Every finding on record at Heritage Rehabilitation Center

Based on interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 followed up and notified the appropriate staff when she received a report of pain from one of three sampled resident (Resident 1). This deficient practice resulted in a delay assessment and immediate treatment for pain to Resident 1's left hand/arm and had the potential to result an increase to Resident 1's pain.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis including acute embolism and thrombosis of deep veins of left upper extremity (sudden blood clot in a deep blood vessel of the left arm). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2026, the MDS indicated Resident 1 had moderately impaired cognitive skills (a person has trouble with thinking, remembering, learning new things and making decisions) and required partial/moderate assistance (helper does less than half the effort) with shower, toileting hygiene, lower body dressing, and chair/bed to chair transfers. During a review of Resident 1's Order Summary Report (Physician's Order) dated 7/22/2026, the Physician's Order indicated Resident 1 to receive Acetaminophen ([Tylenol] medicine used to relieve pain) 325 milligrams ([mgs] metric unit of measurement, used for medication dosage and/or amount), oral tablet two tablets every six hours as needed for moderate and severe pain. During a review of Resident 1's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/13/2026, the MAR indicated Resident 1 received Tylenol 325 mgs. Two tablets on 8/13/2026 at 7:50 a.m., for pain on a pain scale of four out of 10 (a simple numbering tool from 0 to 10 to help measure and assess pain level. 0=no pain, 1 to 3=mild pain, 4 to 6=moderate pain, and 7 to 10=severe pain). During an interview on 8/27/2026 at 2:46 p.m., Certified Nursing Assistant (CNA) 1 stated on 8/13/2026 prior to Resident 1's shower he complained of pain to his left hand. Resident 1 was able to move his left arm, so she did not think he was really in pain and did not notify the charge nurse (Licensed Vocational Nurse [LVN] 1). CNA 1 stated she avoided Resident 1's left arm while showering him and notified LVN 1 following Resident 1's shower because he continued to complain of pain to his left hand/arm. CNA 1 stated she should have notified the LVN 1right away when Resident 1 complained of pain to his left hand and left arm because not notifying LVN 1 delayed treatment and relief of Resident 1' s pain. During an interview on 8/28/2026 at 8:56 a.m., LVN 1 stated CNA 1 only notified her of Resident 1's complaint of pain to his left hand following his shower (8/13/2026). When she was made aware of Resident 1's pain she administered Tylenol to him. Resident 1 had a deep vein thrombosis ([DVT] a blood clot formed in a deep vein inside the body) on his left arm and sometimes he would complain of pain in his left arm. CNA 1 should have notified her immediately when he initially complained of pain so he could have been assessed, administered medication as needed to prevent the pain from increasing and his physician could have been notified if the pain was not relieved. During an interview on 8/28/2026 at 11:17 a.m., the Director of Nursing (DON) stated CNA 1 should have reported Resident 1's pain immediately to a charge nurse so his pain could have been addressed right away. Not addressing Resident 1's pain immediately caused a delay of care and treatment and a possible increase in pain. During a review of facility's undated Job Description (CNA), the Job Description indicated the CNA will report any unusual behavior changes, signs, symptoms or change in a resident's condition to the charge nurse. During a review of facility's Policy and Procedure (P&P) titled, Pain Assessment and Management, dated 1/20/2026, the P&P indicated staff will identify pain and develop interventions to address underlying causes of pain.

Based on interview and record review, the facility failed to provide necessary social service to meet the resident's needs for one of three sampled residents (Resident 1) by failing to provide psychosocial visits (looking at a person's life by combining their mental health with their social environment) after an alleged abuse incident involving Resident 1 and a certified nursing assistant (CNA). This failure had the potential to put Resident 1 at risk for unaddressed emotional trauma, increased mistrust of staff and decline in psychosocial (how the inner mental state and external social surroundings interact and affect each other) well-being.Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), acute embolism and thrombosis of deep veins of left upper extremity (a sudden blood clot in a deep blood vessel of the left arm), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain), and cognitive communication deficit (trouble communicating due to problems with thinking skills, memory, focus and making decisions). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2026, the MDS indicated Resident 1 had moderately impaired cognitive skills (a person has trouble with thinking, remembering, learning new things and making decisions) and required partial/moderate assistance (helper does less than half the effort) with shower, toileting hygiene, lower body dressing, and chair/bed to chair transfers. During a review of Resident 1's Change in Condition (COC) Evaluation dated 8/14/2026 and timed at 1:17 p.m., the COC indicated Resident 1 complained of pain to his left arm and reported he was hit on his left arm yesterday (8/13/2026) by Certified Nursing Assistant (CNA) 1. During a review of Resident 1's Psychosocial Note by the Social Services Director (SSD) dated 8/17/2026 and timed at 3:33 p.m., the Psychosocial Note indicated Resident 1 appeared to be calm and pleasant. Continued review of Resident 1's Psychosocial Noted indicated there was no documentation addressing the alleged incident of abuse that occurred on 8/13/2026 between Resident 1 and CNA 1. During a review of Resident 1's Care Plan titled, Resident 1 verbalized he was hit on the left arm, initiated 8/14/2026, the Care Plan's goal indicated Resident 1 would remain safe and his physical and emotional status would be monitored with no signs of injury or distress. The Care Plan's interventions included providing emotional support and allow Resident 1 to express his concerns and feelings. During an interview on 8/27/2026 at 4:11 p.m., and a subsequent interview on 8/28/2026 at 10:08 a.m., Social Worker Assistant (SWA) 1 stated the role of a social worker following an alleged incident of abuse between a resident and a staff member was to ensure the resident felt protected, safe, and was not in distress by conducting an onsite visit with the resident. SWA 1 stated she saw Resident 1 several times that week (the week of 8/17/2026) but did not document her visits with Resident 1 in his medical record because she did not feel the alleged incident of abuse was serious and the alleged abuse was not substantiated (proven true with facts, evidence or proof) because there was no serious injury. SWA 1 stated she did not think Resident 1 should be seen by a mental health provider because the resident was not tearful or in distress. SWA 1 acknowledged and stated not providing social services to Resident 1 after an alleged incident of abuse, could cause depression, loss of appetite, loss of interest in participating in daily activities which could lead to a decline in Resident 1's overall health. During an interview on 8/28/2026 at 11:17 a.m., the Director of Nursing (DON) stated a social worker should have assessed Resident 1's psychosocial needs after the allegation of abuse for 72 hours. Not addressing Resident 1's psychosocial status after the allegation of abuse could lead to Resident 1 not participating in daily activities of life, feeling unsafe and isolated. During an interview on 8/28/2026 at 11:53 a.m., the Administrator (ADM) stated the social worker should have seen Resident 1 immediately after the allegation of abuse, and the interaction should have been documented in Resident 1's progress notes During a review of facility's undated Policy and Procedure (P&P) titled, Social Service Department Role and Function, the P&P indicated social service staff will identify and promote individualized, non-pharmacological (any treatment or health intervention that does not use drugs or medicines) approaches to care that meet the mental and psychosocial needs of each resident. The facility should provide social services or obtain needed services from outside entities in situations including abuse of any kind to the residents.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents, (Resident 139) who was admitted with intact skin integrity (undamaged skin) did not develop a blood blister (fluid-filled pocket that forms when small blood vessels break under the skin, usually caused by pinching, crushing, or rubbing) on the left calf that deteriorated to a deep tissue injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) and later progressed to a Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon [a tough cord of fibrous tissue that connects a muscle to a bone], ligament, cartilage, or bone) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to:1. Ensure a change of condition (COC a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death ) evaluation was completed when Resident 139 developed a left calf blood blister on 2/20/2026, that progressed to a DTI on 3/3/2026 and later progressed to a Stage 4 pressure injury on 5/26/2026.2. Ensure an Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) meeting was conducted to evaluate and address the progression of Resident 139's left calf wound from a blood blister to a DTI and later to a Stage 4 pressure injury with exposed tendon, and the development of gangrene (death of body tissue caused by a loss of blood flow or a severe bacterial infection) of Resident 139's left toes.3. Ensure the licensed staff obtained a timely referral to a vascular specialist (specialty doctor who diagnoses and treats problems in the blood vessels) and promptly notified the appropriate healthcare provider, when Resident 139's left calf wound deteriorated from a blood blister to a DTI and to a Stage 4 pressure injury with exposed tendon accompanied by gangrene of the left toes. 4. Ensure the Registered Dietician (RD) was informed of Resident 139's worsening left calf wound condition to assess the nutritional status and provide the necessary recommendations to support wound healing.5. Ensure the licensed staff accurately assessed, monitored and documented Resident 139's left lower extremity capillary refill (a medical test that measures how many seconds it takes for color to return to a skin or nail area after it is pressed and turns white) and pedal pulse (heartbeat-like throb felt in the foot) and timely communicated abnormal findings to Resident 139's physician for further evaluation.These failures resulted in delayed recognition and intervention for Resident 139's worsening vascular compromise ( a reduction or stoppage of blood flow to a specific tissue) , resulting in progression of the left calf wound from a blood blister which measured eight (8) centimeter (cm-unit of measurement) by three (3) cm to a deep tissue injury and eventually to a Stage 4 pressure injury with exposed tendon which measured 13 cm by 7 cm by 0.2 cm., development of gangrene of the left toes, hospitalization, and a vascular surgeon's recommendation for a left above the knee amputation (a surgical procedure to remove the leg above the knee joint due to poor blood flow).Findings:During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was admitted to facility on 3/1/2023 and readmitted on [DATE]. The admission Record indicated a diagnoses including malignant neoplasm (cancer) of the right breast, atherosclerotic heart disease (heart condition where fatty plaque builds up in the heart's arteries), long term use of anticoagulant (taking blood-thinning medications for an extended or indefinite period) and mild protein calorie malnutrition (nutritional deficient caused by eating too few proteins and calories).During a record review of Resident 139's Care Plan, titled High risk to further develop pressure ulcer dated 12/15/2023, the Care Plan interventions included to use an alternate pressure mattress (APM- used to prevent and treat pressure injury), check skin for presence of sores, breakdown/impairment, cleanse after each episode of incontinence (accidental loss of bladder or bowel control)., dietary to assess nutritional needs to maintain good skin integrity, offload (remove or reduce weight and pressure from a specific part of the body) feet when in bed or in wheelchair, and turn and position at least every two hours, and as needed.During a review of Resident 139's Minimum Data Set (MDS - a resident assessment tool), dated 3/29/2024, the MDS indicated Resident 139 had moderate cognitive impairment (decline in thinking, memory, and reasoning that interferes with complex daily activities) and was dependent (helper does all the effort and the resident does none of the effort to complete the activity) with self-care activities, such as bathing, toileting, and dressing, and was dependent in functional abilities, such as going from a sitting to a lying position. The MDS further indicated Resident 139 was at risk of developing pressure injuries, and had no Stage 4 pressure injury, or DTI. The MDS also indicated Resident 139 had no venous (veins-carries blood from the body to the heart) and arterial (artery- carries blood from the heart to the rest of the body) ulcers (open wound on the lower legs and feet caused by poor blood circulation) and no foot problems.During a review of Resident 139's COC Evaluation, dated 2/20/2026, the COC Evaluation indicated, Resident 139 was noted with an eight (8) cm by three (3) cm closed blood blister on the left posterior (back) calf. Charge Nurse (CN) assessed and noted with 8 cm by 3 cm closed blood blister on left posterior calf.During a review of Resident 139's Skin Issues Progress Note, dated 2/24/2026, the Skin Issues Progress Note indicated, Resident 139 had an open blood blister on her left posterior calf, measuring eight (8) cm by three (3) cm by 0.1 cm, which was acquired in-house. The Skin Issues Progress Note indicated that the NP was consulted regarding Resident 139's open blood blister and new treatment was ordered. According to the Skin Progress Note the treatment consisted of cleansing with chlorhexidine (wound cleanser), autolytic debridement (wound-care method that uses the body's own moisture and enzymes to soften and liquefy dead or damaged tissue), and dressing with hydrogel (wound dressing) and foam. The Skin Issues Progress Note also indicated that Treatment Nurse (TN) 1 recommended an arterial and venous (AV) doppler ultrasound (a test that uses sound waves to check blood flow in the legs and arms) for Resident 139's left leg to the primary care provider (PCP), but the PCP declined.During a record review of Resident 139's Care Plan titled Impaired skin integrity related to left posterior calf open blood blister-reclassified as an unstageable wound dated 2/24/2026, the Care Plan included interventions to administer treatment as ordered, provide good infection control during treatment, left posterior leg calf wound: report any edema (swelling), erythema (redness), discharge, fluctuance (wavy impulse felt when pressing), or odor., monitor capillary refill on left foot., monitor for signs of infection as redness, drainage, and increased temperature, monitor pedal pulse on left foot., notify medical doctor (MD) of the progress, and offload the left posterior lower extremity at all times.During a review of Resident 139's Nurse Practitioner (NP) Progress Notes, dated 3/3/2026, the NP Progress Notes indicated Resident 139 was seen for an initial wound evaluation of the DTI on the left lower extremity. The NP Progress Notes indicated the left calf wound measured nine (9) cm by 3.5 cm. The note indicated a plan which included to continue autolytic debridement, reassess the wound at each dressing change, and as needed and report any lack of improvement or acute change to the MD or NP.During a review of Resident 139's Nutritional Review/Progress Note, dated 3/15/2026, the Nutritional Review/Progress Note indicated, Resident 139's skin had a blister. The note did not contain new RD recommendations to address Resident 139's left calf wound.During a review of Resident 139's IDT Progress Note dated 3/16/2026, the note indicated that Resident 139 had significant weight loss compared to her weight from the previous month, the third month, and the sixth month. The IDT recommended increasing the Very High Calorie (VHC) Boost (nutritional supplement) to three times a day for additional nutritional support and monitoring her weight for the next three weeks. However, the IDT Progress Note did not include any recommendations addressing Resident 139's left calf wound.During a review of Resident 139's NP Progress Notes, dated 3/24/2026, the NP Progress Notes indicated Resident 139 had a DTI of the left lower extremity. The note further indicated Resident 139 had a bedside debridement (surgical procedure to remove non-viable [dead] tissue) for excisional extraction of devitalized tissue (dead or dying body tissue that lacks blood flow) from wound bed.The note indicated the wound measured nine (9) cm by seven (7) cm by 0.2 cm.During a review of Resident 139's Nutritional Review/Progress Note, dated 3/30/2026, the Nutritional Review/Progress Note indicated, Resident 139's skin had no pressure sore (injury) per nursing at this time. The note indicated no recommendations of any interventions to address Resident 139's left calf wound.During a review of Resident 139's Nutritional Review/Progress Note, dated 4/18/2026, the Nutritional Review/Progress Note indicated, blank under skin assessment. The note indicated no recommendations of any interventions to address Resident 139's left calf wound.During a review of Resident 139's NP Progress Notes, dated 4/28/2026, the NP Progress Notes indicated Resident 139 had a DTI to the left lower extremity. The note indicated Resident 139 had a bedside debridement for excisional extraction of devitalized tissue from wound bed.The note indicated the wound measured nine (9) cm by 5.5 cm by 0.1 cm.During a review of Resident 139's Nutritional Review/Progress Note, dated 5/17/2026, the Nutritional Review/Progress Note indicated, Resident 139's skin had a unit left medial calf. The note indicated no recommendations of any interventions to address Resident 139's left calf wound.During a review of Resident 139's NP Progress Notes, dated 5/19/2026, the NP Progress Notes indicated Resident 139 had a DTI of the left lower extremity. The note indicated Resident 1 had a bedside debridement for excisional extraction of devitalized tissue from wound bed.The note indicated the wound measured 11 cm by eight cm by 0.2 cm. The note indicated a plan to start negative pressure wound therapy (NPWT-medical treatment that uses suction to help complex, acute, or chronic wounds heal) when the wound was clean enough to start.During a review of Resident 139's NP Progress Notes, dated 5/26/2026, the NP Progress Notes indicated assessment of pressure ulcer (injury) of left lower leg Stage 4. The note indicated Resident 139 had a bedside debridement for excisional extraction of devitalized tissue from wound bed.The note indicated the wound measured of 10 cm by 6 cm by 0.2 cm. The note further indicated after multiple serial bedside sharp debridement NPWT started.During a review of Resident 139's NP Progress Notes, dated 6/4/2026, the NP Progress Notes indicated Resident 139 was started on NPWT, however the notes indicated there was a recurrence of slough (soft, yellowish, or white stringy buildup of dead cells and bacteria that blocks wound healing) greater than 20 percent of the wound surface. The note indicated to hold NPWT and restart autolytic debridement.During a record review of Resident 139's Care Plan titled Resident had a left posterior calf Stage 4 pressure ulcer Stage 4 with full thickness loss with exposed bone, tendon, or muscle. dated 6/11/2026, the Care Plan interventions included to administer treatment as ordered, assess effectiveness, notify MD for any redness, assess pain before, during, and after wound care or nursing care, house supplements as ordered, monitor capillary refill on left foot, monitor pedal pulse on left foot (indicate + if present and - for absence) and inform MD accordingly, and reposition at least every two hours and as needed.During a review of Resident 139's NP Progress Notes, dated 6/11/2026, the NP Progress Notes indicated an assessment of the pressure ulcer (injury) of the left lower leg Stage 4. The note indicated slough has resolved resulting in exposure of the tendons. The note indicated the wound measured 11.5 cm by six cm by 0.3 cm. The note indicated a plan to included to reassess wound at each dressing change, and as needed and report any lack of improvement or acute change to the MD or NP.During a review of Resident 139's Nutritional Review/Progress Note, dated 6/13/2026, the Nutritional Review/Progress Note indicated, Resident 139's skin had a Stage IV (4) left medial calf. The note indicated no dietary changes recommended at this time.During a review of Resident 139's NP Progress Notes, dated 6/18/2026, the NP Progress Notes indicated an assessment of the pressure ulcer (injury) of left lower leg Stage 4. The note indicated wound measurement of 11.5 cm by six cm by 0.1 cm.During a review of Resident 139's MDS dated [DATE], the MDS indicated Resident 139 had moderate cognitive impairment and was dependent on self-care activities, such as bathing, toileting, and dressing, and was dependent on functional abilities, such as going from sitting to lying position. The MDS indicated, Resident 139, was frequently incontinent (lacking voluntary control over urination or defecation) of bowel and bladder. The MDS indicated Resident 139 had an unhealed Stage 4 pressure injury and had no venous and arterial ulcers and no foot problems.During a review of Resident 139's Nutritional Review/Progress Note, dated 6/26/2026, the Nutritional Review/Progress Note indicated, Resident 139 was receiving ongoing treatment on her left dorsum (back) foot and left posterior calf. The note indicated no recommendations of any interventions to address Resident 139's left calf wound.During a review of Resident 139's NP Progress Notes, dated 7/20/2026, the NP Progress Notes indicated an assessment of the pressure ulcer (injury) of the left lower leg Stage 4. The note indicated the wound measured 13 cm by seven cm by 0.2 cm. The NP note indicated Resident 139 continued with stable dry eschar (dead tissue that is typically dark, brown or black) over to the second to fourth toes on the left foot. The note indicated dry scabs noted on 6/14/2026. The note indicated attempted to contact Resident 139's family member by phone and left a message.During a concurrent observation and interview on 7/22/2026 at 12:01 p.m., with Treatment Nurse (TN 1) in Resident 139's room, Resident 139 was observed with a left calf wound that was red and moist with yellowish-white drainage, and exposed tendon. TN 1 stated, Resident 139 developed the wound because Resident 139 crossed her legs.During a concurrent interview and record review on 7/22/2026 at 2:15 p.m. with TN 1, Resident 139's Skin Issue Progress Notes dated 2/24/2026 to 7/20/2026 were reviewed. The notes indicated Resident 139's left calf wound began as an open blood blister on 2/24/2026, progressed to an unstageable pressure injury on 4/28/2026, and advanced to a Stage 4 pressure injury on 6/11/2026. TN 1 stated she had recommended an AV doppler to Resident 139's PCP on 2/24/2026, but the physician declined the recommendation. TN 1 stated Resident 139's Stage 4 pressure injury was avoidable.During an interview on 7/23/2026 at 11:08 a.m. with the Registered Dietician (RD), the RD stated, she identified Resident 139 had a left calf unstageable pressure injury (a full-thickness skin and tissue loss where the true depth and severity cannot be measured) on 5/17/2026 and she did not make any new recommendations. The RD stated that she became aware that Resident 139 had a left calf Stage 4 pressure injury on 6/13/2026 and she did not make any new recommendations. The RD stated that she recommended adding zinc supplementation (taking extra amounts of the essential trace mineral zinc via dietary products, pills, or liquids to support wound healing) for Resident 139 on 7/21/2026.During a phone interview on 7/23/2026 at 12:55 p.m. with the RD, the RD stated, she would typically recommend zinc supplementation for a resident with either a Stage 3 (full-thickness loss of skin, dead and black tissue may be visible) or Stage 4 pressure injury. The RD stated that she recommended zinc (on 7/21/2026) for Resident 139 because Resident 139's left calf Stage 4 pressure injury was worsening.During an interview and concurrent record review on 7/23/2026 at 1:08 p.m. with TN 1, Resident 139's COC Evaluation, dated 2/2/2026, was reviewed. The COC Evaluation indicated that Resident 139 had an eight (8) cm x three (3) cm closed blood blister on the left posterior (back) calf. TN 1 stated, there was no COC Evaluation when Resident 139's left calf blood blister opened, progressed into an unstageable pressure injury, and further advanced to a Stage 4 pressure injury. TN 1 stated, Resident's 139's left calf blood blister progressing into a Stage 4 pressure injury was a change of condition in Resident 139's status and COC Evaluations should have been completed. TN 1 stated, a COC Evaluation needed to be completed to communicate changes in Resident 139's baseline with the interdisciplinary team.During a concurrent interview and record review on 7/23/2026 at 1:08 p.m. with TN 1, Resident 139's IDT Progress Notes, were reviewed. The IDT Notes indicated, there were no IDT Progress Notes documented addressing the progression of Resident 139's left calf wound. TN 1 stated, an IDT meeting was not conducted specifically addressing the deterioration of Resident 139's left calf wound because it was not a facility standard of practice. TN 1 stated, an IDT meeting should have been conducted. TN 1 stated, an IDT meeting would have allowed the IDT to discuss the appropriate care and interventions for Resident 139's left calf wound and identify potential risks associated with further wound deterioration, including the risk of possible amputation (surgical or accidental removal of all or part of a body limb or extremity).During a concurrent interview and record review on 7/23/2026 at 1:08 p.m. with TN 1, Resident 139's Care Plan was reviewed. The Care Plan indicated interventions were not revised to address the treatment and management of Resident 139's left calf wound as it progressed from an open blood blister to an unstageable pressure ulcer and later advanced to a Stage 4 pressure ulcer. TN 1 stated the Care Plan interventions were not updated as the wound worsened and that the interventions should have been revised. She stated the existing interventions did not reflect the resident's changing wound care treatment. TN 1 stated updating the Care Plan would have provided nursing staff with appropriate guidance for assessing, monitoring, managing and treating the resident's left calf wound.During an interview on 7/23/2026 at 1:08 p.m. with TN 1, TN 1 stated, she recommended a vascular consult to Resident 139's NP 1 on 6/18/2026, however the NP 1 declined the recommendation.During a phone interview on 7/23/2026 at 2:42 p.m. with NP 1, NP 1 stated, a vascular consultation was not pursued for Resident 139 because the facility was unable to contact Resident 139's family.During a concurrent observation and interview on 7/23/2026 at 5:35 p.m. with Family Member (FM) 2, FM 2 was crying. FM 2 stated that the facility informed her Resident 139 had small scabs on the back of her leg and it was getting better (improving). FM 2 stated that she contacted the facility approximately two days ago (7/21/2026) to inquire whether Resident 139's left calf wound was improving, and the facility informed her that it was. FM 2 stated that she was not aware Resident 139's left calf wound had progressed to the point that the tendon was exposed. FM 2 stated, if she was informed of the actual condition of Resident 139's left calf wound, she would have wanted Resident 139 to go to the hospital and be seen by a vascular consult, however, she was under the impression that Resident 139's left calf wound was improving based on the information provided by the facility. FM 2 stated, she learned on 7/23/2026 that Resident 139 had gangrene (serious medical condition where body tissue dies due to a loss of blood supply or a severe bacterial infection) on her toes.During a concurrent interview and record review on 7/23/2026 at 4:55 p.m. with TN 1, Resident 139's Treatment Administration Record (TAR), dated 6/2026-7/2026 was reviewed The TAR indicated Resident 139 had a present pedal pulse on her left foot from 6/1/2026 to 6/30/2026 and from 7/1/2026 to 7/24/2026. The TAR indicated Resident 139 had a capillary refill of less than 3 seconds (adequate peripheral perfusion [delivery of oxygen-rich blood to small blood vessels in outer body parts, such as toes, fingers, and skin]) on the left foot during those same time periods. TN 1 stated she checked Resident 139's capillary refill on her left toes. She did not respond when asked how she checked capillary refill when Resident 139 had gangrenous toes. TN 1 stated the COC and IDT meeting were not completed when Resident 139's left calf wound progressed from a blood blister to a Stage 4 pressure injury. She stated the COC should have been initiated to inform the nurses and the family about the condition of Resident 139's wound. TN 1 stated that conducting an IDT meeting was important to assess the plan of care and revise it accordingly. TN 1 stated she did not ask Resident 139's primary care physician (PCP) for another vascular consult even after the wound progressed to Stage 4. TN 1 stated she had recommended an AV doppler to Resident 139's PCP on 2/24/2026, but the physician declined the recommendation. TN 1 stated she did not ask the PCP again for the AV doppler after 2/24/2026, even after Resident 139's wound progressed to Stage 4 and gangrene left toes. TN 1 stated she did not escalate to the Director of Nursing (DON) when NP 1 declined the recommendation to obtain an AV doppler.During an interview on 7/23/2026 at 5:55 p.m. with the Director of Nursing (DON), the DON stated the COC and IDT should have been initiated when Resident 139's left calf wound progressed from a blood blister to a DTI and eventually to a Stage 4 pressure injury. He stated the COC should have reflected the wound status and included notification of the attending physician, responsible party, and dietician. He stated the COC served as a guide to inform the physician of the problem and required clear documentation of who was notified, what the physician said, including notification of the family member and what was communicated. He stated that if documentation was not completed, then the notification was not done. The DON stated the IDT should have discussed the condition of the wound and the actions needed to address the deterioration. The DON stated the IDT should have met to address the changes in the residents' wound, document the deterioration, and update the treatment plan to determine whether to continue or modify the current interventions. The DON stated the reason nurses check pedal pulses and capillary refill was to monitor whether the resident's leg circulation was worsening. He stated the capillary refill documentation was not accurate because the resident had gangrenous toes, which made capillary refill assessment invalid.During a concurrent observation and interview on 7/23/2026 at 6:06 p.m. with Registered Nurse Supervisor (RNS) 2 in Resident 139's room, Resident 139's second, third and fourth (2nd, 3rd, and 4th ) digits (toes) were black. RNS 2 checked Resident 139's pedal pulse on the left foot and stated, Resident 139 had no pedal pulse on the left foot. Two (2) Health Facilities Evaluator Nurses (HFENs - licensed registered nurse who inspects, investigates, and evaluates healthcare facilities) verified pedal pulse on left foot and pedal pulse was absent. RNS 2 stated, she was unable to check capillary refill on Resident 139's left foot because there were no blood flow and Resident 139's toes were necrotic (black).During a concurrent observation and interview on 7/23/2026 at 6:32 p.m., with RNS 2 in Resident 139's room, RNS 2 checked the pedal pulse on Resident 139's right foot. RNS 2 stated, the pedal pulse on Resident 139's right foot was faint. Two (2) HFENs verified that the pedal pulse on right foot was faint.During a review of Resident 139's Emergency Department (ED) to Hospital-admission Record, dated 7/25/2026, indicated Resident 139 was diagnosed with peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), left leg ischemic limb pain (severe ache or burning caused by a lack of blood flow to the left leg), and gangrene of the left toe. The Emergency Department (ED) to Hospital-admission Record indicated the left lower extremity was warm with delayed capillary refill, and posterior tibial and dorsalis pedis pulses were not dopplerable (able to measured, detected, or imaged pulse using doppler technology). The record indicated that the only surgical option for Resident 139 was an AKA.During a review of Resident 139's Vascular Surgery Consultation dated 7/25/2026, the Vascular Surgery Consultation indicated the reason for the evaluation was peripheral artery disease (PAD-common circulatory problem where narrowed arteries reduce blood flow to the limbs) and gangrene of the left toes. The note indicated the vascular surgeon was unable to palpate the left popliteal (back of the knee) or pedal pulses and stated it was unclear how long the condition had been present. The note indicated the vascular surgeon spoke with Resident 139's family member and explained that the only surgical option was a left AKA.During a review of the facility's undated policy and procedures (P&P) titled, Change in a Resident's Condition or Status, the policy and procedure indicated, 'A significant change of condition is a decline or improvement in that resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) . The Nurse Supervisor/Charge Nurse will record in the resident's medical record relative to the changes in the resident's medical/mental condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.'. During a review of the facility's undated policy and procedures (P&P) titled, Care Planning - Interdisciplinary Team, indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.During a review of the facility's undated, policy and procedures (P&P) titled, Care Plans - Comprehensive, indicated, The comprehensive care plan is based on a thorough assessment. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change.During a review of the facility's undated, policy and procedures (P&P) titled, Charting and Documentation, indicated, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Documentation of procedures and treatments shall include care-specific details and shall include a minimum: . The assessment data/and/or any unusual findings obtained during the procedure/treatment.During a review of the facility's undated, policy and procedures (P&P) titled, Pressure Ulcer Treatment, indicated, Pressure ulcer treatment requires a comprehensive approach, including: . Managing systemic issues (edema (swelling), venous insufficiency [a long-term condition where leg veins fail to send blood back to the heart], etc.), maximizing the potential for healing.

