Every finding on record at Ignite Medical Resort St Peters

Based on interview and record review, the facility failed to provide an effective pain management program for two residents (Resident #4 and #1), in a review of four sampled residents. The facility failed to consistently monitor the effectiveness of pain medication following administration to Resident #4 and to administer as needed (PRN) pain medication to ensure the resident's pain was controlled. The facility failed to ensure Resident #4 had effective pain management when he/she was out of his/her oxycodone (opioid pain reliever) from 05/16/26 until 05/20/26 and his/her pain was not controlled. The resident frequently rated his/her pain as an eight or higher (on a pain scale of 0-10 with 10 being the most pain) and staff identified the resident's pain affected his/her mood and emotions. The resident's family reported the resident did not sleep well through the night due to his/her pain. The facility failed to ensure Resident #1 had scheduled acetaminophen (pain reliever and fever reducer) as ordered, within an hour of being scheduled. The facility census was 63.Review of the facility policy, Pain Management, dated 5/2024, showed the following:-Expressions of pain may be verbal or nonverbal and are subjective to the resident including by not limited to: -Negative verbalizations and vocalizations (groaning, crying, whimpering, screaming); -Facial expressions (grimacing, frowning, fright, clenching of jaw); -Behaviors such as resisting care, distressed pacing, irritability, depressed mood or decreased participation in usual physical and/or social activities; -Difficulty sleeping.-If the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the resident care providers;-Healthcare providers from any department, that have implemented a pain control mechanism, will reassess the resident timely to determine the amount of pain control or relief achieved. Pain control mechanisms may include, but are not limited to: -Medications administered for the control or relief of pain; -Medication administered for the control or relief of anxiety; -Repositioning the resident; -Ambulation of the resident; -Visitation from family/significant other; -Monitoring appropriately for effectiveness. Review of the facility policy, Pharmacy Services, dated 5/2024, showed the following:-Provide continuity of staff to ensure medications are administered without unnecessary interruptions through; -Assuring the correct medication is administered in the correct dose, to the correct person via the correct route in the correct dosage from and at the correct time; -Defining the schedules for administering medications to maximize the effectiveness of the medication and honor resident choices and activities, as much as possible, consistent with the person centered comprehensive care plan. 1. Review of Resident #4's undated face sheet showed the following:-The resident was admitted on [DATE];-The resident was his/her own responsible party;-Diagnoses included malignant neoplasm of anus (anal cancer), fracture of the right acetabulum (right hip fracture), and wedge compression fracture of T5-T6 vertebra (the front part of the two adjoining bones in the upper back has cracked and collapsed, while the back remains intact). Review of the resident's physician orders, dated 05/07/26, showed the following:-Evaluate pain every shift;-Hydromorphone HCL (opioid pain reliever) 2 milligrams (mg), give one tablet every four hours as needed (PRN) for pain for four days;-Lorazepam (antianxiety) 1 mg, give half a tablet (0.5 mg) every 24 hours as needed for anxiety for four days, nightly;-Oxycodone HCL (opioid pain reliever) 20 mg, give one tablet every four hours PRN for pain. Review of the resident's care plan, dated 05/08/26, showed the following:-The resident had the potential for pain;-Anticipate the resident's need for pain relief and respond immediately to any complaint of pain;-Identify and record previous pain history and management of that pain and impact on function; -Identify previous response to analgesia including pain relief, side effects, and impact on function;-Monitor/document for probable cause of each pain episode. Remove/Limit causes where possible. Review of the resident's pain level log, dated 05/08/26 at 10:41 A.M., showed the resident rated his/her pain at nine out of 10 (on a scale of 0 to 10, with 10 being the worst pain). Review of the resident's physician orders, dated 05/08/26, showed the following:-Oxycodone HCL 10 mg, give two tablets orally one time only for pain for one day; -Oxycodone HCL 20 mg, give one tablet every four hours PRN for pain for four days;-Lidocaine (analgesic) external cream 5%, apply to bilateral buttocks topically every shift for radiation burns. Review of the resident's medication administration record (MAR), dated 05/08/26, showed the following:-At 11:58 A.M., staff administered oxycodone HCL 10 mg two tablets for a pain level of nine out of 10; -Staff documented the effectiveness of the medication was unknown. Review of the resident's nurse practitioner note, dated 05/08/26 at 2:08 P.M., showed the following:-The nurse practitioner assessed the resident to optimize therapy, pain control, and discharge planning;-Physical therapy will work on strengthening, endurance, training, neuromuscular training, gait training, balance training, and stairs;-Occupational therapy will work on activities of daily living (ADL) and functional mobility training;-The resident was high risk for functional impairment without therapy and adequate pain control;-Acute pain: continue to titrate pain regimen to optimize therapy performance and functional gains. Review of the resident's nursing evaluation note, dated 05/08/26 at 3:17 P.M., showed the following:-The resident had constant pain, described as throbbing and burning, that started within the last three months;-The pain affected the resident's mood and emotions;-The current interventions for pain were PRN pain medications, relaxation techniques, and distraction. Review of the resident's physician orders, dated 05/09/26, showed the oxycodone HCL 10 mg give two tablets one time only for pain for one day was discontinued. Review of the resident's MAR, dated 05/11/26 at 12:05 A.M., showed the staff administered the oxycodone HCL 20 mg to the resident for a pain level of eight out of 10. Review of the resident's MAR, dated 5/11/26, showed staff documented the oxycodone HCL 20 mg administered at 12:05 A.M. and was ineffective with the resident reporting a follow up pain level of five out of 10. (No documentation staff administered any pain medication to the resident from 12:05 A.M. through 4:35 A.M.) Review of the resident's nurse note, dated 05/11/26 at 4:28 A.M., showed the following:-The resident refused to allow the certified nurse assistants (CNAs) help with ADLs;-He/She did not sleep well that night and refused to allow staff to provide care;-He/She asked the nurse for pain medication. When the nurse gave the medication cup to the resident, he/she refused to take it and said, Why won't you talk to me? What have I done to you?-The resident gave the cup back to the nurse with the medication still in it and would not take it until the nurse answered his/her questions. Review of the resident's nurse note, dated 05/11/26 at 4:32 A.M., showed the resident was awake all night. Review of the resident's MAR, dated 05/11/26, showed the following:-At 4:36 A.M., staff administered oxycodone HCL 20 mg;-At 5:04 A.M., staff documented the oxycodone was effective with a follow up pain level at zero out of 10. Review of the resident's brief interview for mental status (cognitive assessment) note, dated 05/11/26 at 8:47 A.M., showed the resident was cognitively intact. Review of the resident's care plan, updated 05/11/26, showed the following:-The resident had a behavior problem; -Evaluate the resident for changes in pain levels and, if appropriate, request a scheduled pain medication from the physician;-Provide a calm and safe environment to allow the resident to express feelings as needed;-Anticipate the resident's need for pain relief and respond immediately to any complaint of pain;-Identify and record previous pain history and management of that pain and impact on function. -Identify previous responses to analgesia including pain relief, side effects and impact on function;-Monitor/document for probable cause of each pain episode. Remove/limit causes where possible.(The care plan did not include the interventions of PRN pain medication, relaxation techniques or distractions that were identified on the nursing assessment.) Review of the resident's nurse note, dated 5/11/26 at 12:45 P.M., showed the following:-Upon the nurse entrance into the resident's room, the resident sounded like he/she had been crying;-The resident said he/she was in unbearable pain level of 11 out of 10 due to his/her spine and buttocks;-The nurse notified the physician who ordered acetaminophen 1000 mg that may be administered with the oxycodone;-The nurse explained to the resident the additional method was useful to assist with breakthrough pain. Review of the resident's physician orders, dated 05/11/26, showed a new order for acetaminophen (pain and fever reducer) 500 mg, give two tablets every eight hours PRN for pain. Review of the resident's physician orders, dated 5/12/26, showed the following:-Hydromorphone HCL 2 mg, give one tablet every four hours PRN for pain;-Lorazepam 1 mg, give half a tablet (0.5 mg) by mouth every 24 hours PRN for anxiety;-Oxycodone HCL 20 mg give one tablet by mouth every four hours PRN for pain. Review of the resident's MAR, dated 5/12/26, showed the following:-At 4:00 A.M., staff administered acetaminophen 500 mg two tablets for a pain level five out of 10;-Staff documented the effectiveness of the medication was unknown; -At 8:38 A.M., staff administered oxycodone HCL 20 mg for a pain level of 10 out of 10;-At 2:39 P.M., staff documented the 8:38 A.M. dose of oxycodone was effective with a pain level of eight out of 10. Review of the resident's medical record showed no documentation staff attempted any intervention or administered pain medication when the resident continued to have pain on 5/12/26 at 2:39 P.M. Review of the resident's MAR, dated 5/13/26, showed the following:-At 3:08 A.M., staff administered oxycodone HCL 20 mg to the resident for a pain level of six out of 10;-At 4:24 A.M., staff documented the medication was ineffective with a follow up pain level of five out of 10. (Review showed no documentation staff administered pain medication to address the resident's pain as identified at 4:24 A.M. as ineffective); -At 6:21 A.M., staff administered the hydromorphone 2 mg for a pain level at eight out of 10, (two hours after staff assessed the effectiveness of the oxycodone);-At 7:06 A.M., staff documented the hydromorphone was effective with a follow up pain level of five out of 10. Review of the resident's MAR, dated 5/15/26 at 1:10 A.M., showed staff administered oxycodone 20 mg PRN for pain level of 10 out of 10. Review of the resident's pain log, dated 5/15/26 at 2:27 A.M., showed the resident had pain at a level of five out of 10. Review of the resident's MAR, dated 5/15/26 at 8:51 A.M., showed staff administered hydromorphone 2 mg for buttock pain level of nine out of 10. Review of the resident's MAR, dated 5/15/26 at 2:59 P.M., showed staff documented the effectiveness of the hydromorphone, administered at 8:51 A.M., was unknown. Review of the resident's MAR, dated 5/15/26, showed no documentation the resident received pain medication following administration of the hydromorphone at 8:51 A.M. after staff documented the effectiveness of the medication was unknown. Review of the resident's pain level log, dated 5/15/26 at 4:35 P.M., showed the resident's pain level was 10 out of 10. Review of the resident's MAR, dated 5/15/26 on and after 4:35 P.M., showed no documentation staff administered PRN hydromorphone 2 mg or oxycodone 20 mg when the resident rated his/her pain a 10 out of 10. Review of the resident's nurse notes, dated 5/15/26 between 4:35 P.M. and 9:00 P.M., showed no documentation staff attempted any other pain alleviating interventions to address the resident's pain. Review of the resident's nurse note, dated 5/15/26 at 9:12 P.M., showed the following:-Staff gave the resident nighttime medications along with PRN pain medication, however, the resident refused to take the medication and threw the medication onto the floor;-The resident called his/her family to tell them he/she had not been given the medication, and no one had been in his/her room all night;-The resident was rude and non-compliant with care. He/She was not cooperating with the nurse or staff at the time. Review of the resident's record showed no documentation staff reassessed the resident's pain level, attempted to administer pain medication, or any other pain control interventions for the resident from 5/15/26 at 9:12 P.M. until 5/16/26 at 8:22 A.M. Review of the resident's MAR, dated 5/16/26, showed the following:-At 8:22 A.M., staff administered hydromorphone 2 mg to the resident for buttock pain level at eight out of 10;-At 9:22 A.M., staff administered oxycodone HCL 20 mg to the resident for extreme pain over his/her whole body rated at 10 out of 10; -At 12:16 P.M., staff documented hydromorphone was ineffective with a follow up pain level of 10 out of 10;-At 12:27 P.M., staff administered hydromorphone 2 mg to the resident for a pain level of eight out of 10;-At 1:59 P.M., staff administered oxycodone HCL 20 mg to the resident for a pain level of at 10 out of 10. (This was the last time staff administered the oxycodone to the resident until 05/20/26.); -At 3:45 P.M., staff documented the hydromorphone and oxycodone was effective with a follow up pain level of eight out of 10;-At 4:29 P.M., staff administered hydromorphone 2 mg to the resident for pain level at eight out of 10;-At 11:42 P.M., staff documented a pain follow-up assessment as effective with follow up pain level of zero out of 10, seven hours after the hydromorphone was administered. Review of the resident's medical record showed no documentation staff notified the resident's physician on 5/16/26 when the resident rated his/her pain as an eight or 10 throughout the day and staff documented the pain medication was not effective. Review of the resident's nurse note, dated 5/17/26 at 7:27 A.M., showed the staff administered lorazepam 1 mg half a tablet to the resident because he/she was repeatedly yelling out and had increased anxiety. Staff did not document a pain assessment. Review of the resident's nurse note, dated 5/17/26 at 11:45 A.M., showed the lorazepam was effective with the resident being pleasant and calm. Review of the resident's nurse note, dated 5/17/26 at 3:58 P.M., showed the following:-The resident's family member called regarding calls he/she received from the resident; -The nurse told the resident's family member he/she administered PRN pain medication to the resident at 6:00 A.M., 7:00 A.M., 10:00 A.M., and 11:00 A.M. Review of the resident's MAR, dated 5/17/26, showed no documentation staff administered PRN pain medications at 6:00 A.M., 7:00 A.M., 10:00 A.M., and 11:00 A.M., as staff reported to the resident's family in the nurse's note at 3:58 P.M. Review of the resident's pain level log, dated 5/17/26 at 4:14 P.M., showed the resident reported pain of eight out of 10. Review of the resident's MAR, dated 5/17/26, showed no documentation staff administered PRN pain medication after 4:14 P.M. for the pain level of eight out 10. During an interview on 5/20/26 at 3:34 P.M., Licensed Practical Nurse (LPN) C said the following:-He/She worked on 5/18/26 and found the resident was out of oxycodone;-He/She reordered the oxycodone so the resident wouldn't be out when he/she returned from an appointment. Review of the resident's nurse note, dated 5/18/26 at 3:34 P.M., showed the following:-Staff at the radiology office sent the resident to the hospital from their office appointment due to pain control issues;-The hospital kept the resident for observation. Review of the resident's nurse note, dated 5/19/26 at 3:22 A.M., showed the resident returned to the facility from the hospital. Review of the resident's physician orders, dated 5/19/26, showed oxycodone HCL 20 mg, give one tablet every four hours PRN for pain. During an interview on 5/20/26 at 3:34 P.M., LPN C said the following:-On 5/19/26, the facility was still out of the resident's oxycodone because the prescription needed a signature from the physician;-He/She did not notify the physician because the resident's pain medication was effective;-He/She did not know what the resident's pain level goal was. Review of the resident's MAR, dated 5/19/26, showed the following:-At 7:51 P.M., staff administered acetaminophen 500 mg two tablets for a pain level at eight out of 10;-At 9:25 P.M., staff administered hydromorphone 2 mg for a pain level at eight out of 10;-At 11:58 P.M., staff documented the acetaminophen was ineffective with a follow up pain scale level of