's sweatpants had been removed, he was back in bed, and the nurse was treating his burns. Resident #10 explained he was smoking and he dropped the cigarette on his pants. He was trying to find it, but his pants began smoking and then a fire started. He stated that staff #300 came out and poured a pitcher of juice on his pants and put out the fire. Staff #100 stated that resident #10 has gone back and forth with smoking and not smoking. He had quit for quite some time and just recently started again. He states he completed a BIMS test on him at bedside and resident #10 passed. Staff #300 completed wound care on the resident and paramedics arrived and took resident #10 to the hospital. Staff #100 stated the facility has an open smoking policy, which means residents are assessed to be a safe smoker or a supervised smoker. However, any resident residing in the behavioral unit does require supervision. The most recent evaluation completed on resident #10 prior to the incident was on [DATE] and the resident was deemed a safe smoker. Since this incident, the staff have done a reevaluation and deemed the resident unsafe to smoke on his own and requires supervision. An interview was conducted on [DATE] at 2:54 PM with Resident #10. Upon entrance to his room, it was observed that resident #10 was on a nasal cannula and had a portable oxygen tank on the back of his wheelchair. He stated I just decided to smoke because my friend goes out there and it just looks like they all have a good time so I just decided to start smoking again. I just dropped the cigarette because my hands were slippery, they are just that way. My friend, (resident #75) was out there, he was here before and he just came back. He (resident #75) helped me put the fire out. Then someone came out and threw Gatorade on the flames. I went to the hospital but they did not do much for me really. I don't blame anyone but myself for this. When asked if he had his oxygen on when he went out to smoke, he stated I had the tubing in my nose but I don't think the tank was on because I would've blown up if it was. An interview was conducted on [DATE] at 3:24 PM with Assistant Director of Nursing (ADON), staff # 200. She stated "The process for evaluating a resident as a safe smoker consists of: 1. Identify resident as a smoker. 2. Observe resident smoke. Determine if resident can get the cigarette out of the pack, light the cigarette, hold the cigarette, are cognitive to know what they are doing. 3. Determine if resident can extinguish the cigarette and dispose of it in the container. If they can meet all of these things they are considered a safe smoker and can keep their lighter and cigarettes with them and go in and out on their own. If they are deemed an unsafe smoker, staff keep their cigarettes and lighter. An unsafe smoker will have to inform staff when they want to go out to smoke. Staff will then get their cigarettes and lighter and go out with them to supervise. According to staff #200, resident #10 quit smoking for a long time and just started again. I think it's because his friend (resident #75) was out there. Staff #200 was asked what is the process for a resident smoker who is on oxygen. She stated the oxygen should be turned off and the nasal tubing should be removed before they engage in smoking. Staff #200 indicated that it was unclear if the resident #10 ' s oxygen was off when he went out to smoke. She stated we don't really know for sure because staff did not see what happened. His friend (resident #75) told us the oxygen was off but the cannula was on his face. An interview was conducted on [DATE] at 3:45 PM with Resident #75. He stated I feel like this thing is all my fault. I went out to smoke and resident #10 was there, he's my best friend. He asked me if I had a cigarette and I said yes. I gave him one. Everyone keeps telling me it's not my fault, but if I wouldn't have given him the cigarette, this wouldn't have happened! We were sitting there, and resident #25 was out there too with us, and all of a sudden resident #10's pants started smoking and then a flame came up. I told resident #25 to go and get help. I wheeled myself over to him, and went kind of behind him so I could reach my hand along the side of his pants and put the flames out. As I was doing that, there was a huge whoosh and the flame got bigger. I looked at the oxygen tank and saw it was on and then, the tubing was on fire. I grabbed the tube and pulled it off his face and threw it on the ground. The fire was going up the tubing toward the tank. I was going as fast as I could to turn the tank off and I did. Then the big guy came out with lemonade or whatever is in the pitchers of stuff to drink, he had two of them and poured them on the fire. He's a hero! I just keep blaming myself for giving him that cigarette. I told resident #10, no more, don't ask me for cigarettes anymore because I'm not giving you any. I told him to get a patch. I think he's got the start of dementia or something because he can't remember. Something else, why don't they have signs back there in that area that say if you are on oxygen turn it off before you smoke? Now, I just try to go out and smoke when I know resident #10 is in his room. I just don't ever want to see that happen again. It was just terrible! I was so upset and still am. Again, I know everyone says it's not my fault, but in my mind, if I wouldn't have given him the cigarette that wouldn't have happened. I think I'm traumatized or something. It should be noted that as resident #75 was talking, it was noted that he had a pack of cigarettes between his legs resting on his wheelchair. It was observed that resident #75's right hand had a white gauze wrap around the fingers and top part of his hand. He stated he was burned from trying to help put the fire out that was on resident #10. A follow-up interview was conducted on [DATE] at 4:01 PM with the ADON (staff #200). The ADON stated that when a resident is evaluated, we have them sign a paper that they are educated that if they have oxygen to turn it off and remove the cannula. Residents #10 and #75 were both evaluated as safe smokers but now resident #10 is a supervised smoker. During the interview, the ADON confirmed that if a resident is a safe smoker they can keep their lighter and cigarettes with them, even in their room. Staff #200 stated that she is unsure why resident #75 ' s smoking evaluation indicated that the facility will store his cigarette and lighter since he is deemed a safe smoker. Review of the document signed by resident #10 dated [DATE] states Smoking is prohibited in any area where oxygen is being administered or stored An interview was conducted on [DATE] at 4:45 PM with resident #25. She asked Are you here because of the fire? Resident #25 stated that the incident was terrible! Additionally, resident #25 said that I'm so traumatized by what happened. I cried that night when I went to bed. I just can't believe it! According to resident #25, resident #10 is her friend and he could have died from that incident! In hindsight, she commented that she could not believe that she had not thought think to grab that fire blanket there when she goes past it so many times She noted that she just froze. Resident # 25 commented that it was a good thing resident #75 was there., Resident #75 reacted so fast and then staff #300 came out with 2 pitchers of stuff and poured it on the fire. She stated they are heroes! According to resident #25, resident #75 went over there and started patting at the flames and then this huge whoosh came up. It was awful! She indicated that she froze resident #75 had to yell at her to go get help. She said that she went as fast as she could to get help. Resident #25 stated that resident #10 shouldn't be smoking. He quits then he starts again but he shouldn't do it anymore . She commented that resident #10 has signs of dementia. You can just tell. Review of the facility's policy on Smoking dated [DATE] states This facility has established and maintains safe resident smoking practices. Oxygen use is prohibited in smoking areas. Residents are not permitted to give smoking items to other residents.