Based on observation, interview, and record review, the facility failed to:1.Maintain accountability of four doses of controlled medications (medications with a high risk for abuse or diversion [any use other than that intended by the prescriber]) on the controlled substance accountability record affecting Residents 6, 49, and 132 in one of three inspected medication carts (Station B2 Cart.)This deficient practice of failing to accurate account for controlled substances increased the risk of diversion of controlled mediations, misappropriation of resident property, and the risk that Residents 6, 49, and 132 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.2.Ensure the memantine (a medication that slows memory loss) order for one of three sampled residents (Resident 41) was verified with the neurologist (medical doctor who diagnoses and treats disorders of the brain) after Resident 41 was seen on 4/24/26.This failure had the potential to affect Resident 41's quality of life by not ensuring she received memantine as prescribed by the neurologist on 4/24/26.Findings: During a concurrent observation and interview of Station B2 Cart on 7/21/26 at 11:21 a.m., with Licensed Vocational Nurse (LVN 1), the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1.Resident 49's Narcotic and Hypnotic Record for lacosamide (a medication used to treat seizures) 100 milligrams (mg – a unit of measure for mass) indicated there were 21 doses left; however, the medication card contained 20 doses. 2.Resident 6's Narcotic and Hypnotic Record for alprazolam (a medication used to mental illness) 0.5 mg indicated there were 14 doses left; however, the medication card contained 13 doses. 3.Resident 132's Narcotic and Hypnotic Record for alprazolam 1 mg indicated there were 2 doses left; however, the medication card contained 1 dose. 4.Resident 6's Narcotic and Hypnotic Record for morphine (a medication used to treat pain) 10 mg/ 5 milliliter (ml – a unit of measure for volume) indicated there were 200 ml left; however, the medication bottle contained 195 ml. LVN 1 stated he gave all of the missing doses of controlled substances this morning between 9 a.m. and 10 a.m., but failed to sign the Narcotic and Hypnotic Record at the time of administration. LVN 1 stated he was required to sign the Narcotic and Hypnotic Record immediately after the medication dose was removed from the bubble pack or container. LVN 1 stated this helps to prevent diversion and helps decrease the risk that residents may receive the medication too frequently due to lack of documentation. LVN 1 stated if residents receive medication too frequently it could cause medical complications possibly leading to hospitalization. During a review of the facility's policy and procedure (P&P) titled Controlled Substances (undated), the P&P indicated . a control sheet must be made for each substance. this record must contain: . signature of nurse administering medication. 2.During a review of Resident 41's admission Record, the admission Record indicated, Resident 41 was admitted to the facility on [DATE] with the diagnosis including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), gout (type of arthritis-swelling of joints) and mild cognitive (ability to think, understand, learn, and remember) impairment. During a review of Resident 41's Minimum Data Set (MDS –resident assessment tool), dated 5/20/26, the MDS indicated, Resident 41's cognition was intact. The MDS indicated, Resident 41 was dependent (staff does all the work) with activities of daily living (ADL's- activities such as bathing, dressing, and toileting a person performs daily). The MDS indicated, Resident 41 did not have a diagnosis of Alzheimer's ( a disease characterized by a progressive decline in mental abilities). During a review of Resident 41's History and Physical (H&P) dated 3/27/2026, the H&P indicated Resident 41 had the capacity to understand and make decisions. During a review of Resident 41's Neurologist Progress Note dated 4/24/2026, the note indicated Resident 41 had a diagnosis of Alzheimer's/dementia ( a progressive state of decline in mental abilities) and was prescribed memantine 5 milligrams (mg-unit of measure) by mouth once a day for 30 days with three refills. During a review of Resident 41's Order Summary Report dated 4/27/2026, the Order Summary Report indicated, Resident 41 was prescribed memantine 5 mg give one tablet by mouth in the evening for dementia for 30 days. During a review of Resident 41's Care Plan titled Decline in cognition from baseline, dated 2/18/2025 and revised on 5/5/2026, the Care Plan indicated, Resident 41 had impaired cognition and was prescribed Aricept (medication used to treat confusion, memory loss, and other symptoms of mild, moderate, or severe Alzheimer's disease) and memantine. During a concurrent interview and record review on 7/23/2026 at 10:40 a.m. with Registered Nurse Supervisor 4 (RNS 4), reviewed Resident 41's neurologist progress note dated 4/24/26. The progress note indicated Resident 41 had a diagnosis of Alzheimer's/dementia and was prescribed memantine 5 mg by mouth once daily for 30 days with three refills. RNS 4 stated Resident 41 should have been taking memantine and the order should have been clarified with the neurologist on 4/24/2026 regarding the three refills. RNS 4 stated memantine was prescribed to slow memory loss. During an interview on 7/23/26 at 3:56 p.m. with the Director of Nurses (DON), the DON stated after Resident 41's neurology appointment on 4/24/2026 a nurse should have verified the orders with the neurologist. The DON stated usually memantine does not have a stop date because it was prescribed to help slow down the progression of Alzheimer's disease. During a review of the facility's policy and procedure (P&P) titled Physician Medication orders dated no date, the P&P indicated, the Licensed Nurse on duty at the time the order is received enters it on the physician order sheet/telephone order sheet if not written there by the prescriber and notes the order. The P&P indicated, the Licensed Nurse or the Director of Nursing Services shall call-in the order for all prescribed medications. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) day prior to the last dosage being administered to ensure that refills are readily available.

Based on interview and record review, the facility failed to:1.Monitor for adverse effects (unwanted or dangerous medication side-effects) related to the use of alprazolam (a medication used to treat mental illness) from 7/3/2026 to 7/22/2026 in one of five sampled residents for unnecessary medications (Resident 6).2.Ensure Depakote (a medication used to treat mental illness) was for a clear, documented indication in one of five sampled residents for unnecessary medications (Resident 9.) These deficient practices of failing to define a clear indication for the use of psychotropic medications (medications that affect brain activities associated with mental processes) and monitor for adverse effects related to the use of alprazolam increased the risk that Residents 6 and 9 could have experienced adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status.Findings:1. During a review of Resident 6's admission Record (a document containing a resident's diagnostic and demographic information), the admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anxiety disorder (a mental illness characterized by excessive worry or panic strong enough to interfere with daily activities).During a review of Resident 6's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 7/5/2026, the H&P indicated she had the capacity to understand and make decisions.During a review of Resident 6's Order Summary Report (a summary of all active physician orders), dated 7/22/2026, the Order Summary Report indicated her attending physician prescribed the following medications:Alprazolam 0.5 milligrams (mg - a unit of measure for mass) via gastrostomy tube (g-tube - a tube surgically implanted into the stomach for administration of food or medications) two times a day for anxiety manifested by verbalization of feeling anxious.During a review of Resident 6's Medication Administration Record (MAR - a record of all medications administered and monitoring done for a resident) for July 2026, indicated, after 7/2/2026, the facility was not monitoring for adverse effects related to the use of alprazolam.During an interview on 7/22/2026 at 11:20 a.m., with the Director of Nursing (DON), the DON stated the facility failed to monitor the adverse effects related to alprazolam for Resident 6 since 7/2/2026. The DON stated the monitoring order likely was accidentally discontinued during the resident's last hospitalization and the facility failed to continue it upon her most recent readmission. The DON stated because Resident 6 takes other sedating medications ( medication that slows the activity of the brain) like gabapentin (a medication used to treat pain) and morphine (a medication used to treat pain), failing to monitor the adverse effects of alprazolam contributes to an increased risk of sedation and other adverse effects which could possibly cause medical complications leading to hospitalization or death.2.During a review of Resident 9's admission Record, the admission Record indicated Resident 9 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: bipolar disorder (a mental illness characterized by extreme mood swings from manic highs to depressed lows.)During a review of Resident 9's H&P, dated 4/3/2026, the H&P indicated she did not have the capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS - a comprehensive resident assessment) Section I (active diagnoses), dated 4/8/2026 did not indicate that Resident 9 was diagnosed with schizophrenia.During a review of Resident 9's Psychiatric Assessment/Evaluation Consultation (a progress note from a mental health specialist), dated 4/9/2026, indicated Resident 9's mental health diagnosis was bipolar disorder with psychiatric features and did not indicate that Resident 9 had a diagnosis of schizophrenia.During a review of Resident 9's Psychotherapeutic Drug Informed Consent Form (a document indicating the resident or their representative have been educated about risks and benefits of psychotropic medication), dated 4/10/2026, indicated Depakote was being prescribed for a diagnosis of schizophrenia (a mental illness characterized by hearing or seeing things that are not there.)During a review of the consultant pharmacist's recommendation, dated 5/2/2026, indicated Resident 9 was being given Depakote for schizophrenia which was a non FDA-labeled use of this medication for this particular indication. and advised the prescriber to reconsider its use. Review of the facility's response indicated that the physician wished to continue the medication without changes or clarifying the diagnosis.During a review of Resident 9's Order Summary Report, dated 7/22/2026 indicated Resident 9's attending physician prescribed the following medications:Depakote 250 mg by mouth in the morning for schizophrenic manifested by mood swings and agitationDuring an interview on 7/22/2026 at 11:28 a.m., with the Director of Nursing (DON), the DON stated the facility failed to ensure Resident 9's use of Depakote was for a clear, documented indication. The DON stated the documented diagnosis attached to the use of Depakote was schizophrenia, however, the medical record including the H&P, recent psychiatry notes, and the most recent comprehensive MDS assessment dated [DATE] do not support that diagnosis. The DON stated the informed consent for Depakote indicated the diagnosis was schizophrenia despite no documentation of that diagnosis in the clinical record. The DON stated if the use of psychotropic or antipsychotic medication was unclear, there was an increased risk of experiencing adverse effects of psychotropic medications possibly resulting in a decline in Resident 9's quality of life.During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use and Consent, undated, the P&P indicated . the staff and practitioner. will review an individual's current medication regimen, to identify whether. there is a clear indication for treating that individual with the medication. The physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example. when a medication is being given. without adequate monitoring.

Based on interview and record review, the facility failed to review, update and revise care plan for three of 28 sampled residents (Resident 117, Resident 105, and Resident 139) by failing to: 1.Revise Resident 117's care plan when the resident became incontinent of bowel and bladder (the inability to hold stool and urine). 2. Ensure the Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) initiated a care conference meeting for Resident 105 after receiving an incorrect dose of Phenobarbital on 7/2/2026 at 9:00 a.m. 3. Ensure the IDT initiated a care conference meeting for Resident 139 when Resident 139's left calf open blood blister progressed into an unstageable pressure injury ( a full-thickness skin and tissue loss where the true depth is hidden by dead, covered tissue) and again when Resident 139's unstageable pressure injury further advanced into a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). 4. Ensure Resident 139's care plan interventions were revised when Resident 139's left calf open-blood blister progressed to an unstageable PU and again when Resident 139's unstageable PU further advanced to a Stage 4 PU. These failures had the potential to negatively affect the provision of care and treatment to Resident 117, Resident 105 and Resident 139. Findings: 1.During a review of Resident 117's admission Record, dated 3/1/2026, the admission Record indicated Resident 117 was admitted to the facility on [DATE] with the following diagnosis, but not limited to diabetes (a long-term condition where your body doesn't use insulin properly), end stage renal disease (the last stage of chronic kidney disease when kidneys fail and require) hemodialysis (the process to remove of toxins from the blood through treatment), cirrhosis of the liver (a late-stage liver disease where healthy tissue is replaced by scar tissue), hyperlipidemia (an excess of fats circulating in your blood), and major depressive disorder (a mental health condition characterized by persistent sadness, loss of interest in activities, and low energy). During a review of Resident 117's Minimum Data Set (MDS-a detailed assessment of resident that nursing homes complete), dated 5/6/2026, the MDS indicated that Resident 117 needed minimum to moderate assistance with activities of daily living (everyday tasks that you must do to take care of your own body). During an interview on 7/20/2026 at 9:34a.m. with Resident 117, Resident 117 stated that they are incontinent and require adult disposable briefs (an undergarment that catches urine or poop that can be thrown away after use) changes. During an interview on 7/22/2026 at 9:30a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated that Resident 117 was incontinent of bowel and bladder and requires adult disposable brief changes. During a concurrent interview and record review on 7/22/2026 at 9:22 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 117's care plan dated 3/2/2026 was reviewed. The care plan indicated the resident is continent of bowel and bladder. RNS 1 stated Resident 117 is incontinent of bowel and bladder and uses an adult disposable brief. RNS 1 stated the care plan needs to be revised because the resident may not be getting the necessary care and services that she might need. During an interview on 7/23/2026 at 2:40 p.m. with the Director of Nursing (DON), DON stated care plans are to be updated on admission, quarterly, and when new updates regarding care are given to the LVN or RNS. DON stated that it is important to update the resident's care plans because it helps to provide greater continuity of care. During a review of the facility's policy and procedure (P&P) titled, Care Plans – Comprehensive, (no date), the P&P indicated assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. 2.During a review of Resident 105's admission Record, the admission indicated Resident 105 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including epilepsy (long term condition that causes seizures due to unusual electrical activity in the brain), hypertension (HTN-high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and history of falling. During a review of Resident 105's Minimum Data Set (MDS – resident assessment tool) dated 6/4/2026, the MDS indicated Resident 105 had an intact cognition (ability to think, understand, learn, and remember) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying or contact guard assistance as resident completes the activity) with bathing, dressing, toileting hygiene and personal hygiene. During a review of Resident 105's History and Physical (H&P- physician's comprehensive and initial assessment of a patient) dated 6/8/2026, the H&P indicated Resident 105 had a seizure disorder and cerebellar stroke (happens when blood flow to the part at the back of the brain that controls balance and movement is blocked or bursts). The H& P indicated Resident 105 was able to express needs and able to make healthcare decisions. During a review of Resident 105's Laboratory Results Report dated 7/1/2026, the Laboratory Results Report indicated Resident 105's Phenobarbital level was 40.1 mcg/ml (normal therapeutic range for adults generally between 10 to 40 mcg/mL and toxic levels typically above 40 to 60 mcg/mL). The Laboratory Results Report indicated the result was reported on 7/1/2026 at 3:15 p.m. The report indicated Phenobarbital level of 40.1 mcg/ml was a high level. During a review of Resident 105's Order Summary Report dated 7/1/2026, the Order Summary Report indicated Phenobarbital 64.8 mgs. one tablet by mouth two times a day for seizure. The Order Summary Report indicated the start date was 7/2/2026. During a review of Resident 105's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 7/3/2026, the COC indicated Phenobarbital order was changed from 97.2 milligrams (mgs. - unit of measurement) to Phenobarbital 64.8 mgs. on 7/1/2026 due to Phenobarbital level of 40.1 microgram (mcg- unit of measurement) per milliliter. The COC indicated Resident 105 received Phenobarbital 97.2 mgs. by mouth inadvertently. During a concurrent interview and record review on 7/22/2026 at 11:32 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 105's Phenobarbital orders dated 7/25/2026 and 7/1/2026, Phenobarbital level dated 7/1/2026, COC dated 7/3/2026 and IDT Conference Note were reviewed. LVN 2 stated Phenobarbital level was collected on 7/1/2026 at 10:50 a.m., and the result came back on 7/1/2026 at 3:15 p.m. LVN 2 stated there was a physician order to lower Phenobarbital dose to 64.8 mgs. on 7/1/2026 at 7:09 p.m. due to high Phenobarbital level. LVN 2 stated she administered 97.2 mgs. of Phenobarbital instead of 64.8 mgs. on 7/2/2026 at 9:00 a.m. LVN 2 stated she did not see the previous Phenobarbital 97.2 mg order had been discontinued by the physician, which was why she administered the 97.2 mg dose to Resident 105. LVN 2 stated Resident 105 could become very lethargic (drowsy, and lacking energy) and unconscious, which could lead to respiratory arrest. LVN 2 stated no IDT meeting was conducted after Resident 105 received the incorrect dose of Phenobarbital on 7/2/2026 and the last IDT meeting held was on 5/28/2026. During a concurrent interview and record review on 7/23/2026 at 10:01 a.m. with the Minimum Data Set Nurse (MDSN), Resident 105's IDT Meeting Notes dated 5/28/2026 were reviewed. MDSN stated there was no IDT Meeting performed after the resident received a wrong dose of Phenobarbital. MDSN agreed that the facility should have done an IDT Meeting when Resident 105 received an incorrect dose of Phenobarbital on 7/2/2026 to review the resident's current status and plan of care. MDS Nurse (MDSN) stated IDT meeting was conducted upon admission, quarterly, and when there was a significant change in a resident's condition. During an interview on 7/23/2026 at 2:24 p.m. with the Director of Nursing (DON), the DON stated there should be an IDT meeting conducted after Resident 105 received a wrong dose of Phenobarbital to prevent recurrence of the incident. During a review of facility's policy and procedure (P&P) titled, Care Plans- Comprehensive, undated, the P&P indicated IDT Team in coordination with resident's representative will develop and maintain a comprehensive care plan that identifies and aids in preventing or reducing declines in the resident's functional status. 3. During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was admitted to facility on 3/1/2023 and readmitted on [DATE]. The admission Record indicated a diagnoses including malignant neoplasm (cancer) of the right breast, atherosclerotic heart disease (heart condition where fatty plaque builds up in the heart's arteries), long term use of anticoagulant (taking blood-thinning medications for an extended or indefinite period) and mild protein calorie malnutrition (nutritional deficient caused by eating too few proteins and calories). During a review of Resident 139's Minimum Data Set (MDS-resident assessment tool) dated 6/26/2026, the MDS indicated Resident 139 had moderate cognitive (ability to think, understand, learn, and remember) impairment and was dependent on self-care activities, such as bathing, toileting, and dressing, and was dependent on functional abilities, such as going from sitting to lying position. The MDS indicated, Resident 139, was frequently incontinent (lacking voluntary control over urination or defecation) of bowel and bladder. The MDS indicated Resident 139 had an unhealed Stage 4 pressure injury and had no venous and arterial ulcers and no foot problems. During a concurrent observation and interview on 7/22/2026 at 12:01 p.m., with Treatment Nurse (TN 1) in Resident 139's room, Resident 139 was observed with a left calf wound that was red and moist with yellowish-white drainage, and exposed tendon. TN 1 stated, Resident 139 developed the wound because Resident 139 crossed her legs. During a concurrent interview and record review on 7/22/2026 at 2:15 p.m. with TN 1, Resident 139's Skin Issue Progress Notes dated 2/24/2026 to 7/20/2026 were reviewed. The notes indicated Resident 139's left calf wound began as an open blood blister on 2/24/2026, progressed to an unstageable pressure injury on 4/28/2026, and advanced to a Stage 4 pressure injury on 6/11/2026. During a concurrent interview and record review on 7/23/2026 at 1:08 p.m. with TN 1, Resident 139's IDT Progress Notes, were reviewed. The IDT Notes indicated, there were no IDT Progress Notes documented addressing the progression of Resident 139's left calf wound. TN 1 stated, an IDT meeting was not conducted specifically addressing the deterioration of Resident 139's left calf wound because it was not a facility standard of practice. TN 1 stated, an IDT meeting should have been conducted. TN 1 stated, an IDT meeting would have allowed the IDT to discuss the appropriate care and interventions for Resident 139's left calf wound and identify potential risks associated with further wound deterioration, including the risk of possible amputation (surgical or accidental removal of all or part of a body limb or extremity). During a concurrent interview and record review on 7/23/2026 at 1:08 p.m. with TN 1, Resident 139's Care Plan was reviewed. The Care Plan indicated interventions were not revised to address the treatment and management of Resident 139's left calf wound as it progressed from an open blood blister to an unstageable pressure ulcer and later advanced to a Stage 4 pressure ulcer. TN 1 stated the Care Plan interventions were not updated as the wound worsened and that the interventions should have been revised. She stated the existing interventions did not reflect the resident's changing wound care treatment. TN 1 stated updating the Care Plan would have provided nursing staff with appropriate guidance for assessing, monitoring, managing and treating the resident's left calf wound. During an interview on 7/23/2026 at 5:55 p.m. with the Director of Nursing (DON), the DON stated the COC and IDT should have been initiated when Resident 139's left calf wound progressed from a blood blister to a DTI and eventually to a Stage 4 pressure injury. He stated the COC should have reflected the wound status and included notification of the attending physician, responsible party, and dietician. He stated the COC served as a guide to inform the physician of the problem and required clear documentation of who was notified, what the physician said, including notification of the family member and what was communicated. He stated that if documentation was not completed, then the notification was not done. The DON stated the IDT should have discussed the condition of the wound and the actions needed to address the deterioration. The DON stated the IDT should have met to address the changes in the residents' wound, document the deterioration, and update the treatment plan to determine whether to continue or modify the current interventions. During a review of the facility's policy and procedures (P&P) titled, Care Planning – Interdisciplinary Team, undated, indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. During a review of the facility's policy and procedures (P&P) titled, Care Plans - Comprehensive, undated, indicated, The comprehensive care plan is based on a thorough assessment. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Cross Reference F684

Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented for three of six sampled residents (Resident 32, Resident 7 and Resident 139). The facility failed to:1.Ensure Resident 139 who had a stage IV pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon [a tough cord of fibrous tissue that connects a muscle to a bone], ligament, cartilage, or bone) pressure injury on the left posterior calf (back of leg) was placed on enhanced barrier precautions (EBP-use of gown and gloves during high contact care [any activity where staff have close, physical contact with a resident's skin, clothing or body fluids] to stop the spread of tough germs in nursing homes).2. Ensure Treatment Nurse (TN) 1 removed personal protective equipment(PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) inside the Resident 7's room and not worn the PPE outside resident's room to dispose the trash bag used in changing the dressings of Resident 7's bilateral (both) nephrostomy tubes (medical procedure that places a thin, flexible tube through the skin of the back directly into the kidney to drain urine) in the treatment cart's trash container.3. Enforce its own policy related to a safe, sanitary environment and infection control by not ensuring staff followed infection control practices for Resident 32 on enhanced isolation precautions.These deficient practices had the potential to result in the transmission of infectious organisms (germs) between residents, staff, and visitors, leading to cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) with the facility, and potential outbreak ( sudden rise in disease cases that is higher than normal in a specific community, area, or time) situations among a vulnerable population.1. During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was admitted to facility on 3/1/2023 and readmitted on [DATE]. The admission Record indicated a diagnoses including malignant neoplasm (cancer) of the right breast, atherosclerotic heart disease (heart condition where fatty plaque builds up in the heart's arteries), long term use of anticoagulant (taking blood-thinning medications for an extended or indefinite period) and mild protein calorie malnutrition (nutritional deficient caused by eating too few proteins and calories). During a review of Resident 139's MDS dated [DATE], the MDS indicated, Resident 139 had moderate cognitive impairment. The MDS indicated, Resident 139 was dependent on self-care activities, such as bathing, toileting, and dressing, and dependent in functional abilities, such as going from sitting to lying position. The MDS indicated, Resident 139 was frequently incontinent (lacking voluntary control over urination or defecation) to bowel and bladder. The MDS indicated Resident 139 had an unhealed Stage 4 pressure injury. The MDS indicated Resident 139 with no venous and arterial ulcers and no foot problems During a review of Resident 139's Annual History and Physical (H&P) dated 5/06/2026, the H&P indicated, Resident 139 was alert and forgetful. During a review of Resident 139's Order Summary Report dated 7/23/2026, the Order Summary Report indicated Resident 139 had a left posterior calf wound and staff to report any changes to the nurse practitioner (NP- advanced practice registered nurse who provides patient care, diagnoses and treats illnesses, orders and interprets tests, and prescribes medications) or medical doctor (MD). During a record review of Resident 139's Care Plan titled Resident had a left posterior calf Stage 4 pressure injury dated 6/11/2026, the Care Plan indicated a goal was to not develop an infection in the next 30 days. During an observation on 7/22/26 at 12:35 p.m. at Resident 139's bedside, Treatment Nurse 1(TN 1) and Certified Nursing Assistant 4 (CNA 4) were observed to be providing high contact care ( including wound care: any skin opening requiring a dressing ) for Resident 139 and not wearing personal protective equipment (PPE-gown, gloves). During an interview on 7/23/26 at 9:45 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 139 had been on EBP for her left leg wound a while ago. CNA 4 stated she was not sure what changed but had been informed Resident 139 no longer required EBP and staff no longer needed to wear PPE when providing care. CNA 4 stated she should have worn PPE when providing care to Resident 139 to help prevent infection. During an interview with the Infection Preventionist (IP) on 7/23/26 at 10:15 a.m., with the Infection Preventionist (IP), the IP stated EBP was an infection control measure for residents with open wounds. The IP stated Resident 139's left calf Stage IV pressure injury met the criteria for placing her on EBP. The IP stated Resident 139 was at risk for contracting an infection and staff needed to wear PPE when providing her care. During an interview on 7/23/26 at 1:55 p.m. with TN 1, TN 1 stated Resident 139 had a Stage IV pressure injury on her left posterior calf and should have been on EBP to help prevent infection. TN 1 stated she should have worn PPE when providing care to Resident 139. She stated PPE was used to protect the resident from cross contamination of germs (tiny living things that can cause disease). During an interview on 7/23/26 at 3:55 p.m. with the Director of Nursing (DON), the DON stated Resident 139 should have been on EBP because she had a Stage IV pressure injury on her left calf. The DON stated EBP protected residents from cross contamination of bacteria (microscopic single celled organisms that can cause illness) and staff needed to wear PPE when providing care to Resident 139. During a review of the facility's policy and procedure (P&P) titled Enhanced Barrier Precautions (undated), the P&P indicated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing facilities. EBP involve gown, and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). The P&P indicated, High-contact resident activities include, dressing, bathing / showering, transferring or providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tube, tracheostomy / ventilator and wound care (any skin opening requiring a dressing). 2. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including resistance to multiple antibiotics (ability of microorganisms to withstand the effects of several antibiotics), neuromuscular dysfunction of bladder( occurs when nerve or muscle problems disrupt normal bladder control, leading to difficulty storing or emptying urine), paraplegia(loss of movement and/or sensation, to some degree, of the legs), hydronephrosis ( swelling of one or both kidneys due to inability to drain urine from the kidney)and ureteral calculous obstruction (blockage of the ureter caused by kidney stones), and personal history of methicillin resistant staphylococcus aureus( MRSA - a bacteria that does not respond to antibiotics). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool) dated 5/7/2026, the MDS indicated Resident 7 had severely impaired cognitive skills (ability to think, understand, learn, and remember) and was dependent (helper does all the effort to complete an activity) on staff with personal hygiene, toileting hygiene, oral hygiene, and lower body dressing. During a review of Resident 7's Order Summary Report dated 5/26/2026, the Order Summary Report indicated Resident 7 was on Enhanced Barrier Precaution (EBP-use of gown and gloves during high contact care [any activity where staff have close, physical contact with a resident's skin, clothing or body fluids] to stop the spread of tough germs in nursing homes) due to left and right nephrostomy tubes. During a concurrent observation and interview on 7/23/2026 at 12:32 p.m. with Treatment Nurse (TN) 1, TN 1 was observed exiting Resident 7's room wearing a gown and gloves after changing the dressings on Resident 7's left and right nephrostomy tubes. TN 1 then proceeded to discard a trash bag containing the used dressings into the treatment cart's trash container. TN 1 stated she should have removed and discarded her gown and gloves inside Resident 7's room before disposing of the trash bag. She stated remaining in the gown and gloves while using the treatment cart created a risk of contaminating the cart and potentially spreading infection among residents. During an interview on 7/23/2026 at 1:44 p.m., with the Infection Preventionist Nurse (IPN). The IPN stated Resident 7 was on EBP due to the nephrostomy tubes. The IPN stated TN 1 should have removed her gown and gloves in the room and performed handwashing after providing care to Resident 7. The IPN stated failing to removed TN 1 gown and gloves in the room and perform handwashing after providing care to Resident 7 created a risk for cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and increased the likelihood of spreading infection to other residents, staff, and visitors. During an interview on 7/23/2026 at 2:24 p.m. with the Director of Nursing (DON), the DON stated not removing the gown and gloves in the resident's room and wearing them outside the room to discard the trash bag in the treatment cart posed a risk for cross contamination. The DON stated TN 1 should have disinfected the treatment cart. 3.During a review of Resident 32's admission Record , the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including, muscle wasting and atrophy (loss of muscle mass in more than one part of the body), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), other lack of coordination (loss of full control of bodily movements). During a review of Resident 32's Minimum Data Set (MDS-resident assessment tool) dated 05/12/2026, the MDS indicated Resident 32 had impaired cognitive function for daily decision-making. The MDS indicated Resident 32's was dependent (helper does ALL the effort, Resident does none of the effort to complete the activity) with activities of daily living (ADLs-activities such as bathing dressing and toileting a person performs daily). During a concurrent observation and interview on 07/22/2026 at 3:37 p.m. with Restorative Nursing Assistant (RNA 1), observed RNA 1 enter Resident 32's room while the resident was on EBP without first performing hand hygiene. RNA 1 applied the resident's hand roll ( a small device placed inside a patient's hand) and hand splint ( device used to immobilize, protect, and support the hand, wrist, or fingers) without donning (put on) the required personal protective equipment (PPE). While still wearing contaminated gloves, RNA 1 opened the resident's bedside drawer to look for the hand splint, creating the potential for cross contamination by contaminating clean environmental surfaces. RNA 1 stated she should have performed hand hygiene and put on PPE. RNA 1 stated failing to perform hand hygiene and wear PPE could result in cross contamination and was not good for the resident's safety or the safety of others. During an interview on 07/23/2026 at 10:33 a.m. with the Director of Staff Development (DSD), the DSD stated staff were expected to perform hand hygiene at all times and follow the facility's infection prevention and control procedures, including the appropriate use of personal protective equipment (PPE). The DSD stated staff were expected to consistently perform hand hygiene and wear the appropriate PPE to prevent cross contamination and protect resident safety. During an interview on 07/23/2026 at 2:44 p.m. with the Director of Nursing (DON), the DON stated staff should perform hand hygiene and put on PPE to prevent cross contamination. During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, undated, the P&P indicated EBP is recommended for residents with indwelling medical devices (medical tool that stays inside the body for a period of time) and wounds because they carry a higher risk of acquiring multi-resistant drug organisms (MDRO- a germ that is resistant to many antibiotics). The P&P indicated trash can should be inside the resident room and near the exit for discarding PPE after removal and prior to exiting the room of the resident. During a review of facility's P&P titled, Personal Protective Equipment- using Gowns, undated, the P&P indicated Disposable gown should be discarded into the waste receptacle inside the room and perform hand washing.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 32 and 5) received the necessary care and services to prevent avoidable pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). The facility failed to:1.Ensure Resident 32 and 5 were turned and repositioned every two hours and offload remove or reduce weight and pressure from a specific part of the body) Resident 32's bilateral heels as ordered.2.Maintain a documentation system that accurately reflected the completion of required repositioning interventions.These failures resulted in increased risk of pressure injury development or worsening, and limited the facility's ability to verify that the residents received care as ordered.Findings:During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including, muscle wasting and atrophy (loss of muscle mass in more than one part of the body), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), other lack of coordination (loss of full control of bodily movements). During a review of Resident 32's Minimum Data Set (MDS-resident assessment tool) dated 05/12/2026, the MDS indicated Resident 32 had impaired cognitive (ability to think, understand, learn, and remember) function for daily decision-making. The MDS indicated Resident 32's was dependent (helper does all the effort, resident does none of the effort to complete the activity) with activities of daily living (ADLs-activities such as bathing dressing and toileting a person performs daily).During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle wasting and atrophy, contracture (stiffening and shortening of muscles, tendons, or other tissues that leads to a loss of movement, ), other lack of coordination (loss of full control of bodily movements).During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had severe cognitively impaired for daily decision-making. The MDS indicated Resident 5's was dependent (helper does all the effort with ADLs.During a record review of Resident 32's Physician Order Summary, dated 05/07/2026, the Physician Order Summary indicated an orders to: Check skin for wetness/dryness every two hours. Turn and reposition every two hours. Offload bilateral heels with pillows at all times.During a record review of Resident 5's Physician Order Summary, the Physician Order Summary indicated an orders to: Check skin for wetness/dryness every two hours. Turn and reposition every two hours. Offload bilateral heels with pillows at all times.During an observation on 07/22/2026 at 8:16 a.m., Resident 32 was observed lying on her back. During a subsequent observation on 07/22/2026 at 10:06 a.m., approximately 1 hour and 50 minutes later, Resident 32 remained lying on her back in the same position, and the bilateral heels continued not to be offloaded with pillows, contrary to the physician's orders.During an observation on 07/22/2026 at 10:04 a.m., Resident 5 was observed lying on the left side. During a subsequent observation on 07/22/2026 at 12:28 p.m., approximately 2 hours and 24 minutes later, Resident 5 remained lying on the left side. The resident position was verified with Licensed Vocational Nurse (LVN) 3, who confirmed that Resident 5 had not been repositioned in a timely manner in accordance with the physician's order by certified Nursing Assistance (CNA1)During a concurrent interview and record review on 07/22/2026 at 12:06 p.m. with CNA 1, reviewed CNA task list dated 7/22/2026. CNA 1 documented the repositioning task at 7:57 a.m. When asked how she could demonstrate that Resident 32 had been repositioned every two hours as ordered, despite only one entry for the entire shift, CNA 1 stated she could not provide evidence. She explained that the current documentation system required staff to sign the repositioning task only once per shift and did not capture each two hour repositioning event or the resident's position. When further asked how she could verify that residents were repositioned every two hours according to physician orders, CNA 1 stated she was unable to prove compliance. C CNA 1 stated she was aware that Residents 32 and 5 were required to be repositioned every two hours per physician orders. CNA 1 stated she last repositioned both residents at approximately 10:00 a.m. However, she could not recall which position Resident 32 had been turned to, explaining that the facility's CNA task charting system does not include documentation of the resident's position (e.g., left side, right side, or supine) after each repositioning. CNA 1 stated that the facility previously provided staff with a visual reference on their identification badge to assist with tracking resident positioning, but that tool was no longer available. She further stated that she typically remembers to reposition residents either by reminding herself or after being reminded by the charge nurse. She stated the current task list did not allow staff to document each repositioning or the position to which the resident was turned. CNA 1 stated she did perform the repositioning but acknowledged she could not provide documentation showing that the physician's orders were followed.During an interview on 07/23/2026 at 8:16 a.m. with Family Member 1, who was present at the bedside of Resident 32, Family Member 1 reported the resident was not being repositioned every two hours as ordered. Family Member 1 stated Resident' 32 s bilateral heels were not being properly offloaded, explaining that staff placed the resident's legs on top of the pillow rather than positioning the pillow under the calves to float the heels off the bed surface. Family Member 1 stated she had repeatedly informed facility staff that Resident 32 needed to be repositioned and that the heels should be offloaded correctly, but stated staff had not consistently followed the physician's orders. FM 1 stated she had observed only one nurse consistently reposition the resident and properly offload the resident's heels during their shifts. FM 1 reported she visits the facility daily from approximately 7:30 a.m. until late morning/noon and has frequently observed the Resident 32 remaining in the same position for extended periods. FM 1 showed the surveyor multiple photographs, which she stated documented occasions when the resident had not been repositioned or had not had the heels properly offloaded. FM 1 stated she had previously met with facility staff to discuss her concerns but believed the issues had not been corrected. She stated Resident 32 had been admitted to the facility approximately five months earlier and believed the resident's skin condition had worsened because the resident was not consistently repositioned every two hours and the bilateral heels were not properly offloaded in accordance with the physician's orders.During an interview on 07/23/2026 at 2:24 p.m. with the Director of Nursing (DON), the DON stated the facility's current CNA documentation system did not allow verification that residents were repositioned every two hours as ordered. The DON stated the CNA task list did not show whether the required two hour repositioning had occurred. The DON stated charting system required CNAs to document the repositioning task only once per shift and did not capture each individual repositioning event or the resident's position. The DON stated repositioning residents every two hours was essential to prevent skin breakdown, pressure injuries, and worsening of existing skin conditions. The DON acknowledged the facility could not demonstrate compliance with physician orders under the current documentation process.During a review of the facility's policy and procedure (P&P) titled Turning and Repositioning (undated) the P&P indicated To provide guidelines for appropriate positioning and repositioning practices to support patient/resident comfort, safety, and overall care needs. Staff will provide assistance with positioning and repositioning as needed and within their scope of practice. Care will be provided in a manner that considers resident's comfort, and individual needs.

Based on interview and record review the facility failed to ensure the McGeer criteria (a set of guidelines used to define and classify healthcare-associated infections (HAIs) in long-term care facilities) was used for one of one sampled residents (Resident 7) when Mupirocin ointment (medicine that treats infection) was prescribed for Resident 7's nephrostomy (medical procedure that places a thin, flexible tube through the skin of the back directly into the kidney to drain urine) siteThis failure had the potential to result in Resident 7 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.Findings:During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including resistance to multiple antibiotics (ability of microorganisms to withstand the effects of several antibiotics), neuromuscular dysfunction of bladder( occurs when nerve or muscle problems disrupt normal bladder control, leading to difficulty storing or emptying urine), paraplegia(loss of movement and/or sensation, to some degree, of the legs), hydronephrosis ( swelling of one or both kidneys due to inability to drain urine from the kidney)and ureteral calculous obstruction (blockage of the ureter caused by kidney stones), and personal history of methicillin resistant staphylococcus aureus( MRSA - a bacteria that does not respond to antibiotics).During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool) dated 5/7/2026, the MDS indicated Resident 7 had severely impaired cognitive skills (ability to think, understand, learn, and remember) and was dependent (helper does all the effort to complete an activity) on staff with personal hygiene, toileting hygiene, oral hygiene, and lower body dressing.During a review of Resident 7's Order Summary Report dated 7/22/2026, the Order Summary Report indicated a telephone order of Mupirocin external ointment two percent (%- weight of the active medicine in a total of 100 grams of the ointment) apply to left nephrostomy site topically every day shift for redness for 10 days.During a review of Resident 7's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 7/22/2026 at 3:00 p.m., the COC indicated Resident 7 had redness on the site of the left and right nephrostomy tubes and the physician was notified. The COC Evaluation indicated Resident 7's temperature was 97.3(normal temperature) degrees Fahrenheit (F- unit of measurement) and resident had no pain.During a review of Resident 7's Other Skin Issues dated 7/22/2026, the Other Skin Issues indicated left nephrostomy site had redness, no exudate (fluid that leaks out of blood vessels, cuts into nearby tissues as a result of injury), no edema (swelling) and temperature of the peri wound (skin or tissue surrounding the site) was normal.During a review of Resident 7's Other Skin Issues dated 7/22/2026, the Other Skin Issues indicated right nephrostomy site had redness, no exudate, no swelling or edema, and temperature of the peri wound was normal.During an interview on 7/23/2026 at 12:32 p.m. with Treatment Nurse (TN) 1, TN 1 stated Resident 7 had redness on both nephrostomy sites and she notified the physician on 7/22/2026. TN 1 stated redness could be a sign of infection. She stated Resident 7 had no fever, swelling, discharge, or pain at either nephrostomy site. TN 1 stated the Mupirocin was ordered as prophylaxis; however, the order indicated it was for redness on the nephrostomy sites. TN 1 stated Resident 7 could be at risk for antibiotic resistance from using Mupirocin for redness.During a concurrent interview and record review on 7/23/2026 at 1:44 p.m. with the Infection Preventionist Nurse (IPN), Resident 7's electronic health record (EHR) and McGeer's Criteria (used to track and measure infections) were reviewed. The IPN stated the Change of Condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death ) dated 7/22/2026 was completed for redness at the sites of the left and right nephrostomy tubes. The IPN stated the use of Mupirocin external ointment for redness at both nephrostomy tube sites did not meet McGeer's Criteria for skin or mucosal infection. She stated McGeer's Criteria required the presence of pus at a wound, skin or soft tissue, or mucosal site, and at least four symptoms such as heat, redness, swelling, tenderness or pain, or serous drainage to meet the definition of infection. The IPN stated Mupirocin could be an unnecessary medication for redness at the nephrostomy sites and that Resident 7 could develop skin irritation or a reaction from its use. The IPN stated TN 1 should have assessed and monitored the nephrostomy sites when she observed redness on 7/22/2026.During an interview on 7/23/2026 at 2:24 p.m. with the Director of Nursing (DON), the DON stated Mupirocin ointment for the redness of bilateral nephrostomy tubes was not an appropriate order because there should be other signs and symptoms of infection like fever, inflammation (body's normal protective response to injury, infection or harmful irritants), and presence of discharge (any fluid that leaks or oozes out of a cut, scrape, or wounds) on the sites of nephrostomy tubes. The DON stated the use of Mupirocin did not meet the McGeer criteria for an infection. The DON stated Resident 7 could develop antibiotic resistance from the use of Mupirocin.During a review of facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 1/1/2017, the P&P indicated The facility will promote appropriate use of antibiotics while optimizing treatment of infections.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA- process used to systematically evaluate care delivery, identify quality deficiencies, and develop corrective action plans) and Quality Assurance Performance Improvement (QAPI- process to continuously monitor and elevate the safety and quality of care) committee established an effective system to monitor residents at risk for developing or acquiring pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) or wound.This deficient practice placed residents at risk for not receiving the quality of care and treatment necessary to meet their highest practicable well-being.Findings:During an interview on 7/23/2026 at 3:52 p.m., with the Administrator (ADM), the ADM stated the ongoing issues with pressure injury were likely due to lack of communication and collaboration between the team and the physicians. The ADM stated there was no cohesiveness between the team and physicians.During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Program, undated, the P&P indicated, The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: provide a means to measure current and potential indicators for outcomes of care and quality of life, provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators, reinforce and build upon effective systems and processes related to the delivery of quality of care and services, and establish systems through which to monitor and evaluate corrective actions.