six out of 10;-At 11:59 P.M., staff documented the hydromorphone was ineffective with a follow up pain scale level of six out of 10. Review of the resident's nurse notes, dated 5/19/26, showed no documentation staff notified the resident's physician when the resident's pain medication was not effective, the resident was out of oxycodone, nor any attempts for non-pharmacological interventions to address the resident's pain. Review of the resident's MAR, dated 5/20/26, showed the following:-At 1:25 A.M., staff administered hydromorphone 2 mg over an hour after the resident reported pain of six out of 10;-At 4:13 A.M., staff administered oxycodone HCL 20 mg for a pain level of seven out of 10;-At 5:07 A.M., staff documented the hydromorphone effectiveness was unknown with a follow up pain level of five out of 10;-At 5:08 A.M., staff documented the oxycodone effectiveness was unknown with a follow up pain level of five out of 10;-At 5:46 A.M., staff administered hydromorphone 2 mg for a pain level of five out of 10;-At 9:54 A.M., staff documented the hydromorphone effectiveness was unknown. During an interview on 5/20/26 at 3:32 P.M., LPN B said the following:-The resident was out of oxycodone on the night shift of 5/19/26 until it was delivered the early morning of 5/20/26;-Once the oxycodone was delivered, he/she administered 20 mg to the resident;-He/She did not notify the physician the facility did not have the oxycodone available;-He/She did not have access to get the oxycodone out of the emergency medication machine;-He/She explained to the family and the resident the medication was supposed to be delivered, and he/she would give the resident the pain medication that was available in the facility. During an interview on 5/20/26 at 11:40 A.M., the resident said the following:-The facility was out of his/her PRN oxycodone 20 mg; -The hydromorphone alone was not effective to control his/her pain;-The facility finally received the oxycodone and administered it in the early morning on 5/20; -He/She had to wait sometimes for two hours before the staff administered the pain medications after he/she requested them;-His/Her goal for a pain level would be no pain, but a tolerable pain level would be four or below;-The resident had a terrible time the night before and couldn't sleep due to the pain. During an interview on 5/20/26 at 11:42 A.M., the resident's family member said the following:-The resident had trouble sleeping at night related to pain;-The family member said the resident was trying to catch up on the PRN pain medication so he/she could get some sleep;-The family did not feel the staff kept the resident's pain tolerable. The resident called the family to complain about being in pain and no staff checked on him/her nor gave any pain medications;-When the resident was in the hospital, the pain medication was on a schedule and that worked well, but at the facility, the physician only ordered pain medication on a PRN basis;-He/She, another family member, and a family friend had to ask staff for pain medication for the resident, otherwise, it was a long wait or the staff forgot;-Since the resident's last visit to the hospital, the resident's family took turns to ensure there was someone with the resident around the clock to ensure his/her pain was controlled. During an interview on 5/20/26 at 3:32 P.M., LPN B said the following:-The resident was able to tell staff he/she was in pain and how bad the pain felt.-He/She did not know what the resident's pain level goal was. He/She just administered pain medication when the resident or family requested it;-The staff were supposed to follow up with the resident on the effectiveness of the pain medication and document it;-When he/she documented the effectiveness was unknown, it was because the resident had an improvement on pain severity, but it was still present, therefore, the medication was neither effective nor ineffective but unknown. 2. Review of Resident #1's face sheet, undated, showed the following:-The resident was admitted on [DATE];-He/She was his/her own responsible party;-Diagnosis of displaced trimalleolar fracture of left lower leg (severe and unstable three-part break of the ankle joint where the bones have shifted out of their normal position). Review of the resident's nursing evaluation, dated 5/7/26 at 5:16 P.M., showed the following:-He/She described pain as it hurts a little bit, did not radiate, occasional/intermittent that was aching with onset within last seven days, and it affected sleeping;-Current pain medication regimen was narcotics on PRN basis. Review of the resident's physician orders, dated 5/7/26, showed the following:-Acetaminophen (pain reliever and fever reducer) 500 mg give two tablets by mouth every eight hours scheduled for pain;-Baclofen (skeletal muscle relaxant) 10 mg give one tablet by mouth, every eight hours PRN for spasms;-Hydrocodone/Acetaminophen (narcotic analgesic combination) 7.5/325 mg, give one tablet by mouth every twelve hours PRN for severe pain;-Ibuprofen (non-steroidal anti-inflammatory) 600 mg give one tablet by mouth every six hours PRN for pain. Review of the resident's MAR, dated 5/8/26, showed staff administered acetaminophen 500 mg, two tablets at 9:01 P.M. for pain level of eight out of 10. Staff did not document the effectiveness of the medication. Review of the resident's MAR, dated 5/9/26, showed staff administered acetaminophen 500 mg two tablets at 2:00 P.M. without assessment of the resident's pain level. Staff did not document the effectiveness of the medication. Review of the resident's MAR, dated 5/10/26, showed staff administered the acetaminophen 500 mg two tablets at 2:00 P.M., without assessment of the resident's pain level. Staff did not document the effectiveness of the medication. Review of the resident's physician orders, dated 5/10/26, showed evaluation pain every shift. Review of the resident's brief interview for mental status, dated 5/11/26 at 8:45 A.M., showed the resident was cognitively intact. Review of the resident's pain level log, dated 5/12/26 at 3:18 P.M., showed staff administered the acetaminophen scheduled at 2:00 P.M. over an hour late, for pain level at eight out of 10. Review of the resident's pain level log, dated 5/15/26 at 3:15 P.M., showed staff administered the acetaminophen scheduled for 2:00 P.M., over an hour late, for a pain level at five out of 10. Review of the resident's MAR, dated 5/19/26, showed the staff administered the acetaminophen 500 mg two tablets at 2:00 P.M., without assessment of the pain level. Staff did not document the effectiveness of the medication. Review of the resident's pain level log, dated 5/19/26 at 11:06 P.M., showed staff administered the acetaminophen scheduled for 10:00 P.M. over an hour late, for a pain level at five out of 10. During an interview on 5/20/26 at 1:05 P.M., the resident said the following:-His/Her goal was to have a pain level at four or below;-On the night shift, he/she experienced the longest wait time for pain medication;-He/She observed a staff member administer everyone's scheduled medications prior to administering his/her PRN pain medications when requested;-It felt like he/she had to wait two hours for the PRN pain medication;-That was frustrating because when he/she was in pain and had to wait for the PRN pain medication, then he/she had to wait for the pain medication to become effective;-It was also frustrating when the staff were late with his/her scheduled pain medication, because he/she experienced breakthrough pain. 3. During an interview on 5/20/26 at 3:37 P.M., the Director of Nursing (DON) said the following:-Staff were to follow the physician orders of checking resident's pain level every shift, prior to administration of the medication, and after administration of the medication;-If a resident's pain was not tolerable with current interventions, then the nurse should contact the physician;-If a resident had a current prescription for a narcotic but none were available, then the nurse could obtain the medication from the emergency kit;-If a resident did not have a current prescription for a narcotic, then he/she had to contact the physician to send an electronically signed order to the pharmacy, then the pharmacy made the medication available to obtain from the emergency kit;-The nurse had to be entered into the system and fingerprinted to get medication from the emergency kit;-Newer nurses may not be in the system or fingerprinted yet;-He/She was unaware LPN B did not have access to the emergency kit;-Staff was to administer scheduled medications within an hour of the scheduled time and PRN medications as soon as possible after being requested. During an interview on 5/20/26 at 4:06 P.M., the Administer said the following:-Staff were to follow the physician orders on administering pain medications and follow up to ensure the medication was effective;-The staff was to follow the policy on medication administration times;-If the resident's pain level was not tolerable, then the nurse was to contact the physician. Complaint # 3017040

Based on observation, interview and record review, the facility failed to follow standards of practice for three residents (Resident #1, #2, and #6), when staff failed to complete neurological assessments (to detect brain injury), for two residents (Resident #1and #6) who sustained falls of seven sampled residents. Staff failed to do complete a thorough assessment, provide first aid and stay with Resident #1 following a fall with injury to the head. Staff failed to provide a report to emergency personnel who responded to transport the resident to the hospital. The facility also failed to monitor Resident #2 after the resident experienced a change in condition and developed a blood clot in the leg. The facility failed to provide a report to emergency personnel with pertinent health history information when they were on scene to transport the resident to the hospital. The census was 69. The facility did not provide a policy for resident change of condition or information to report to emergency personnel when emergency services responded to a call at the facility. Review of the facility policy for Neurological assessment dated 09/19 showed the following:-Neurological assessments are done upon physician order when indicated for a change of condition, unwitnessed fall and head injuries;-Observe behavior and note and significant change from normal;-Determine the location and type of any pain;-Determine level of consciousness and responsiveness as compared to baseline;-Determine orientation to person, place and time as compared to baseline;-Determine capability of movement and strength of all extremities as compared to baseline;-Check pupil size and reaction to light;-Note speech to determine if it is clear, rambling, incoherent and absent as compared to baseline;-Check vital signs;-The neurological assessment should be documented on the neurological flow sheet or in the nurses notes;-Any significant change will be reported to the physician. Review of the undated Neurological Flow Sheet showed the following:-Vital Signs and Neuro Checks: every 15 minutes for one hour, then every 30 minutes for one hour then every hour for four hours, then every four hours for 24 hours;-Notify physician IMMEDIATELY of signs and symptoms of intracranial pressure (headache, vomiting (often without nausea), changes in mental status (restlessness, confusion, lethargy), blurred/double vision, and pupil changes). 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of osteomyelitis (infection in the bone) of the left ankle and foot, peripheral vascular disease (PVD-a circulatory disease) and hypertension (high blood pressure). Review of the resident's physician orders for March 2026 showed an order for Eliquis (a prescription blood thinning medication) 2 milligrams (mg) two times a day (BID). Review of the resident's nurses notes dated 03/1/26 at 4:30 P.M. signed by Registered Nurse (RN) C showed the following:-The resident rolled out of his/her bed, reaching for his/her phone charger, landing on the right side of his/her body. Resident found on the floor, on the left side of his/her bed, between the bed and the recliner. The resident had a gash to the right temple, with swelling and reported headache. Vital Signs: Blood pressure (BP) 160/90 (normal 120/80), pulse (P) 110 (normal 60-100), temperature (T) 97.6 (normal 98.6), respirations (R) 24 (normal 12-20). The dressing to the resident's left foot was no longer intact. 911 contacted to take to the emergency room for evaluation. There was no documentation of a neurological assessment. Review of the resident's nurses notes dated 03/1/26 at 7:51 P.M. showed the following:-Resident returned via EMS (Emergency Medical Services) from a local hospital after a fall during day shift. The resident fell out of the bed and hit his/her head;-CT scan of the head (computed tomography -x-ray images of structures inside the body converted to pictures on a monitor) negative;-Sutures to the forehead intact. Dressing to forehead clean, dry and intact. Vital Signs stable. Denies pain at this time. Safety checks in place. Bed is low. Instructed to report dizziness or light headedness to this nurse;- Physician notified. No new orders. Plan of care ongoing. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] showed the following:-Able to make self-understood and able to understand others;-BIMS (Brief Interview for Mental Status tool used in long-term care settings to assess cognitive function) of 15 indicating intact cognition. During an interview on 03/10/26 at 10:20 A.M. the resident said the following:-He/ was in the facility for some therapy after a stroke;-About a week ago, he/she was reaching for his/her cell phone and fell off the bed hitting his/her head on the chair;-He/She could not find the call light, so he/she tried yelling for help. He/she lay on the floor for a long time before someone came in the room;-When staff came in, they said they could not get him/her off the floor because he/she hit his/her head, and they had to call 911; staff then left the room;-No one came and put anything on his/her head to stop the bleeding. He/She found a pair of pants on the floor and put them on his/her head to stop the bleeding;-After a long time, EMT's came in and took him/her to the hospital. During an interview on 03/11/26 at 5:30 P.M. Emergency Personnel Staff C said the following:-He/She responded to the call for the resident. When he/she entered the resident's room, there was no staff member in the room with the resident. The resident was on the floor and had placed a pair of pants on his/her forehead to stop the bleeding from a laceration he/she sustained from the fall. The resident said no one had come to assess him/her;-He/She left the room to find a staff member, and a staff member pushing a food cart down the hall told him/her where to find the nurse;-He/She located a nurse at the nurses' station completing paperwork. The nurse identified him/herself as Registered Nurse (RN) C and came to the room after EMS had the resident on the gurney. RN C handed them the paperwork and said he/she was going to get an ice pack. RN C left the room without giving them any type of report or providing care to the resident;-He/She was concerned if the resident was on any blood thinners and had received the appropriate care after the fall. During a telephone interview on 03/19/26 at 4:00 P.M. RN C said the following:-He/She was notified by staff members the resident was on the floor, and he/she went into the room and assessed the resident;-He/She did not get the resident off the floor as the resident had a laceration to the head and he/she did not know if the resident had sustained internal injuries;-He/She left the room to notify EMS and complete paperwork and thought the nurse aides were still in the room with the resident. He/She was not aware they had left the room;-He/She must have been at a different nurses station on a different hall completing paperwork and making copies when the EMS personnel came to the nurses station, he/she assumed the nurse aides were in the resident's room;-He/She did not start neuro checks after the resident had fallen because the resident was going to the emergency room;-He/She could not remember if the resident was on any type of blood thinners;-He/She did not apply any pressure to the laceration or give the staff anything to put on the laceration to the resident's head, he/she was focused on sending the resident out to the emergency room;-He/She knew that when a resident falls and it was not witnessed then neuro checks should be done. During an interview on 03/10/26 at 2:40 P.M. the Assistant Director of Nurses (ADON) B said the following:-Resident #1 did not have any neurological assessments completed after the fall on 03/01/26;-Nursing staff should stay with a resident after they had fallen and have injuries until emergency services arrive. 2. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of fractured pelvis, toxic encephalopathy (degenerative brain disease), acute respiratory failure, interstitial pulmonary disease (a chronic disease of the lungs making it difficult to breathe), atrial fibrillation (irregular heart rhythm) and anemia. Review of the resident's physician orders dated 03/01/26 showed and order for apixaban (Eliquis) 2.5 milligrams (mg) two times a day (BID) with a start date of 02/23/26. Review of the resident's care plan for anticoagulant therapy dated 02/24/26 showed the following:-The resident will be free from discomfort or adverse reactions related toanticoagulant use;-Labs as ordered. Report abnormal lab results to the MD; Monitor/document/report as needed adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the resident's progress notes signed by a Nurse Practitioner dated 03/3/26 showed mild bluish discoloration noted on the dorsum (upper portion of the foot) of both feet, has two pair of socks on each foot. Discussed with family to avoid use of tight socks or double socks as it can place pressure on skin and cause pressure injury.Case discussed with physician who went to see resident today. Physician ordered an ultrasound arterial and venous doppler stat (immediately) results pending. Review of the results of the resident's doppler study dated 03/5/26 at 8:34 A.M. showed the following:-Venous Doppler: There is intraluminal thrombus ( a blood clot formed within the lumen of a vessel) in the left saphenous (large vein in the leg), left popliteal ( vein located directly behind the left knee joint) , and left peroneal veins (deep veins in the lower leg) with non-compressibility and lack of augmentation (acute deep vein thrombosis (DVT) of the lower extremity, likely with concomitant superficial vein involvement; -Conclusion: Deep vein thrombosis (blood clot) involving the left saphenous, left popliteal, and left peroneal veins.No right deep vein thrombosis). Review of the resident's progress note dated 03/5/26 at 8:36 A.M. showed physician notified of doppler findings. Review of the resident's medical record dated 03/05/26 showed no further documentation regarding the resident's condition, any further physician orders as a result of the doppler study, or a transfer of the resident to the hospital. Review of the resident's Patient Care Report from the local ambulance provider dated 03/05/26 at 9:33 A.M. showed the following:-Dispatched to transfer/Interfacility, responded with lights and sirens (emergent);-Complaint: dyspnea (shortness of breath);-History provided by the family at bedside, facility staff not reporting to room despite the call being initiated as an emergency call. Family reporting noticing deep tissue bruising bilateral lower extremities on 02/26. Arterial/venous doppler performed on 03/03/26 due to bruising found bilaterally to both lower extremities. Results from the doppler were received. Family noticed the resident having increased respiratory effort over the past couple of days. Per family staff reported the resident being fine when asked about his/her respiratory status. Contacted facility staff only after the resident had been assessed, interventions initiated and the resident had been transferred and secured to the stretcher exiting the room, approximately 20 minutes after EMS personnel arrived on seen; -Upon arrival found the resident consistent with the reported baseline information per the family. Resident on 4 liters of oxygen via nasal cannula. The resident noted to have increased work of breathing and see-saw like respirations (an abnormal, paradoxical breathing pattern where the chest sinks in while the abdomen expands during inhalation, and vice versa during exhalation). Has noticeable bruising and tenderness to lower extremities bilaterally;-Resident admitted to the hospital. During an interview on 03/17/26 at9:00 A.M. Emergency Personnel Staff D said the following:-When they arrived on the scene on 03/05/26 there was no staff in the resident's room;-The resident was having some difficulty breathing; they were surprised that no staff was available;-A family member was in the room, who seemed to have medical background and told them about the doppler study and what the physician had said;-They were in the room about 20 minutes, had assessed the resident, transferred the resident to a stretcher, and were leaving the room when a staff member came in and identified themselves as a nurse;-This person did not know what was going on with the resident or that the resident was having some respiratory distress. During an interview on 03/11/26 at 5:11 P.M. Family Member (FM) A and FM B said the following:-They were in the room when the emergency personnel arrived to take the resident to the hospital, there were no staff available for the emergency personnel;-FM B informed emergency personnel of the doppler study and results, the conversation with the physician earlier and why they were called to transport the resident to the hospital;-Emergency personnel had the resident on the stretcher and were about to the leave the room when RN D arrived;-They had not seen RN D all morning and RN D had not taken care of the resident that day;-When emergency personnel asked about the resident's shortness of breath, RN D told them that this was normal for the resident, RN D did not have all the information about the resident to give to emergency personnel. During an interview on 03/10/26 at 3:30 P.M. LPN D said he/she was not the nurse who sent the resident to the hospital, Registered Nurse (RN) E was the nurse who sent the resident to the hospital During an interview on 03/10/26 at 5:20 P.M. RN E said the following:-He/She was going back to the resident's hall as emergency personnel were leaving the resident's room [ROOM NUMBER]/05/26;-He/She told the resident's nurse he/she would give the emergency personnel report;-He/She told emergency personnel about the doppler study, and that the resident had some pressure ulcers. During an interview on 03/10/26 at 5:00 P.M. the Interim Director of Nursing said the following:-She would expect nurses to give report to emergency personnel and staff be available when emergency personnel arrive;-Staff should inform the emergency personnel as to why the resident was being sent to the hospital, medications they may be on, what medications were given and any pertinent information regarding their care. During an interview on 03/10/26 the Corporate Director of Nursing said the following:-A nurse practitioner examined the resident on 03/03/26 and ordered the doppler studies due to bruising to the lower legs. When the results were in on 03/05/26, the physician ordered the resident to be sent to the hospital for evaluation;-The nurses should have documented this in the medical record;-Licensed Practical Nurse (LPN) C was the nurse on duty who sent the resident to the hospital;-LPN C should have given the emergency personnel report on the resident. 3. Review of Resident #6's face sheet showed admitted to the facility on [DATE] with diagnoses of stroke and dementia. Review of the resident's quarterly MDS dated [DATE] showed the following:-Usually able to make self-understood and usually able to understand other;-BIMS of 4 (severe cognitive impairment);-Dependent upon staff for ADL's, assist with rolling side to side, standing and transfers, dependent upon staff for walking and wheelchair mobility;-History of falls with two or more falls since admission with no injuries. Review of the resident's nurses' note dated 03/4/26 at 7:19 P.M. showed the following:-The resident rolled out of bed. His/Her bed was in the lowest position with a fall mat. He/She rolled to the right side of his/her bed, with fall mat being on the left side of the bed. He/She was found on his/her side. The resident said he/she hit his/her head. ROM and neuro assessment within normal limits for the resident. VS: BP 120/60, P 65, R 18, T 97.6. Two staff members transferred the resident back to bed. Physician and responsible party made aware. Review of the resident's medical record showed no documentation staff completed neurological checks per policy following the resident's fall on 3/4/26 at 7:19 P.M. During an interview on 03/10/26 at 3:00 P.M. the Assistant Director of Nursing said the following:-Neurological flow sheets should be completed on every unwitnessed fall;-These are documented on a paper form and uploaded into the resident's electronic medical record (EMR);-When a resident has a fall, the nurses are to complete an initial assessment in the risk management section of the EMR, this will trigger an assessment for the fall, if any neurological assessment needs to be completed and 72 hour post fall follow-up documentation;-Resident #1's fall was not entered into the EMR correctly, so no post fall assessment or documentation was triggered. No further documentation or assessment was completed after the fall. No neurological assessment was completed, and no care plan was generated to address the fall with any interventions;-Resident #6 did not have the Neurological flow sheets completed per policy. During an interview on 03/10/26 at 5:00 P.M. the Interim Director of Nursing said the following:-She would expect nurses to give report to emergency personnel and staff be available when emergency personnel arrive;-Staff should inform emergency personnel as to why the resident was being sent to the hospital, medications they may be on and what medications were given and any pertinent information regarding their care. 27912112796035

Based on observation, interview and record review, the facility failed to plan care to address one resident's (Resident #1) of seven sampled residents, risk for falls. The facility assessed the resident for high fall risk with no care plan addressing falls. The resident fell from bed on 3/1/26 and sustained a laceration to the head. The facility failed to plan care after the resident's fall to prevent further falls. The facility census was 69. Review of the facility policy for Fall Prevention dated 11/20 showed the following:-Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains free from accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility and after every fall in the facility;-Use of the temporary, initial care plan and communication tool to identify activities or habits that place the resident at risk for falls;-The Interdisciplinary team (IDT) will develop a plan for services to improve or maintain the residents standing and sitting balance and other interventions to reduce the residents' risk for falls. The plan will include specific, individualized information about the resident's routine and personal habits that may place the resident at risk for falls;-Every team member was responsible for checking the care plan of residents who are at risk for falls when beginning each day and throughout the assigned shift. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of osteomyelitis (infection in the bone) of the left ankle and foot, peripheral vascular disease (a circulation disorder) and high blood pressure. Review of the resident's Fall Risk Evaluation dated 02/16/26 showed the resident was at high risk for falls. Review of the resident's nurses notes dated 03/1/26 at 4:30 P.M. showed the following:-The resident rolled out of his/her bed, reaching for his/her phone charger, landing on the right side of his/her body. He/She was found on the floor, on the left side of the bed, between the bed and the recliner;-He/She obtained a gash to the right temple, with swelling and reported headache. 911 contacted to take the resident to the emergency room for evaluation Review of the resident's nurses' notes dated 03/1/26 at 7:51 P.M. showed the following:-Resident brought back by EMS from local hospital after fall during day shift. Resident fell out of the bed and hit head;- CT scan (a type of x-ray) of the head negative. Sutures to the forehead are intact;- Safety checks in place. Bed is low. Instructed to report dizziness or light headedness to this nurse. Plan of care ongoing. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/03/26 showed the following:-Able to make self-understood and able to understand others;-Cognitively intact;-At risk for falls with no history of falls (resident sustained a fall on 3/1/26). Review of the resident's medical record from 03/01/26 through 03/10/26 showed no care plan to address the resident's fall risk or actual fall. Observation on 03/10/26 at 10:20 A.M. showed the following:-The resident lay in a low bed. The call light was located on the floor and was not within the resident's reach;-The resident had a small, closed laceration to the forehead. During an interview on 03/10/26 at 10:20 A.M. the resident said the following:-He/She had a stroke and was in the facility for therapy;-About a week ago, he/she was reaching for his/her cell phone and fell off the bed hitting his/her head on the chair;-He/She could not find the call light, so he/she tried yelling for help. He/she lay on the floor for a long time before someone came in the room. During an interview on 03/10/26 at 3:00 P.M. the Assistant Director of Nursing said the following:-When a resident has a fall, the nurses are to complete an initial assessment in the risk management section of the EMR (electronic medical record), this will trigger an assessment for the fall, if any neurological assessment needs to be completed, and 72 hour post fall follow-up documentation;-Resident #1's fall was not entered into the EMR correctly, so no post fall assessment or documentation was triggered. No further documentation or assessment was completed after the fall. No care plan was generated to address the fall with any interventions; During an interview on 03/10/26 at 4:30 P.M. the MDS coordinator said the following:-The Director of Nurses, (DON), therapy, dietary meet as a team to discuss the resident and develop a comprehensive care plan;-Resident #1 was at risk for falls and had a fall on 03/01/26 and should have a care plan;-The resident did not have a care plan for falls. During an interview on 03/10/26 at 2:40 P.M. Assistant Director of Nurses (ADON) B said the resident had no care plan to address the resident's high risk for falls or the most current fall. During an interview on 03/10/26 at 5:30 P.M. the Interim DON said the following:-She would expect any resident who was at risk for falls to have a care plan in place with interventions to help prevent falls or to limit the injury of a fall;-After a resident has a fall, the fall was investigated, and interventions should be in place. During an interview on 03/10/26 at 5:30 P.M. the Administrator said he would expect staff to follow the facility Fall Policy and develop care plans. 2791211