Based on clinical record review, observation, staff interviews, and review of policies and procedures, the facility failed to ensure one of two sampled residents (#10) received consistent treatment and services related to a suprapubic catheter. The deficient practice could result in complications for residents with indwelling urinary catheters. Findings include: Resident #10 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on January 8, 2021 revealed the resident had a suprapubic catheter. The goals included the resident would show no signs/symptoms of urinary infection. The interventions included monitor for signs/symptoms of discomfort on urination and frequency; monitor/document for pain/discomfort due to catheter; Monitor/record/report to medical doctor (MD) for signs/symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated January 8, 2021 for a suprapubic catheter, size 18 French, 10 milliliter (ml) bulb to drainage bag. -An order dated January 8, 2021 to change suprapubic drainage bag every two weeks and as needed (PRN) related to obstructive and reflux [CONDITION(S)]. -An order dated January 31, 2021 for the suprapubic catheter: cleanse insertion site with normal saline and pat dry, wrap tube with calcium alginate rope as close to insertion site as able, cover with split gauze, notify primary care physician (PCP) if signs/symptoms of infection. A lab report dated as collected on February 15, 2021 and reported on February 20, 2021 revealed the resident urine culture grew Pseudomonas aeruginosa over 100,000 colony-forming unit (CFU)/milliliter (ml). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for March 2021 revealed: -No documentation that the order to cleanse the suprapubic catheter insertion site was completed: March 5, 9 see nurse notes; March 6 and 12, 7 sleeping. -No documentation that the order to do suprapubic catheter care was completed on the first shift March 7, 5 hold/see nurse notes. -No documentation that the order to change the suprapubic drainage bag was completed on March 6, 9 see nurse notes. A nurse progress note dated March 5, 2021 included: suprapubic catheter/cleanse insertion site; with a note that the resident was up in chair. Review of the nurse progress notes dated March 5, 2021 did not reveal the referred note regarding the suprapubic catheter care each shift. Review of a nurse progress note dated March 6, 2021 included: Change suprapubic drainage bag every two weeks with a note that it was changed at the last urologist appointment. However, review of the clinical documentation revealed the last urology appointment occurred February 11, 2021, which was over 14 days before the scheduled change. Review of the nurses' progress notes dated March 15, 2021 revealed: -The resident was very confused and yelling that he needed to urinate. -The resident was encouraged to drink more water because he was more confused than baseline, some redness remained around suprapubic catheter insertion site. Review of the March 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] However, review of the clinical documentation, including a Nurse Practitioner (NP) note dated March 16, 2021, did not reveal that the physician was notified of the elevated temperature, need to urinate, or increased confusion. Review of the nurses' progress notes dated March 17, 2021 at 2:58 a.m. revealed: -The resident was almost non-responsive and soaking wet on his head and shirt when checked at first round of the night shift. Doctor was called and gave order to put in intravenous (IV) and give one liter of normal saline. -By 0630 the liter bag was nearly empty, the resident's arm was swollen up as if infiltrated, but there was no redness at insertion site and no pain reported by the resident. Fluid and IV side were discontinued. Resident continued to have no output to bag, but Certified Nursing Assistant (CNA) reported his brief had been wet yesterday and split gauze around catheter insertion site was damp today. Resident also had a temperature of 100.6 which resolved to 98.3 by 10:00 a.m. without medication. Attempt was made to flush catheter at 10:00 a.m., but no fluid could be pushed into or pulled out of catheter. Urologist was contacted to report issues. He said to send the resident to the emergency department for work up. Resident transported to the hospital at 12:20 p.m. Review of the hospital records for the admitted [DATE] revealed the resident had a clogged suprapubic catheter for 48 hours and was unable to urinate. Doctor from urology at bedside to replace Foley (urinary catheter), lots of sludge coming out. Labs noted white blood cells 16+(normal range 4.50 to 11.00) and patient started on [MEDICATION(S)]. Urinalysis with red and white blood cells >20, 2+ protein, leukocyte esterase 3+, mucous present, occasional urine bacteria, 2+ blood and cloudy urine. Pubic region very tender. Patient had a catheter associated complicated UTI. Patient with replacement of his suprapubic catheter. Resident received IV [MEDICATION(S)] during the hospital visit and was directed to continue [MEDICATION(S)] 300 mg oral two times a day through March 23, 2021. Review of the clinical record revealed the resident was readmitted on [DATE]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses' progress notes dated March 19, 2021 at 3:10 a.m. revealed: -Suprapubic catheter in place draining dark yellow urine with sediment. Site cleansed with normal saline, covered with split gauze. Large amounts of thick discharge noted at site. -Suprapubic catheter in place draining dark amber urine. Resident on oral antibiotic for UTI. A review of the care plan did not reveal the UTI (March 2021) was addressed on the care plan. Review of the TAR for March 2021 revealed: -No documentation that the order to change the suprapubic drainage bag was completed on March 20, blank/no initials of completion. -No documentation that the order to do suprapubic catheter care each shift was completed on first shift March 21, blank/no initials of completion. -No documentation that the order to cleanse the suprapubic catheter insertion site was completed on March 21, blank/no initials of completion. A nurse progress note dated March 22, 2021 at 7:08 p.m. stated supra pubic catheter present and draining clear yellow urine to bag. Insertion cleaned, possible scant leakage around insertion. Site looks more irritated than previous, but is under treatment. Resident afebrile with mentation more consistent with baseline. Will continue to monitor. A nurse's progress note dated April 3, 2021 stated purulent drainage present on suprapubic catheter dressing. No other signs/symptoms of infection noted. Catheter is patent and flowing with clear yellow urine. Will continue to monitor. Continued review of the nurses' progress notes for April 3, 2021 did not reveal the physician was notified of the purulent drainage. Review of the TAR for April 2021 revealed: -No documentation that the order to change the suprapubic drainage bag was completed on April 3, blank/no initials of completion. -No documentation that the order to cleanse the suprapubic catheter insertion site was completed: on April 10, code 7 sleeping. -A code of 9 for suprapubic catheter care every shift on April 8 (second shift) and April 16 (first shift). Nursing progress notes dated April 8, 2021 included the resident refused suprapubic catheter care, refused all cares, was angry and combative, yelling leave me alone. A nurse progress note dated April 11, 2021 at 12:17 a.m. revealed the supra pubic catheter was in place draining dark orange urine, site cleaned with normal saline and covered with split gauze, small amount of redness noted. A nurse progress note dated April 13, 2021 at 2:39 p.m. stated the resident was taken to the urologist for a catheter replacement. Review of a nurse progress note dated April 14, 2021 at 5:44 p.m. revealed the suprapubic catheter was draining dark orange urine, there was yellow drainage noted in the resident's brief at the insertion site, some frank blood leaked from the insertion site after dressing change. The nurse progress note dated April 15, 2021 at 11:09 a.m. revealed the suprapubic catheter was in place draining dark, bloody urine. Review of the clinical record, including the NP notes dated April 6 and 15, 2021, did not reveal the provider was notified of the drainage or bleeding at the insertion site or the dark bloody urine. A nurse progress note dated April 16, 2021 at 6:30 a.m. revealed the resident was sent to the hospital for altered mental status. Review of the facility's discharge assessment dated [DATE] included: The resident was transferred to the hospital emergency department because of altered mental status including confusion and aggression. The assessment included the resident's skin was cool and clammy and the suprapubic catheter was intact and draining dark, bloody urine. Review of the emergency room records for April 16, 2021 revealed the resident had a positive urinalysis with a clinical impression of an acute UTI with a prescription for [MEDICATION(S)] (antibiotic) 300 mg two times a day for treatment. Review of a nurses' progress note dated April 16, 2021 at 10:34 a.m. revealed the resident returned from the hospital, Foley (urinary catheter) in place and draining dark red urine. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No medication dose was included in the order. Review of the progress notes revealed a late entry/infection surveillance report note with an effective date of April 16, 2021 that included symptoms of hematuria and altered level of consciousness were first observed April 15, 2021. That the resident had a UTI with a culture showing >100,000 Pseudomonas aeruginosa, [CONDITION(S)]-resistant Staph aureus (MRSA), and Enterococcus faecalis. The note included that [MEDICATION(S)] and [MEDICATION(S)] (antibiotic) were ordered and that [MEDICATION(S)] was added for duplicate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not assessed. The assessment included, under bowel and bladder, that the resident had an indwelling catheter (including suprapubic catheter and nephrostomy tube) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment did not code the presence of a UTI. A NP progress note dated April 19 2021 included the resident had a MRSA urinary tract infection and that the antibiotic treatment with [MEDICATION(S)] would be lengthened from 5 days to 15 days given the chronicity of the resident's urinary tract infections. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR for April 2021 revealed: -No documentation that the order to cleanse the suprapubic catheter insertion site was completed on April 18, blank/no initials of completion. -No documentation that the order to change the suprapubic drainage bag was completed on April 17, blank/no initials of completion. -No documentation that the order to do suprapubic catheter care each shift was completed on the first shift April 18 or the second shift April 21 and 26, blank/no initials of completion. Review of the care plan revealed a focus dated April 23, 2021 that the resident was on antibiotic therapy related to infection (MRSA UTI) with [MEDICATION(S)] and [MEDICATION(S)] prescribed for treatment. The goal was that the resident would be free of any discomfort or adverse side effects of antibiotic therapy. The interventions included to administer medication as ordered and observed for possible side effects every shift. A urology consult dated May 4, 2021 stated the resident had a partially blocked suprapubic catheter tube and that the tube was changed. A nurse progress note dated May 4, 2021 at 12:49 p.m. revealed the suprapubic catheter was leaking and draining dark yellow urine to the bag. The resident went to a urology appointment on May 4 and the catheter was changed, they reported partial blockage. A NP progress note dated May 4, 2021 at 10:08 p.m. revealed the resident had confusion and malaise and that the nurse would check another urinalysis with a culture and sensitivity as the resident had experienced a change in his overall health. Review of a lab report dated as collected on May 3, 2021 and reported on May 5, 2021 revealed a routine urine culture and was abnormal as it showed gram negative rods greater that 100,000 Cfu (colony forming unit) per ml. The report further included that the test was not performed as the specimen was not received at refrigerated temperature. Tests: urinalysis. complete with microscopic examination with reflex to urine culture, routine. Review of the clinical record did not reveal that the test was repeated to include the specific tests ordered. Review of the TAR for May 2021 revealed: -No documentation that the order to cleanse the suprapubic catheter insertion site was completed: on May 2 and 12, blank/no initials of completion. The code of 9 (see nurse notes) was documented on May 1, 7, and 8. -No documentation that the order to do suprapubic catheter care each shift was completed: on May 1 and 12 (first shift) or May 1, 3, or 10 (second shift), blank/no initials of completion. The nurses' progress notes dated May 1, 7, and 8, in regards to cleansing the suprapubic catheter insertions site indicated that the resident refused the care. Review of the nurses' progress notes dated May 10, 2021 revealed: -The suprapubic catheter was in place and intact draining 200 milliliters (ml) of dark yellow urine. Redness noted around the insertion site as well as purulent drainage mixed with blood. Resident stated that he had pain with cleaning. -The resident stated that he was seeing buffalo outside of his window. A NP note dated May 13, 2021 at 11:54 a.m. revealed a [CONDITION(S)] medication review and included that the resident had been having increased behaviors. The note included the resident was aggressive threating staff at times, smearing feces, trying to pull out catheter, and quite resistant to cares at times. A nurse progress note dated May 13, 2021 at 4:12 p.m. revealed that the suprapubic catheter was draining cloudy yellow urine with sediment. Review of the clinical record, including the NP note from May 13, 2021, did not reveal that the provider was notified of the redness, pain, and purulent drainage at the suprapubic insertion site, nor did the record include that the resident was transported to the hospital or for what reason. The hospital records for the visit starting May 13, 2021 included the resident presented to the emergency room with clogging of the catheter, fever (initial temperature 102.1), and some altered mental status from baseline. The resident met [CONDITION(S)] criteria and was given [MEDICATION(S)] (antibiotic). Catheter was changed out and was flowing. [CONDITION(S)] criteria: systemic [CONDITION(S)] response syndrome (SIRS) criteria met evidenced by abnormal heart rate >90; Suspected infection evidenced by UTI; organ dysfunction evidenced by elevated [MEDICATION(S)] >2. Urinalysis dated May 13, 2021 revealed red blood cells and white blood cells >20, 2+ protein (negative at normal), positive [MEDICATION(S)] (negative at normal), 3+ leukocyte esterase (negative at normal), mucous present, moderate bacteria, 3+ blood (negative at normal), cloudy urine, and white blood cell clumps 11-20. The assessment and plan included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Final blood culture for Proteus mirabilis, critical value. The resident received IV antibiotics: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] during the hospital stay and was directed to take [MEDICATION(S)] 500 mg oral tablet orally 2 times a day through May 24, 2021. Review of the clinical record revealed the resident was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse progress note dated May 18, 2021 at 6:41 p.m. revealed the resident arrived back to the facility from the hospital at 4:20 p.m. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse infection progress note dated May 19, 2021 revealed the resident was on oral antibiotics for a UTI. Review of the care plan did not reveal that the UTI (May 2021) was addressed on the care plan. Review of the TAR for May 2021 revealed: -The order to cleanse the suprapubic catheter insertion site was not re-instated after the resident's return from the hospital. -No order was obtained, and no documentation was completed, for suprapubic catheter care on the resident's return from the hospital on May 18, 2021. A review of the clinical record revealed no evidence that suprapubic catheter care was provided to the resident from May 18 - 23, 2021. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Suprapubic catheter, size 18 French, 10 cubic centimeter (cc) bulb. -Catheter care with soap and water, or wipes, every shift related to obstructive and reflux [CONDITION(S)]. -Change suprapubic drainage bag every 14 days and PRN related to obstructive and reflux [CONDITION(S)]. Review of the TAR for May 2021 revealed no documentation that the order to do suprapubic catheter care each shift was completed on May 30 on the first shift. A nurse progress note noted June 4, 2020 at 1:17 a.m. revealed the resident's catheter was changed yesterday at the urology appointment. The note included the catheter was draining dark brown urine with blood and that fluids were offered frequently. Review of the TAR for June 2021 revealed no documentation that suprapubic catheter care was completed on the first shift on June 20, 27, or 28 and the second shift on June 4, 10, 20, or 24, blank/no initials of completion. A urology appointment consultation report dated July 1, 2021 revealed the suprapubic catheter was changed and that [MEDICATION(S)] (antibiotic) 500 mg was given. Review of the TAR for July 2021 revealed no documentation that suprapubic catheter care was completed on the first shift on July 3, 4, or 10, and the second shift on July 1, 3, or 5, blank/no initials of completion. A nurse progress note dated July 10, 2021 stated that the resident was admitted to the hospital. Review of the clinical record did not reveal the reason that the resident was transferred to the hospital. Review of the hospital records for the visit starting July 10, 2021 revealed that the patient was sent to the hospital for a clogged catheter but it was draining foul looking urine and the patient's temperature was 101.7, white count 16,200 and [MEDICATION(S)] 3.36. Severe [CONDITION(S)] criteria was met related to SIRS criteria evidenced by abnormal temperature >100.9, abnormal white blood cells; suspected infection evidenced by UTI, Pneumonia/respiratory; and organ dysfunction evidenced by elevated [MEDICATION(S)] >2. Assessment and Plan included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Urine culture for hospital stay showed >100.000 Cfu/ml proteus mirabilis. Discharge diagnosis, severe [CONDITION(S)]. Received IV [MEDICATION(S)] and [MEDICATION(S)] (antibiotics) during hospital stay with orders to continue [MEDICATION(S)]-clavulanate (antibiotic) 875 mg-125 mg oral tablet two times a day until July 18, 2021. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse admission progress note dated July 13, 2021 at 12:08 a.m. stated the resident was admitted to the facility at approximately 7:00 p.m. in stable condition. Resident's catheter was patent and flowing with clear yellow urine, redness present at suprapubic catheter site and purulent drainage present on catheter dressing. NP and wound nurse notified. The NP progress note dated July 13, 2021 at 11:29 a.m. included that the resident was being seen for hospital follow up. The NP stated that the resident was taken to the hospital for malaise and found to have a urinary tract infection. The NP stated that the resident did not return on antibiotics and that as the resident was asymptomatic the NP would watch for now. Review of the care plan did not reveal that the UTI (July 2021) was addressed on the care plan. Review of the clinical record up to July 15, 2021 at 9:36 a.m. revealed no orders were obtained for the use of the suprapubic catheter (including size and amount of bulb inflation), or suprapubic catheter care at the resident's return from the hospital on July 12, 2021. During an observation conducted of suprapubic catheter care on July 15, 2021 at 2:09 p.m. with an RN (staff #71) and a Certified Nursing Assistant (CNA/staff #79), the catheter was observed draining clear amber urine with a small amount of sediment present in the dependent loop of the tubing. The insertion site was not observed to be red or with drainage. An interview was conducted with a Registered Nurse (RN/staff #37) on July 15, 2021 at 9:36 a.m. She stated that she would expect to see a check mark and the nurse's initials on the MAR/TAR to show that care was given. The RN stated that blanks on the administration record meant that the care had not been signed as completed and that there would be no evidence to show the care had been given. She stated that suprapubic catheter care was usually done one time a day and that there should be orders for the care. The RN stated that she would have to check the resident's order to see when the site care should be done. She did a review of the resident's orders and stated that there were no orders for the resident to receive suprapubic catheter care. The RN stated that the last suprapubic catheter care was documented for day shift on July 12th, however, per the clinical documentation the resident was at the hospital at that time. An interview was conducted with a Licensed Practical Nurse (LPN/staff #41) on July 15, 2021 at 12:22 p.m. She stated that when a resident has a suprapubic catheter, staff are to monitor the area for redness or inflammation every shift and document the monitoring on the administration record, and monitor the characteristics of the urine. The LPN stated that it would be concerning if the urine was dark, cloudy, had sediment, or an odor when emptied. She stated that if changes occur, the physician should be notified and the nurse should document the communication and observations/assessment in the clinical record. The LPN stated that if an infection was suspected the nurse should look for signs/symptoms including changes in behavior and fever. She stated that if a suprapubic catheter became clogged and the physician decided the resident was to be sent to the hospital, the nurse should document the change of condition and do a discharge assessment in the electronic clinical record. The LPN stated that the change of condition documentation should include vital signs and a progress note. The LPN stated the risk of not providing suprapubic catheter care could be infection of the site, redness or drainage around the site. She stated that if the suprapubic catheter was clogged, the nurse would not see urine output in the drainage bag and the resident may have a distended bladder. The LPN stated that any change in the resident's condition should be documented in the progress notes, the physician and family should be notified, and staff should follow orders as directed by the physician. She stated that if the emergency room found the resident to have an elevated temperature and purulent urine on arrival, the facility staff should have identified the problems before transfer. The LPN stated that things do not develop overnight and that the facility staff should catch signs/symptoms of infection. An interview was conducted on July 15, 2021 at 1:07 p.m. with the Clinical Compliance nurse/interim Director of Nursing (DON/staff #82). She stated that it was her expectations that documentation of care be completed as close to real time as possible. She stated that if care was not completed, the nurse should document the reason in the progress notes. She stated that she expected documentation on the MAR/TAR to include the nurse's initials to show the care was completed. The DON stated that if there were blanks on the MAR/TAR, it meant that staff did not document that the care was completed, or did not give the care. Staff #82 stated that you have to assume that the care was not given. She stated that any resident clinical record found with blanks on the MAR/TAR would not meet expectations, and would pose a risk for a decline in status, acute problems, or not being to manage the resident's acute illnesses. She stated that care plans were to be updated with the resident's changes and that the resident should have his current infection on the care plan. The DON stated that if the care plan was not followed the resident may not get medication/treatments as ordered. She stated that if interventions on the care plan were not followed then the care plan was not being implemented as required and it could lead to complications/declines for the resident. She stated that when a resident is transferred to the hospital there should be a discharge assessment on the resident including vital signs. She stated that the clinical record should show what was happening with the resident and why they were sent to the hospital. On review of the clinical record for this resident, the DON stated that she was unable to find complete vital signs for the March 17, 2021 hospitalization ; she was unable to find the required assessment before the hospital transfer on May 13, 2021; and she was unable to find an assessment, vital signs, or transfer information relating to the resident hospitalization on [DATE]. She stated that there was no further transfer information other than what was provided for this resident. On review of the emergency room record she stated that the facility staff should have identified that the suprapubic catheter was draining foul looking urine, that the resident had an elevated temperature, and a history of [CONDITION(S)] and UTIs. The DON stated that she did not believe that the signs/symptoms developed between the resident leaving the facility and arriving at the emergency room . She stated that the risk of not identifying an illness timely was the risk of unidentified infection, hospitalization , or death. The DON stated that if the staff had identified the signs/symptoms of infection for the resident, the hospitalization may have been prevented. She stated that if a resident had a change in condition, staff are to assess the resident, obtain vital signs, notify the physician, take appropriate actions, notify the family, and document. The DON stated the resident should have current orders for the suprapubic catheter including the size, an order to monitor the suprapubic site, an order to change the catheter bag, an order to provide catheter care, and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the nurse should assess and document the condition of the insertion site each shift. She stated the CNA would assist with the catheter care and the nurse would make sure the care was done and would document the care on the TAR. On review of the clinical record she stated that the site had not been documented as assessed on the TAR from July 13, 2021 at 12:58 a.m. through her review on 7/15/21. She stated that there was no way to show that the resident received the catheter care required each shift since returning from the hospital. The DON stated that if a suprapubic catheter did not receive care or was not properly monitoring for infection, the risk would be that the resident's current infection could have worsened and staff would be unable to tell if the infection was improving or resolving. Review of a facility policy on suprapubic catheter care revised October 2010 included: The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. The guidelines included: Observe the resident's urine level for noticeable increases or decreases; should the resident indicate that his/her bladder is full or that he/she needs to void, report it immediately to your supervisor; check urine for unusual appearance (i.e., color, blood, etc.); and observe the resident for signs and symptoms of urinary tract infection and urinary retention, report findings to your supervisor. The steps in the procedure included to inspect the stoma site and skin around the stoma for any redness or skin breakdown, and check the urine for color and clarity. The documentation that should be recorded in the resident's medical record included: all assessment data obtained during the procedure, the results of the skin assessment around the stoma site, and the character of the urine such as color, clarity, and odor. Review of a facility policy on change in a resident's condition or status revised December 2016 included: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call including when there is a need to alter the resident's treatment significantly. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on clinical record review, facility documentation, staff and resident interviews, and policy review, the facility failed to ensure one resident (#16) was transferred safely, via a Hoyer lift. Findings include: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Per the Minimum Data Set (MDS) assessment dated [DATE], the resident was totally dependent on the assistance of two people for transferring from his bed to his wheelchair. Review of the facility's investigation revealed that on April 26, 2014 at approximately 7:05 a.m., two certified nursing assistants (CNAs) were transferring the resident from his bed to his wheelchair, via a Hoyer lift. Prior to the transfer, the CNAs checked the Hoyer/sling for safety. While positioning the resident for transfer into the chair, the sling on the resident's left should became unattached and the CNAs were unable to prevent him from sliding out of the sling to the floor. The resident sustained [REDACTED]. The resident received nine stitches to his forehead and his tooth had to be pulled, as a result of the fall. Review of a Nursing Assistant Skill Competency Checklist for March 13 and 15, 2014, revealed that both CNAs involved in transferring the resident had received Hoyer lift training, which included an observation of the skill. During a phone interview conducted on June 30, 2014 at 1:55 p.m., one of the CNAs involved in the resident's transfer stated that on the day of the incident, he was controlling the Hoyer lift and the other CNA was controlling the resident's feet. The CNA stated that they set up the sling and double checked the connections, and then moved the resident around the bed to the chair. The CNA stated that the left corner of the sling came off the Hoyer and he was unable to keep the resident from falling to the floor. The CNA also stated he had received previous training with the Hoyer lift and had used it many times. During an interview conducted on June 30, 2014 at 2:20 p.m., the other CNA involved in the accident stated that they had checked the Hoyer and it was ok. She stated they thought the strap had broken, but it had just popped off. The CNA stated she had been trained on the Hoyer lift earlier in the year and uses it practically every day. During an interview, the resident stated that the CNA's did not check the straps that connect to the Hoyer lift, before they lifted him. During an interview conducted on June 30, 2014 at 2:50 p.m., the DON stated that after the accident occurred, the facility identified the issue regarding safe transfer of residents, while using Hoyer lifts. As a result, the facility set in place a Performance Improvement Plan (PIP). The PIP included retraining of all CNA staff on the proper use of the Hoyer lift. She also stated the facility conducts training throughout the year on safety issues, which includes the Hoyer lift. The facility submitted documentation of their corrective action, which included additional training that was provided to staff regarding the use of Hoyer lifts. The documentation further included that two maintenance staff had inspected the Hoyer lift that was used during the transfer and it was found to be in good working order. The sling was also checked and was found in excellent condition. During the survey, there were no concerns related to unsafe transfers using Hoyer lifts or lifts not functioning properly. As a result of the corrective action taken by the facility and that there were no concerns with any current practice, the findings will be cited at past non compliance. A review of the facility's policy titled Hoyer Lift included the facility is committed to ensuring that each resident is transferred in a safe manner. Each clinical staff member will be evaluated per their skills list for the ability to transfer a resident safely using the Hoyer lift and will be accompanied by a second team member while making all transfers using the lift.

Based on clinical record review, staff and pharmacist interviews, hospital records and policy review, the facility failed to ensure one resident (#35) was free of a significant medication error, by failing to provide physician ordered medication, which resulted in hospitalization . Findings include: Resident #35 was readmitted to the facility July 2, 2013, with [DIAGNOSES REDACTED]. Review of the November 2013 recapitulation of physician orders [REDACTED]. Further review of the MAR for November 2013 included that beginning with the mid-day dose of [MEDICATION NAME] on November 18, staff had circled chart code #5 with their initials, through the mid-day dose on November 22, for a total of 9 doses not administered. Chart code #5 indicated that the medication was held and to see the nursing notes. On the back side of the MAR, one nursing staff documented that on November 21, 2013, the medication was not available and that the pharmacy was notified. Review of the nursing notes from November 18 through November 21, revealed there was no documentation regarding the missed doses of [MEDICATION NAME]. A nursing note dated November 22, 2013, documented that the resident was admitted to the hospital for altered level of consciousness. Review of the hospital records dated November 22, 2013, revealed that the chief complaint was decreased mental status and decreased responsiveness. The records documented that the resident had not received the [MEDICATION NAME] for three days, because the facility ran out, and that upon admission the resident's ammonia level was 142 umol/liter, with the normal range between 9-30 umol/liter. Further review of the hospital records revealed a history and physical which documented the following: Impression; hepatic [MEDICAL CONDITION] secondary to skilled nursing facility not providing appropriate management of her ammonia level; Plan and Recommendations; back to skilled nursing facility, with instructions to never run out of [MEDICATION NAME]. During an interview conducted on June 30, 2014 at 1:30 p.m., a staff nurse stated that chart code #5 was documented when a medication was not available. She stated that the pharmacy is notified by telephone when a medication is missing, and that the medication is usually sent the next day. She also stated that the pharmacy was not open on Sunday and did not answer calls or faxes, and did not deliver any medications on a Sunday, which may be one of the reasons a medication delivery took longer than 24 hours. During an interview conducted on June 30, 2014, the Director of Nursing (DON) stated that she was unable to determine from the pharmacy, as to why the medication could not be sent when first requested. She stated that there was no way to find out who called the pharmacy and when. She said that if the resident had to be admitted to the hospital again due to an increased ammonia level, it would be because the resident refused the medication and not because the facility could not obtain the medication. During an interview conducted on July 1, 2014 at 9:30 a.m., the pharmacist stated that his records did not include any staff requests for the [MEDICATION NAME] to be refilled for November 2013. A facility policy titled, Ordering Medications included that the facility was committed to ensuring accurate, timely and appropriate ordering of all medications for the residents. The policy stated that medications will be ordered weekly and as needed to keep the appropriate amount on hand that is needed for each resident. The policy also included the following: 1. nursing staff will reorder all medications with seven doses or less every week, if the order is not delivered the following day, the nurse will call the pharmacy and question the missing medication's whereabouts. If the medication does not arrive after two attempts, the nurse will notify the DON/assistant DON for administrative follow-up with pharmacy.