Based on observation, interviews, and record review, the facility failed to store food in a safe and sanitary manner. The facility failed to:1.Ensure staff did not ensure a bag of pork sausages was properly sealed in the refrigerator.This failure had the potential to place residents at risk for food borne illness (illness caused by consuming contaminated or spoiled food) and increased the risk of cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another due to improper or unsanitary equipment, procedures, or products).Findings:During a concurrent initial kitchen observation and interview on 7/20/2026 at 8:20 a.m. with the Dietary Supervisor (DS), a brown box containing an open plastic bag of pork sausages was stored in the refrigerator. DS stated the open bag of pork sausages should be wrapped in a saran wrap (a thin plastic film used to seal food, keep items fresh and block out air) or repackage by placing the sausages in a closed container to prevent risk of cross- contamination.During an interview on 7/23/2026 at 8:06 a.m. with Dietary Aide (DA) 1, DA 1 stated the kitchen staff should wrap the open bag of pork sausage or tie the open bag to keep the food item sealed. DA 1 stated there was a risk of the open bag of sausages getting contaminated with bacteria and this could lead to residents getting sick from eating the food.During an interview on 7/23/2026 at 2:24 p.m. with the Director of Nursing (DON), the DON stated keeping an open bag of pork sausages in the refrigerator posed a risk for bacterial contamination (when germs or bacteria enter places they should not, such as food or water, making it unsafe). The DON stated contamination could cause stomach upset, indigestion, and gastroenteritis (inflammation of the stomach and intestines) in residents.During a review of facility's policy and procedure (P&P) titled, Procedure for Refrigerated Storage, dated 2023, the P&P indicated food should be covered and leftovers will be covered, labeled and dated in the refrigerator.

Based on observation, interview, and record review, the facility failed to 1.Store one unopened Humalog insulin pen (a medication used to treat high blood sugar) in the refrigerator per the manufacturer's requirements affecting Resident 8 in one of three inspected medication carts (Station B2 Cart.) 2.Store gabapentin solution (a medication used to treat nerve pain) in the refrigerator per the manufacturer's requirements affecting Resident 6 in one of three inspected medication carts (Station B2 Cart.)This deficient practice of failing to store medications in the refrigerator according to the manufacturer's requirements increased the risk that Residents 6 and 8 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.Findings:During a concurrent observation and interview on [DATE] at 11:21 a.m., of Station B2 Cart with the Licensed Vocational Nurse (LVN 1), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:1.One unopened Humalog insulin pen for Resident 8 was found stored in the medication cart and room temperature.According to the product labeling, unopened Humalog insulin pens should be stored in the refrigerator. 2.One bottle of gabapentin solution for Resident 6 was found stored in the medication cart at room temperature.According to the product labeling, gabapentin solution should be stored in the refrigerator.LVN 1 stated the Humalog insulin for Resident 8 was unopened and should be stored in the refrigerator. LVN 1 stated the gabapentin solution for Resident 6 should be stored in the refrigerator. LVN 1 stated storing medication at improper temperatures could make them less likely to work which could cause Resident 6 and Resident 8 medical complications possibly leading to hospitalization.During a review of the facility's policy and procedure (P&P) titled Storage of Medications undated, the P&P indicated The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses' station or other secured locations.

Based on interview and record review, the facility failed to ensure resident was free from significant medication errors for one of six sampled residents (Resident 105) by failing to:1.Ensure correct dose of Phenobarbital (medication used to control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), was administered to Resident 105 on 7/2/2026 at 9:00 a.m.This failure had the potential to put Resident 105 at risk for Phenobarbital overdose (taking too much of a medicine or drug), adverse drugs effects (unintended, harmful responses to a medication taken) leading to respiratory depression (a serious medical condition where breathing becomes too slow or shallow), and drug toxicity (happens when too much of a medicine builds up in the body and causes harmful effects).Findings:During a review of Resident 105's admission Record, the admission indicated Resident 105 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including epilepsy (long term condition that causes seizures due to unusual electrical activity in the brain), hypertension (HTN-high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and history of falling.During a review of Resident 105's Minimum Data Set (MDS - resident assessment tool) dated 6/4/2026, the MDS indicated Resident 105 had an intact cognition (ability to think, understand, learn, and remember) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying or contact guard assistance as resident completes the activity) with bathing, dressing, toileting hygiene and personal hygiene.During a review of Resident 105's History and Physical (H&P- physician's comprehensive and initial assessment of a patient) dated 6/8/2026, the H&P indicated Resident 105 had a seizure disorder and cerebellar stroke (happens when blood flow to the part at the back of the brain that controls balance and movement is blocked or bursts). The H& P indicated Resident 105 was able to express needs and able to make healthcare decisions.During a review of Resident 105's Laboratory Results Report dated 7/1/2026, the Laboratory Results Report indicated Resident 105's Phenobarbital level was 40.1 mcg/ml (normal therapeutic range for adults generally between 10 to 40 mcg/mL and toxic levels typically above 40 to 60 mcg/mL). The Laboratory Results Report indicated the result was reported on 7/1/2026 at 3:15 p.m. The report indicated Phenobarbital level of 40.1 mcg/ml was a high level.During a review of Resident 105's Order Summary Report dated 7/1/2026, the Order Summary Report indicated Phenobarbital 64.8 mgs. one tablet by mouth two times a day for seizure. The Order Summary Report indicated the start date was 7/2/2026.During a review of Resident 105's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 7/3/2026, the COC indicated Phenobarbital order was changed from 97.2 milligrams (mgs. - unit of measurement) to Phenobarbital 64.8 mgs. on 7/1/2026 due to Phenobarbital level of 40.1 microgram (mcg- unit of measurement) per milliliter. The COC indicated Resident 105 received Phenobarbital 97.2 mgs. by mouth inadvertently.During a concurrent interview and record review on 7/22/2026 at 11:32 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 105's Phenobarbital orders dated 7/25/2026 and 7/1/2026, Phenobarbital level dated 7/1/2026, COC dated 7/3/2026 and IDT Conference Note were reviewed. LVN 2 stated Phenobarbital level was collected on 7/1/2026 at 10:50 a.m., and the result came back on 7/1/2026 at 3:15 p.m. LVN 2 stated there was a physician order to lower Phenobarbital dose to 64.8 mgs. on 7/1/2026 at 7:09 p.m. due to high Phenobarbital level. LVN 2 stated she administered 97.2 mgs. of Phenobarbital instead of 64.8 mgs. on 7/2/2026 at 9:00 a.m. LVN 2 stated she did not see the previous Phenobarbital 97.2 mg order had been discontinued by the physician, which was why she administered the 97.2 mg dose to Resident 105.During a subsequent interview on 7/22/2026 at 3:24 p.m. with LVN 2, LVN 2 stated Resident 105 could be at risk for an overdose of Phenobarbital, which could lead to lethargy (drowsy, and lacking energy), shallow and slow breathing causing lack of oxygen, and potentially death. LVN 2 stated she should have followed the five rights (fundamental safety protocol used by licensed nurses to prevent and reduce mistakes) of medication administration to prevent the medication error. She stated the five rights of medication administration were the right patient, right drug, right dose, right route, and right time/frequency.During a concurrent interview on 7/22/2026 at 4:17 p.m. with Registered Nurse Supervisor (RNS) 3, RNS 3 stated Resident 105 could be at risk for side effects of Phenobarbital, including sleepiness, dizziness, confusion, drowsiness, and an increased risk of falling due to receiving the incorrect dose. RNS 3 stated LVN 2 should have followed the five rights of medication administration and checked the physician's order before administering the medication to Resident 105.During a concurrent interview and record review with the Director of Nursing (DON) on 7/23/2026 at 10:47 a.m., Resident 105's Narcotic and Hypnotic Record for Phenobarbital 97.2 mgs, and bubble pack (presorted packaging method where pills or capsules are sealed in individual plastics) of Phenobarbital 97.2 mgs were reviewed. The DON stated the bubble pack of Phenobarbital 97.2 mgs had four remaining tablets after Phenobarbital 97.2 mgs. was administered on 7/2/2026 at 9:00 a.m. to Resident 105.During an interview on 7/23/2026 at 2:24 p.m. with the DON, the DON stated Phenobarbital toxicity( occurs when the amount of phenobarbital in the body reaches a level that causes slowing down of the brain and body too much), sedation( a state of calm, relaxation or sleepiness caused by a medicine), and respiratory depression ( a serious condition where breathing becomes too slow or too shallow causing dangerous level of carbon dioxide[ odorless gas produced by breathing] to build up in the body while reducing oxygen) could occur from administering incorrect dose of Phenobarbital to Resident 105.During a review of facility's policy and procedure (P&P) titled, Administering Medications, undated, the P&P indicated Medications should be administered according to the orders, and the licensed nurse should check the label three times to verify the right medication, right dosage, right time and right method of administration before the medication.

Based on interview and record review, the facility failed to discontinue the use of cefdinir (an antibiotic medication used to treat infections) after it had been determined to be medically unnecessary in one of five residents sampled for unnecessary medications (Resident 9.)This deficient practice of failing to discontinue unnecessary antibiotic therapy increased the risk that Resident 9 may have experienced adverse effects of cefdinir possibly leading to a decline in her quality of life and the development of multi-drug resistant organisms (MDROs - microscopic organisms that become resistant to antibiotic therapy.)Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: bipolar disorder (a mental illness characterized by extreme mood swings from manic highs to depressed lows).During a review of Resident 9's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 4/3/2026, indicated she did not have the capacity to understand and make decisions.During a review of Resident 9's Order Summary Report (a summary of all active physician orders) dated 7/22/2026, indicated her attending physician prescribed the following medications:1.Cefdinir 300 milligrams (mg-unit of measurement) by mouth every 12 hours for Urinary Tract Infection (UTI- a medical condition characterized by burning or stinging during urination as well as urgency and frequency of urination.)During a review of Resident 9's McGeer's Criteria for Infection Control Surveillance (a document containing objective criteria used to determine if antibiotic therapy is clinically warranted), dated 7/21/2026, indicated Resident 9's did not meet the criteria for a true infection and thus did not warrant the use of antibiotic therapy.During a review of the nurses' progress notes from the Infection Prevention Nurse (IPN), dated 7/21/2026 at 1:37 p.m., the note indicated IPN contacted the physician regarding Resident 9 not meeting criteria for true infection and the physician decided to discontinue the cefdinir. The progress note also indicated that IPN then contacted Resident 9's responsible party (RP - a person designated to make medical decisions for a resident who does not have capacity to make them for themselves) who wanted Resident 9 to complete the antibiotic therapy. The progress note then indicated that IPN explained the risks of unnecessary use of antibiotics to the RP and informed the physician.During an interview on 7/22/2026 at 9:14 a.m., with the IPN, the IPN stated the antibiotic stewardship program was meant to ensure antibiotics were only used when absolutely necessary to treat true infections which were defined clinically by objective criteria. The IPN stated this helps to prevent residents from experiencing side effects from antibiotics if they do not need them and the development of MDROs which can threaten the community at large. The IPN stated Resident 9 was sent to general acute care hospital (GACH) emergency room on 7/20/2026 for evaluation of a possible UTI. The IPN stated Resident 9 was sent back the same day on a course of cefdinir 300 mg twice daily for five days. The IPN stated, when evaluated, Resident 9 did not meet the McGeer's criteria for a true infection. IPN stated she informed the physician who made the decision to discontinue the antibiotic therapy. IPN stated she then contacted Resident 9's RP who was adamant that Resident 9 complete the antibiotic therapy and after informing her about the risks of unnecessary antibiotic therapy, obtained permission from the physician to complete the antibiotic therapy. IPN stated she should have informed the RP that the physician made the decision to discontinue the antibiotic as it was deemed clinically unnecessary. The IPN stated, by continuing the unnecessary antibiotic, it increased the risk that Resident 9 could have adverse effects related to the cefdinir which could lead to medical complications and a decline in her quality of life. During a review of the facility's undated policy Physician Medication Orders, indicated Orders for medications must include. reason or problem for which given.

Based on observation interview and record review, the facility failed to:1. Ensure a Restorative Nursing Assistant (RNA 1) demonstrated the competency necessary to safely and accurately implement a physician-ordered restorative nursing program for one of one sampled resident (Resident 32) reviewed for restorative nursing services when RNA 1 did not verify the physician's order before providing care, attempted to apply the ordered hand splint ( device used to immobilize, protect, and support the hand, wrist, or fingers) to the wrong extremity, was unfamiliar with the ordered splint, and did not seek supervisory assistance before performing the intervention.This deficient practice had the potential to result in improper therapeutic treatment, decreased effectiveness of the restorative program, and harm to the residents.2. Ensure licensed nursing staff demonstrated competency when assessing and documenting pedal pulses (a heartbeat like throb felt in the foot) and capillary refill (a quick test measuring how many seconds it takes for color to return to skin or nail after blanching) on the left foot for one of one sampled resident (Resident 139).This failure had the potential to result in inaccurate assessment of Resident 139's peripheral perfusion (delivery of oxygen rich blood to the small vessels in outer body parts, such as toes, fingers, and skin), thereby delaying identification of impaired circulation in Resident 139's left lower extremity and delaying appropriate treatment. Findings: During a review of Resident 32's admission Record , the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including, muscle wasting and atrophy (loss of muscle mass in more than one part of the body), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), other lack of coordination (loss of full control of bodily movements). During a review of Resident 32's Minimum Data Set (MDS-resident assessment tool) dated 05/12/2026, the MDS indicated Resident 32 had impaired cognitive (ability to think, understand, learn, and remember) function for daily decision-making. The MDS indicated Resident 32's was dependent (helper does all the effort, resident does none of the effort to complete the activity) with activities of daily living (ADLs-activities such as bathing dressing and toileting a person performs daily). During a record review of Residents 32's Order Summary Report) dated 07/20/2026, the Order Summary Report indicated RNA program to left elbow extensive splint for two to four hours every day, five times per week or as tolerated. Skin integrity check before and after application. RNA program apply hand rolls ( a small device placed inside a patient's hand) for two to four hours every day 5 times a week as tolerated. During a concurrent observation and interview on 07/22/2026 at 3:37 p.m. with RNA 1, Resident 32 was observed without the ordered hand splint or hand roll in place during the shift. When asked whether she had completed the assigned restorative nursing services, including application of the hand splint and hand roll, RNA 1 stated she had completed the restorative program earlier in the shift but had not yet documented it because she was behind on her workload. The surveyor accompanied RNA 1 to Resident 32's room. RNA 1 applied a hand splint to the resident's right hand instead of the physician ordered left elbow. After adjusting the splint multiple times, RNA 1 stated she was unfamiliar with that splint and looked through the resident's bedside drawers for another one but did not find an alternative. RNA 1 stated she was not familiar with the splint because it was not part of her usual assignment and that she intended to verify the correct device with her supervisor. When asked whether she had reviewed the physician's order before entering the resident's room, RNA 1 stated she had written it down earlier but forgot to double check the order. RNS 1 stated she needs to review orders before providing care, and should ask for assistance when uncertain to ensure resident safety. During an interview on 07/23/2026 at 12:31 p.m. with the Physical Therapist (PT) and the Director of Rehabilitation (DOR), the DOR stated all RNAs received training before becoming certified and completed annual competency evaluations during the facility's skills week. The DOR stated RNAs were instructed to review physician orders before performing restorative nursing services because those orders guide the implementation of each resident's restorative program. The DOR stated RNAs were expected to communicate with the rehabilitation team and seek assistance from the rehabilitation supervisor or other leadership staff whenever they were uncertain about how to perform a restorative intervention, including the application of splints or other therapeutic devices. The PT stated RNAs were expected to follow physician orders when providing restorative nursing services. The PT stated that failure to perform an ordered intervention correctly placed a resident at risk for functional decline and could prevent the resident from receiving the intended therapeutic benefit of the restorative program. During an interview on 07/23/2026 at 2:44 p.m. with the Director of Nursing (DON), the DON stated Restorative Nursing Assistants (RNAs) were expected to be competent in performing their assigned restorative nursing duties. The DON stated that validating competency was essential to ensure RNAs could safely and correctly carry out physician ordered restorative interventions. The DON stated applying an incorrect splint would fail to achieve its intended therapeutic purpose and could place the resident at risk of not receiving the ordered treatment. During a review of the facility's policy and procedure (P&P) titled Competency of Nursing staff (undated) the P&P indicated, All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: basic restorative services. 2.During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was admitted to facility on 3/1/2023 and readmitted on [DATE]. The admission Record indicated a diagnoses including malignant neoplasm (cancer) of the right breast, atherosclerotic heart disease (heart condition where fatty plaque builds up in the heart's arteries), long term use of anticoagulant (taking blood-thinning medications for an extended or indefinite period) and mild protein calorie malnutrition (nutritional deficient caused by eating too few proteins and calories). During a review of Resident 139's Annual History and Physical (H&P), dated 5/6/2026, the H&P indicated, Resident 139 was diagnosed with major vascular neurocognitive disorder (severe decline in thinking skills caused by reduced blood flow to the brain) and moderate protein calorie malnutrition (mid-level nutritional deficient caused by eating too few proteins and calories). The H&P indicated, Resident 139, does not have decision making capacity. During a review of Resident 139's MDS dated [DATE], the MDS indicated Resident 139 had moderate cognitive impairment and was dependent on self-care activities, such as bathing, toileting, and dressing, and was dependent on functional abilities, such as going from sitting to lying position. The MDS indicated, Resident 139, was frequently incontinent (lacking voluntary control over urination or defecation) of bowel and bladder. The MDS indicated Resident 139 had an unhealed Stage 4 pressure injury and had no venous and arterial ulcers and no foot problems. During a concurrent observation and interview on 7/22/2026 at 12:01 p.m., with Treatment Nurse (TN 1) in Resident 139's room, Resident 139 was observed with a left calf wound that was red and moist with yellowish-white drainage, and exposed tendon. TN 1 stated, Resident 139 developed the wound because Resident 139 crossed her legs. During a concurrent interview and record review on 7/22/2026 at 2:15 p.m. with TN 1, Resident 139's Skin Issue Progress Notes dated 2/24/2026 to 7/20/2026 were reviewed. The notes indicated Resident 139's left calf wound began as an open blood blister on 2/24/2026, progressed to an unstageable pressure injury on 4/28/2026, and advanced to a Stage 4 pressure injury on 6/11/2026. TN 1 stated she had recommended an arterial and venous (AV) doppler ultrasound (a test that uses sound waves to check blood flow in the legs and arms) to Resident 139's primary care physician (PCP) on 2/24/2026, but the physician declined the recommendation. TN 1 stated Resident 139's Stage 4 pressure injury was avoidable. During a review of Resident 139's Treatment Administration Record (TAR) dated June 2026, the TAR indicated staff documented a present pedal pulse on Resident 139's left foot from 6/1/2026 through 6/30/2026. The TAR also showed staff documented a capillary refill of less than 3 seconds (adequate peripheral perfusion) on the left foot for the same dates. During a review of Resident 139's TAR dated July 2026, the TAR indicated staff documented a present pedal pulse on Resident 139's left foot from 7/1/2026 through 7/24/2026. The TAR also showed staff documented a capillary refill of less than 3 seconds on the left foot between 7/1/2026 and 7/24/2026. During a concurrent interview and record review on 7/23/2026 at 4:55 p.m. with TN 1, Resident 139's Treatment Administration Record (TAR), dated 6/2026–7/2026 was reviewed The TAR indicated Resident 139 had a present pedal pulse on her left foot from 6/1/2026 to 6/30/2026 and from 7/1/2026 to 7/24/2026. The TAR indicated Resident 139 had a capillary refill of less than 3 seconds (adequate peripheral perfusion [delivery of oxygen-rich blood to small blood vessels in outer body parts, such as toes, fingers, and skin]) on the left foot during those same time periods. TN 1 stated she checked Resident 139's capillary refill on her left toes. She did not respond when asked how she checked capillary refill when Resident 139 had gangrenous toes. During a concurrent observation and interview on 7/23/2026 at 5:35 p.m. with Family Member (FM) 2, FM 2 was crying. FM 2 stated they had received a phone call from Resident 139's primary care physician and learned that Resident 139's toes had gangrene (a serious condition in which body tissue dies due to loss of blood supply or severe infection). During a concurrent interview and record review on 7/23/2026 at 5:55 p.m. with the Director of Nursing (DON), Resident 139's TAR dated June 2026 and July 2026. The DON stated the reason nurses check pedal pulses and capillary refill was to monitor whether the resident's leg circulation was worsening. He stated the capillary refill documentation was not accurate because the resident had gangrenous toes, which made capillary refill assessment invalid. During a concurrent observation and interview on 7/23/2026 at 6:06 p.m. with Registered Nurse Supervisor (RNS) 2 in Resident 139's room, Resident 139's second, third and fourth (2nd, 3rd, and 4th ) digits (toes) were black. RNS 2 checked Resident 139's pedal pulse on the left foot and stated, Resident 139 had no pedal pulse on the left foot. Two (2) Health Facilities Evaluator Nurses (HFENs - licensed registered nurse who inspects, investigates, and evaluates healthcare facilities) verified pedal pulse on left foot and pedal pulse was absent. RNS 2 stated, she was unable to check capillary refill on Resident 139's left foot because there were no blood flow and Resident 139's toes were necrotic (black). During a concurrent observation and interview on 7/23/2026 at 6:32 p.m., with RNS 2 in Resident 139's room, RNS 2 checked the pedal pulse on Resident 139's right foot. RNS 2 stated, the pedal pulse on Resident 139's right foot was faint. Two (2) HFENs verified that the pedal pulse on right foot was faint. During a review of Resident 139's Emergency Department (ED) to Hospital-admission Record, dated 7/25/2026, indicated the left lower extremity was warm with delayed capillary refill, and posterior tibial and dorsalis pedis pulses were not dopplerable (able to measured, detected, or imaged pulse using doppler technology). The record indicated that the only surgical option for Resident 139 was an AKA. During a review of the facility's job description titled, Job Description Charge Nurse, undated, indicated, Maintain an acceptable standard of nursing practice. accurately assess, document and report the resident's symptoms, reactions, progress to the attending physician, Nursing Supervisor, Director of Nursing Services, Administrator and other participating in care and treatment of the resident; Includes but not limited to the resident's status in hydration, nutritional intake, weight, skin integrity. Ensure the documentation in the medical record is current and complete and reflects the resident's physical. status with changes as appropriate in the plan of care and as often as the resident's condition warrants. During a review of the facility's job description titled, Job Description Registered Nurse (RN) Supervisor, undated, indicated, To provide nursing care to residents as prescribe by the physician and in accordance with standards of nursing practices and regulations. Prepare and review medical records and nurse notes, and assess residents to evaluate their physicals emotional status. Montior resident activity, evaluate nursing care in accordance with professional standards, and provide nursing care according to the physician 's orders, care plans, established standards and facility practices. During a review of the facility's policy and procedures (P&P) titled, Competency of Nursing Staff, undated, indicated, All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as basic nursing skills. skin and wound care. Cross Reference F684

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 78) oxygen tubing and humidifier (a small water bottle attached to an oxygen machine that adds moisture to the oxygen before you breathe it) were dated and labeled.This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.Findings:During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (long-term condition where the lungs cannot properly move enough oxygen into the blood or get rid of enough carbon dioxide) and asthma (long-term lung condition that causes shortness of breath, wheezing, and coughing).During a review of Resident 78's Minimum Data Set (MDS- a resident assessment tool) dated 6/19/2026, the MDS indicated Resident 78's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 4 required clean-up assistance (helper sets up or cleans up) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 78's Order Summary, the Order Summary indicated an order dated 7/13/2026 to change the oxygen tubing and humidifier every Sunday with a label and date when changed.During a concurrent observation and interview on 7/20/2026 at 10:04 a.m. with Registered Nurse Supervisor (RNS) 5 in Resident 78's room, RNS 5 stated Resident 78's oxygen tubing and humidifier were not labeled or dated, but they should have been. RNS 5 stated the oxygen tubing and humidifier were supposed to be changed, labeled, and dated weekly to prevent bacteria from building up, which could result in an infection for the resident.During an interview on 7/23/2026 at 2:24 p.m., with the Director of Nursing (DON), the DON stated oxygen tubing and humidifiers were changed once a week for infection control. The DON stated not changing the tubing and humidifiers can place the residents at risk for infection.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration undated, the P&P indicated, The purpose is to provide safe oxygen administration. Verify there is a physician's order and review the physician's orders or facility protocol for oxygen administration.