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #11) of 18 sampled residents received the necessary care and services including appropriate individualized interventions to prevent the development and identification of a Stage 3 pressure ulcer on the resident's buttock. The facility census was 77.Review of the facility policy for Skin Policy and Procedure dated 3/20 showed the following:-Policy: based on the comprehensive assessment of the resident, facility clinical staff will ensure that the resident who enters the facility without pressure injury will not develop pressure injury unless the resident's clinical condition demonstrates that the condition was unavoidable;-The licensed nurse and interdisciplinary team (IDT) will assess and periodically reassess each resident's risk for developing pressure ulcer and take actions to address any identified risks;-The IDT will create a written plan for the identification of risk for and prevention of pressure ulcers;-Identification and evaluation of risk factors of increased/decreased mobility and decreased functional ability, cognitive impairment, under-nutrition, malnutrition including significant weight loss with mobility/positioning concerns;-The nurse will perform a full-body initial skin assessment to identify if the resident is at risk for a pressure ulcer within 6 hours of admission to the facility and weekly;-The nurse will conduct a full-body skin assessment for each resident weekly to ensure no risks have developed;-Each direct care partner will examine each resident's total body skin with each bathing experience and will report any abnormalities to the nurse using the Skin Sheet;-The nurse will conduct a systemic risk assessment for pressure ulcers using the Braden Scale (is a widely used, evidence-based nursing tool to assess a patient's risk of developing pressure injuries) quarterly;-If the resident is determined to be at risk or has developed any skin integrity abnormalities, the nurse will implement action according to the specific skin issues;-The nurse and the IDT will plan and implement preventative care to avoid complications resulting from a resident's inactivity, incontinence;-The nurse and the Staff Development Clinical Educator will educate staff on how to identify risk for and prevent pressure ulcers. Review of Resident #1's face sheet showed the resident was admitted to the facility on [DATE] with the diagnoses of congestive heart failure (CHF a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently), end stage renal disease (ESRD when the kidneys begin or have stopped filtering toxins and waste from the blood), heart failure, anemia and depression. Review of the resident's medical record on 02/24/26 showed no Braden Scale completed upon admission. Review of the care plan for Risk for alteration of the skin dated 02/12/26 showed the following:-The resident is at risk for alteration of the skin;-The resident will be free from skin impairment;-Apply barrier cream, assist with turning and positioning every two to three hours and provide treatments as ordered. Review of the resident's Physician Order Sheet (POS) showed an order for barrier cream to affected areas as needed with an order dated of 02/12/26. Review of the resident's medical record showed no documentation staff had applied barrier cream. Review of the resident's admission progress notes dated 02/12/26 showed the following:-Skin normal color and temperature with no open areas;-Superficial skin loss on buttocks. Review of the resident's progress note dated 02/23/26 showed the following:-The resident is at risk for the development of pressure ulcers;-No documentation of any skin impairments. Observation on 02/23/26 at 5:30 P.M. showed the resident sat in a recliner in his/her room with no pressure relieving cushion in the chair. During an interview on 02/23/26 at 5:30 P.M. the resident said the following:-He/She sat in the recliner all the time. He/She will get up to go to the bathroom and transfer into the wheelchair for therapy;-He/She slept in the recliner because he/she was afraid of rolling out of the bed;-He/She will shift his/her body in the recliner, but basically sleeps on his/her back;-His/Her bottom was sore, and it hurt;-He/She told staff; they just put some type of cream back there;-No nurse had looked at the area. Observation on 02/23/26 at 7:30 P.M. showed the resident in the recliner on his/her back with his/her eyes closed. There was no pressure relief cushion in the recliner. Observation on 02/24/26 at 6:00 A.M. showed the resident in the recliner on his/her back with his/her eyes closed. There was no pressure relief cushion in the recliner. Observation on 02/24/26 at 7:10 A.M. showed the following:-Certified Nurse Aide (CNA) E answered the resident's call light;-The resident said he/she needed to use the bathroom;-CNA E assisted the resident to transfer to a wheelchair and pushed the resident into the bathroom;-CNA E assisted the resident to stand and transfer to the toilet;-As the resident sat down on the toilet, he/she winced and said Ouch, that hurt! when; CNA E asked what hurt, the resident replied, my bottom;-CNA E assisted the resident to stand and looked at the residents bottom;-There was an open area on the inner left buttock the size of a quarter; the open area had bloody drainage. The center of the open area was white with red to pink tissue surrounding the white area;-CNA E said he/she had not seen this before and he/she would have to report to the nurse;-The resident said he/she slept in the recliner all night; the area was very sore. During an interview on 02/24/26 at 7:30 P.M. CNA E said he/she had taken care of the resident before, and the resident complained of his/her bottom being sore, but he/she had not seen the open area. Observation on 02/24/26 at 7:16 A.M. showed the following:- Licensed Practical Nurse (LPN) F entered the resident's bathroom to look at the open area;-There was also a superficial open area on the resident's left buttock. During an interview on 02/24/26 at 7:16 A.M. LPN F said the following:-The larger open area was deep with white tissue and some drainage;-The wound had the appearance of a Stage 3 pressure ulcer (full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss);-He/She would have to notify the physician for a treatment;-He/She had not been notified prior to today of the open areas. Review of the resident's medical record on 02/24/26 showed no completed skin assessments after the resident's admission assessment on 02/12/26;-There were no skin sheets completed per the facility policy. During an interview on 02/24/26 at 2:00 P.M. the Interim Director of Nursing said the following:-The Braden Scale should be completed within 24 hours of admission;-Weekly skin assessments should be completed and documented in the resident's electronic medical record;-The facility did not have a wound nurse; nurses were responsible for the assessment of the skin and the documentation in the record;-If there was skin impairment, the nurses should notify the physician for an appropriate treatment;-The DON would be responsible for monitoring to ensure that wounds are assessed and had appropriate treatments;-Staff should encourage the resident to sleep in the bed, and if not, staff should provide the resident with a cushion for the recliner as needed. During an interview on 02/24/26 at 5:30 P.M. the Administrator said he would expect nursing staff to identify any skin impairment and notify the physician for treatment orders. During an interview on 03/09/26 at 10:00 A.M. the Medical Director said the following:-He would expect the nurse aides to observe the skin when they provide care to the resident and notify the nurse. He would expect the nurse to inspect the resident's skin and report any concerns to the wound care team for assessment and treatment;-Issues with the resident's skin should be identified immediately for treatment and to prevent complications. 2746473

Based on interview and record review, the facility failed to complete a comprehensive facility assessment specific to the facility and failed to ensure the assessment determined the appropriate number of staff and resources needed to care for the residents within the facility. The facility census was 70. Review of the facility's policy, Facility Assessment, dated 8/01/24, showed the following:-The facility will evaluate the resident population and identify the resources needed to provide the necessary care and service the residents require on an annual basis and at any time any significant changes are made to the care or services provided in the facility;-The purpose of the Facility Assessment included but was not limited to inform staffing decisions to ensure sufficient staff with appropriate competencies and skill sets necessary to care for all residents' needs as identified through resident assessments and care plans as required, consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to the resident population, inform contingency planning for events that do not require activation of the resident's emergency plan, but do have the potential to affect resident care including but not limited to, availability of direct care nurse staffing or other resources as needed for resident care;-The Facility Assessment will address but is not limited to the facility's resident population, both resident number of residents and the facility's resident capacity, the care required by the resident population using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral needs, cognitive disabilities, overall acuity and any other pertinent facts that are present within the population, consistent with and informed by individual resident assessments as required by regulation. Staff competencies and skill set that are necessary to provide the level and types of care needed for the resident population;-To ensure the required thoroughness, individuals involved in the facility assessment will include but are not limited to facility leadership, direct care staff including registered nurses (RN), licensed practical nurses (LPN), certified nurse assistants (CNA), certified medication technicians (CMT), environmental operations manager and other department heads;-The individualized approach of the facility assessment is the foundation to determine staffing levels and competencies. Therefore, the facility assessment will include an evaluation of the overall number of facility staff needed to ensure sufficient number with required competencies of qualified staff are available to meet each resident's needs. Furthermore, the assessment will include a competency based approach to determine the knowledge and skills required among staff to ensure resident are able to maintain or attain their highest practicable physical, functional, mental and psychosocial well-being and meet current professional standards of practice, The assessment will consider a review of individual staff assignments and systems for coordination and continuity of care for residents within and across these staff assignments. Review of the Facility Assessment, dated 06/21/24 (prior to the facility's initial licensure and certification date), showed the following:-The number of residents needing assistance with eating 30%, toileting hygiene 65%, sit to lying 69%, lying to sitting 69%, sit to stand 86%, chair/bed to chair 86%; toilet transfer 81%; -This facility assessment documents resources required to provide necessary care to residents regarding staffing across all shifts and on each nursing unit. The General Manager, Chief Nursing Officer (CNO), and Director of Culture and Engagement or designee will update the staffing portion of the Facility Assessment to reflect how staffing is determined/adjusted based on acuity information of residents currently residing in the facility and residents screened for admission to the facility;-Ember and Kindle units (the units of the facility designated for acute rehab residents) staffing is adjusted dependent on the volume of the unit for short-term and long-term residents with a focus on continuity of care. Additionally, acuity and care needs are considered. Staffing levels are provided that allow for adequate direct service provision to residents. These units generally have a large population of short-term residents with higher acuities that require increased staffing needs compared to Sparkle (the unit designated for long-term care residents) unit;-Review of the Recruitment and Retention Plan for the staffing portion showed the resources to be used were designated for another facility in another city in the state and not for this facility;-Review of the Risk Assessment portion showed inaccurate information regarding the facility regarding the age of the facility and the contractors used to provide services within the facility. Review of the facility Resident Matrix (a form used to show the residents' care needs), dated 4/14/26, provided by the facility, showed the following:-Eight residents with urinary catheters;-Nine residents who had infections;-Twenty-six residents who had fallen;-Four residents with pressure ulcers;-Sixteen residents with a diagnosis of dementia or Alzheimer's disease;-Four residents received intravenous (IV) medications;-Four residents received enteral feedings (a tube placed in the stomach and provided nutrition through the tube);-Four residents received dialysis;-Two residents on Hospice services;-One resident received therapy services;-Two bariatric residents. Review of the Facility Assessment, dated 6/21/24, showed the facility did not include the following information:-The services or the equipment needed to care for bariatric residents; -The number of nursing personnel required to provide care and meet the residents' needs;-The facility assessment did not contain any signatures showing completion. During an interview on 04/16/26 at 1:20 P.M., the Administrator said the following:-He was responsible for the Facility Assessment;-The amount of staff required to meet the residents' needs should be indicated on the facility assessment. During an interview on 4/28/26 at 11:50 A.M., the Assistant Administrator said the following:-The completion date of 6/21/24 on the Facility Assessment was a clerical error. Every facility within the corporation used the same template to complete the assessment. The previous administrator who completed the Facility Assessment did not change the date showing when it was completed;-The facility opened in August of 2025 and the facility assessment was completed shortly thereafter but he did not know the exact date.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain good hygiene for three residents (Residents #4, #5 and #6), who required assistance with bathing, in a review of 23 sampled residents. The facility census was 70. Review of the facility policy for bathing, revised April 2023, showed all residents received a bath or a shower in accordance with their preferences. If the residents do not provide a preference, staff will offer a bath or a shower.1. Review of Resident #4's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff), dated 3/30/26, showed the following:-Alert and oriented and able to make decisions;-Dependent on staff for bathing.Review of the resident's medical record showed no documentation regarding the resident's preference for bathing/showers and no documentation to show how frequently the resident was to receive bathing/showers.Review of the resident's Point of Care (POC, a place in the resident's electronic medical record where staff document when bathing occurred) response history for bathing, dated 03/16/26 through 04/16/26, showed the resident received a shower/bath on 03/20/26 and 04/03/26. (Review showed no documentation the resident received a bath or shower on any other date in the 30-day period.)During an interview on 04/16/26 at 11:30 A.M., the resident said the following:-He/She had not had a shower in several weeks;-He/She would like to have a shower at least two times per week;-There were not enough staff to give him/her a shower.Observation on 04/16/26 at 11:30 A.M. showed the resident had a slight body odor. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed the following:-Alert and oriented and able to make decisions;-Dependent on staff for bathing.Review of the resident's medical record showed no documentation regarding the resident's preference for bathing/showers and no documentation to show how frequently the resident was to receive bathing/showers.Review of the resident's POC response history for bathing, dated 03/16/26 through 04/16/26, showed the resident received a bath on 03/21/26. (Review showed no documentation the resident received a bath or shower on any other date in the 30-day period.)During an interview on 04/16/26 at 11:35 A.M., the resident said the following:-He/She had not had a shower or a bed bath in a long time. He/She did not remember the last time he/she had a bath;-He/She would like to have a bath at least two times a week.Observation on 04/16/26 at 11:35 A.M. showed the resident's hair appeared disheveled and slightly greasy. The resident had a slight body odor.3. Review of Resident #6's quarterly MDS, dated [DATE], showed the following:-Alert and oriented and able to make decisions;-Dependent on staff for bathing.Review of the resident's medical record showed no documentation regarding the resident's preference for bathing/showers and no documentation to show how frequently the resident was to receive bathing/showers.Review of the resident's POC response history for bathing, dated 03/16/26 through 04/16/26, showed the resident received a shower on 03/20/26, 03/24/26 and 04/03/26. (Review showed no documentation the resident received a bath or shower on any other date in the 30-day period.)During an interview on 04/16/26 at 11:35 A.M. the resident said he/she would like to have a shower at least two times a week.Observation on 04/16/26 at 11:35 A.M. showed the resident had body odor and his/her hair was disheveled and greasy.4. During an interview on 04/16/26 at 11:37A.M., Licensed Practical Nurse (LPN) A there was only one aide for the hall where Residents #4, #5 and #6 resided and it was difficult to get the residents' care completed. The aides did not have time to give showers as often as the residents wished. It had been a while since staff were able to give residents two showers a week. During an interview on 04/16/26 at 1:30 P.M., the Regional Director of Clinical Services said the following:-The residents had not received showers as they should or as they desired;-She expect the residents to receive their showers.During an interview on 04/16/26 at 12:45 A.M. the Director of Nursing said he expected the residents to receive at least two showers per week.2985624