Based on clinical record reviews, staff interviews, facility documentation, review of hospital records and facility policy, the facility failed to ensure one resident (#169) received timely care and services regarding elevated laboratory levels and subsequently was hospitalized . The facility also failed to ensure pre and/or post [MEDICAL TREATMENT] assessments were consistently completed for one resident (#92). Findings include: -Resident #169 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A review of the hospital history and physical prior to the resident's admission to the facility revealed that the resident had no history of kidney dysfunction. On May 30, 2012, the resident's Blood Urea Nitrogen (BUN) level was 14 and creatinine level was 1.1, which were within normal limits. A review of the admission nursing assessment from June 2, 2012, revealed that the resident was alert and disorientated to time and place. According to a dietary progress note dated June 6, 2012, the resident's current intakes were between 5 to 10 percent. It was recommended that extra fluids be added to meal trays. A fax from dietary was sent to the resident's physician on June 6, which also included meal intakes were below 10 percent. Laboratory tests were ordered for June 7, 2012. Review of the laboratory results revealed a BUN of 67 (normal range between 9-20) and a creatinine level of 3.2 (normal range between .7-1.5). Further review revealed there were initials noted on the report. Per the Director of Nursing, the initials on the lab results were the physician's initials. However, the date of when the results were reviewed was not documented. A review of the clinical record revealed no documented evidence that there were any new physician's orders related to the resident's abnormal lab values or any additional interventions. Review of a therapy screen request dated June 8, 2012, revealed documentation from dietary that the residents intakes were very low and she had been refusing meals. It was also documented that the resident's family was very concerned. A physician's progress note from June 13, 2012, documented the physician received a call that the resident had been confused with decreased mental status. It was also reported that the resident had not been eating or drinking well. However, there were no corresponding nurse's notes or any nursing assessment documentation regarding the concern of the resident's decreased mental status. Labs were then ordered on June 13, and results showed that her BUN was now 120 and creatinine was 5.9. Physician's orders were obtained on June 13, to send the resident to the hospital for acute [MEDICAL CONDITION] and confusion. A review of the hospital history and physical from June 14, 2012, revealed that the resident had "altered mental status and decreased appetite in conjunction with severe laboratory abnormalities indicating acute [MEDICAL CONDITION]." It was documented that the resident's BUN was 125 and creatinine was 6 and that the resident had bilateral moderate hydro[DIAGNOSES REDACTED], and was admitted to the telemetry unit for monitoring. During an interview conducted on April 9, 2013 at 3:52 p.m., a Licensed Practical Nurse (LPN) stated if there was an abnormal lab value and the physician needed to be notified, it would be documented in the nursing notes. During an interview conducted on April 10, 2013 at 9:45 a.m., a Registered Nurse (RN) reported that lab results are always faxed to the physician and if there are abnormal lab values, the physician is called to see if there are any new orders. He stated he would document the notification in the computer under the nurse progress notes. An interview was conducted with the Director of Nursing (DON) on April 10, 2013 at 9:53 a.m. She stated that the physician receives the lab results from the lab and from the facility, and would expect to see the physician's notification documented. She stated that the abnormal lab values on June 7, should have been addressed. The DON admitted that there was no documentation stating that any interventions were done related to the abnormal lab results. During an interview conducted on April 11, 2013 at 2:40 p.m., the resident's physician stated that he receives lab results to his office. He was not sure whether he was receiving the lab results to his office last June. He reported that if he sees an abnormal lab value that needs an intervention he would call the resident's nurse. He stated that he takes into account the resident and their history when reviewing lab results. The physician reported that he mostly looks at the creatinine level and that he would order some sort of an intervention for a creatinine level of 2 or more. He reported that the abnormal lab values on June 7, could have been overlooked. He stated that it was his initials on the lab results; however, he did not know the day he actually saw the results. The physician stated if anything was done regarding the lab values, there was no documentation stating what was done. He reported that the labs were ordered on June 13, because of the resident's mental status change. A review of the facility's policy on laboratory results documented "when abnormal values are noted, the nurse must use critical judgment to determine if the physician should be called...document in nurses' notes any notifications of lab values and if orders are given as a result of the lab values." The purpose of the policy is "to ensure laboratory results are reported and acted on in a timely manner." -Resident #92 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders revealed there were no orders for [MEDICAL TREATMENT]. Review of the resident's care plan revealed the resident received [MEDICAL TREATMENT] three times per week. Interventions included monitoring intake and output and monitoring for [MEDICAL CONDITION]. The resident also had a care plan in place for [MEDICAL CONDITION] related to end stage kidney disease and fluid overload. Interventions included keeping the resident on a one to two liter per day fluid restriction. Review of the facility documentation revealed that no vitals were present on the pre-[MEDICAL TREATMENT] assessment on March 15, 2013. There was no documented evidence of any pre or post assessments present in the medical record for March 18 or 20, 2013. No post [MEDICAL TREATMENT] assessment was documented on March 22 or 25, 2013. Review of the [MEDICAL TREATMENT] nursing assessment for April 1, 3 and 5 revealed no pre-[MEDICAL TREATMENT] assessment had been completed. An interview was conducted with the resident's registered nurse (RN) on April 10, 2013 at 11:20 a.m. The RN stated that the resident was assessed before and after [MEDICAL TREATMENT]. The assessment was to include the resident's weight and blood pressure. The [MEDICAL TREATMENT] was to be checked for bruit and thrill. When the resident returned to the facility the access site was to be monitored for bleeding. He further stated that the form that is used to chart this information is with the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurse further stated that communication with the [MEDICAL TREATMENT] center would occur by the [MEDICAL TREATMENT] center calling the facility and asking to speak with the nurse caring for the resident if there needed to be any changes in the resident's care An interview was conducted with the DON on April 10, 2012. She stated that the orders that come with the resident from the hospital were followed by the facility. She searched the medical record and stated there were no orders for the resident's [MEDICAL TREATMENT], she further stated that she would contact the physician for an order. An interview was conducted with the medical director on April 12, 2013. He stated that he would expect an end stage renal resident that required [MEDICAL TREATMENT] to come to the facility with those orders already in place. He further stated that the physician should have noticed that [MEDICAL TREATMENT] was not previously ordered and ordered it. Review of the facility policy regarding [MEDICAL TREATMENT] care stated "...Residents are assessed by nurses before and after [MEDICAL TREATMENT], and such assessments are documented in the medical record."