Based on interview and record review, the facility failed to ensure informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was accurately completed and obtained from the resident and/or responsible party for three of three sampled resident (Resident 35, 45, and 139). The facility failed to:1. Ensure Resident's 35's informed consent for psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) was signed by the physician.2.Ensure Resident 45's informed consent for psychotropic medication contained the correct medical diagnosis.These failures violated the residents' right to make an informed decision regarding the use of psychoactive medications.3.Ensure Nurse Practitioner (NP-advanced practice registered nurse who provides specialty healthcare services) 1 informed Resident 139's family member and obtained an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) before performing sharp wound debridement (surgical procedure to remove non-viable [dead] tissue) on (3/24/2026, 4/7/2026, 4/21/2026, 4/28/2026, 5/7/2026, 5/19/2026, and 5/26/2026) to Resident 139's left calf wound. This failure resulted in Resident 139 undergoing an invasive procedure (medical treatment that requires breaking the skin or inserting instruments into the body) without the resident's representative being informed of the purpose of the debridement, its risks, benefits, and alternatives, preventing the resident's representative from making an informed medical decision on the resident's behalf. Findings: 1. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including depression (constant sadness, low energy, and loss of interest in life) and vascular dementia (a progressive state of decline in mental abilities) with severe agitation (a state of severe restlessness, jumpiness, and inner tension where a person cannot relax or stay still). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool) dated 6/5/2026, the MDS indicated Resident 35's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 35 required maximal assistance (helper does more than half the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 35's Psychotherapeutic Drug Informed Consent Form dated 6/10/2026, indicated an informed consent for Depakote Sprinkles (medicine used to treat mood disorders) 125 milligrams (mgs- a unit of measurement), once daily with no indication, was obtained from the resident representative on 6/10/2026, and signed by the licensed vocational nurse (LVN). The Psychotherapeutic Drug Informed Consent Form did not include the physician's signature. During a review of Resident 35's Physician Order Summary Report dated 6/18/2026, the Physician Order indicated an order for Depakote Sprinkles 125 mgs twice a day for mood swing (sudden, extreme, or rapid change in a resident's emotional state, shifting quickly between feelings like happiness, sadness, anger, or irritability), agitation, and restlessness. During a review of Resident 35's Physician Order Summary Report dated 6/18/2026 indicated an order for Ativan (medication to treat anxiety {feelings of worry, nervousness, and fear about what might happen in the future}) 0.5 mgs, every 12 hours as needed for anxiety manifested by restlessness or irritability. During a review of Resident 35's Psychotherapeutic Drug Informed Consent Form dated 6/18/2026, the Psychotherapeutic Drug Informed Consent Form indicated an informed consent for Ativan 0.5 mgs, every 12 hours as needed for anxiety was obtained from the resident representative on 6/18/2026, signed by the LVN. The Psychotherapeutic Drug Informed Consent Form did not include the physician's signature. 2.During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including dementia and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 45's Physician Order Summary Report dated 2/19/2026 indicated an order for Olanzapine (a medication to calm and rebalance brain activity)) 2.5 mgs one tablet in the morning for atypical psychosis manifested by visual hallucinations (seeing things that are not actually there). During a review of Resident 45's Psychotherapeutic Drug Informed Consent Form dated 2/19/2026, indicated an informed consent for Olanzapine 2.5 mgs every morning for schizophrenia (a mental illness that is characterized by disturbances in thought) was obtained from the resident representative on 2/19/2026, signed by the LVN. During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 8's cognition was severely impaired. The MDS indicated Resident 45 required maximal assistance with ADLs. During a concurrent interview and record review on 7/22/2026 at 11:26 a.m. with Registered Nurse Supervisor (RNS) 1, the Psychotherapeutic Drug Informed Consent Forms were reviewed. RNS 1 stated Resident 45's Psychotherapeutic Drug Informed Consent Forms were inaccurate because neither form contained a physician's signature. RNS 1 stated it was important for the physician to sign the informed consent to confirm the physician was aware the resident or resident representative agreed to and consented to the prescribed medication. During a concurrent interview and record review on 7/22/2026 at 2:18 p.m. with RNS 1, Resident 45's Psychotherapeutic Drug Informed Consent Form was reviewed. RNS 1 stated the form was inaccurate because Resident 45 did not have a diagnosis of schizophrenia. RNS 1 stated an incorrect diagnosis on the informed consent form placed the resident and the resident's representative at risk of being improperly informed, which could affect their rights. RNS 1 stated informed consent forms must be completed accurately to ensure the resident and the resident representative were fully aware of the treatment being provided. During an interview on 7/23/2026 at 2:24 p.m., with the Director of Nursing (DON), the DON stated the Psychotherapeutic Drug Informed Consent Form should be signed by the physician immediately to confirm it was ordered for the resident and if it was not signed, the form would be invalid. The DON stated Psychotherapeutic Drug Informed Consent Form should have the correct diagnosis documented because the treatment should match the resident's diagnosis. During a review of the facility's Psychotherapeutic Drug Informed Consent Form Instruction Sheet, dated 12/2025, the Psychotherapeutic Drug Informed Consent Form Instruction Sheet indicated, The prescriber is required to read and sign. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use and Consent, undated, the P&P indicated, .the staff and practitioner will review an individual's current medication regimen, to identify whether there is a clear indication for treating that individual with the medications. 3. During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was admitted to facility on 3/1/2023 and readmitted on [DATE]. The admission Record indicated a diagnoses including malignant neoplasm (cancer) of the right breast, atherosclerotic heart disease (heart condition where fatty plaque builds up in the heart's arteries), long term use of anticoagulant (taking blood-thinning medications for an extended or indefinite period) and mild protein calorie malnutrition (nutritional deficient caused by eating too few proteins and calories). During a review of Resident 139's Annual History and Physical (H&P), dated 5/6/2026, the H&P indicated, Resident 139 was diagnosed with major vascular neurocognitive disorder (severe decline in thinking skills caused by reduced blood flow to the brain) and moderate protein calorie malnutrition (mid-level nutritional deficient caused by eating too few proteins and calories). The H&P indicated, Resident 139 did not have decision making capacity. During a review of Resident 139's MDS dated [DATE], the MDS indicated Resident 139 had moderate cognitive impairment and was dependent on self-care activities, such as bathing, toileting, and dressing, and was dependent on functional abilities, such as going from sitting to lying position. The MDS indicated, Resident 139, was frequently incontinent (lacking voluntary control over urination or defecation) of bowel and bladder. The MDS indicated Resident 139 had an unhealed Stage 4 pressure injury and had no venous and arterial ulcers and no foot problems. During a concurrent observation and interview on 7/22/2026 at 12:01 p.m., with Treatment Nurse (TN 1) in Resident 139's room, Resident 139 was observed with a left calf wound that was red and moist with yellowish-white drainage, and exposed tendon. TN 1 stated, Resident 139 developed the wound because Resident 139 crossed her legs. During a concurrent interview and record review on 7/22/2026 at 2:15 p.m. with TN 1, Resident 139's Skin Issue Progress Notes, dated 2/24/2026 to 7/20/2026, was reviewed. The Skin Issue Progress Notes indicated Resident 139 had received multiple debridement sessions on her left calf wound on 3/24/2026, 4/7/2026, 4/21/2026, 4/28/2026, 5/7/2026, 5/19/2026, and 5/26/2026. TN 1 stated, Resident 139's left calf wound started as a popped blood blister on 2/24/2026, progressed to unstageable pressure injury on 4/28/2026, and advanced into a Stage 4 pressure injury on 6/11/2026. During a record review of the Wound Care Nurse Practitioner's Progress Notes, dated 3/3/2026 to 7/20/2026, the Progress Notes indicated the Resident 139 received bedside sharp wound debridement on the left calf wound on 3/24/2026, 4/7/2026, 4/21/2026, 4/28/2026, 5/7/2026, 5/19/2026, and 5/26/2026. During an interview on 7/23/2026 at 4:14 p.m. with TN 1, TN 1 stated she was present when the Wound Care Nurse Practitioner (WCNP) was doing the wound debridement. TN 1 stated, debridement was an invasive procedure (any medical procedure that enters the body, either by breaking the skin or by inserting instruments into the body). TN 1 stated, an informed consent was not obtained prior to debridement of Resident 139's left calf wound and an informed consent should have been done for Resident 139's debridement. During a concurrent interview and record review on 7/23/2026 at 4:44 p.m. with the Assistant Director of Nursing (ADON), Resident 139's consents were reviewed. The ADON stated, Resident 139 does not have an informed consent for wound debridement. The ADON stated, Resident 139 required an informed consent to be completed prior to wound debridement. The ADON stated, the informed consent ensures the residents' right to receive information about the proposed care and to accept or refuse care before it was provided. During an interview on 7/23/2026 at 5:35 p.m. with FM 2, FM 2 stated she did not provide informed consent for Resident 139's debridement procedure. FM 2 stated her brother did not provide informed consent for Resident 139's debridement procedure either. During an interview on 7/23/2026 at 5:55 p.m. with the DON, the DON stated the Nurse Practitioner should obtain consent from the family representative before performing sharp wound debridement, as it was an invasive medical procedure. The DON stated the NP should explain the purpose of the procedure, its risks and benefits, and any alternative options. During a review of the facility's policy and procedures (P&P), there was no P&P on informed consent for invasive procedures. Cross reference F684.

Based on observation, interview and record review, the facility failed to honor resident's choice and preference for one of six sampled residents (Resident 15) by failing to:1.Ensure Certified Nursing Assistant (CNA) 2 was not assigned to Resident 15 as the resident had requested.This failure resulted in Resident 15 becoming upset and frustrated and had the potential for violating the resident's right to choose.Findings:During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 15's diagnoses including legal blindness (person's vision is very poor even with regular glasses), hemiplegia (paralysis)and hemiparesis (partial weakness) following cerebral infarction affecting left non-dominant side (total paralysis of the arm, leg, and trunk on the left side of the body after a stroke[medical emergency that happens when blood flow to a part of the brain stops]) and hypertension(HTN-high blood pressure).During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 5/8/2026, the MDS indicated Resident 15 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 15 was dependent (a helper completed all the activities for the resident) on staff with eating, oral hygiene, toileting hygiene and lower body dressing. The MDS indicated the resident had severely impaired vision (no vision, sees only light, colors or shapes, and eyes do not appear to follow objects).During a concurrent observation and interview on 7/20/2026 at 3:47 p.m. in Resident 15's room, Resident 15 was lying in bed and appeared upset. Resident 15 stated CNA 2 had been assigned to her, and she did not get along with her. Resident 15 stated she did not want CNA 2 to provide incontinent unable to control your bladder or bowels) care or feed her.During a concurrent interview and record review on 7/20/2026 at 4:04 p.m. with Licensed Vocational Nurse (LVN) 6, facility's staff assignment for 7/20/2026 3:00 p.m. to 11:00 p.m. shift was reviewed. LVN 6 stated CNA 2 was assigned to Resident 15 on 7/20/2026 from 3:00 p.m. to 11:00 p.m. shift.During an interview on 7/20/2026 at 4:06 p.m. with CNA 2, CNA 2 stated Resident 15 was assigned to her for the 3:00 p.m. to 11:00 p.m. shift on 7/20/2026. CNA 2 stated Resident 15 did not want her to be her CNA and the supervisors were aware she was not supposed to be assigned to Resident 15. CNA 2 stated she did not know why Resident 15 did not like her. CNA 2 stated the Assistant Director of Staff Development (ADSD) was responsible for making the CNA assignments.During an interview on 7/20/2026 at 4:48 p.m. with the ADSD, the ADSD stated she was aware CNA 2 should not have been assigned to Resident 15 because the resident refused care from CNA 2. The ADSD stated she forgot and assigned CNA 2 to Resident 15, even though other assignment options were available to ensure CNA 2 was not assigned to the resident. The ADSD stated it was important to follow the resident's preference because the resident had the right to refuse care from a staff member. She stated Resident 15 could become upset and her rights could be violated if her preferences were not followed and honored.During an interview on 7/20/2026 at 4:36 p.m. with the Director of Staff Development (DSD), the DSD stated CNA 2 was aware that Resident 15 did not want CNA 2 to be the CNA providing care. The DSD stated she usually rechecked the assignments made by the ADSD, but she was not able to review them on 7/20/2026. The DSD stated Resident 15's rights could be violated and the resident might refuse to call for help if her preference was not honored. The DSD stated the facility should honor Resident 15's preference because it was the resident's right.During an interview on 7/22/2026 at 4:24 p.m. with Registered Nurse Supervisor (RNS) 3, RNS 3 stated CNA 2 should have informed the supervisors that she had been assigned to Resident 15 so the assignment could be changed. RNS 3 stated Resident 15's care could be affected if the resident's preference was not honored.During an interview with the Director of Nursing (DON) on 7/23/2026 at 2:24 p.m., the DON stated it was important to honor a resident's preference for a CNA because residents had the right to choose caregivers for their comfort and convenience. The DON stated not following or honoring Resident 15's choice of CNA could cause emotional distress and affect the resident's well being.During a review of facility's policy and procedure (P&P) titled, Quality of Life- Self Determination and Participation, reviewed 1/202/2026, the P&P indicated The facility respects, promotes the right of each resident and facilitates resident's choices.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 41's), Minimum Data Set (MDS - a resident assessment tool) accurately reflected Resident 41's diagnosis of Alzheimer ( a disease characterized by a progressive decline in mental abilities)/dementia ( a progressive state of decline in mental abilities).This deficient practice had the potential to result in Resident 41 not receiving the necessary care and services.Findings:During a review of Resident 41's admission Record, the admission Record indicated, Resident 41 was admitted to the facility on [DATE] with the diagnosis including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), gout (type of arthritis-swelling of joints) and mild cognitive (ability to think, understand, learn, and remember) impairment.During a review of Resident 41's History and Physical (H&P) dated 3/27/2026, the H&P indicated Resident 41 had the capacity to understand and make decisions.During a review of Resident 41's Minimum Data Set (MDS -resident assessment tool), dated 5/20/26, the MDS indicated, Resident 41's cognition was intact. The MDS indicated, Resident 41 was dependent (staff does all the work) with activities of daily living (ADL's- activities such as bathing, dressing, and toileting a person performs daily). The MDS indicated, Resident 41 did not have a diagnosis of Alzheimer's ( a disease characterized by a progressive decline in mental abilities).During a review of Resident 41's Neurologist Progress Note dated 4/24/2026, the note indicated Resident 41 had a diagnosis of Alzheimer's/dementia and was prescribed memantine 5 milligrams (mg-unit of measure) by mouth once a day for 30 days with three refills.During a review of Resident 41's Care Plan titled Decline in cognition from baseline, dated 2/18/2025 and revised on 5/5/2026, the Care Plan indicated, Resident 41 had impaired cognition and was prescribed Aricept (medication used to treat confusion, memory loss, and other symptoms of mild, moderate, or severe Alzheimer's disease) and memantine.During a concurrent interview and record review on 7/23/2026 at 3:31 p.m. with the MDS nurse (MDSN), Resident 41's Neurologist Progress Note dated 4/24/26 was reviewed. The note indicated, Resident 41 had a diagnosis of Alzheimer's/dementia. The MDSN stated Resident 41 MDS was inaccurate Resident 41 did have a diagnosis of Alzheimer's/dementia. The MDSN stated the MDS was a comprehensive assessment and needs to reflect the current status of the resident to ensure the plan of care meets the resident's needs.During an interview on 7/23/2026 at 3:56 p.m. with the Director of Nurses (DON), the DON stated Resident 41 does have a diagnosis of Alzheimer's/dementia. The DON stated Resident 41's MDS was inaccurate and it did not reflect Resident 41's diagnosis of Alzheimer's/dementia. The DON stated there was a potential for Resident 41not to receive sensory (sight, sound and smell) and cognitive stimulation when there was no plan of care.During a review of the facility's policy and procedure (P&P) titled MDS Assessment Accuracy and Completion undated , the P&P indicated, Facility shall complete all MDS assessments accurately, timely, and in accordance with the Center of Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual. A Registered Nurse (RN) shall coordinate each assessment using an interdisciplinary team (IDT) approach. Assessment responses shall be supported by clinical documentation and accurately reflect the resident's condition during the applicable observation period. The P&P indicated, that routine MDS accuracy audits shall be conducted through the facility's Quality Assurance and Performance Improvement (QAPI) program, with corrective actions implemented when indicated.Cross Reference F755

Based on interview and record review, the facility failed to develop and implement a comprehensive person center care plan for one of three sampled residents (Resident 4) by failing to:1. Develop a comprehensive person-centered care plan to address Resident 4's antibiotic (medication to treat infection).This failure had the potential to negatively affect the delivery of care and services to Resident 4.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and cerebral infarction (stroke- loss of blood flow to part of the brain).During a review of Resident 4's Order Details dated 6/15/2026, the Order Details indicated an order for Amoxicillin-Pot Clavulanate (medication used to treat an infection) 875-125 milligrams (mgs- a unit of measurement) one tablet two times a day for a right lower lung infiltrate (abnormal substance or fluids within the lung tissue) for seven days.During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 6/18/2026, the MDS indicated Resident 4 had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 4 required moderate assistance (helper does less than half the effort).During a concurrent interview and record review on 7/22/2026 at 8:35 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 4 did not have a care plan for the antibiotic, but one should have been developed. RNS 1 stated care plans were designed with specific interventions based on identified problems for each resident.During a concurrent interview and record review on 7/22/2026 at 8:49 a.m. with the Infection Prevention Nurse (IPN), the IPN stated she should have developed a care plan when a resident was placed on an antibiotic so staff would know how to care for the resident. She stated Resident 4 did not have a care plan for the antibiotic, but there should have been developed.During an interview on 7/23/2026 at 2:24 p.m. with the Director of Nursing (DON), the DON stated when a resident was prescribed an antibiotic, a care plan needed to be developed because the care plan guided the nurses on how to care for the resident.During a review of the facility's policy and procedure (P&P) titled, Care Plans- Comprehensive, undated, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to reflect treatment goals, timetables, and objectives in measurable outcomes.