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the residents' needs for ten residents (Residents #4, #5, #6, #2, #4, #8, #7, #10, #12 and #1), in a review of 23 sampled residents. Staff failed to provide routine showers for three residents (Residents #4, #5 and #6) to ensure good personal hygiene, failed to provide supervision while eating for three residents (Residents #2, #4, and #8) as directed in their plan of care, failed to assist three residents (Residents #7, #10 and #12) timely with a breakfast meal, failed to administer medications timely for one resident (Resident #1), and failed to ensure the Director of Nursing (DON) did not function as a charge nurse when the facility census was greater than 60. The facility census was 70. Review of the unsigned Facility Assessment, dated 6/21/24, showed the following:-Ember and [NAME] hallways: Staffing is adjusted dependent on the volume of the unit for short-term patients with a focus on continuity of care. Additionally, acuity and care needs are considered. Staffing levels are provided that allow for adequate direct services provision to patients. This unit generally has a larger population of short-term residents with higher acuities that require increased staffing and needs compared to Sparkle Unit;-The facility did not identify the number of nursing personnel that would be required to provide the care and services to meet the needs of the residents. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff), dated 3/30/26, showed the following:-Alert and oriented and able to make decisions;-Dependent on staff for bathing. Review of the resident's Point of Care (POC, a place in the resident's electronic medical record where staff document when bathing occurred) response history for bathing, dated 03/16/26 through 04/16/26, showed the resident received a shower/bath on 03/20/26 and 04/03/26. (Review showed no documentation the resident received a bath or shower on any other date in the 30-day period.) During an interview on 04/16/26 at 11:30 A.M., the resident said the following:-He/She had not had a shower in several weeks;-He/She would like to have a shower at least two times per week;-There were not enough staff to give him/her a shower. Observation on 04/16/26 at 11:30 A.M. showed the resident had a slight body odor. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed the following:-Alert and oriented and able to make decisions;-Dependent on staff for bathing. Review of the resident's POC response history for bathing, dated 03/16/26 through 04/16/26, showed the resident received a bath on 03/21/26. (Review showed no documentation the resident received a bath or shower on any other date in the 30-day period.) During an interview on 04/16/26 at 11:35 A.M., the resident said the following:-He/She had not had a shower or a bed bath in a long time. He/She did not remember the last time he/she had a bath;-He/She would like to have a bath at least two times a week. Observation on 04/16/26 at 11:35 A.M. showed the resident's hair was disheveled and slightly greasy. The resident had a slight body odor. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed the following:-Alert and oriented and able to make decisions;-Dependent on staff for bathing. Review of the resident's POC response history for bathing, dated 03/16/26 through 04/16/26, showed the resident received a shower on 03/20/26, 03/24/26 and 04/03/26. (Review showed no documentation the resident received a bath or shower on any other date in the 30-day period.) During an interview on 04/16/26 at 11:35 A.M., the resident said he/she would like to have a shower at least two times a week. Observation on 04/16/26 at 11:35 A.M. showed the resident had body odor, and his/her hair was disheveled and greasy. 4. During an interview on 04/16/26 at 11:37A.M., Licensed Practical Nurse (LPN) A there was only one aide for the hall where Residents #4, #5 and #6 resided and it was difficult to get the residents' care completed. The aides did not have time to give showers as often as the residents wished. It had been a while since staff were able to give residents two showers a week. During an interview on 04/16/26 at 1:30 P.M., the Regional Director of Clinical Services said the following:-The residents on the Sparkle hall had not received showers as they should or as they desired;-There should be enough staff to provide care to the residents and for residents to receive their showers. During an interview on 04/16/26 at 12:45 A.M., the Director of Nursing said he expected the residents to receive at least two showers per week. 5. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:-Unable to make decisions;-Required supervision with eating. Review of the resident's care plan, dated 10/20/25, showed the following:-The resident had performance deficits and limitations in physical mobility;- The resident required staff supervision or touching assistance with eating. Review of the resident's care plan, dated 10/22/25, showed the following:-At risk for swallowing problem related to dysphagia (difficulty swallowing) from stroke and at risk for aspiration (when something, other than air, enters into the airway);-Instruct the resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly; -Monitor for shortness of breath, choking, labored respirations, or lung congestion;-Monitor/document/report as needed any signs or symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, making several attempts at swallowing, refusing to eat, or appears concerned during meals. Review of the residents' physician order sheet (POS), dated April 2026, showed an order for mechanical soft, ground texture, nectar consistency. Observation on 04/14/26 at 5:30 P.M. to 6:22 P.M. on the Sparkle hall showed:-Ten residents, including Resident #2, sat in the dining room;-A dietary aide served the residents' meal trays from the kitchen area;-There were no direct care staff in the dining room during the entire observation period;-Several staff walked by the dining room, but no staff provided supervision for the resident as directed in his/her care plan;-The resident ate his/her meal unsupervised. 6. Review of Resident #4's care plan, dated 10/25/25, showed the following:- The resident has a swallowing problem related to edentulous (without teeth) status without dentures;-Diet to be followed as prescribed. Encourage and assist resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Monitor for shortness of breath, choking, labored respirations, lung congestion;-Monitor/document/report as needed any signs or symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals;-Resident to eat with supervision. Review of the residents POS, dated April 2026, showed a diet order of regular texture, cut food into bite size pieces, and staff to supervise the resident while eating. Observation on 04/14/26 at 5:30 P.M. on the Sparkle hall showed the dietary aide served the resident a grilled cheese sandwich and a bowl of soup. The grilled cheese sandwich was not cut up into little pieces as ordered on the resident's POS. Observation on 04/14/26 from 5:30 P.M. to 6:22 P.M. on the Sparkle hall showed the following:-Ten residents, including Resident #4, sat in the dining room;-A dietary aide served the residents' meal trays from the kitchen area;-There were no staff in the dining room during the entire observation period;-Several staff walked by the dining room, but no staff provided supervision for the resident;-The resident ate his/her meal unsupervised. 7. Review of Resident #8's quarterly MDS, dated [DATE], showed the following:-Unable to make decisions;-Required supervision with eating. Review of the resident's POS, dated April 2026, showed an order for mechanical soft diet with ground meat and nectar thickened liquids. Review of the resident's care plan, dated 03/18/25, showed the following:-The resident had ADL self-care performance deficits and limitations in physical mobility;-The resident required staff supervision or touching assistance with eating. Observation on 04/14/26 at 7:30 A.M. to 8:30 A.M. showed the resident sat alone in the main dining room with a breakfast tray of oatmeal, a slice of bacon, muffin and a glass of juice. No staff were in the dining room to supervise the resident as directed in the resident's plan of care. 8. Observation on 04/15/26 at 7:20 A.M. showed one nurse and one certified nurse assistant (CNA) on the [NAME] rehab hall for 28 residents. During an interview on 04/15/26 at 7:20 A.M., Licensed Practical Nurse (LPN) D said he/she was the only nurse for the [NAME] hall, and CNA B was the only aide for the [NAME] hall. Observation on 04/15/26 at 7:25 A.M. showed a dietary staff began to pass meal trays to the residents on the west end of the [NAME] hall. The dietary staff took the trays off the dietary cart and placed the trays onto the residents' over-the-bed tables in their rooms and then exited the rooms. Observation on 04/15/26 at 7:35 A.M. showed a dietary staff brought the food cart for the east end of the [NAME] hall and then left the hall. The food cart sat on the hall untouched for 10 minutes until 7:45 A.M when the Business Office Manager (BOM) began to pass the trays to the residents and placed the tray on the residents' over-the-bed tables. 9. Review of Resident #7's quarterly MDS, dated [DATE], showed the following:-Alert and oriented with some difficulty making decisions;-Required staff supervision with eating. Observation on 04/15/26 showed the following:-At 7:43 A.M. on the [NAME] hall, the dietary staff entered the resident's room and sat the breakfast tray on the over-the-bed table. The resident was asleep in bed;-At 8:18 A.M. and at 8:35 A.M., the resident lay in bed with his/her eyes closed, and the uncovered breakfast tray sat on his/her over the bed table;-At 8:38 A.M. (55 minutes after staff delivered the resident's meal tray to the resident), CNA B entered the resident's room. The resident was awake in bed. CNA B raised the resident up in the bed, brought the over-the-bed table to the resident, and removed the cover from the food. The resident had a bowl of oatmeal, a scrambled egg, muffin, and a slice of bacon. CNA B handed the resident a glass of juice to drink. The resident took a bite of the muffin. CNA B then exited the room. 10. Review of Resident #10's care plan, dated 04/15/26, showed he/she required setup or clean-up assistance with eating. Observations on 04/15/26 showed the following:-At 7:40 A.M., the dietary staff entered the resident's room on the [NAME] hall and sat the breakfast tray on the over-the-bed table. The resident was asleep in bed;-At 8:18 A.M. and at 8:35 A.M., the resident was in bed with his/her eyes closed, and the uncovered breakfast tray sat on the over-the-bed table;-At 8:44 A.M. (an hour and four minutes after staff delivered the meal tray to the resident), three family members were in the resident's room. The resident's breakfast tray was on the over-the-bed table. A family member raised the head of the bed and then brought the breakfast tray of a muffin, bowl of oatmeal, a slice of bacon and a small glass of juice to the resident. The resident picked up the muffin and took a bite. Family Member A said he/she had not seen a staff member on the hall and wondered why the resident had not had breakfast yet. 11. Review of Resident #12's comprehensive MDS, dated [DATE], showed the resident required supervision with eating. Review of the resident's POS, dated April 2026, showed an order for a regular diet and to cut food up into bite size pieces. Observation on 04/15/26 at 7:48 A.M. showed the BOM entered the resident's room on the [NAME] hall and sat the breakfast tray on the over-the-bed table. The resident was asleep in bed. During an interview on 04/15/26 at 7:45 A.M., the BOM said he/she was not a CNA or a nurse and he/she could only pass the meal tray to the resident. He/She had to leave the food tray in the resident's room, and then nursing staff would assist the resident. Observation on 04/15/26 at 8:13 A.M. (30 minutes after staff delivered the meal tray to the resident) showed CNA B entered the resident's room. The resident was awake in bed. The resident's breakfast tray sat on the over-the-bed table where the resident could not reach the food. CNA B assisted the resident to sit up in the bed, brought the breakfast tray containing oatmeal, a slice of bacon and a muffin to the resident, and began to assist the resident to eat the meal. During an interview on 04/15/26 at 9:00 A.M., CNA B said the following:-He/She was the only aide on the floor (Ember hall) since 6:30 A.M.;-He/She answered call lights, took residents to the bathroom when he/she could, and helped the residents with breakfast;-There was a lot to do for one staff;-He/She was doing the best he/she could. 12. Observation at 04/15/26 at 11:45 A.M. showed LPN D passed medications on the west end of the [NAME] hall. During an interview on 04/15/26 at 11:45 A.M., LPN D said he/she had not completed the morning medication pass. He/She would not be done administering the morning medications before it was time to pass the medications scheduled to be given at 12:00 P.M. Review of Resident #1's physician orders sheets (POS), dated April 2026, showed the following:-Azithromycin (an antibiotic medication) 250 milligrams (mg), give enterally (administered through a tube inserted through the abdomen and into the stomach) one time a day every Monday, Wednesday, and Friday;-Dapagliflozin propanediol (a medication used to treat diabetes) 5 mg, give enterally one time a day for diabetes;-Omeprazole (an antiacid medication) 20 mg, give one tablet enterally in the morning; -Roflumilast (a medication used to treat chronic obstructive pulmonary disease by reducing airway inflammation) 500 microgram (mcg) tablet, give 250 mcg by mouth one time a day;-Metoprolol tartrate (a medication used to treat high blood pressure) 25 mg, give one tablet enterally two times a day. Review of the resident's Medication Administration Record (MAR), dated April 2026, showed the following:-Azithromycin 250 mg, give enterally one time a day every Monday, Wednesday, and Friday in the A.M.;-Dapagliflozin 5 mg, give enterally one time a day in the AM;-Omeprazole 20 mg, give enterally in the morning;-Roflumilast 500 mcg tablet, give 250 mcg by mouth one time a day in the AM;-Metoprolol tartrate 25 mg, give two times a day in the AM and PM. Observation on 04/15/26 at 11:55 A.M. showed the following:-LPN D administered azithromycin, dapagliflozin, roflumilast, metoprolol, and omeprazole via the resident's enteral tube (tube inserted into the resident's abdomen). During an interview on 04/15/26 at 12:10 P.M., LPN D said he/she just administered the resident's morning medications and still had several residents' medications to administer from this morning. During an interview on 04/16/26 at 12:15 P.M., LPN D said the following:-Yesterday, 04/15/26, it was after 1:00 P.M. before he/she was able to administer all the residents' morning medications; -The residents who had medications scheduled more than one time a day received their medications late all day;-He/She should have notified the physician of the medications being late, but he/she did not have the time. 13. Observation on 04/14/26 at 4:19 P.M. showed the Director of Nursing (DON) conducted performed blood finger sticks on residents on the Sparkle hall. During an interview on 04/14/26 at 4:19 P.M., the DON said the following:-He worked at the facility for a couple of weeks;-He worked as a nurse on the floor several shifts, including the day shift for that day (4/14/26), due to the scheduled nurse calling off work. No other nurses would come in to work. During an interview on 04/14/26 at 8:40 A.M., the Staffing Coordinator said the following:-There should be at least two nurses, two CNAs, and one Certified Medication Technician (CMT) on the [NAME] and Kindle halls, and one nurse and two aides on the Sparkle hall;-Several staff called off work that morning (4/14/26), and one staff, who was in training, left work, leaving the facility short-staffed;-He/She had been working on getting staff to come in to cover the call offs. -The shower aides had to be re-assigned to provide care on the floor, so the aides needed to give the showers to the residents on their halls. During an interview on 04/16/26 at 12:45 P.M., the DON said the following:-He was not aware he could not work the floor if the facility census was over 60;-The census had been over 60 since he started working at the facility;-He expected a staff member in the dining room at all times when residents were eating;-He expected enough staff on the floor to meet the residents' needs;-There should be at least a nurse on each hall and two to three aides on each hall;-He was not aware there was only one nurse and one aide on the [NAME] hall for the morning on 04/15/26. During an interview on 04/16/26 at 1:20 P.M. the Administrator said he expected there to be enough staff to meet the residents' needs. MO2966660MO2969159MO2969176MO2969487MO2970613MO2971146MO2985624MO2979335