Based on clinical and hospital record reviews, resident and staff interviews, observations of current facility practice, review of facility documentation, and review of facility policy and procedure, the facility failed to ensure one resident (#26) was provided timely physician ordered laboratory testing which resulted in emergency air transport to a major medical center, and failed to ensure three residents (#s 84, 2, and 3) were assessed and monitored both before and after narcotic pain medication administration. The sample size was 10 residents. Findings include: -Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Clinical record review revealed a hospital history and physical dated August 13, 2011, prior to admit, that included a current laboratory level for potassium of 3.6 millimoles per liter (mmol/L), with a normal range indicated to be from 3.5 to 5.1. Also noted was the resident had [MEDICAL CONDITION] stage IV. Clinical record review also revealed a history and physical dated August 26, 2011, that included the resident's cardio vascular status included regular rate and rhythm with occasional premature beats. Also documented was that the resident had [MEDICAL CONDITION]. A telephone order dated August 26, 2011, included to administer both [MEDICATION NAME] 40 milligrams (mg), a diuretic, and Potassium 10 milliequivalents, a supplement, for seven days. Also included was an order for [REDACTED]. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The box was blank and contained no initials. A facsimile (fax) sheet labeled "urgent" and dated August 31, 2011, was sent to resident #26's physician by the dietary technician requesting approval to obtain current laboratory results and included "concerned with recent lab values - no current." Also noted on fax sheet was a notation "Nursing: Follow-up on all 'URGENT' requests within one hour." Despite this, on September 16, 2011, the dietary technician crossed through the August 31, 2011, date and wrote "9-16-11" and re-requested approval for the laboratory testing. Review of facility documentation revealed that the physician approved the laboratory tests requested on September 19, 2011. However, the laboratory tests were not drawn until September 27, 2011. Clinical record review revealed laboratory test results that included a potassium level of 7.7 mmol/L. The 7.7 level was further noted to be "high critical" and that the resident's nurse had been notified by telephone at 1:35 p.m. Normal ranges were indicated to be between 3.50 and 5.10. No evidence was revealed that the physician had been notified regarding the critical nature of resident #26's laboratory test results. A telephone order dated September 28, 2011, at 1:35 a.m., 12 hours after the facility received notification of the critical nature of the laboratory values, included to transport the resident to the emergency room for evaluation and treatment of [REDACTED]. Further review of hospital records dated September 28, 2011, included the resident received multiple treatments locally, and that the "patient and spouse were counseled many times regarding the patient's serious condition." Further documented was that the resident was transported via air transport to a higher level of care. Review of facility documentation regarding resident #26 included that the facility had been made aware that after transfer to a higher level of care the resident was in acute [MEDICAL CONDITION] and was receiving [MEDICAL TREATMENT]. In an interview conducted January 11, 2012, the dietary technician stated she needed the laboratory values to ensure her dietary recommendations would meet the needs of the resident. Upon review of the chart documentation, staff stated she originally asked for approval to order laboratory results on August 31, 2011, then noticed in a follow-up review of the chart that the labs had not been obtained and on September 16, 2011, re-requested approval. In an inteview conducted January 11, 2012, at 10:45 a.m., the director of nursing (DON) stated that the nurse involved was counseled at the time regarding the delay in reporting the results to the physician. In response to a question regarding the nearly one month delay in obtaining the laboratory test results, staff stated that once an order was noted, it was put on the medication administration record. Staff further stated 24 hour chart checks were performed by night nurses as well as audits of the medication and treatment administration records completed by the weekend supervisor. When asked specifically what was done related to determine if the 24 hour chart check system was working, the DON stated she was uncertain since she had just started in September, 2011, and was sort of in the middle of this situation. Staff further stated she was uncertain as to why the lab ordered on August 29, 2011, was not completed until September 26, 2011. Review of facility documentation revealed that the facility had identified laboratory testing and "holes" in medication and treatment administration records as a problem, but additional findings during the survey revealed continuing and unresolved problems. Review of facility policy "Laboratory Results" included "2. Critical values: When a critical lab value is received, the nurse will notify the physician immediately..." -Resident #84 was admitted to the facility March 28, 2011, with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE], included resident #84 had frequent pain and had had to limit day to day activities because of severe pain. Also included was the resident was administered both scheduled and as needed pain medications, and received non-medication interventions for pain. Clinical record review revealed a care plan dated April 13, 2011, included to "Monitor/document for side effects of pain medication. Additional record review revealed current pain medications administered to resident #84 included the following: -[MEDICATION NAME] 100 micrograms/hour once a day every 3 days for pain. -[MEDICATION NAME] 60 milligrams Extended Release three times daily for chronic pain. -[MEDICATION NAME] 10/325 milligrams one tab every 4 hours as needed for pain. Review of the December Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s pain level had been documented. In an interview conducted at 12:00 p.m. on January 13, 2012, licensed staff demonstrated that beginning January 11, 2012, a sheet was on her current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. -Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed that on May 19, 2011 the resident had a number of teeth extracted and was prescribed [MEDICATION NAME] 5/325 mg, 1 every four hours as needed for oral pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no evidence that the medication was given for oral pain. A interview was conducted with a registered nurse on the 200 Hall on January 12, 2012 at 2:40 p.m. and was asked how pain was assessed and he responded that the resident is assessed daily for pain and it is recorded on the pain management flow sheet on a 0-10 scale where no pain is a zero and ten is the worst. The pain is the re-evaluated for effectiveness later after administration. -Resident #3 was admitted to the facility January 11, 2011 with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) assessment, dated July 27, 2011, included in Section J that the resident was on a scheduled pain regimen, received as needed pain medications, and non-medication interventions for pain. The assessment continued that pain made it hard for her to sleep at night, and that she had curtailed her activities due to pain. A pain interview was conducted, with the resident responding that she had pain, frequently, on a 7/10 scale. An MDS assessment dated [DATE], coded the resident with pain, frequently, on a 9/10 scale. physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Pain management flowsheet (a facility form to document pain level prior to medication, location of pain, medication given, pain level after medication administration, and nurse signature) included that the resident's pain WAS NOT ASSESSED PRIOR TO AND AFTER THE ADMINISTRATION OF THE PAIN MEDICATION on December 1, 2, 5, 6, 10, 11, 14, 15, 16, 18, 19, 20, 21, 22, 28, and 29. For the administrations that were documented, the pain level decreased from pain level 5-10 prior to the medication, to pain level 2-4 after the medication. During an interview conducted January 11, 2012 at 2:00 p.m., a licensed nurse stated that for every pain medication administered to a resident, there should be a corresponding entry on the pain management flowsheet, documenting the resident's response to the medication. A facility policy, entitled "Pain management" included, under 'Procedure'--3. Assessment of pain is documented "...the appropriate pain scale is used...Pain management is documented on the pain management flowsheet, 7. When pain interventions are used, the nurse must follow up with the resident at an interval appropriate to the intervention to determine if the intervention was effective..."

Based on hospital and clinical record review, observations of current facility practice, staff and resident interviews, review of facility documentation, and review of facility policy and procedure, the facility failed to provide physician ordered care and services to prevent the worsening of a pressure ulcer for one resident (#169), and failed to ensure appropriate care and services were provided to one resident (#86) with a leg/knee immobilizer. The sample size was four. Findings include: -Resident #169 was admitted to the facility on [DATE], for wound care following an above the knee amputation related to a history of gangrenous heel. Resident #169 had other pertinent [DIAGNOSES REDACTED]. Clinical record review revealed that despite resident #169's history, a Braden scale skin assessment for predicting pressure sore risk was completed on admission resulting in a score of 15 which represented mild risk. An admission skin assessment dated [DATE], included that the resident had a reddened coccyx as well as slight discoloration on the right heel. An initial care plan dated October 20, 2011, included an area for risk for skin breakdown and pressure ulcers but these areas were observed to be blank. A consolidated orders report printed November 27, 2011, included a physician's orders [REDACTED]. On December 4, 2011, a physician's progress note included resident "Has a stage II coccyx decubitus ulcer. Allevyn (treatment) being applied." Review of the resident's treatment administration record (TAR) for December 2011, included boxed areas for licensed staff to initial after completing the weekly skin assessment. However, only two of five skin assessments were documented as completed, including on December 15, 2011, which noted only an open wound to the coccyx that was documented to have a treatment in place. A wound assessment worksheet dated December 16, 2011, included that the resident now had