Based on interview and record review, the facility failed to provide the necessary care and treatment for four of six sampled residents (Resident 19, 14. 61 and 39). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 8, LVN 9 and Registered Nurse (RNS) 4 assessed and monitored Resident 19 when the resident had a change in condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, and understand] behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by shivering and shaking on 6/8/2025 at 11:10 p.m., and every two hours thereafter. 2. Ensure LVN 8 informed LVN 9 of Resident 19's shivering and shaking on 6/8/2025 at 11:10 p.m. during change of shift handoff. These failures resulted in Resident 19 found unresponsive on 6/9/2025, at 4:14 a.m., pronounced dead on 6/9/2025 at 5:03 a.m. after cardiopulmonary resuscitation (CPR- an emergency procedure used to restart a person's heart and breathing by giving strong, rapid pushes to the chest to keep blood moving through the body) efforts. 3. Ensure Resident 14 was provided with medications for constipation ( a condition in which stool becomes hard, dry , difficult to pass, and bowel movements become infrequent) when Resident 14 had no bowel movement ( the movement of feces through bowel and out of anus) for three days. This failure had the potential to put Resident 14 at risk for fecal impaction ( hardened stool that is stuck in the rectum) that could lead to bowl obstruction ( partial or complete blockage of small or large intestine which is life threatening). 4.a.Ensure licensed staff document a change in condition each time Resident 61's nasogastric tube (NG tube- a thin flexible tube inserted through the nose, down the throat, and into the stomach) was pulled out by Resident 61. b. Ensure an order was obtained prior to reinserting Resident 61's NG tube. Document the location of the NG tube placement for Resident 61. These failures had the potential to cause delay in provision of necessary care and treatment to Resident 61 and complications of prolonged used of NG tube. 5. Ensure Resident 39's physician was notified that Resident 39 was taking clopidogrel (a medication used to prevent blood clots with a side effect of bleeding), after the resident sustained a fall. This failure prevented the physician from being able to make informed decisions regarding the care and treatment of Resident 39. Findings: 1. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy ( a long term condition that affects the heart muscle making it harder to pump blood), Covid -19 (highly contagious respiratory disease caused by Coronavirus which is transmitted thru coughing, talking , sneezing and touching contaminated surfaces ), and end stage renal disease (ESRD- irreversible kidney failure) with dependence on renal hemodialysis (procedure to remove waste products and excess fluids from the blood when kidneys stop working properly). The admission Record indicated the resident was discharged to a funeral home on 6/9/2025 at 10:25 a.m. During a review of Resident 19's Minimum Data Set (MDS-resident assessment tool) dated 5/15/2025, the MDS indicated Resident 19 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) and was dependent on staff (helper does all the effort to complete the activity) with bathing, dressing, toilet transfer (ability to get on and off a toilet or a commode) and toileting hygiene. During a review of Resident 19's Weights and Vital Signs (VS- basic functions of the body such as temperature, blood pressure (a pressure of the blood against the artery walls when the heart beats), pulse and respiratory rate [breathing] rate), the Weights and Vital Signs Summary indicated the following: 1. On 6/8/2025, at 5:57 p.m. Resident 19's blood pressure (bp reading was 130/72 millimeters of mercury (mmHg-unit of blood pressure measure) 2. On 6/8/2025, at 10:59 a.m. Resident 19's heart rate (HR- number of times the heart beats per minute; reference range is between 60 to 100 beats per minute) was 65 beats per minute, respiratory rate (RR-number of breaths a person takes per minute; reference range is between 12 to 18 breaths per minute) was 18 RR per minute, temperature was 97.5 degrees Fahrenheit (°F- unit of measurement; reference range between 97 degrees F to 99 degrees F), and oxygen saturation (O2 Sat- concentration of oxygen in the blood; reference range between 95 percent to 100 percent) was 97 percent (%) on room air (no supplemental oxygen used). During a review of Resident 19's Transfer/Discharge summary, dated [DATE] and timed at 8:09 a.m., the Transfer/Discharge Summary indicated on 6/9/2025, at 4:30 a.m. , the charge nurse was summoned due to Resident 19 not responding and not breathing. The Transfer/Discharge Summary indicated Registered Nurse (RNS) 4 responded to the summon right away. The Transfer/Discharge Summary indicated chest compressions ( applying pressure on someone's chest in order to help blood flow through the heart in an emergency situation) were started, oxygen was delivered to Resident 19 via Ambu bag (a portable, hand held device used to provide respiratory support to patients in emergency situation), and 911( number that is called in order to contact the emergency services) was called. The Transfer /Discharge Summary indicated paramedics (highly trained healthcare professionals who provide emergency medical care) arrived on 6/9/2025 at 4:35 a.m. and continued cardiopulmonary resuscitation (CPR- an emergency procedure used to restart a person's heart and breathing by giving strong, rapid pushes to the chest to keep blood moving through the body) on Resident 19. The Transfer/Discharge Summary indicated paramedics' team leader pronounced Resident 19 expired on 6/9/2025 at 5:03 a.m. During a review of Resident 19's Emergency Medical Services (EMS-a system that respond to emergencies in need of highly skilled prehospital clinicians) Incident Information dated 6/9/2025, at 4:35 a.m., the EMS Incident Form indicated EMS team was notified on 6/9/2025 at 4:35 a.m. of Resident 19's cardiac arrest ( heart malfunctions and stops beating on its own caused by an electrical problem in the heart). The EMS Incident Information indicated a team was dispatched to the facility and arrived at 4:40 a.m. The EMS Incident Information indicated facility staff stated to the EMS team that Resident 19 was last seen on 6/9/2025, at 4:15 a.m. sleeping and breathing. The EMS Incident Form indicated Resident 19 was in asystole ( when heart's electrical system fails entirely causing the heart to stop pumping and is also known as flat line) upon assessment and throughout the entirety of the resuscitative effort provided to the resident. The EMS Incident Information indicated the time of death of Resident 19 was 5:03 a.m. on 6/9/2025. During a review of Resident 19's Medication Administration (MAR) dated 5/18/2025, the MAR indicated an order for Humulin (Insulin NPH- intermediate acting insulin to treat DM that reaches the blood stream in about 2 to 4 hours) suspension 100 unit/milliliter (ml-unit of measurement) inject 10 unit subcutaneously (applied under the skin ) in the evening for DM with food. During a review of Resident 19's Care Plan titled, Potential for hyperglycemia (condition in which the level of sugar in the blood) /hypoglycemia (low blood sugar). related to DM, initiated on 5/31/2024 and revised on 5/20/2025, the Care Plan indicated Resident 19 had an episode of hyperglycemia and hypoglycemia The Care Plan indicated the goal for Resident 19 was to be asymptomatic ( not showing symptoms) of hyperglycemia and hypoglycemia daily for three months. The Care Plan indicated the interventions included to notify the physician of the resident's change in condition and to monitor, document, and report to the physician as needed any signs and symptoms of hypoglycemia such as sweating, tremor ( shaking movements in one or more parts of the body), increased heart rate, pallor (skin paleness), nervousness, confusion, slurred speech and lack of coordination. During a telephone interview on 6/12/2025 at 10:49 a.m., with Certified Nursing Assistant (CNA) 8, CNA 8 stated on 6/8/2025, at 11:10 p.m. he noticed Resident 19 was shaking and shivering. CNA 8 stated he gave him (Resident 19) a blanket. CNA 8 stated he told Licensed Vocational Nurse (LVN) 8 about Resident 19's shaking and shivering and that Resident 19 did not look good because his upper body was shaking. CNA 8 stated LVN 8 took Resident 19's temperature and told CNA 8 that Resident 19 was okay, and that Resident 19 had been shaking and shivering because had taken a shower. CNA 8 stated on 6/9/2025, from12:00 a.m. to 12:30 a.m. Resident 19 was awake, and was no longer shaking, appeared awake but was staring at the ceiling. CNA 8 stated he asked Resident 19 at that time if he was okay, and the Resident 19 stated he was okay. CNA 8 stated on 6/8/2025, after 12:30 a.m. he got busy with other residents and did not see Resident 19 until 4:14 a.m. on 6/9/2025. CNA 8 stated on 6/9/2025, at 4:14 a.m. he entered Resident 19's room and turned on the lights upon entrance., CNA 8 stated he did not hear Resident 19 talking but he (CNA 8) did not look at Resident 19 as he was to changing Resident 19's roommate. CNA 8 stated after he almost finished changing Resident 19's roommate incontinent pad (diaper), he looked at Resident 19 and saw Resident 19 not moving, his chest did not rise or fall and looked dead. CNA 8 stated he notified LVN 9 immediately. LVN 9 called RNS 4 and called Code Blue (announcement in the facility that someone is experiencing a life-threatening medical emergency). CNA 8 stated LVN 8 and LVN 9 did not tell him to monitor or check on Resident 19 after he had an episode of shaking and shivering on 6/8/2025 at 11:10 p.m. During a concurrent interview and record review on 6/12/2025, at 7:19 a.m. and subsequent telephone interview on 6/12/2025, at 10:14 a.m. with LVN 9, Resident 19's electronic medical records (EHR) was reviewed. LVN 9 stated he did not see Resident 19 after 11:30 p.m. on 6/8/2025 when Resident 19 had episode of shaking and shivering because he was busy with another resident (unknown) who was restless, confused and was trying to get out of bed. LVN 9 stated most of his time on 6/9/2025 was spent with that resident (unknown) . LVN 9 stated he saw Resident 19 awake, resting comfortably at 11:30 p.m. on 6/8/2025 but did not talk to the resident. LVN 9 stated the last time he saw Resident 19 was on 6/8/2025 at 11:30 p.m. LVN 9 stated LVN, RN, or CNA should conduct rounding (in general) every two hours. LVN 9 stated he received report from LVN 8 from outgoing 7 p.m.- 11 pm shift but LVN 8 did not mention any change in Resident 19's condition such as shaking and shivering and reported Resident 19 was okay. LVN 9 stated he notified RNS 4 that he was busy with another resident (unknown) on 6/9/2025. LVN 9 stated RNS 4 did not come to see him (LVN 9) or see Resident 19. LVN 9 stated on 6/9/2025, at 4:30 a.m., CNA 8 notified him that Resident 19 was not breathing, and code blue was announced. LVN 9 stated they initiated CPR and EMS arrived on 6/9/2025 at 4:35 a.m. and took over the CPR During a telephone interview on 6/12/2025, at 11:39 a.m. with LVN 8, LVN 8 stated on 6/8/2025, at around 11:00 p.m., CNA 8 notified LVN 8 that Resident 19 was shivering and shaking. LVN 8 stated he provided an extra blanket and took Resident 19's temperature. LVN 8 stated he took the temperature, and it was normal but did not remember what the temperature was when Resident 19 was shivering and shaking. LVN 8 stated he did not document the temperature on Resident 19's health record. LVN 8 stated Resident 19's shivering and shaking considered a change in the resident's condition because it probably was indicating the resident had a fever or hypoglycemia (low blood sugar). LVN 8 stated he did not do a change of condition because he had done his intervention already by checking Resident 19's temperature and providing Resident 19 with a blanket. LVN 8 stated he did not inform Resident 19's physician about the shivering and shaking and did not check Resident 19's other vital signs including blood pressure, pulse rate, respiratory rate, oxygen saturation, and blood sugar. LVN 8 stated he should have checked the Resident 19's vital signs, notified the physician to address the change in condition , initiate a COC, monitor Resident 19 frequently (at least every two hours) and checked his blood sugar when Resident 19 was shivering and shaking as Resident 19 had a history of hypoglycemia (low blood sugar) and was receiving insulin (medication to treat DM). LVN 8 stated Resident 19 had a change in condition due to low blood sugar last month (May). LVN 8 stated he administered NPH Insulin (intermediate acting insulin to treat DM that reaches the blood stream in about 2 to 4 hours) on 6/8/2025 at 6:00 p.m., LVN 8 stated NPH insulin could lower the blood sugar within 4 to 5 hours of administration. LVN 8 stated failure to monitor Resident 19 after the resident was having symptoms of shaking and shivering could have contributed to Resident 19's death. LVN 8 stated he should have checked Resident 19's vital signs, notify the physician who could have ordered a transfer to the hospital for further evaluation, monitor the resident by conducting a COC to ensure Resident 19's condition would not worsen. LVN 8 stated he should have informed LVN 9 and RNS 4 regarding Resident 19's shaking and shivering to keep an eye on Resident 19 on 6/8/2025. During an interview on 6/12/2025, at 8:29 a.m., with RNS 4, RNS 4 stated on 6/8/2025, at 10:30 p.m. Resident 19 was asleep. RNS 4 stated she did not go to Resident 19's room until the resident was found pulseless and not breathing on 6/9/2025 at 4:30 a.m. RNS 4 stated on 6/9/2025, at 4:30 a.m. Resident 19 was pulseless and they were unable to check his vital signs. RNS 4 stated they initiated CPR on Resident 19 and another staff called 911. During an interview on 6/12/2025, at 3:19 p.m. with RNS 2, RNS 2 stated when Resident 19 had shaking and shivering on 6/8/2025 at 11:10 p.m., Resident 19 should have been monitored closely as it was considered a COC. RNS 2 stated a COC should be performed when the condition of a resident deviated from his baseline (an initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes in condition) . RNS 2 stated doing COC was important to ensure monitoring of the change of condition was performed, assessment and evaluation of the resident's condition done, and the physician informed to obtain physician orders for treatment. During an interview on 6/12/2025, at 4:49 p.m. with the Director of Nursing (DON), the DON stated facility staff should checked resident every two hours. The DON stated Resident 19's symptoms of shaking and shivering were considered a change of condition. The DON stated LVN 8 should have done a COC, checked the full set of vital signs, not just the temperature, including blood sugar because Resident 19 received 10 units of NPH insulin on 6/8/2025 at 4:38 p.m., and 2 units of sliding scale Regular insulin at 9:32 p.m. The DON stated LVN 8 should have informed LVN 9 and RNS 4 when Resident 19's had episode of shivering and shaking on 6/8/2025 at 11:10 p.m., during handoff. The DON stated COC was a monitoring tool and not having vital signs documented meant VS were not done. The DON stated the licensed nurse should have done a COC, took a full set of vital signs, rechecked resident's blood sugar, notified the physician, assessed and monitored Resident 19 when he had shivering and shaking. The DON stated Resident 19 should have been monitored and assessed and could have transferred to general acute care hospital (GACH) in a timely manner. The DON stated Resident 19 expired on 6/9/2025, at 5:03 a.m. 3. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including constipation, repeated falls, urinary tract infection (UTI- an infection in the bladder/urinary tract), polyp of the colon (mall clump of cells that forms in the lining of the colon), and major depressive disorder( serious mental illness characterized by persistent sadness, loss of interest in activities, and significant impairment in daily functioning). During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had an intact cognition and required partial/moderate assistance (helper does less than half the effort) with toilet transfer( ability to get on and off a toilet commode), bed mobility, and bathing. The MDS indicated Resident 14 was always incontinent ( having no or insufficient voluntary control ) of stool. During a review of Resident 14's Activities of Daily Living (ADL- activities such as bathing, dressing and toileting a person performs daily) Task for bowel and bladder elimination, the ADL Task indicated Resident 14 did not have a bowel movement (BM-process of emptying the bowels of solid or semisolid feces) on 6/1/2025, 6/2/2025, 6/3/2025 and on 6/7/2025, 6/8/2025, 6/9/2025. During a review of Resident 14's Care Plan titled, Potential Alteration in Bowel Elimination related to Constipation, initiated on 4/26/2025. the Care Plan indicated the goal for Resident 14 to have bowel movement regularly for the next three months. The Care Plan indicated the interventions included monitoring for bowel movement, for amount, consistency and frequency, review medication that cause constipation, and administer medication as ordered. During a review of Resident 14's Physician's Order Summary Report , the Physician's Order Summary Report, dated 5/5/2025 indicated an order of Sertraline (medication used to treat depression) 25 milligrams (mg-. unit of measurement) one tablet at bedtime for depression. During a review of Resident 14's Physician's Order Summary Report, the Physician's Order Summary Report dated 5/5/2025 indicated a physician's order to monitor side effects of anti-depressant (medication used to treat depression) medication such as constipation. During a review of Resident 14's Physician's Order Summary Report, the Physician's Order Summary Report dated 5/23/2025 indicated an order of Bisacodyl ( used to treat constipation) 10 mg Suppository, to insert one suppository rectally ( given via rectum) as needed for constipation if no BM in 24 hours. During a review of Resident 14's Physician's Order Summary Report, the Physician's Order Summary Report indicated an order for 70 percent (%- quantify the amount or concentration of the medicine) Sorbitol solution (used to treat occasional episodes of constipation) 30 milliliter (ml- unit of measurement) every 6 hours as needed for constipation. During an interview on 6/9/2025, at 11:03 a.m. with Resident 14, Resident 14 complained of constipation and stated she did not have a bowel movement for a while. Resident 14 stated she kept telling the staff about her concern (constipation). During an interview on 6/10/2025, at 12:06 p.m. with Certified Nursing Assistant (CNA 5), CNA5 stated if the resident (in general) has no bowel movement for three days, the CNA notifies the charge nurse CNA 5 stated she did not check Resident 14 if the resident had BM for the past few days (6/7/2025, 6/8/2025, 6/9/2025). CNA 5 stated she should have checked if Resident 14 had a bowel movement for the past few days (6/7/2025, 6/8/2025, 6/9/2025). CNA 5 stated Resident 14 would get constipated with the risk to go to the hospital. During a concurrent interview and record review on 6/10/2025 at 3:22 p.m., with LVN 11, Resident 14's MAR and ADL Task for Bowel and Bladder Elimination were reviewed. LVN 11 stated Resident 14 had no bowel movement on 5/28/2025, 5/29/2025, 5/30/2025 and on 6/7/2025, 6/8/2025, 6/9/2025, and 6/10/2025. LVN 11 verified through MAR review that Resident 14 did not receive any as needed (prn) medications for constipation on the days Resident 14 had no BM for 3 days. LVN 11 stated the licensed nurse should have assessed Resident 14 for abdominal pain, asked the resident if she had a bowel movement monitored BM frequency, and administered prn medications for constipation. LVN 11 stated Resident 14 could be at risk for bowel obstruction (occurs when something blocks the normal passage of digested food, and fluids), sepsis ( serious condition in which the body responds improperly to an infection) or infection that could lead to death if constipation was not addressed. During an interview on 6/12/2025, at 3:08 p.m. with RN Supervisor (RNS 2), RNS 2 stated Resident 14 could be at risk for fecal impaction ( a large lump of dry, hard stool that stays stuck in the rectum), bowel obstruction, abdominal discomfort, nausea, vomiting and could increase Resident 14 risk for hospitalization if constipation was not addressed. RNS 2 stated the licensed nurse should have monitored Resident 14's BM frequency and on if there was no BM on the third day, the licensed nurse should have administered the prn medication for constipation as ordered. During an interview on 6/12/2025, at 4:43 p.m. with the DON, the DON stated the LVN (in general) should have monitored Resident 14's BM frequency, informed the physician and administered prn medication for constipation on the third day if the resident had no bowel movement. The DON stated if Resident 14's constipation was not addressed the resident appetite would be affected by the resident would have an abdominal discomfort and vomiting, and possible bowel obstruction. 4. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including dementia ( a progressive state of decline in mental abilities) and dysphagia (difficulty swallowing). During a review of Resident 61's MDS dated [DATE], the MDS indicated Resident 61's cognition was severely impaired and was dependent for toileting, showering, dressing, personal hygiene, and rolling to either side in bed. During a review of Resident 61's Order Summary Report, the Order Summary Report indicated there were a total of seven orders (5/9/2024, 8/12/2024, 10/27/2024, 11/19/2024, 1/11/2025, 4/24/2025, and 5/25/2025) placed for chest X-rays (pictures of the inside of your body) for NG tube placement. During a review of Resident 61's Order Summary Report, the Order Summary Report indicated an order was placed 1/11/2025 and 4/24/2025 for a chest X-ray for NG tube placement with no order to re-insert the NG tube. During a review of Resident 61's COC dated 1/11/2025, timed 10:30 a.m., the COC indicated Resident 61 pulled out her NG tube. No COC for 4/24/2025 for when Resident 61 pulled out her NG tube. During a review of Resident 61's Care Plan title Potential for injury related to pulling out NG tube, the Care Plan indicated there were no revisions made to the care plan after Resident 61 pulled her NG tube out on 5/9/2024, 8/12/2024, 10/27/2024, 11/19/2024, 1/11/2025, 4/24/2025 and 5/25/2025. During an interview on 6/11/2025 at 9:19 a.m., with Certified Nurse Assistant (CNA) 9, CNA 9 stated Resident 61 has mitten restraints (prevents someone from grabbing something) because she tends to pull out her NG tube. During a concurrent interview and record review on 6/12/2025 at 8:29 a.m., the Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 61 pulls her NG tube out at least every three months. LVN 9 stated there should be an order for NG tube re-insertion, a COC documented, and documentation indicating when and which nostril the NG tube was placed. LVN 9 validated there were no orders to re-insert Resident 61's NG tube on 1/11/2025 and 4/24/2025. LVN 9 validated there were no COC documented on 4/24/2025. LVN 9 validated there were no documentation when and where the NG tube was re-inserted on 5/9/2024, 8/12/2024, 10/27/2024, 11/19/2024, 1/11/2025, 4/24/2025, and 5/25/2025. LVN 9 stated there should be a progress note indicating which nostril the NG tube was placed. During an interview on 6/12/2025 at 10:10 a.m., with the Registered Nurse Supervisor (RNS) 2, RNS 2 stated when Resident 61 pulls out her NG tube, there should be an order to re-insert the NG tube, a COC documented, and documentation of which nostril the NG tube was placed. RNS stated it was important to document which nostril the NG tube was placed to better monitor for complications of the affected nostril and to ensure they rotate sites of where the NG tube was placed. During an interview on 6/13/2025 at 9:24 a.m., with the Director of Nursing (DON), the DON stated Resident 61 had removed her NG tube several times and each time there should be an order to re-insert, a COC documented, and documentation of re-insertion and which nostril the NG tube was re-inserted and if not, this was to be considered inaccurate documentation. During a review of the facility's policy and procedure (P&P) titled Nasogastric Tube Insertion and Care, undated, the P&P indicated, Verify that there is a physician's order for insertion of the nasogastric tube. The person performing this procedure should record the following information in the resident's medical records: the date and time the procedure was performed, the size and length of the nasogastric tube, and verification of tube placement. During a review of the facility's P&P titled, Charting and Documentation, undated, the P&P indicated, The following documentation is to be documented in the resident medical record: treatments or services performed, changes in the residents condition, events, incidents, or accidents involving the resident and progress toward or changes in the care plan goals and objectives. 5. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with the diagnoses including malignant neoplasm of prostate (prostate cancer) and cerebral vascular accident (CVA - a stroke, loss of blood flow to a part of the brain). During a review of Resident 39's Medication Administration Record (MAR) for 11/ 2024, the MAR indicated Resident 39 was receiving clopidogrel 75 milligrams (mg- unit of measurement) daily to prevent a stroke During a review of Resident 39's care plan, titled Resident was at risk for bleeding/bruising/skin tear/hematuria (blood in the urine) /melena (blood in the stool) secondary to clopidogrel, the Care Plan interventions included to monitor Resident 39 for bruises or bleeding episodes. The care plan interventions also indicated the physician should be notified accordingly for unusual observation related to clopidogrel. During a review of Resident's 39's Change of Condition Evaluation (COC- a tool used by health care professionals when communicating about critical changes in residents' status) dated 11/9/2024, the COC indicated Resident 39 fell from the wheelchair to the ground. The COC did not indicate Licensed Vocational Nurse (LVN) 10 reported the resident was on clopidogrel to the on-call physician. During an interview on 6/12/2025 at 2:27 p.m., with LVN 10, LVN 10 stated they should have notified Resident 39's physician that Resident 39 was on clopidogrel because of the potential risk for bleeding. LVN 10 stated the physician would have ordered labs and an x-ray (create images of the inside of the body) immediately to see if Resident 55 was bleeding internally had they been notified. LVN 10 stated it was important to notify the doctor of antiplatelets (medications used to prevent blood clots) when a resident falls because of the risk for internal bleeding. During an interview on 6/12/2025 at 1:59 p.m., with Registered Nurse Supervisor (RNS) 3, RNS 3 stated, If a resident falls and the physician just orders to monitor the resident when they are on antiplatelet therapy, the nurse was responsible to take the initiative and notify the physician to recommend an x-ray and evaluation. This resident (Resident 39) should have at least had an x-ray done for possible internal bleeding. During an interview on 6/12/2025 at 5:13 p.m., with the Director of Nursing (DON), the DON stated that notifying the physician of a resident being on blood thinners or antiplatelets after they fall will determine the physician's course of actions and what they would order; it was part of the facility's protocol to accurately report to the doctor. During a review of facility's policy and procedure (P&P)titled, Change in a Resident's Condition, undated, the P&P indicated the facility will promptly notify resident's attending physician and representatives of changes in the resident's medical/ mental condition. The P&P indicated the Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition. During a review of facility's Job Description of a Charge Nurse undated, the Job Description of a Charge Nurse indicated the charge nurse will accurately assess, document, and report the resident's symptoms, reactions, progress to the attending physician ,nursing supervisor , DON, Administrator and other participating in care and treatment of the resident. The Job Description of a Charge Nurse indicated the charge nurse will promptly notify the attending physician and responsible party, family of change in resident's condition and in accordance with the facility's policies and procedures.