Based on observation, interview, and record review, the facility failed to secure medications behind at least one locked door or cabinet when staff left medications unattended on the nurses station and treatment cart and failed to lock treatment and medication carts when unattended. The facility failed to secure medications for one resident (Resident #9), in a review of 18 sampled residents. The facility census was 77. Review of the undated facility policy, Medication Labeling and Storage, showed medications and biologicals in medication rooms, carts, boxes and refrigerators are maintained within secured (locked) locations, accessible only to designated staff. Review of the facility policy, Administration of Medications, revised April 2023, showed to never leave the medication cart open and unattended. 1. Observation on 2/23/26 at 7:35 P.M., showed the following:-Eighteen medication cards were stacked on top of the desk at the nurses station; -Five medication bottles sat unattended on top of the treatment cart at the nurse's station; -The treatment cart was not in use and was in front of the nurse's station counter easily accessible to residents and visitors;-Residents and visitors walked past the nurse's station and treatment cart;-No staff was in the area or in line of sight of the unsecured medications. Observation on 2/23/26 at 7:44 P.M., showed the following:-Eighteen medication cards lay on the desk at the nurse's station;-Five medication bottles sat on top of the treatment cart at the nurse's station;-No staff was in the area or in line of sight of the unsecured medications;-One resident and his/her visitors walked past the unattended medications at the nurse's station. Observation on 2/23/26 at 7:47 P.M., showed Licensed Practical Nurse (LPN) B put the 18 medication cards from the nurse's station desk and the five medications from on top of the treatment cart in the locked medication room. During interview on 2/23/26 at 7:47 P.M., LPN B said the following:-Medications were not to be left unlocked or unattended;-The 18 medication cards on the desk at the nurse's station and the five medications on top of the treatment cart had been there since 6:45 P.M. when the pharmacy delivered them to the facility;-He/She had not had time to put the medications away. Observation on 2/24/26 at 6:15 A.M. showed the following:-The treatment cart, which contained medications, was unlocked at the nurse's station;-No staff was at the nurse's station or in line of sight of the treatment cart. Observation on 2/24/26 at 6:24 A.M., showed the following:-The treatment cart, which contained medications, and the medication cart were unlocked at the nurse's station;-No staff was at the nurse's station or in line of sight of the treatment and medication carts. During interview on 2/24/26 at 6:28 A.M., LPN B, who was responsible for passing medications and completing treatments on the night shift on 2/24/26, said staff were to lock medication and treatment carts when the carts were unattended. Observation on 2/24/26 at 6:36 A.M., Registered Nurse (RN) C locked the medication cart and treatment cart at the nurse's station. During interview on 2/24/26 at 6:40 A.M. and 7:31 A.M., Registered Nurse (RN) C said the following:-Staff should always lock medication and treatment carts when the carts were unattended;-He/She locked the medication and treatment carts at the nurse's station when he/she arrived at the facility (on 2/24/26);-Staff should never leave medications unattended at the nurse's station or on a medication or treatment cart. During an interview on 2/24/26 at 5:10 P.M., the Director of Nursing (DON) said the following:-Staff should lock the medication carts and treatment carts when they left the carts unattended; -Staff was not to leave medications unattended on the counter at the nurse's station;-Staff should secure the medications with a lock when they received the medications from the pharmacy. During an interview on 2/24/26 15 5:10 P.M., the Administrator said he expected staff to lock medication carts and treatment carts when they left them unattended. 2. Review of Resident #9's undated Face Sheet showed the resident's diagnoses included influenza A virus with pneumonia (highly contagious respiratory virus), bacterial pneumonia, chronic obstructive pulmonary disease (COPD; a condition caused by damage to the lung and airway that restricts breathing), and acute respiratory failure with hypoxia (low oxygen) and hypercapnia (elevated carbon dioxide in the blood). Review of the resident's nurse's notes, dated 2/23/26, showed the resident admitted to the facility from the hospital. During an interview on 2/23/26 at 8:05 P.M., the resident said the following:-He/She was admitted to the facility today at 4:00 P.M.;-He/She had inhalers at his/her bedside and self-administered them;-He/She brought the inhalers to the facility from his/her home. During interview on 2/24/26 at 11:10 A.M., Licensed Practical Nurse (LPN) A said the following: -He/She was not aware the resident had prescription inhalers at his/her bedside;-The prescription inhalers were not supposed to be at the bedside without an order to self-administer the medication. Observation on 2/24/26 at 11:00 A.M., showed the following:-Four prescription inhalers lay at the foot of the resident's bed on top of the covers.-The four inhalers included one tiotropium inhaler (inhaled medication to treat chronic obstructive pulmonary disease (COPD) and asthma), one albuterol inhaler (inhaled medication to treat or prevent bronchospasms), and two Arnuity inhalers (inhaled medication to treat asthma). Review of the resident's Physician's Orders, dated February 2026, showed the following: -An order for fluticasone furoate inhalation aerosol powder breath verbal activated 100 mcg, inhale one puff orally one time a day for shortness of breath;-No physician order for tiotropium inhaler and albuterol inhaler; -No physician order to keep medications at the resident's bedside. During interview on 2/24/26 at 5:10 P.M., the interim DON said the following: -Staff had to assess residents prior to residents administering their own medications, and staff had to obtain an order for a resident to self-administer the medications; -She was not aware the resident had inhalers at his/her bedside;-Even if a resident had an order to self-administer, the medications should be kept in a secure location and not on the resident's bed. 3. During an interview on 03/09/26 at 10:00 A.M., the Medical Director said staff should secure all medications behind at least one locked door or drawer. 2731445

Based on observation, interview, and record review, the facility failed to ensure the necessary equipment was available, upon admission, for one resident (Resident #9), in a review of 23 sampled residents, to safely transfer the resident in/out of bed and to complete bathing and toileting needs. The facility census was 70. The facility did not provide policies related to accommodation of needs and equipment to meet the residents' needs. 1. Review of Resident #9's undated face sheet showed the resident admitted to the facility on [DATE] with a diagnosis of morbid obesity. Review of the resident's hospital discharge records, dated 04/14/26, showed on 03/27/26 the resident weighed 574 pounds. Observation on 04/15/26 at 8:30 A.M. in the resident's room showed the following:-The resident had a bariatric wheelchair that measured 35 inches across the seat of the wheelchair. The wheelchair would not fit through the door to the bathroom in the resident's room;-The resident had a regular sized bed pan. During an interview on 04/15/26 at 10:47 A.M., the resident said the following: -He/She had not been out of bed since admitted on [DATE];-He/She was not able to bear enough weight on his/her legs to walk;-He/She thought he/she could pivot, but had not tried to do so, and therapy staff had not been in to evaluate him/her;-The bed pan the facility provided was not large enough and urine spilled onto the bed when he/she used the bed pan. Observation on 04/15/26 at 2:00 P.M. showed the following:-The main shower room doors on the [NAME] and Kindle hallways measured 37 inches wide. The resident's wheelchair measured 35 inches across the seat, not including the wheels. The wheelchair would not fit into the shower room doors;-There were no bariatric shower chairs in either shower room. Observation on 04/15/26 at 3:45 P.M. showed the following:-The Assistant Administrator and Certified Nurse Assistant (CNA) B placed the resident on the mechanical lift pad and hooked the lift pad to the mechanical lift;-The mechanical lift would not lift the resident off the bed;-The Assistant Administrator said the battery for the lift was dead, and it would take several hours to charge the battery;-The staff attempted to push the resident's wheelchair into the bathroom in the resident's room and the wheelchair would not fit through the door. During an interview on 04/16/25 at 1:20 P.M., the Administrator said the following:-Regional staff read the resident's medical documentation prior to admission and determined the facility could meet the resident's needs;-Staff ordered equipment for the resident before his/her admission;-The wheelchair and the mechanical lift were not delivered until the day after the resident was admitted ;-Staff should have charged the battery on the mechanical lift when it was delivered;-He did not realize the resident's wheelchair would not fit into the bathroom or the shower room doors and there was not a shower chair large enough in the facility for the resident to use.

Based on interview and record review, the facility failed to notify two residents' physician or family of a change in the residents' condition. Staff failed to notify Resident #17's physician when staff did not obtain daily weights as ordered, failed to notify the physician of weight gain as directed by the physician's ordered parameters, and failed to notify the physician when the resident's diuretic medication was unavailable for administration. Staff failed to notify Resident #15's family when the resident was transferred to the emergency department for treatment of hypoglycemia (low blood sugar). This deficient practice affected two out of 23 sampled residents. The facility census was 70. Review of the facility policy, Change in Resident Condition, revised April 2023, showed the following:-Should there be a change in the resident's physical, mental or emotional status, the attending physician should be notified;-Documentation will be present in the resident's record. 1. Review of Resident #17's care plan, dated 2/12/26, showed the following:-Diagnoses of cardiac pacemaker (implanted device to regulate the electrical system in the heart), ischemic cardiomyopathy (weakened heart muscle), atrial fibrillation (irregular heart rate), hypertension (high blood pressure), chronic congestive heart failure (CHF), and history of heart attack;-The resident had potential for alterations in nutrition and hydration. Staff should evaluate any weight changes, monitor for decreased urine output and signs of dehydration. Weigh the resident and document weights per physician orders;-Staff should administer medications as ordered. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/12/26, showed the resident weighed 170 pounds. Review of the resident's physician progress note, dated 3/04/26, showed the following:-admitted to the facility following hospitalization for CHF exacerbation (recurrence of symptoms) and acute chronic kidney disease. The resident was managed with intravenous (IV, medications given through the vein) diuretics previously with stabilization and transfer to rehabilitation for therapy services;-Still had leg edema, 1 + pitting (measurement of the accumulation of excess fluid in the tissue, commonly the legs, ankles or feet, that left a lasting indentation (pit) after pressure was applied. The higher the number the greater the swelling) to lower legs;-Monitor intake and output (amount of fluid intake and amount of urine output), daily weights and assess need for diuretics based on current volume status;-Add compression stockings (tight stockings applied to force excess fluid from tissues into circulation) daily and keep legs elevated;-Lasix (diuretic medication) increased to 40 milligrams (mg) daily. Review of the resident's medical record showed on 3/04/26 staff documented the resident weighed 175 pounds. Review of the resident's Physician Order Sheet (POS), dated 3/06/26, showed an order for daily weights to monitor fluid retention. Notify the physician of greater than 2-pound weight gain in 24 hours or 5 pounds in one week. Review of the resident's medical record showed the following:-On 3/06/26 and 3/07/26, staff did not document the resident's weight;-On 3/08/26, staff documented the resident weighed 191 pounds (16-pound weight gain since 3/04/26). Review of the resident's medical record showed no documentation staff notified the resident's physician on 3/08/26 of the 16-pound weight gain. Review of the resident's POS, dated 03/13/26, showed Lasix 40 mg twice daily for congestive heart failure. Review of the resident's medical record showed staff documented the following:-On 3/14/26, the resident weighed 177.8 pounds;-On 3/15/26, the resident weighed 181.5 pounds (3.7-pound weight gain in one day). Review of the resident's medical record showed no documentation staff notified the resident's physician on 3/15/26 of a 3.7-pound weight gain in one day. Review of the resident's medical record showed on 3/16/26, the resident weighed 184.5 pounds (a 3-pound weight gain in one day and a 6.7-pound weight gain in two days). Review of the resident's medical record showed no documentation staff notified the resident's physician on 3/16/26 of a 3-pound weight gain in one day and a 6.7-pound weight gain in two days. Review of the resident's nurse's note, dated 3/27/26 at 11:35 A.M., showed staff spoke with cardiology and was instructed to discontinue Lasix. Torsemide 40 mg twice daily replaced Lasix. Review of the resident's medication administration record (MAR), dated 3/28/26, showed no documentation staff administered torsemide 40 mg twice daily. Review of the resident's nurses' note, dated 3/28/26 at 10:39 A.M., showed torsemide 40 mg medication was not available for administration. Review of the resident's MAR, dated 3/29/26, showed no documentation staff administered torsemide 40 mg in the morning. Review of the resident's nurses' note, dated 3/29/26 at 9:00 A.M., showed torsemide 40 mg was not available and on order. Review of the resident's MAR, dated 3/30/26, showed no documentation staff administered torsemide 40 mg twice daily. Review of the resident's nurses' note, dated 3/30/26 at 8:35 A.M., showed torsemide 40 mg medication was not available and on order. Review of the resident's MAR, dated 3/31/26, showed no documentation staff administered torsemide 40 mg twice daily. Review of the resident's nurses' note, dated 3/31/26 at 9:24 A.M., showed torsemide 40 mg medication was not available and on order. Review of the resident's MAR, dated 4/01/26, showed no documentation staff administered torsemide 40 mg twice daily. Review of the resident's nurses' note, dated 4/1/26 at 1:34 P.M., showed torsemide 40 mg medication was not available and on order. Review of the resident's MAR, dated 4/2/26, showed no documentation staff administered torsemide 40 mg twice daily. Review of the resident's nurses' note, dated 4/02/26 at 9:01 A.M., showed torsemide 40 mg medication was not available and on order. Review of the resident's MAR, dated 4/04/26, showed no documentation staff administered torsemide 40 mg twice daily for CHF. Review of the resident's medical record showed no documentation staff notified the resident's physician when the torsemide was unavailable and/or not administered on 3/28/26 through 4/04/26. During an interview on 4/15/26 at 10:30 A.M., the resident's physician said staff should notify the physician if orders were not followed or completed. Staff did not make him aware the torsemide 40 mg was not administered as ordered. Staff should document if medication were not available or not given and notify the physician for alternate medications or orders. 2. Review of Resident #15's care plan, dated 3/02/26, showed the following:-Diagnosis of diabetes;-The resident received insulin (a hormone produced by the pancreas that regulates blood sugar levels);-Staff should monitor blood glucose levels as ordered by the physician and monitor, document and report adverse effects including hypoglycemia (low blood glucose levels). Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-The resident took insulin daily. Review of the resident's POS, dated 3/02/26, showed the following:-Lantus (long-acting insulin used to treat diabetes) 100 unit/milliliter (ml), inject 36 units subcutaneously (under the skin) in the morning. Notify the physician of blood glucose less than 70 or greater than 350;-Novolog (short acting insulin used to treat diabetes) 100 unit/ml, inject 6 units subcutaneously with meals three times daily. Hold for blood glucose less than 70. Notify physician of blood sugar less than 70 or greater than 350;-Novolog 100 unit/ml, sliding scale insulin (SSI, additional insulin administered based on the current blood glucose level). For blood glucose 150-200, administer 2 units; 201-250, administer 4 units; 251-300, administer 6 units; 301-350, administer 8 units. Review of the resident's MAR, dated 3/30/26, showed Licensed Practical Nurse (LPN) F documented at 4:30 P.M., the resident's blood glucose was 26. Novolog 6 units not administered, Novolog SSI not administered. Review of the resident's nurses' note, dated 3/30/26 at 3:41 P.M., showed LPN F documented the resident's blood sugar was critically low at 26. The resident was cool and clammy. Staff administered glucose gel (sugar in the form of gel used to treat low blood glucose level) and rechecked the resident's blood glucose with results of 27. Glucagon (injectable glucose) administered with increase of blood glucose to 30. Staff notified the physician of the resident's condition and status. Orders received to administer an additional dose of glucagon if blood glucose did not sufficiently improve and transfer to the emergency department if no significant response. Additional glucagon administered per physician orders, final blood glucose reading was 38. The resident was sent to the hospital. Review of the resident's medical record showed no documentation the facility notified the resident's family or responsible party of the resident's low blood sugar and transfer to the hospital. During an interview on 4/14/26 at 5:15 P.M., LPN F said on 3/30/26 the resident's blood sugar was low. Staff administered two doses of glucagon as ordered by the physician with no immediate improvement in the resident's blood sugar or responsiveness. The physician gave orders to send the resident to the emergency department by ambulance. Staff called EMS, and the resident was transported to the hospital. He/She should have notified the resident's family of the resident's condition and the resident being transferred to the hospital. During an interview on 4/24/26 at 7:45 A.M., the resident's family member and Power of Attorney (POA) said he/she was not aware the resident's blood glucose level was low on 3/30/26 and staff transferred the resident to the emergency department by ambulance. No staff called and informed him/her of the resident's condition. Staff called him/her on 3/30/26 at 10:30 P.M. when the resident was on the way back to the facility from the hospital. The resident had dementia and was confused. No family was with the resident at the emergency department to calm him/her or help the resident. The facility nurse (unknown name) said he/she was busy and did not have time to call the family when the resident's blood glucose dropped, and the resident was sent to the emergency department by ambulance. 3. During an interview on 4/16/26 at 7:15 A.M., LPN L said staff should notify the resident's physician of any changes in the resident's condition. Staff should notify the physician if staff did not administer medications as ordered or medications were not available. Staff should follow the physician's orders. During an interview on 4/16/26 at 12:35 P.M., the Director of Nursing (DON) said staff should follow physician orders, notify the physician if weights were outside ordered parameters, and document all communication with the physician in the resident's medical record. If medications are not administered, staff should notify the resident's physician. Staff should notify family or responsible party of any change in the resident's condition, transfers to the hospital and any incidents or accidents, and document all communication with the family in the resident's medical record. During an interview on 4/16/26 at 1:20 P.M., the Administrator said staff should notify the physician as ordered and document communication with the physician in the resident's medical record. Staff should notify the physician if medications were not administered as ordered. Staff should notify family or responsible party of the resident's change in condition, change in treatment and transport to the emergency department. Staff should document all communication in the resident's medical record. MO 2969497

Based on observation, interview, and record review, the facility failed to ensure staff administered medications as ordered on admission for two residents (Resident #2 and #9), in a review of 18 sampled residents. The facility census was 77. The facility did not provide a policy related to obtaining newly ordered medications from the pharmacy or procedures to follow when the medications were not available. 1. Review of Resident #2's Face Sheet showed the resident's diagnoses included Type 2 diabetes mellitus, pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus) and coronavirus (COVID; highly contagious respiratory virus). Review of the resident's January 2026 Physician Order Sheet (POS) showed an order for stat (immediate) chest x-ray one time for shortness of breath and hypoxia (low oxygen levels) (ordered 1/13/26). Review of the resident's Progress Notes, dated 1/13/26, showed the following:-Chest x-ray results received and showed pneumonia;-Doxycycline (antibiotic) 100 milligrams (mg) twice a day (BID) for five days;-Augmentin (antibiotic) 500/125 mg daily for five days. Review of the resident's January 2026 POS, dated 1/13/26, showed the following:-Augmentin 500-125 mg, give one tablet one time a day for pneumonia for five days;-Doxycycline hyclate 100 mg, give one tablet two times a day for pneumonia for five days. Review of the resident's January 2026 Medication Administration Record (MAR) showed the order for Augmentin and doxycoycline hyclate was dated 1/13/26 at 4:30 P.M. Review showed no documentation staff administered the Augmentin and doxycycline hyclate on 1/13/26. Review of the facility's emergency medication supply inventory list, undated, showed the following medications available for use:-Augmentin 500/125 mg, quantity of seven.-Doxycycline 100 mg, quantity of four. Review of the resident's Progress Notes, dated 1/13/26, showed no documentation staff notified the resident's physician or the pharmacy when the medications were not available. 2. Review of Resident #9's undated Face Sheet showed the resident's diagnoses included influenza A virus with pneumonia (highly contagious respiratory virus), bacterial pneumonia, chronic obstructive pulmonary disease (COPD; a condition caused by damage to the lung and airway that restricts breathing), acute respiratory failure with hypoxia and hypercapnia (elevated carbon dioxide in the blood), and chronic atrial fibrillation (irregular heart rate). Review of the resident's nurse's notes, dated 2/23/26, showed the resident was admitted to the facility from the hospital. Review of the resident's hospital discharge orders, dated 2/23/26, showed the following: -Atorvastatin (medication used to treat high cholesterol) 80 milligrams (mg) at bedtime. Next dose due at bedtime on 2/23/26;-Eliquis (blood thinning medication) 5 mg two times a day. Next dose due evening 2/23/26;-Metoprolol (blood pressure medication) 25 mg, take 1/2 tab (12.5 mg total) two times a day. Next dose due at bedtime on 2/23/26; -Nystatin suspension (antifungal medication) 100,000 unit/ml, give 5 milliliters (ml) four times a day for antifungal for seven days. Next doses due evening and bedtime on 2/23/26;-Ipratropium-Albuterol (DuoNeb; inhaled medication used to treat bronchospasm) 0.5-2.5 milligrams (mg)/3 milliliters (ml) nebulizer solution, take 3 ml every six hours. Last dose given on 2/23/25 at 7:32 A.M. Next dose: nebulizer every six hours. Review of the resident's POS, dated 2/23/26, showed the following:-Atorvastatin calcium 80 mg, give one tablet by mouth at bedtime;-Eliquis 5 mg, give one tablet by mouth two times a day; -Metoprolol tartrate 25 mg, give 12.5 mg by mouth two times a day;-Nystatin mouth/throat suspension (antifungal medication) 100,000 unit/ml, give 5 ml four times a day for antifungal for seven days;-Ipratropium-Albuterol 0.5-2.5 mg/ml, 3 ml inhale four times a day for shortness of breath. During an interview on 2/23/26 at 8:05 P.M., the resident said he/she admitted to the facility at 4:00 P.M. today. Review of the resident's MAR, dated 2/23/26, showed the following:-Staff did not administer atorvastatin 80 mg at bedtime (ordered for bedtime); -Staff did not administer Eliquis 5 mg tablet at bedtime (ordered for morning and bedtime);-Staff did not administer metoprolol tartrate 12.5 mg at bedtime (ordered for morning and bedtime);-Staff did not administer nystatin mouth/throat suspension 100,000 unit/ml at 4:00 P.M. and 8:00 P.M. (ordered for 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.);-Staff did not administer DuoNeb Solution 0.5-2.5 mg/ml 3 ml at 8:00 P.M. (ordered for 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Review of the facility's emergency medication supply inventory list, undated, showed the following medications available for use: -Eliquis 5 mg, quantity of one;-Metoprolol 25 mg, quantity of three. During an interview on 2/24/26 at 6:20 P.M., the resident said he/she did not get his/her bedtime medications last night because the facility did not have the medications. During interviews on 2/24/26 at 6:00 A.M. and 6:28 A.M., Licensed Practical Nurse (LPN) B said the following:-The pharmacy delivered the resident's medications this morning (2/24/26) before 6:00 A.M.; -He/She did not administer any medications to the resident last night (2/23/26) due to no doses were due;-He/She did not have access to the emergency medication kit;-On 2/24/26, he/she pulled up the discharge paperwork where it showed the medication doses that were given at the hospital and when the next doses were due at the facility;-The hospital probably gave the doses that were due on 2/23/26;-After reviewing the discharge orders (on 2/24/26), the resident's hospital discharge orders showed the resident received a dose of Eliquis at 8:00 A.M. on 2/23/26 and the next dose was due in the evening of 2/23/26; -Eliquis was in the emergency medication kit;-He/She could have administered the Eliquis on 2/23/26. During interviews on 2/24/26 at 10:05 A.M., 10:51 A.M. and 11:10 A.M., LPN A said the following: -The facility had an e-kit staff could utilize for medications that were ordered after hours or for new admissions;-He/She was unsure which medications were in the emergency medication kit;-He/She had access to the emergency medication kit if needed;-The resident did not receive his/her medications last night (02/23/26) because the pharmacy had not delivered the resident's medications to the facility;-The facility was waiting on a nebulizer (a medical device used to turn liquid into a mist for inhalation), so the resident still had not received the DuoNeb medication. Review of the resident's MAR, dated 2/24/26, showed staff had not administered DuoNeb Solution 0.5-2.5 mg/ml, 3 ml at 8:00 A.M. and 12:00 P.M. (ordered for 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). 3. During interviews on 2/24/26 at 2:40 P.M., 3:35 P.M. and 5:10 P.M., the interim Director of Nurses (DON) said the following: -A resident's medications should be available when the resident admitted to the facility, even if the resident admitted in the evening, and staff should administer the medications per the resident's physician orders; -If a medication was not available from the pharmacy on admission, staff should check the emergency medication kit for the medication;-If the medication was not available in the emergency medication supply, staff should contact the resident's physician and the pharmacy; -Staff should document if a medication was not in the emergency medication kit or if a medication was not available for administration per orders;-Central supply maintained a supply of medical equipment, including nebulizers;-Nurses were to get ordered medical equipment from central supply. During an interview on 2/24/26 at 5:10 P.M., the Administrator said he expected the nurses to utilize the emergency medication kit until the medication arrived from the pharmacy or to notify him. The facility had a backup pharmacy they could utilize if needed. During an interview on 03/09/26 at 10:00 A.M., the Medical Director said the following:-He expected the nurses to utilize the emergency medication kit until the pharmacy delivered the medication to the facility; -If the emergency medication kit did not contain the medication, he expected the facility to utilize the back-up pharmacy until the pharmacy could deliver the medication. -If the medication was not available, the nurses should notify the physician for alternate orders. Complaints 2731434, 2731445, 2733928

Based on observation, interview, and record review, the facility failed to implement, evaluate and modify interventions to prevent weight loss for one resident (Resident #18) of eighteen sampled residents. The resident experienced a 13.98% weight loss in two months. The census was 77.Review of the facility policy for Weight Change Investigation with a revision date of 05/2023 showed the following:-The weight change investigation will be initiated with the following: a significant weight change of 5% or more in one month, 7.5% or more in three months and/or 10% or more in six months;-Once the weight change investigation is completed, the dietician and the physician will be contacted for interventions;-The interventions will be updated in the resident chart and if appropriate, the resident or resident's representative will be notified of the interventions;-If the resident or resident representative refuses any of the interventions, education regarding rationale for the interventions will be given. If they continue to refuse, documentation of the refusal will occur in the resident chart and the physician will be notified;-The weight change investigation will occur each month until the weight has stabilized;-If based on the resident's condition, weight stability is the most appropriate goal;-If the weight loss is unavoidable based on resident condition and stabilization is unlikely, a physician should document as to why weight loss is medically unavoidable. Review of Resident #18's undated face sheet showed the resident was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, pulmonary edema ( a serious, often life-threatening condition caused by excess fluid accumulating in the lungs), congestive heart failure (CHF a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently), diabetes, protein-calorie malnutrition, osteoporosis (a chronic bone disease making bones fragile and highly susceptible to fractures) and osteomyelitis (infection in the bone) of the left ankle and foot. Review of the resident's care plan for nutrition and hydration initiated 12/06/25 showed the following:-The resident has the potential for alterations in nutrition and hydration;-The resident/guest will maintain adequate nutrition and hydration status throughout the review period;-Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change; -Monitor/record/report to physician as needed any signs or symptoms malnutrition: Emaciation (a state of extreme, dangerous thinness from severe malnutrition, muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in six months; -Obtain and document weights per physician orders and facility protocol;-Registered Dietician to evaluate and make diet change recommendations as needed. Review of the comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/10/25 showed the following:-Usually able to make self-understood and usually able to understand others;-Severe cognitive impairment;-Dependent upon staff for Activities of Daily Living (ADL's);-Has one unstageable pressure ulcer (a severe full-thickness wound where the base is completely covered by dead tissue (slough or eschar), making it impossible to determine the true depth or stage);-Weight of 186, height 5 foot 5 inches, no difficulty swallowing, no nutritional approaches, no history of weight loss or weight gain and receives a therapeutic diet.