a right buttock/ischium stage II pressure ulcer and a left ischium unstageable pressure ulcer that measured 2.3 centimeter (cm) x 1.8 cm with an unable to be determined depth. Both the right and left ulcers were noted to be deep tissue injuries. A physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. Review of the December 2011 TAR included boxed areas to initial completion of the dressing changes but were observed to be blank. Specifically, dressing scheduled to be completed December 19, 22, 25, and 28 were not documented as complete. No documentation was included regarding unavailability of the resident, refusal by the resident or any other complications preventing completion of the dressing changes. A physician's progress note dated December 30, 2011, included that nursing staff reported that the resident has developed a pressure necrosis of his hip area and that the resident had a fever today. Further documented was that the resident was started on [MEDICATION NAME] (antibiotic) and will need debridement and a surgical consultation. A physician's progress note dated January 7, 2012, included the resident was back from his hospitalization for surgical debridement. Also documented was that an area 7 x 8.5 x 5 cm including skin, subcutaneous tissue and muscle down to the ischial bone was debrided and that the resident was now utilizing a wound vac for healing. In an interview conducted January 11, 2012, licensed wound care staff stated the resident could be difficult to work with at times, but that had he refused his dressing changes that would have needed to be documented. In an interview conducted January 11, 2012, a second licensed wound care staff stated that the resident always had an ongoing coccyx wound, but on December 16, 2011, he discovered the additional pressure areas and they progressed very rapidly. In response to a specific question related to the Braden pressure ulcer risk assessment, staff stated that it probably was not correct, but that he based that on the fact he was familiar with the resident from another facility. In an interview conducted January 11, 2012, at 10:45 a.m., the director of nursing (DON) stated 24 hour chart checks were performed by night nurses as well as audits of the medication and treatment administration records completed by the weekend supervisor. Review of facility documentation revealed that the facility had identified "holes" in medication and treatment administration records as a problem in September and October of 2011, but findings during the survey revealed continuing and unresolved problems. Review of facility policy "Pressure Ulcer Prevention" included that "It is the policy of Sierra Blanca Rehabilitation that the resident does not develop pressure ulcers unless clinically unavoidable and that care and services are provided to prevent the development of pressure ulcers, promote the healing of existing pressure ulcers..." Also included was "3. All residents receive skin screening at least weekly. All areas of skin are examined and any disruption of normal skin integrity is documented and reported to the physician as appropriate. Orders for early treatment are obtained to prevent a minor disruption from becoming a major wound." -Resident #86 was admitted to the facility July 23, 2011, with [DIAGNOSES REDACTED]. Review of the closed clinical record included a nursing admission assessment, dated the day of admission, which documented the resident's skin to be without pressure ulcers. She had a full cast on the right leg. Skin assessments were completed weekly. The cast was irritating to the resident's right posterior thigh; the cast was trimmed down, and finally removed on September 12, 2011. Further review of the clinical record included a copy of a physician's prescription, with an order for [REDACTED]. Review of the physician telephone orders, physician's recapitulation of orders, and the treatment administration record for September, October and November, 2011 did not include that the prescription order for the knee immobilizer was re-written or clarified. During an interview conducted January 13, 2012, the therapy supervisor stated that she remembered, and was present, when the cast was removed, but she did not recall any details related to the right knee immobilizer. She was unable to locate any therapy documentation related to the immobilizer. There was no documentation, either in the therapy notes, nor the remainder of the chart related to the fitting or the application of the immobilizer, no orders or documentation of how many hours it was to remain on or off, when it could be repositioned, who was authorized to reposition it, could it be worn in the shower, how the resident tolerated it, or any other necessary information related to the resident's successful use of the immobilizer. Further review of the closed clinical record included two separate nursing notes, both dated October 13, 2011. The first note, a skilled narrative nursing note, stated 'Resident has wound to right calf. Black eschar noted, red around edges, no drainage, no odor. Area measures 6.5 cm x 1.5 cm x 0.2 cm. Resident complains of pain when touched. Appears to have been caused by the leg brace, physician notified via fax.' A second note, timed later that same day, and written by a wound care staff member, included 'New unstageable wound to right lateral calf. Origin believed to be from right knee brace. Incident report and change of condition initiated per nurse. Measures 6 centimeters x 2.5 centimeters x ?. Hard black callous red blanching periwound present.' An interview conducted January 13, 2012, with the assistant director of nursing revealed that no incident report or change of condition charting could be located. During another interview conducted January 13, 2012, therapy staff located a physician's consultation report, with the same information as was written on the prescription form; therapy staff identified this as the physician's orders [REDACTED]. Review of nursing notes, from September 13 forward, included inconsistent documentation of the immobilizer; sometimes it was documented as being on, sometimes there was no documentation related to the immobilizer. Review of weekly skin assessment forms did not include that the skin under the immobilizer was visually checked for any skin breakdown. When a policy was requested related to the use of immobilizers or braces, the assistant administrator stated that the facility did not have a policy. Review of facility policies related to wound care and skin assessments did not include information related to braces, immobilizers, or potential complications.

Based on clinical record review, observations, staff interviews, and review of facility policy, the facility failed to ensure that appropriate care and services were provided to promote the healing of a pressure ulcer for one resident (#6). The sample size was three. Findings include: -During review and observation of the care and services provided for resident #6's stage III pressure sore, the following was noted: Clinical record review included a Braden scale skin assessment conducted upon admission to the facility on [DATE], documented that the resident was at moderate risk for a pressure ulcer with a score of 14. Review of the physician's orders [REDACTED]. Review of the weekly wound reports dated March 3, 9, and 17, 2012, revealed that the same wound to the right lateral ankle had been documented as "deteriorated, stage III, with serous drainage." However, based on the documentation it was not possible to determine what aspect of the wound had deteriorated so that the resident's physician could be notified. Review of the treatment administration record (TAR) for March 2012, revealed documentation that a wound care order for a collagen dressing every other day and prn had been completed on Friday, March 9, 2012, but was not completed again until three days later on Monday, March 12, 2012. In addition, the two areas (2 PM and 8 PM) on the TAR to be initialed that would indicate that the resident's lower extremity was floated per physician's orders [REDACTED]. The TAR included no evidence that the resident's weekly skin assessment scheduled for March 14, 2012, had been completed. Further review of the TAR for March 2012, revealed no documentation that a wound care order for a collagen dressing every other day and as needed had been completed on Sunday, March 18, 2012. In addition, the 8 PM area on the TAR to be initialed indicating the resident's right lower extremity was floated per physician's orders [REDACTED]. On the afternoon of March 20, and again at 2:45 p.m. on March 21, 2012, the resident was observed to be lying in her bed, on her back, with legs extended and rotated outward. Heel protectors were observed to be in place to both feet, however, the right lower extremity was not observed to be floated with a pillow. Observations of the resident's wound care to the right lateral ankle were conducted March 21, 2012, 2:45 p.m., with a licensed staff treatment nurse. The nurse removed the resident's heel protector's and stated that the resident did not have her right lower extremity floated on a pillow because the resident was "[MEDICAL CONDITION]" and was not compliant regarding having her leg floated when in bed. Review of the nurse's notes revealed no documentation that the resident's physician had been notified that the intervention of floating the resident's lower extremity was not possible related to the resident's non-compliance. During an interview conducted March 20, 2012, licensed staff stated that on Sunday's the hall nurse that cared for the resident provided wound care and treatments because there were no treatment nurses available on Sundays. During an interview conducted March 21, 2012, at 1:06 p.m., a CNA (certified nursing assistant) stated that resident #6 had heel protectors in place, that her heels were padded when up in a wheelchair, and that her heels were not floated while in bed. During an interview conducted March 21, 2012, the licensed staff treatment nurse stated that documentation of wound care being provided was evidenced by initialing the treatment on the TAR, that a decline in the status of the wound would be documented in the nurse's notes, and that the doctor would be notified if the wound was not healing or to discuss a different treatment that may be used. She further stated that she would notify the other licensed staff treatment nurse, that conducts the weekly wound assessments, of any wound changes or deterioration she observed during her wound treatment to the resident. Staff also stated that deterioration documented on the weekly wound report would mean that there was a decline or that the wound was not healing. A facility policy titled "Pressure Ulcer Prevention" included that all residents receive skin screening at least weekly. No further policies regarding pressure ulcers or wound care were provided by the facility.