Based on observation, interview and record review, the facility failed to ensure residents, who were identified at risk for falls, did not fall and sustain injury for two of three sampled residents (Resident 50 and Resident 89). The facility failed to: 1. Ensure Resident 50's talking device (recordable voice alarm with a personalized message that plays when an alarm is triggered) was turned on as one of the interventions of fall risk prevention program for Resident 50. 2. Ensure the licensed nurses evaluated the effectiveness of interventions of Resident 50's care plan titled, At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls initiated on 12/25/2024, after the resident's fall on 4/19/2025, to develop new interventions to prevent the resident's fall on 5/22/2025 with injuries. 3. Ensure staff followed the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, which indicated, The care team will target interventions that will reduce individual risks related to hazards in the environment including adequate supervision and assistive devices (equipment that can help you perform tasks and activities). 4. Ensure Resident 89, who required supervision at all times, was supervised while smoking on 2/27/2025 at 1:45 p.m., in accordance with the facility's policy and procedure (P&P) titled, Smoking Policy-Residents (undated). 5. Ensure Restorative Nursing assistant (RNA) 1 did not leave Resident 89 unsupervised on 2/27/2025 at 1:45 p.m., when RNA 1 wheeled Resident 89 to designated smoking area in front of the facility. 6. Ensure staff followed Resident 89's Care Plan, titled Resident 89 is at risk for injury related to smoking, dated 9/11/2023, by not leaving Resident 89 unsupervised while smoking. 7. Ensure the spray bottle containing clear liquid was labeled to identify ingredients inside the bottle, affecting one of four medication carts (Medication Cart B2). These failures resulted in: A. Resident 50 falling from a bed to the floor on 5/22/2025 around 7:25 a.m., sustaining a right inferior (lower) pubic ramus (a bone in the pelvis, specifically a thin, flat part of the pubic bone) fracture (broken bone) right superior (above) pubic ramus (a break in the upper part of the pubic bone on the right side of the pelvis) fracture, right sacral (tail bone) fracture, and bilateral rib fractures which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. B. Resident 89 falling from a wheelchair and sustaining a nose fracture small cut on a forehead that was bleeding, bruised ( skin is not broken but is discolored) and swollen. Resident 89 sustained abrasions (superficial wound caused by scraping away of the skin's outer layer) to the forehead and left knee. Resident 89 was transferred to GACH on 2/27/2025 at 3:42 p.m., for further evaluation and treatment of swelling to both eyes. C. Had the potential to result in accidental exposure to or ingestion of isopropyl alcohol. Findings: A. During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), osteoporosis (weak and brittle bones due to a lack of calcium [mineral needed for healthy bones] and Vitamin D {nutrients needed to keep bones healthy}), fractures of left and right humerus (the long bone of the upper arm), repeated falls, and lack of coordination. During a review of Resident 50's Change in Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition) Form dated 12/22/2024 and timed at 2:16 p.m., the COC Form indicated Resident 50 informed the charge nurse (unknown) that she fell in the bathroom the day before (12/21/2024) after getting up unassisted. The COC Form indicated Resident 50 stated she lost her footing, fell on the ground, but was able to get up and went back to her bed on her own without calling for assistance. The COC Form indicated Resident 50 had a hematoma (a solid swelling of clotted blood within the tissues) to her right side of the head. The COC Form indicated Resident 50 was on toileting every two hours and as needed, frequent visual checks and talking device in place and working. During a review of Resident 50's Care Plan titled, At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls initiated on 12/25/2024, the Care Plan goal for Resident 50 was to have decrease in significant injury as a result from falls and to minimize the risk for falls in the next three months. The Care Plan interventions included to apply and check the talking device while in bed and or wheelchair to remind and redirect Resident 50 to call for assistance and to have frequent visual checks. During a review of Resident 50's Interdisciplinary Team (IDT team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Note dated 1/9/2025 timed at 11:14 a.m., the IDT Note indicated on 12/22/2024 around 7:15 a.m., Licensed Vocational Nurse (LVN) 12 observed Resident 50 with a hematoma to the right side of her head. IDT Note indicated Resident 50 stated she fell in the bathroom on 12/21/2024. Resident 50 stated she went to the bathroom unassisted and when she was returning back to bed, she lost her footing, bumped herself ( unknown where) and ended up on the floor. Resident 50 stated she got up and went back to bed. The IDT Note indicated Resident 50 was on fall management program which consist of a talking device to remind and redirect Resident 50 to call for assistance, and a perimeter mattress (type of mattress designed with raised edges or bolsters to prevent falls and provide a safer sleep environment) for extra support. The IDT Note indicated Resident 50 was able to silence or turned off her talking device because she wanted to go to the bathroom by herself. During a review of Resident 50's COC dated 4/19/2025 and timed at 6:30 a.m., the COC indicated Resident 50 was found sitting on the bathroom floor after getting out of bed unassisted and suddenly feeling weak. During a review of Resident 50's IDT Note dated 4/28/2025 timed at 10:25 a.m., the IDT note indicated Resident 50 had an incident on 4/19/2025 around 6 a.m., when Resident 50 was observed sitting on the floor outside the bathroom. The IDT note indicated Resident 50 was assessed with no injury. The IDT note indicated Resident 50 was currently on a toileting schedule and has a talking device to remind and redirect Resident 50 to call for assistance. The IDT note indicated Resident 50 was observed by staff that she can manipulate the talking device. During a review of Resident 50's Minimum Data Set ( MDS-resident assessment tool) dated 5/22/2025, the MDS indicated Resident 50 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and was dependent (helper does all the effort) with toileting hygiene, showering and bathing. During a review of Resident 50's Physician's Order Summary Report, the Physician's Order Summary Report indicated an order to apply and check talking device while in bed and or wheelchair to remind and redirect the resident to call for assistance. During a review of Resident 50's COC dated 5/22/2025 and timed at 7:25 a.m., the COC indicated Resident 50 had an unwitnessed fall and was found lying on the floor. During a review of the facility's Investigation Report, (undated), the Investigation report indicated at the time of the incident (on 5/22/2025), Resident 50's talking device was noted to be disconnected. During a review of Resident 50's COC dated 5/22/2025 and timed at 2:58 p.m., the COC indicated Resident 50 had an open area to her right eyebrow. Registered Nurse Supervisor (RNS) called 911 and Resident 50 was transferred to GACH on 5/22/2025 (unknown time). During a review of Resident 50's GACH's Consultation Notes report dated 5/23/2025, the Consultation Note report indicated Per the facility, Resident 50's bed alarm (talking device) did not alarm, and she got out of bed by herself and fell. The Consultation Note report indicated Resident 50 had a computed tomography scan (CT- a medical imaging procedure that uses x-rays to create detailed, cross-sectional images of the body's internal structures) of the abdomen and pelvis on 5/22/2025. The CT scan indicated Resident 50 had a right inferior pubic ramus fracture, a right superior pubic ramus fracture, a right sacral fracture, and multiple bilateral rib fractures. During a concurrent observation and interview on 6/10/2025 at 8:22 a.m., Resident 50 was observed with a right eye bruise. Resident 50 stated she fell the other day (unable to state exact date). During an interview on 6/11/2025 at 1:46 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 50 had a fall on 5/22/2025 and sustained a fracture. CNA 1 stated Resident 50 was confused and forgot to use her call light. During a concurrent interview and record review on 6/12/2025 at 8:55 a.m., with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 50 was a high fall risk. LVN 9 stated Resident 50's room was close to the nurse's station. LVN 9 stated after each fall, the care plan should be revised to evaluate the effectiveness of interventions to prevent future falls from occurring. Reviewed Resident 50's Care Plan, LVN 9 stated Resident 50's care plan was not revised following her fall on 4/19/2025 and it should have been done because additional interventions could have prevented the resident's fall on 5/22/2025 which resulted in multiple fractures. LVN 9 stated Resident 50's fall was preventable if she had been monitored more closely and had a bedside commode (portable toilet) at her bedside as she gets up without assistance to use the bathroom. During a concurrent interview and record review on 6/12/2025 at 10:10 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 50's Care plan was reviewed. RNS 2 stated Resident 50 was a high risk for fall and recently had a fall on 5/22/2025. RNS 2 stated after a resident falls, the care plan should be revised to add new interventions. RNS 2 stated after Resident 50's fall on 4/19/2025, the care plan was not reviewed and revised. RNS 2 stated it was important to revise the care plan after a fall because the interventions in place were not effective, therefore, a new intervention could be added to prevent future falls. During an interview on 6/13/2025 at 9:24 a.m., with the Director of Nursing (DON), the DON stated a care plan was a guide that outlines the plan of care for the resident. The DON stated the care plan includes goals and interventions and should be revised when interventions were not effective. The DON stated Resident 50's care plan should have been revised after each fall so new interventions could be added to prevent future falls. During an interview on 6/13/2025 at 10:16 a.m., with the Quality Assurance Licensed Vocational Nurse (QA LVN), the QA LVN stated Resident 50 tends to disconnect the talking device. During a review of the facility's P&P titled, Safety and Supervision of Residents undated, the P&P indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Implementing interventions to reduce accident risks and hazards shall include the following: ensuring that interventions are implemented and documenting interventions. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered undated, the P&P indicated, Assessments of residents are ongoing, and care plans are revised as information about the residents and residents' conditions change. C.During a concurrent observation and interview on 6/10/2025 at 9:20 a.m. during medication pass with the Licensed Vocational Nurse (LVN) 1, LVN 1 used a few sprays from an unlabeled spray bottle containing clear liquid to sanitize his hands. LVN 1 stated the spray bottle contained hand sanitizer and they transferred the liquid from the original large container into the smaller spray bottle that was in use at medication cart. LVN 1 showed a large bottle labeled with 70 percent (%) isopropyl alcohol stating that the contents of the unlabeled spray bottle were the same as the large container. During an interview on 6/12/2025 at 12:51 p.m. with the Director of Nursing (DON), the DON stated it was important that the unlabeled spray bottle with clear liquid was labeled to identify its ingredients inside, which was isopropyl alcohol, to prevent any accidental ingestion by facility residents. During a concurrent observation and interview on 6/12/2025 at 12:13 p.m. with the Quality Assurance Licensed Vocational Nurse (QA LVN), observed Medication Cart B2 contained an unlabeled spray bottle. QA LVN stated the facility started receiving the large isopropyl alcohol containers recently and so they had to transfer the liquid into a smaller spray bottle to be stored on medication carts. QA LVN stated it was important to label the small spray bottle to identify that it contained 70% isopropyl alcohol, to maintain safety of facility's staff and residents. QA LVN stated it would be a risk for residents if they just grabbed it and ingested by accident. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated, Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. B. During a review of Resident 89's admission Record, the admission Record indicated, Resident 89 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including repeated falls, nicotine (the additive drug found in tobacco products) dependency, bone density disorder (the bones are weak and more likely to break than normal), osteoarthritis (a degenerative joint disease, in which the tissues in the joint breakdown over time), and muscle wasting (the weakening, shrinking, and loss of muscle tissue). During a review of Resident 89's Care Plan, titled Resident 89 is at risk for injury related to smoking, dated 9/11/2023, the Care Plan indicated the interventions included not to leave Resident 89 alone while smoking, and provide supervision when resident is smoking. During a review of Resident 89's Physician's Order Summary, dated 11/28/2024, the Physician's Order Summary indicated Resident 89 had an order for fall precautions (measures taken to reduce the risk of falling and the likelihood of serious injury if a fall does occur). During a review of Resident 89's Smoking Safety Evaluation, dated 2/13/2025, the Smoking Safety Evaluation indicated, Resident 89 required supervision to smoke safely. During a review of Resident 89's Fall Risk Evaluation, dated 2/13/2025, the Fall Risk Evaluation indicated Resident 89 was at risk for fall. The Fall Risk Evaluation indicated Resident 89 was chairbound (confined to a chair, typically due to illness, injury, or disability) and had a balance problem while standing and walking. During a review of Resident 89's COC Evaluation dated 2/27/2025 timed at 2:27 p.m., the COC indicated that on 2/27/2025 around 2:05 p.m., Resident 89 was found on the ground in front of the facility (designated smoking area). The COC indicated Resident 89 sustained a bump on the forehead with open area. The COC indicated Resident 89 stated that she dropped her cigarettes and wanted to pick it up. The COC indicated Resident 89's physician was informed and ordered to transfer Resident 89 to GACH. During a review of Resident 89's Physician's Order Summary, dated 2/27/2025, the Physician's Order Summary indicated an order to transfer Resident 89 to GACH for further evaluation of the bump on the head after falling. During a record review of Resident 89's GACH's Emergency Department (ED) Notes, dated 2/27/2025, the ED Notes indicated Resident 89 had a bilateral nasal (nose) bone fracture with, moderate soft tissue swelling over the left periorbital (around the eye) and nasal region. The ED Noted indicated a Computerized Topography (CT -medical imaging that create detailed images of the body) of the head was done and CT scan result was bilateral (both) nasal bone fracture with moderate soft tissue swelling over the left periorbital and nasal region. The ED Notes indicated Resident 89 had an abrasion (superficial wound caused by scraping the skin) to the left forehead and mild laceration (a wound where the skin and underlying tissues are torn or cut) which was repaired with Steri-Strips (thin sticky adhesive bandages used to close small, shallow wounds or surgical incisions, often as an alternative to stiches or staples) During a review of Resident 89's Physician's Order Summary, dated 2/27/2025, the Physician's Order Summary indicated to apply Betadine (solution used to treat or prevent skin infection in minor cuts, or scrapes) to the left forehead abrasion topically (to the skin) in the morning. The Physician's Order Summary indicated the following order: 1. Monitor Resident 89's forehead bump with Steri-Strips for increase discoloration, bleeding, drainage, increase swelling, discharges, pain, and signs and symptoms of infection. 2. Cleanse forehead bump with Normal Saline (salt solution used for cleansing wounds), pat dry, apply Steri-Strips, and cover with gauze dressing. 3. Monitor Resident 89's right periorbital purplish discoloration for presence of increase discoloration, open area, bleeding, drainage, increase swelling, discharges, pain, signs and symptoms of infection every shift. 4. Apply Vitamin A&D external ointment (skin protectant and can aid in the healing of minor cuts, cuts, scrapes) to Resident 89's left knee abrasion daily. During a review of Resident 89's Physician's Order Summary, dated 2/28/2025, the Physician's Order Summary indicated an order to monitor Resident 89 nose discoloration and left periorbital area for increase of purplish discoloration, open area, bleeding, drainage, increase swelling, discharges, pain, signs and symptoms of infection every shift. The Physician's Order Summary indicated an order for ice compress to the forehead and facial affected area for 10 to 20 minutes to reduce swelling three times a day. During a review of Resident 89's Minimum Data Set (MDS-resident assessment tool), dated 5/15/2025, the MDS indicated, Resident 89 was dependent on nursing staff for toileting, dressing, and transferring. The MDS indicated Resident 89 needed partial to moderate assistance from nursing staff with walking, standing and sitting. During a review of Resident 89's Physician's Progress Note dated 6/4/2025, the Physician's Progress Note indicated, Resident 89 was able to express needs and make healthcare decisions. During an interview on 6/11/2025 at 2:52 p.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated on 2/27/2025 at 1:45 p.m., RNA 1 wheeled Resident 89 to the designated smoking area in front of the facility. RNA 1 stated she stayed for 10 minutes and supervised Resident 89 while the resident was smoking. RNA 1 stated Resident 89 wanted to stay longer in the designated smoking area to get some fresh air. RNA 1 stated she left Resident 89 alone at the designated smoking area and went back inside the facility to assist another resident with RNA services. RNA 1 stated she asked the Receptionist (RCPT) to call her when Resident 89 was ready to come back inside the facility. RNA 1 stated she heard RCPT responded okay. RNA 1 stated she heard from another staff that Resident 89 fell from his wheelchair while trying to pick up a cigarette from the ground. RNA 1 stated Resident 89 was on the ground and was bleeding from the forehead. RNA 1 stated other staff helped her (RNA 1) to put Resident 89 back on the wheelchair and wheeled Resident 89 back to the facility. RNA 1 stated that she should have not left Resident 89 unsupervised while smoking in the designated smoking area for safety and prevent Resident 89 from falling. RNA 1 stated facility did not have an assigned staff to supervise the smoking area. RNA 1 stated a certified nursing assistant (CNA) assigned to the resident was responsible for supervising the resident while the resident smokes. During an interview on 6/12/2025 at 1:52 p.m., with RCPT, RCPT stated there have been instances when facility staff were supervising residents' while smoking in the designated smoking area and will step out for few minutes and return right away. RCPT stated she does not recall RNA 1 telling her to call her when Resident 89 was ready to come back inside the facility. RCPT stated she saw Resident 89 at the designated smoking area before the fall. RCPT stated she stepped away from the receptionist desk and heard about Resident 89 fall. RCPT stated she no longer supervised residents outside the designated smoking area because she was not at the receptionist's desk continuously. During an interview on 6/12/2025 at 4:04 p.m., with the Director of Nursing (DON), the DON stated if a resident requires supervision during scheduled smoking time, the facility staff should always be at the designated smoking area to supervise residents for safety and prevent fall. The DON stated Resident 89 needed supervision for safety when smoking in the designated smoking area. During a review of the facility's P&P titled, Safety and Supervision of Residents, undated, the P&P indicated the facility strives to make the environment as free from hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled, Smoking Policy-Residents, undated, the P&P indicated any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on interview, and record review, the facility failed to prevent the resident's unplanned severe weight loss (a weight loss greater than 5 % in one month, greater that 7.5% in three months and greater than 10 % in 6 months) of nine (9) pounds ([lbs.] 9.57 percent [%] in one month for one of two sampled residents (Resident 129). The facility failed to: 1. Ensure the Registered Dietician's ([RD] a health professional who has a special training in diet and nutrition) recommendation to increase Resident 129's enteral (form of nutrition that is delivered into the digestive system as liquid) feeding from 250 milliliter ([ml] unit of measurement) four times per day to 250 ml five times per day totaling 1500 calories ([kCal] energy people get from the food and drink they consume, and the energy they use in physical activity) were followed and provided. 2.Ensure staff monitored Resident 129's weight and reported the resident's five pounds weigh loss to Resident 129's physician and RD in accordance with the care plan titled Risk for Malnutrition (lack of significant nutrients [substance used in the body to function] leading to physical decline). 3. Ensure the facility's staff informed the RD when Resident 129 had a 9.57 % weight loss from 4/29/2024 through 6/1/2024 for RD to evaluate and make necessary recommendations on Resident 129's enteral feeding formula to provide Resident 129 with a sufficient amount of calories and nutrients to prevent Resident 129's severe weight loss of 9.57 % in 34 days in accordance with the facility's policy and procedure (P&P) titled, Nutrition (Impaired/Unplanned Weight Loss-Clinical Protocol. 4. Ensure licensed staff followed facility's P&P titled, Weight Assessment and Intervention and immediately notified the Dietician in writing of Resident 129's weight loss of 5% or more since the last weight assessment on 4/29/2024. 5. Ensure the RD completed Resident 129's full nutritional assessment upon admission to the facility on [DATE] and monitor Resident 129's weight and caloric intake, who was receiving tube feeding nutrition, and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of tube feedings per facility's P & P. These deficient practiced resulted in Resident 129's severe weight loss of 9.57 % in 34 days and placed Resident 129 at risk for malnutrition, dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake), skin break down, having feelings of depression and hopelessness. Findings: During a review of Resident 129's Admission Record, indicated Resident 129 was admitted to the facility on [DATE], with diagnoses including amyotrophic lateral sclerosis ( a nervous system disease that affects nerve cells in the brain and spinal cord), dysphagia (difficulty of swallowing), gastrostomy tube ([GT] a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition), deep tissue injury ([DTI] purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) to a sacral (tailbone) area, and muscle wasting (loss of muscle tissue). During a review of Resident 129's History and Physical (H&P), dated 4/28/2024, the H&P indicated, Resident 129 did not have decision making capacity. During a review of Resident 129's Minimum Data Set ([MDS], a standardized assessment and care screening tool]) dated 5/1/2024, the MDS indicated Resident 129 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident 129 height was five feet (unit of measurement) and three inches (unit of measurement) and weighed 94 pounds ([lbs.] unit of weight). The MDS indicated Resident 129 was receiving nutrition via GT. During a review of Resident 129's Weights and Vitals Summary from 4/29/2024 to 6/1/2024, the Weights and Vitals Summary indicated the following resident's weekly weight: 1. On 4/29/2024 - 94 pounds. 2. On 5/5/2024- 93.4 pounds. 3. On 5/12/2024- 87 pounds (7.0 pounds [7.45%] weight loss). 4. On 5/19/2024- 87.4 pounds (6.6 pounds [7.02%] weight loss). 5. On 5/26/2024- 85.4 pounds (8.6 pounds [9.15 %] weight loss). 6. On 6/1/2024- 85 pounds (9.0 pounds [9.57 %] weight loss). During an interview on 6/12/2024 at 10:30 a.m., the License Vocational Nurse (LVN 5) stated when Resident 129 had a weight loss of nine (9) pounds from 4/29/2024 to 6/1/2024, a change of condition (COC) documentation should have been done, Resident 129's physician and RD should have been informed and an Interdisciplinary team ([IDT]- group of healthcare professional s working together to plan the care needed for each residents) meeting should be held immediately in order to address the resident's weight loss and recommend interventions to prevent further resident's weight loss. LVN 5 stated Resident 129 was getting weighed weekly due to a weight loss. LVN 5 stated she did not report Resident 129's severe weight loss of 9 pounds (9.57 %) to RD and the physician. LVN 5 stated severe weight loss should be reported immediately to Resident 129's physician and RD because Resident 129 could lose more weight that can lead to hospitalization due to malnutrition. During a review of Resident 129's care plan titled, Risk for Malnutrition, dated 4/28/2024 indicated a goal for Resident 129 was not to have significant weight loss of five lbs. in one month (5 % in one month, 7.5 % in 3 months, 10 % in 6 months). The care plan interventions included to monitor the resident's weight and report five lbs. weight loss to the physician and RD promptly and notify the physician of significant weight change and refer to dietician. During a review of Resident 129's Care Plan titled GT feeding, dated 4/28/2024 indicated a goal for Resident 129 was to maintain adequate nutrition and hydration (fluid intake) status and to have a stable weight with no signs and symptoms of malnutrition or dehydration. During a review of RD's Nutrition/Dietary Progress Note dated 4/28/2024 and timed at 6:55 p.m., the Nutrition/Dietary Progress Note indicated Resident 129 was receiving 250 ml of enteral feeding with formula Fibersource 1.2 four times daily. Resident 129 body mass index ([BMI] measure body weight to height and whether a resident has a healthy weight) was 17.9 (BMI between 18.5 and 24.9 -underweight, BMI healthy range -between 25 and 29.9, and BMI between 30 and 39.9- overweight). The RD's Nutrition/Dietary Progress Note indicated RD's recommendation to change GT enteral feeding formula to 250 ml five times a day to provide Resident 129 with 1250 ml (1500 kcal) daily. The RD's Nutrition/Dietary Progress Note indicated the RD's full assessment of Resident 129 nutritional needs will follow. During a review of Resident 129's Nutritional Review Screening, dated 4/29/2024 completed by Dietary Supervisor (DS) indicated based on Resident 129's usual body weight (UBW) of 115 lbs. the resident's estimated daily need for calories were 1495-1709 kcal. The Nutritional Review Screening indicated recommendation including change enteral feeding to 250 ml five times daily to provide 1250 ml equal to 1500 kcal, 67 grams of protein, 1512 ml of free water (fluids with no salt content), and Multivitamins (dietary supplement containing all or most of the vitamins) with Minerals. During a review of Resident 129's Medication Administration Record (MAR) dated 5/2024, the MAR indicated the Enteral Feeding Order for Fibersource HN 1.2 four times a day as follows: 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). During a review of Resident 129's Physician Order Summary dated 5/2024, indicated Enteral Feeding Order for Fibersource HN 1.2 four times a day as follows: 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). During a review of Resident 129's MAR for the month 5/2024 indicated Resident 129 only received 250 ml of Fibersource for lunch instead of 500 ml as ordered: 1. From 5/3/2024 to 5/13/2024 (10 days) - Fibersource 250 ml. 2. On 5/14/2024- Fibersource 300 ml. 3. From 5/18/2024 to 5/20/2024 (there days)- Fibersource 250 ml. 4. On 5/27/2024- Fibersource 250 ml. During a concurrent interview and record review on 6/12/2024 at 11:05 a.m., the Director of Nursing (DON) stated residents (in general) with weight loss will trigger for weekly weight variance review (report generated to determine how much weight a resident has lost and recommendations to prevent further weight loss) and a weekly weight variance meeting to discuss the plan of care for a residents (in general). The DON stated Resident 129 was triggered for a weight variance weekly review meetings because the resident was at high risk for weight loss. The DON stated weekly weight variance meeting allows the facility to monitor Resident 129's weight and allows the facility to ensure that implemented interventions were successful. The DON stated weekly weight variance meeting also allows to evaluate if other interventions could be implemented to prevent further weight loss. The DON stated the weekly weight variance meetings were documented on the Progress Notes by nursing and the RD. After a review of Resident 129's Nurses Progress Notes and RD Progress Notes the DON stated, there was no documentation from nursing and the RD for the weekly variance meetings to address the resident's weight loss. The DON stated, if there was no documentation it means it was not done. After the DON reviewed Resident 129's Initial Nutritional Assessment, the DON confirmed the last documentation from the RD was the initial mini nutritional assessment (nutrition screening and assessment tool that can identify residents who are malnourished or at risk of malnutrition) done on 4/29/2024. The DON stated 9.57 % weight loss was considered a severe weight loss and required weekly monitoring by the facility. The DON stated the RD should have monitor Resident 129 to ensure the resident did not lose additional weight. The DON stated the staff communicates with the RD via text message regarding the weekly weight variance meetings. The DON stated it was the licensed nurses responsibility to ensure Resident 129's weight loss was communicated to the resident's physician and RD in order to prevent negative outcomes such as severe weight loss and dehydration. The DON stated when residents (in general) do not receive adequate nutrition they could have negative effects such as skin break down and malnutrition. During a concurrent interview and record review on 6/12/2024 at 1:30 p.m. with RD, the RD stated she was responsible for nutritional assessments of residents on admission and quarterly assessment which includes evaluating and addressing residents' (in general) high risk for weight loss. RD stated residents (in general) who were on GT feedings should be weighed weekly and a weekly variance meeting should be held to discuss interventions to prevent weight loss. The RD stated she does not attend the weight variance meeting; the licensed staff communicates with her via text message about any weight loss and other concerns discussed during the weight variance meeting. The RD stated she follows up with residents (in general) that have weight loss weekly. The RD stated she has done Resident 129's mini nutritional assessment on 4/29/2024 and a full assessment of Resident 129 nutritional status and needs should have been done as well. The RD confirmed that Resident 129's full assessment had not been done since the resident's admission to the facility on [DATE]. After RD reviewed her weekly progress notes, for Resident 129, she stated there was no weekly documentation for Resident 129's weight loss. Resident 129's Nutrition/Dietary Progress, dated 4/28/2024, indicated recommendation to change GT feeding to 250 ml five times daily to provide 1250 ml equivalent of 1500 kcal. with full assessment to follow. Reviewed Resident 129's MAR date 5/2024, the MAR indicated Enteral Feed Order four times a day Fibersource HN 1.2 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). The RD stated Resident 129's enteral feeding order for 250 ml four times a day was not providing enough calories to Resident 129 and confirmed the facility's staff did not follow with her recommendation to increase the feeding to 250 ml five times a day. The RD stated Resident 129 did not receive the estimated needs of 1511 to 1727 kcal a day. The RD stated 9.57 % weight loss in 34 days was considered a severe weight loss and the facility's staff should have reported it immediately to Resident 129's physician and her. The RD stated Resident 129 could have become malnourished which would cause further skin breakdown from not receiving enough calories and protein per day. During a concurrent interview and record review on 6/12/2024 at 2:09 p.m., with LVN 1, LVN 1 stated during weekly weight variance meetings residents (in general) weight loss was discussed. LVN 1 stated any recommendations from the weekly weight variance meetings were communicated to the RD via text message and documented on the Nurses Progress Notes. LVN 1 reviewed Resident 129's Nurses Progress Notes and stated there was no documentation RD was notified about Resident 129's severe weight loss. LVN 1 confirmed that there was no documentation for Resident 129's weekly weight variance meeting and it was not held since Resident 129's admission on 4/27/2024. LVN 1 stated if it was not documented it means it was not done. LVN 1 stated 9.57 % weight loss in 34 days was considered a severe and had the potential to cause a negative outcome for Resident 129's health. During an interview on 6/12/2024 at 2:23 p.m., the Dietary Supervisor (DS) stated she attends the weekly weight variance meetings. The DS stated she communicates with RD on Mondays regarding the weekly weight variance meeting. The DS stated there was no weight variance meeting held for Resident 129's severe weight loss of 9.57 % in 34 days from 4/27/2024 to 6/1/2024. The DS stated it was important to monitor Resident 129's weight to ensure that the interventions were effective in order to prevent further weight loss. The DS stated Resident 129's severe weight loss put the resident at risk for dehydration, malnutrition, skin breakdown and hospitalization . The DS stated nursing staff document the weekly weight variance meetings in a resident's (in general) Progress Notes. The DS stated 9.57% of weight loss in 34 days was considered a severe weight loss. During a review of the facility's P&P titled, Weight Assessment and Intervention dated 9/2008, indicated, Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will review the unit weight record by the 15th of the month for follow individual weight trends over time. During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, The dietician with input from the provider and nurses: estimate calorie, protein, nutrients, and fluid needs. Determine whether the resident's current intake is adequate to meet his or her nutritional needs. The dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of enteral feedings. During a review of the facility's P&P titled, Nutritional Assessment, [undated], indicated, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that place the resident at risk for impaired nutrition. During a review of the facility's P&P titled, Nutrition Impaired/Unplanned Weight Loss-Clinical Protocol, [undated], indicated, The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include evaluating the care plan to determine if the interventions are being implement and whether they are effective in attaining the established nutritional and weight goals.

Based on observation, interview and record review, the facility failed to ensure the resident, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to sacrum (tailbone area), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning for one of five sampled residents (Resident 73). The facility failed to: 1. Ensure the Registered Nurse (RN 6) provided Resident 73 with effective pain relieve when Resident 73 loudly screamed and moaned during the sacral pressure ulcer treatment. 2. Evaluate the pain relieve effectiveness of Tylenol (pain medication) 325 milligrams ([mg]-a unit of measurement) two tablets given to Resident 73's as ordered prior to pressure ulcer treatment before the start of pressure ulcer treatment. 3. Notify Resident 73's physician (MD 1) of Resident 73's pain management with Tylenol was unsuccessful when Resident 73 continue to moan and scream during the pressure ulcer treatment on 6/10/2024 and 6/13/2024. 4. Ensure RN 6 identified frequency, location, quality, onset, and manner of pain when Resident 73's experienced pain, in accordance with the resident's Care Plan titled, Potential for altered comfort which maybe evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacral area, bilateral knee osteoarthritis (degenerative joint disease) and pancreatic mass (tumor that forms in the cells of pancreas) dated 4/20/2023. These failures resulted in Resident 73's to experience severe, unrelieved, and uncontrolled pain manifested by loud screaming and moaning during pressure ulcer treatment and personal care on 6/10/2024 and 6/13/2024. Findings: During an observation and concurrent interview on 6/10/2024, at 10:09 a.m., Resident 73 was observed screaming, groaning, and moaning with facial grimaces (facial expression usually suggesting pain or disgust). Concurrently, during an interview, Resident 73 nodded the head Yes and grimaced when asked if she was having pain. During an interview on 6/10/2024, at 10:09 a.m. with Resident 62 (Resident 73's roommate) Resident 62 stated Resident 73 was constantly groaning and moaning especially when staff was cleaning or doing personal care. Resident 62 stated staff members were aware of Resident 73's moaning and screaming. During an observation of RN 6 preparation for Resident 73's sacral pressure ulcer treatment on 6/10/2024, at 10:30 a.m., in Resident 73's room, Resident 73's physician (MD 1) entered the resident 's room and informed RN 6 he (MD 1) will put an order for Norco (narcotic [used to treat moderate to severe pain] pain medication) to administer prior to pressure ulcer treatment as Resident 73 was observed moaning and screaming. RN 6 replied to MD 1 that Resident 73 does not need Norco as Resident 73 will receive Lidocaine spray (anesthetic topical [applied to the skin] spray) prior to the pressure ulcer treatment. During an observation Resident 73's pressure ulcer treatment on 6/10/2024, at 10:32 a.m., Resident 73 was observed screaming and moaning when RN 6 positioned Resident 73 on her back with head of the bed in a flat position. RN 6 left Resident 73's room and ask another staff member to assist during pressure ulcer treatment. RN 6 came back with the Director of Staff Development (DSD). RN 6 and DSD turned Resident 73 to her right side. Resident 73 continuously moaned and screamed. RN 6 was observed to spray Resident 73's sacral Stage 4 pressure ulcer surrounding area with Lidocaine spray before the start of treatment. Resident 73 screamed and moaned louder when RN 6 cleaned the reddened surrounding area of Stage 4 sacral pressure ulcer with Hibiclens (liquid antibacterial cleanser) and applied Collagen powder (wound dressing that is applied topically) to the pressure ulcer. RN 6 completed the pressure ulcer treatment despite Resident 73's moaning and screaming. During a review of Resident 73's Admission Record, the Admission Record indicated Resident 73 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), osteoarthritis of both knee (degenerative joint disease), a Stage 4 pressure ulcer to the sacral region, and attention/ concentration deficit. During a review of Resident 73's History and Physical (H& P) dated 5/9/2024, indicated Resident 73 was not able to express needs, communicate, not to follow commands and talked in full sentences. Resident 73 had no decisions making capacity. During a review of Resident 73's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 5/1/2024, indicated Resident 73 was dependent on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 73 had a Stage 4 pressure ulcer on the sacrum (sacral area). During a review of Resident 73's Physician's Order dated 6/10/2024, the Physician's Order indicated the order for Lidocaine spray to apply to the resident's sacral area topically every day for pain management during sacral pressure ulcer treatment. During a review of Resident 73's Physician Order dated 4/20/2024, the Physician order indicated to cleanse sacral wound with Hibiclens, pat dry, apply Collagen powder to the pressure ulcer base then apply Hydrofera Blue (special dressing type) then cover with Allevyn (dressing) every day (7 a.m.to 3 p.m.) Monday, Wednesday, and Friday. During an interview on 6/10/2024, at 10:45 a.m., and subsequent interview on 6/10/2024, at 11:22 am., with RN 6, RN 6 stated the Lidocaine spray was the only medicine he used to help with Resident 73's pain during pressure ulcer treatment. During a concurrent interview and record review on 6/12/2024 at 9:36 a.m., with DSD, the DSD stated for residents, who are not able to verbalize pain, the facility was using the facial pain scale tool (a picture with of different facial expressions referencing different pain level to help a resident effectively communicate the severity of their physical pain) to assess pain level. The DSD stated Resident 73 screamed loudly when RN 6 cleansed Resident 73's pressure ulcer with Hibiclens and when the Collagen powder was applied to the resident's Stage 4 sacral pressure ulcer. The DSD stated when Resident 73 screamed loudly during the pressure ulcer treatment, RN 6 should have stopped the treatment, assessed Resident 73 pain level, including the non-verbal cues like facial grimacing, notified the physician, and provide Resident 73 pain medication. The DSD reviewed Resident 73's Medication Administration Record (MAR) and stated Resident 73 received Tylenol 325 mg two tablets on 6/10/2024, at 10:07 a.m., prior to pressure ulcer treatment for pain level 3 out of 10 on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). The DSD stated based on Resident 73 screaming and moaning during sacral pressure ulcer treatment Tylenol given at 10:07 a.m. was not effective to alleviate Resident 73's pain. The DSD stated Resident 73 experienced excruciating (extremely painful, causing intense suffering) pain and discomfort during the pressure ulcer treatment which was unnecessary pain. The DSD stated RN 6 should have asked the physician for a stronger pain medication after the resident screamed during sacral pressure ulcer treatment on 6/10/2024. During an interview on 6/12/2024, at 3:31 p.m., with Treatment Nurse (TN 1), the TN 1 stated she coordinated Resident 73's pressure ulcer treatment with the charge nurse in order to give pain medication to the resident before pressure ulcer treatment. TN 1 stated for residents, who could not verbalize pain and its severity, the staff used non-verbal indication of pain like screaming, moaning, or crying, and facial grimace. TN 1 stated Resident 73 screamed and moaned during pressure ulcer treatment, and it was an indication the resident was in excruciating pain. TN 1 stated Lidocaine spray was used topically and only applied on the skin and would not be enough to help with the pain during treatment. TN 1 stated if the resident screamed and moaned during pressure ulcer treatment RN 6 should have stopped the treatment, call the physician because the Lidocaine spray was not effective in managing Resident 73's pain. TN 1 stated Resident 73 should be assessed for pain before and during pressure ulcer treatment. TN 1 stated Resident 73's unrelieved pain could affect her health and comfort if her pain was not managed effectively. During an interview and record review on 6/12/2024 at 4:08 p.m., RN 6 stated when Resident 73 screamed from pain during the pressure ulcer treatment, he should stopped the treatment and notified the Resident 73's MD 1. RN 6 stated on 6/10/2024, MD 1 came to the resident's room and told him (RN 6) about ordering Norco for pain because of the moaning and crying, and confirmed he told MD 1 Resident 73 did not need Norco because the Lidocaine spray was being applied to the pressure ulcer. RN 6 stated Resident 73's family did not want the resident to have any strong pain medication. RN 6 confirmed thru record review of Interdisciplinary Team Meeting ([IDT]-a healthcare team members and resident / family representative collaborate, solve problems, plan, and coordinate care of the resident) Notes and Care Plan there was no documentation of Resident 73's family not wanting strong pain medication to be given to Resident 73 during pressure ulcer treatment. RN 6 stated Resident 73 was suffering from pain during a sacral pressure ulcer treatment manifested by the resident's screaming and moaning. RN 6 stated Resident 73 continued to suffer from pain because her pain was not addressed and managed during the pressure ulcer treatment on 6/10/2024. RN 6 stated Tylenol's pain relieve effectiveness was not evaluated prior to begin the treatment. During an observation on 6/13/2024, at 10:54 a.m., with TN 1 and Certified Nursing Assistant (CNA 5) in Resident 73's room, Resident 73 was observed starting moaning during repositioning. Resident 73 observed moaned louder as the TN 1 started to clean the surrounding skin area of the sacral pressure ulcer and applying the Collagen powder on the pressure ulcer. TN 1 observed to pause the pressure ulcer treatment and started reassuring the resident and massaging the resident's skin. TN 1 was observed to resume the treatment when Resident 73 stopped moaning. During an interview on 6/13/2024, at 12:45 p.m. the TN 1 stated Resident 73 moaned during pressure ulcer treatment due to pain. TN 1 stated the resident had dementia and it was hard to tell when the resident was in pain, but the presence of pain should still be addressed by staff by using the resident's facial clues, grimacing, moaning and jerky movement during treatment. During an interview on 6/13/2024, 2:04 p.m., CNA 5 stated every time she would clean and change Resident 73 after a bowel movement, the resident would moan and cry. CNA 5 stated Resident 73 would also moan during pressure ulcer treatment. During a review of Resident 73's Care Plan titled Potential for altered comfort evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacrum, bilateral knee osteoarthritis and pancreatic mass (tumor that forms in the cells of pancreas), dated 4/20/2023, the goal for Resident 73 was to be comfortable. The Care Plan's interventions included to identify frequency, location, quality, onset, and manner of expressed pain and administer medication as ordered. During a review of Resident 73's Care Plan titled, Resident has a Stage 4 sacral pressure ulcer on admission, initiated on 10/30/2023 indicated one of the interventions was to assess pain and discomfort at site of the altered skin area. During a concurrent interview and record review of Resident 73's Physician Order on 6/13/2024, at 3:31 p.m. with Director of Nursing (DON), the DON confirmed the physician order for Tylenol 325 mg two tablets for pain relief did not include the pain parameters, however, Resident 73 had an order to monitor the intensity of pain using numerical pain rating scale. The DON stated pain level was not assessed properly and Resident 73's pain was not managed effectively during pressure ulcer treatment. The DON stated Resident 73 should be assessed for pain during and after pressure ulcer treatment. The DON stated if the resident was experiencing pain by screaming and moaning, the pressure ulcer treatment should be stop, the staff should have assessed the resident for pain, addressed the pain if pain was present, called Resident 73's physician to notify about the presence of pain. The DON stated Resident 73 had experienced undue suffering which could have been prevented if the resident was assessed properly for pain management. During a review of facility's policy and procedure (P&P) titled Pain Assessment and Management, undated, the P&P indicated to observe the resident during rest and movement for physiologic and behavioral (non-verbal) signs of pain. The P& P indicated possible behavioral signs of pain are verbal expressions such as groaning, crying, screaming, facial expressions such as grimacing, frowning, behavior such as resisting care, irritability, or depression. The P&P indicated to review resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatment like wound care or dressing changes. During a review of facility's P&P titled Pressure Ulcer Treatment, undated, the P&P indicated to review the resident's care plan to assess for any special needs of the resident. The P&P indicated for residents who had a Stage 4 Pressure Injury one of the guidelines was to manage pain during wound care. According to a review the article titled The Symptoms of Pain with Pressure Ulcer: A Review of the Literature, dated 5/2008 on website for Wound Care Leading Management and Prevention, pain is an issue in persons with pressure ulcers, measuring and managing pain will become more important for effective care with an aging population at risk for pressure ulcer development. https://www.hmpgloballearningnetwork.com/site/wmp/content/the-symptom-pain-with-pressure-ulcers-a-review-literature

Based on interview, and record review, the facility failed to ensure a resident was placed securely in the sling (part of a lift system placed under and around patients who have mobility issues to assist them to be lifted and transferred safely from a bed, wheelchair, toilet, or shower) for a mechanical lift (a device used to ensure the safe transfer of patients from one location to another), prior to being transferred from a bed to a wheelchair, for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling from the mechanical lift onto his bed and sustaining a fracture (partial or complete break in the bone) of his clavicle (the collar bone) and his rib (chest bone). Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation, treatment, and a Computed Tomography scan ([CT scan] a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) of his head. Findings: During a review of Resident 1's Admission Record (Face sheet), the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The Face Sheet indicated, Resident 1 had diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction (a stroke) affecting the left dominant side of Resident 1's body, epileptic seizures (a disorder of the brain causing uncontrolled electrical activity in the brain, which may produce a physical convulsion, thought disturbances, or a combination of symptoms and a nontraumatic intracranial hemorrhage (bleeding into the brain in the absence of trauma or surgery). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/29/2023, the MDS indicated, Resident 1's cognition (thinking, attention, language, learning, memory, and perception) was intact. The MDS indicated, Resident 1 required extensive one-person physical assist for bed mobility. Resident 1 was totally dependent and required a two-person physical assist for transfers and toilet use. During a review of Resident 1's Care Plan, dated 4/5/2022, the Care Plan indicated Resident 1 had an activity of daily living ([ADL] activities related to personal care) self-care performance deficit related to hemiplegia and hemiparesis. The goals indicated, Resident 1 would improve his functional abilities with less support from staff while maintaining comfort and safety. The Care Plan interventions indicated, Resident 1 required assistance and may use a mechanical lift for transfers. During a review of Resident 1's Nursing Progress Notes, dated 6/13/2023, timed at 5:15 p.m., the Progress Notes indicated, at approximately 12:30 p.m., Resident 1 was found on the floor with his head on the lap of Certified Nurse Assistant (CNA) 1. The Progress Notes indicated CNA 1 reported that Resident 1 had an assisted fall while being transferred from his bed to his wheelchair using a mechanical lift. The Progress Notes indicated Resident 1 had a bump on his left forehead and Resident 1 reported he hit his head but stated he did not remember where he hit his head. The Progress Notes indicated Resident 1's physician was called, and an order was obtained to transfer Resident 1 to a GACH for further evaluation and a CT scan of Resident 1's head. During a review of Resident 1's Situation, Background, Assessment, & Recommendation ([SBAR] a form of communication between members of a health care team) dated 6/13/2023 and timed at 1:14 p.m., the SBAR indicated, Resident 1's left upper extremity was sensitive to touch, he was unable to move, and he had a left forehead bump with discoloration and slight bleeding at the site that was sensitive to touch. During a review of Resident 1's Physician Orders, dated 6/13/2023, the Physician's Orders indicated, to transfer Resident 1 to a GACH emergency room (ER) for further evaluation after Resident 1 fell and sustained a head injury. During a review of Resident 1's Nursing Progress notes, dated 6/13/2023, at 6:29 p.m., the Nursing Progress notes indicated, Resident 1was picked up by an ambulance and transported to the GACH. During a review of the GACH's CT report of Resident 1's chest dated 6/13/2023, and timed at 8:01 p.m., the CT indicated, Resident 1 had a nondisplaced (a fracture in which the bone cracks or breaks but retains its proper alignment) left sixth posterior (direction toward the back of the body) rib fracture. During a review of the GACH's X-ray of Resident 1's left shoulder, dated 6/13/2023, and timed at 9:56 p.m., the X-ray indicated, Resident 1 had an anterior (front) subluxation (dislocation) of the left humeral head (shoulder) and a nondisplaced fracture of the distal (away from the trunk of the body) left clavicle (collar bone). During a review of the GACH's Emergency Department (ED) Physician Notes, dated 6/13/2023 and timed at 10:36 p.m., the ED notes indicated, Resident 1 had a shoulder reduction (the process of returning the shoulder to its normal position following a shoulder dislocation) and Resident 1's left shoulder was placed in a sling (a device that keeps the arm against the body and prevents too much movement). During an observation on 10/24/2023, at 12:38 p.m., CNA 1 prepared to transfer Resident 2 using a mechanical lift. CNA 1 quickly attached each hook on the mechanical lift to the sling that was under Resident 2. CNA 1 got assistance from another CNA (CNA 2) but CNA 1 nor CNA 2 did not check to ensure all hooks were safely connected and secured to the mechanical lift prior to transferring Resident 2 from his bed. During an interview on 10/24/2023, at 1:09 p.m., CNA 1 stated, there should be two people assisting while using a mechanical lift at all times. CNA 1 stated, regarding the fall incident on 6/13/2023, she looked for assistance to transfer Resident 1, but everyone was busy, and Resident 1 told her to hurry up because his family was visiting so she transferred Resident 1 using the mechanical lift alone without assistance from another staff member. CNA 1 stated, she put the sling under Resident 1's body and placed the hooks from the mechanical lift into the sling's openings. Resident 1 held onto the bar on the mechanical lift with his right hand while she lifted him using the mechanical lift. CNA 1 stated, one of the hooks on the upper left side of the sling came off and Resident 1 fell on top of the upper left side of his bed. CNA 1 stated Resident 1's legs were still in the sling and hanging from the mechanical lift and he was at an angle diagonally across his bed. CNA 1 stated she lowered the mechanical lift and Resident 1 fell on to the bed with his body slightly raised in the air while still attached to the sling that was still attached to the mechanical lift. Resident 1's right foot was hanging off the bed touching the ground and his left leg was on the bed. CNA 1 stated Resident 1 was holding onto her and would not let her go. Resident 1 was too heavy, and she had to lower Resident 1 onto the floor. CNA 1 stated she used the mechanical lift alone, because everyone was busy, and she felt confident enough to transfer Resident 1 on her own. CNA 1 stated it was important to use two people to assist when using the mechanical lift to keep the resident safe. CNA 1 stated she was instructed during in-services that two people were to always be present and assist when using a mechanical lift. During an interview on 10/24/2023, at 2:50 p.m., LVN 1 stated, CNA 1 reported to her that Resident 1 fell , she (LVN 1) went to Resident 1's room where she saw Resident 1 on the floor next to his bed. LVN 1 stated she assessed Resident 1 and noted a bump on the left side of Resident 1's head. During an interview on 10/24/2023, at 3:01 p.m., Registered Nurse Supervisor (RNS) 1 stated, two people were needed to transfer a patient using a mechanical lift. RNS 1 stated, CNA 1 reported that she was transferring Resident 1 from his bed to his wheelchair when Resident 1 slipped from the mechanical lift. RNS 1 stated when she entered Resident 1's room, CNA 1 was holding Resident 1's head in her lap and CNA 1 told her that she (CNA 1) caught Resident 1 when Resident 1 slipped from the mechanical lift. RNS 1 stated she assessed Resident 1 and found a bump on Resident 1's left forehead During an interview on 10/24/2023, at 3:37 p.m., the Director of Staff Development (DSD) stated, if a resident could only use one side of his body, then two people should assist when using a mechanical lift. The DSD stated Resident 1 required two people to transfer him using a mechanical lift because Resident 1 had left sided weakness and Resident 1's right side might not be strong enough to hold onto the mechanical lift. The DSD stated this injury was avoidable if the policy and procedure had been followed. The DSD stated, staff should make sure the sling is safely secured on the hooks of the mechanical lift, the second person provides a second check for safety and supports the upper back of the resident during the transfer. The DSD stated if everyone was busy, CNA 1 should have waited until someone came to assist before transferring Resident 1 by herself. During an interview on 10/25/2023, at 4:39 p.m., Director of Nursing (DON) 2 stated, it was reported to her that Resident 1 slipped from a mechanical lift, complained of chest pain, and was transferred to a GACH for a CT scan. DON 2 stated the hooks of the mechanical lift that go into the sling should have been checked to make sure the hooks were secured properly, and CNA 1 must have missed a step when using the mechanical lift. DON 2 stated the importance of using two people and checking that the hooks were secured properly was to prevent an accident such as a fall from the mechanical lift. During a review of the facility's Policy and Procedure (P/P), Lifting Machine, using a Portable revised 4/2007, the P/P indicated the portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two nursing assistants will be required to perform the procedure.

Based on observation, interview and record review, the facility failed to adhere to the plan of care and provide adequate supervision and the use of an assistive to prevent falls for one of three sampled residents (Resident 1). Resident 1, who was assessed as a high risk for falls and required close monitoring and the use of an alarm to prevent falls was left unattended in the bathroom and fell sustaining injuries. This deficient practice resulted in Resident 1 falling while in the bathroom unattended and sustained a non-displaced fracture (broken bone) to the cervical spine (bones of the neck), laceration (skin cut) to the left cheek (face) and left upper eye that required a 911 transfer to the hospital for wound closure, evaluation and treatment. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of a Fall Risk assessment, dated 1/17/17, indicated the Resident 1 was assessed as a high risk for fall, had problems balancing while standing and walking, decreased muscular coordination, jerking with an unstable gait when making turns and required the use of an assistive device while walking. A review of Resident 1's plan of care titled, High Risk for fall, dated 1/18/17, the listed staff interventions included to apply a tab alarm (a pressure alarm placed under specific body areas to detect movement to prevent falls) while the resident was in the toilet and to monitor the resident's whereabouts at all time. A review of Resident 1's Quarterly Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 5/2/17, indicated the resident required extensive assistance with transferring, toileting, bed mobility, dressing, and hygiene. During an interview on 7/28/17 at 12:10 p.m., Resident 1 stated she fell in bathroom after attempting to stand from the commode and did not call for the staff's assistance. The resident stated as a result of the fall she has to wear a neck collar (used to stabilize a neck fracture) due to the fall. A review of the facility's undated investigation report indicated on 7/14/17 at approximately 4:30 p.m., the resident was assisted to the toilet and CNA1 left the resident unattended with the door ajar. CNA 1 was assisting another resident in the adjacent room when she heard a banging noise and went and found the resident on the floor bleeding from the left facial area. The report indicated first aid was provided and 911 was called for further evaluation and treatment. Resident 1 returned to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 7/28/17 at 1:30 p.m., during an interview, Certified Nurse Assistant 1 (CNA1) stated she assisted Resident 1 to the bathroom, but was called by another resident for help. CNA 1 stated she left Resident 1 and gave her the call button and instructed the resident to call when she was ready to get off the commode. CNA 1 stated while assisting the resident in the next room, she heard Resident 1 call for help and fall. CNA 1 stated she accompanied the Charge Nurse into the resident's bathroom and observed Resident 1 lying on her left side on the bathroom floor bleeding from the left side of the eye and cheek. CNA 1 stated that she did not apply the tab alarm to Resident 1 while she was on the toilet, as per the resident's plan of care and should have. During an interview on 8/14/17 at 4:46 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 should not have been left alone in the bathroom because she had the tendency of getting up without calling for help, and all the CNAs who had provided care for the resident were aware of the behavior. A review of the general acute care hospital's (GACH) history and physical (H/P), dated 7/18/17 (four days after the resident fell ), indicated the resident was transferred to the GACH after a fall with cervical spine fracture, facial laceration requiring four sutures (used to close open wounds) to the left temple area. The H/P indicated the resident was required to wear the neck collar at all times and to follow up with the neurosurgeon (a physician who specializes in the care and treatment of [REDACTED]. A review of the facility's undated policy titled Falls-Clinical Protocol, indicated frail elderly individuals are often at a greater risk for serious adverse consequences of falls, thus the interventions should be followed.