-Dental status not assessed. Review of the resident's weights documented in the electronic medical record (EMR) on 02/24/26 showed the following:-On 12/06/25 a weight of 192 pounds;-On 12/11/25 a weight of 185 pounds;-On 12/13/25 a weight of 185.2 pounds. Review of the resident's Registered Dietician's evaluation note dated 12/16/25 showed the following:-Diet - 2 gram sodium heart healthy diet;-Weight of 185.2 pounds;- Increased nutrient needs related impaired skin integrity; the resident has a large chronic unstageable pressure ulcer to the left heel;- Recommend discontinuing 2 gm, hearth healthy and calorie controlled diet restrictions. Contact physician to see if fluid restriction was still necessary;-Recommend: Regular No Added Salt Diet, sugar free beverages, diet condiments; Add 30 ml (milliliters) Pro Heal (a liquid protein supplement) two times (BID) a day; add Juven (a therapeutic nutritional drink powder designed to support wound healing, including pressure ulcers, diabetic foot ulcers, and surgical incisions) BID. Review of the resident's EMR on 02/24/26 showed the following:-No weights documented from 12/14/25 through 01/21/26;-On 01/22/26 a weight of 159.8 pounds. Review of the resident's POS dated January 2026 showed the following:- No Added Salt (NAS) diet regular texture, thin consistency, sugar free beverages and dietcondiments;- Juven oral packet give one packet by mouth two times a day for wound healing;- ProHealth give 30 ml by mouth two times a day for wound healing. Review of the resident's RD evaluation note dated 01/29/26 showed the following:-On 1/22/25 weight of159.8 pounds;-25.4 pound significant weight loss since 12/13/25 (-13.7%). December weight thought to be an error;-Resident sent out to hospital 1/22/26 and readmitted [DATE] with diagnosis of osteomyelitis. Resident on intravenous (IV) antibiotics, reports she is not interested in food. The resident was ten pounds below her usual body weight. Unstageable wound to left heel debrided (dead tissue removed) at hospital. Wound Vac (a non-surgical device that uses negative pressure therapy to accelerate healing for complex, chronic, or infected wounds) ordered;- Continue NAS diet, 2000 ml fluid restriction. Continue 30 ml Pro Heal BID and Juven BID for wound support. Recommend Magic Cup (a high-calorie, protein-rich nutritional supplement dessert) BID at lunch and dinner, (include as 240 ml of dietary fluids). Review of the resident's January POS on 2/24/26 showed no order for Magic Cup. Review of the resident's weights on 02/24/26 showed the following:-No weights from 01/22/26 through 02/22/26;-On 02/23/26 a weight of 163.8 pounds. Review of the resident's February POS on 02/24/26 showed no order for Magic Cup. Review of the resident's care plan for nutrition and hydration on 02/24/26 and dated 12/6/25 showed no interventions for weight loss. Observation on 02/23/26 at 12:30 P.M. showed the following:-The resident was in bed and staff served a lunch tray of a grilled cheese sandwich and a bowl of fruit;-The resident had his/her own teeth;-The resident ate half of the sandwich;-There was no Magic Cup on the meal tray. During an interview on 02/23/26 at 12:30 P.M. Family Member (FM) A said the following:-He/She usually was with the resident at the noon meal;-He/She had never seen staff serve a Magic Cup. Observation on 02/23/26 at 5:03 P.M. showed the following:-The resident was in bed with his/her meal. Staff served meat and mashed potatoes;-There was no Magic Cup served with the meal. During an interview on 02/23/26 at 5:03 P.M. the resident said he/she did not know what a Magic Cup was and when explained it was like an ice cream, he/she replied he/she had not received Magic Cups. During an interview on 02/24/26 at 9:30 A.M. Licensed Practical Nurse (LPN) G said the following:-If the Registered Dietician made any recommendations they would show up in the queuefor orders;-He/She does not see in the resident's record any recommendations for Magic Cups. Observation on 02/24/26 at 12:15 P.M. showed the following:-The resident was in bed with the noon meal tray on an over the bed table. The meal consisted of ground meat, macaroni and cheese and green beans;-There was no Magic Cup on the meal tray. During an interview on 02/24/26 at 1:15 P.M. the Registered Dietician said the following:-He/She comes to the facility on a weekly basis and reviews any new admission's chart and any resident who may be of concern;-He/She does not attend any meetings with the Director of Nursing (DON), the Administrator or the Interdisciplinary Team to discuss any concerns he/she may have;-He/She does make recommendations and will email the report to the Administrator, Director of Nursing, Dietary Manager (DM) and the Care Plan Coordinator;-He/She reviews weights and has noted some discrepancies, but these had not been addressed;-He/She reviewed the resident's chart on 01/29/26 and noted the resident had a significant weight loss and made the recommendation to add a Magic Cup to the lunch and dinner meals;-He/She did not know why these recommendations were not communicated to the physician. During a telephone interview on 03/05/26 at 11:15 A.M. the DM said the following:-The RD comes in weekly and reviews new admission and any other residents of concern;-The RD emails a report to him/her with recommendations;-He/She reviews the emails and if a recommendation is made, then he/she will change the diet card to reflect those recommendations;-The resident did not have Magic Cup in his/her diet order;-He/She must have missed that RD recommendation. During an interview on 02/24/26 at 5:10 P.M. the Interim DON said the following:-She would expect the RD's recommendation be communicated to the physician for approval;-She would expect the DON and DM to be reviewing these recommendations and communicate them to the physician. During an interview on 02/24/26 at 5:10 P.M. the Administrator said he would expect the RD's recommendations to be reviewed and communicated to the physician for approval. During a telephone interview on 03/05/26 at 11:15 A.M. the DM said:-The RD comes in weekly and reviews new admission and any other residents of concern;-The RD emails a report to him/her with recommendations;-He/She reviews the emails and if a recommendation is made, then he/she will change the diet card to reflect those recommendations;-The resident did not have magic cup in his/her diet order;-He/She must have missed that RD recommendation. During an interview on 03/09/26 at 10:00 A.M. the Medical Director said he would expect the nursing staff and the Interdisciplinary Team (IDT) to review and communicate any recommendations from the RD to the physician for residents who have had a weight loss to address the weight loss. 2733928

Based on interview and record review, the facility failed to administer medications without a significant medication error to one resident (Resident #17), in a review of 23 sampled residents, when staff failed to administer the resident's diuretic medications (medications used to remove excess fluid from the body) as ordered by the resident's physician from 03/20/26 through 04/04/26 resulting in an exacerbation of lower extremity edema and shortness of breath. The facility census was 70. Review of the facility policy Administration of Medications, dated April 2023, showed the following:-All medications are administered safely and appropriately, to aid residents to help with and overcome illness, relieve and prevent symptoms and help in diagnosis;-A physician or nurse practitioner order is required for administration of all medication;-If a medication is not administered, record the reason on the electronic Medication Administration Record (MAR) and notify the physician or nurse practitioner;-If a medication is ordered but not available, check to see if it was misplaced and then call the pharmacy to obtain the medication. Review of the facility policy, Physician Orders, revised May 2023, showed the following:-Orders may be called, hand-written, faxed, or electronically generated by the physician;-The physician's order must be documented completely with sufficient content to clearly convey the provider's intent;-After the authorized provider has completed the order, the Registered Nurse (RN) or Licensed Practical Nurse (LPN) is responsible to promptly and accurately transcribe all written orders. 1. Review of Resident #17's care plan, dated 02/12/26, showed the following:-Diagnoses of cardiac pacemaker (implanted device to regulate the electrical system in the heart), ischemic cardiomyopathy (weakened heart muscle), atrial fibrillation (irregular heart rate), hypertension (high blood pressure), chronic congestive heart failure (CHF, a chronic, progressive condition where the heart muscle cannot pump blood efficiently, leading to fluid backup in the lungs and body, fatigue and swelling), and history of heart attack;-The resident had potential for alterations in nutrition and hydration. Staff should evaluate any weight changes, monitor for decreased urine output and signs of dehydration;-Staff should administer medications as ordered. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 02/12/26, showed the resident was cognitively intact. Review of the resident's physician progress note, dated 03/04/26, showed the following:-admitted to the facility following hospitalization for CHF exacerbation (reoccurrence of symptoms) and acute on chronic kidney disease. The resident was managed with intravenous (IV, medications given through the vein) diuretics previously with stabilization and transfer to rehabilitation for therapy services;-Still had leg edema, 1 + pitting (measurement of the accumulation of excess fluid in the tissue, commonly the legs, ankles or feet, that left a lasting indentation (pit) after pressure was applied. The higher the number the greater the swelling) to lower legs;-Monitor intake and output (amount of fluid intake and amount of urine output), daily weights and assess need for diuretics based on current volume status;-Add compression stockings (tight stockings applied to force excess fluid from tissues into circulation) daily and keep legs elevated;-Lasix (diuretic medication) increased to 40 milligrams (mg) daily. Review of the resident's POS, dated 03/13/26, showed Lasix 40 mg twice daily for congestive heart failure. Review of the resident's cardiologist's progress note, dated 3/20/26, showed the following:-Chronic heart failure, struggling with swelling, was placed on higher dose of Lasix without improvement;-2+ pitting edema in lower extremities;-Volume up with worsening edema;-Start torsemide (a diuretic medication) 40 mg twice daily;-Discontinue Lasix 40 mg. Review of the resident's POS, dated 3/20/26, showed staff had not transcribed the physician's order for torsemide 40 mg twice daily or the order to discontinue Lasix 40 mg twice daily. Review of the resident's MAR, dated 3/20/26, showed staff administered Lasix 40 mg twice daily. Review showed no documentation staff administered torsemide 40 mg as ordered. Review of the resident's MAR, dated 3/21/26, showed staff administered Lasix 40 mg twice daily. Review showed no documentation staff administered torsemide 40 mg twice daily as ordered. Review of the resident's MAR, dated 3/22/26, showed staff administered Lasix 40 mg twice daily. Review showed no documentation staff administered torsemide 40 mg twice daily as ordered. Review of the resident's MAR, dated 3/23/26, showed staff administered Lasix 40 mg twice daily. Review showed no documentation staff administered torsemide 40 mg twice daily as ordered. Review of the resident's MAR, dated 3/24/26, showed staff administered Lasix 40 mg twice daily. Review showed no documentation staff administered torsemide 40 mg twice daily as ordered. Review of the resident's MAR, dated 3/25/26, showed staff administered Lasix 40 mg twice daily. Review showed no documentation staff administered torsemide 40 mg twice daily as ordered. Review of the resident's nurse's note, dated 3/26/26 at 8:47 P.M., showed staff spoke with the resident's family member and discussed the recent cardiology appointment. Staff requested the cardiology notes from the family member and the physician order for torsemide 40 mg to be administered twice daily. Review of the resident's POS, dated 3/26/26, showed an order for torsemide 20 mg, two tablets twice daily for CHF. Review of the resident's MAR, dated 3/26/26, showed staff administered Lasix 40 mg twice daily. Review showed no documentation staff administered torsemide 40 mg twice daily as ordered. Review of the resident's nurse's note, dated 3/27/26 at 11:35 A.M., showed staff spoke with cardiology and was instructed to discontinue Lasix. Torsemide 40 mg twice daily replaced Lasix. Review of the resident's MAR, dated 3/27/26, showed staff administered Lasix 40 mg was administered in the morning and then the medication was discontinued. Staff also documented staff administered torsemide 40 mg in the morning. Review showed no documentation staff administered torsemide 40 mg twice daily as ordered. Review of the resident's MAR, dated 3/28/26, showed no documentation staff administered torsemide 40 mg twice daily for CHF. Review of the resident's nurses' note, dated 3/28/26 at 10:39 A.M., showed torsemide 40 mg medication was not available for administration. Review of the resident's MAR, dated 3/29/26, showed no documentation staff administered torsemide 40 mg in the morning. Review of the resident's nurses' note, dated 3/29/26 at 9:00 A.M., showed torsemide 40 mg was not available and on order. Review of the resident's MAR, dated 3/30/26, showed no documentation staff administered torsemide 40 mg twice daily for CHF. Review of the resident's nurses' note, dated 3/30/26 at 8:35 A.M., showed torsemide 40 mg medication was not available and on order. Review of the resident's MAR, dated 3/31/26, showed no documentation staff administered torsemide 40 mg twice daily for CHF. Review of the resident's nurses' note, dated 3/31/26 at 9:24 A.M., showed torsemide 40 mg medication was not available and on order. Review of the resident's MAR, dated 4/01/26, showed no documentation staff administered torsemide 40 mg twice daily for CHF. Review of the resident's nurses' note, dated 4/1/26 at 1:34 P.M., showed torsemide 40 mg medication was not available and on order. Review of the resident's MAR, dated 4/2/26, showed no documentation staff administered torsemide 40 mg twice daily for CHF. Review of the resident's nurses' note, dated 4/02/26 at 9:01 A.M., showed torsemide 40 mg medication was not available and on order. Review of the resident's MAR, dated 4/04/26, showed no documentation staff administered torsemide 40 mg twice daily for CHF. During an interview on 4/14/26 at 5:00 P.M., the resident's family member said the resident saw the cardiologist on 3/20/26 and received new medication orders. The resident's legs were weeping, and the resident was weaker and had declined overall. The cardiologist ordered torsemide for the swelling and it was over two weeks before staff provided the medication. The facility lost the order from the 3/20/26 physician visit and asked the family for a copy of the report. The resident's legs were swollen and got worse without the new medication. During an interview on 4/14/26 at 5:05 P.M., the resident said staff did not give him/her the new medication for swelling and his/her legs were swollen and draining. He/She was huffing and puffing and did not want to get out of bed for therapy. Since taking the new medication, the swelling was gone, and he/she was not as short of breath. Observation on 4/14/26 at 5:10 P.M. showed the resident lying in bed. The resident's lower extremities were without swelling. During an interview on 4/16/26 at 7:15 A.M., Licensed Practical Nurse (LPN) L said staff should notify the resident's physician if staff did not administer medications as ordered or if medications were not available. There should not be a delay in administration of medications. Staff should follow the physician's orders. During an interview on 4/16/26 at 12:35 P.M., the Director of Nursing (DON) said there should be no delay in administering medications. Staff should enter the new physician orders and obtain the medications from the pharmacy. If the medications were not administered, staff should document the cause of the delay and notify the physician. Staff should follow physician orders, and document all communication in the resident's medical record. During an interview on 4/16/26 at 1:20 P.M., the Administrator said staff should administer medications as the physician ordered without delay. Staff should notify the physician if medications were not administered as ordered and document communication with the physician in the resident's medical record. The facility process should include follow-up after a physician appointment, review of the new physician orders and to ensure staff implemented the new orders. During an interview on 4/15/26 at 10:30 A.M., the resident's physician said staff did not make him aware the torsemide 40 mg was not administered as ordered for two weeks. The resident's cardiologist made medication changes due to the resident's edema and CHF. Staff should implement those medication changes without delay. Staff should notify the physician if medications were not administered as ordered. The resident had significant cardiac history and not giving the medication as ordered affected the resident's outcome and overall condition. All medications should be administered as ordered and without delay. Staff should document administration of medications, and if not available or not given, notify the physician for alternate medications or orders. MO 2979335

Based on observation, interview and record review, the facility failed to provide one resident (Resident #10), in a sample of 18 residents with an evening meal. The resident admitted to the facility on the evening shift and staff provided no meal tray for the resident. The resident's family had to go to a local restaurant and bring food to the resident. The census was 77.The facility did not provide a policy for meal service to new admissions upon request. Review of Resident #10's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of fracture pelvis, respiratory failure and protein-calorie malnutrition. Review of the resident's physician order sheet dated 02/23/26, showed a diet order of a regular diet with mechanical soft foods. Observation and interview on 02/23/26 at 7:27 P.M. showed the following:-The resident and Family Member (FM) B in the resident's room;-FM B said the resident arrived at the facility on 02/23/26 at 5:55 P.M. from a local hospital for therapy due to a fractured pelvis;-No staff offered or brought the resident any food when they first got to the facility, so he/she went to a local restaurant and bought food for the resident;-He/She only saw one staff member that evening, a nurse who told him/her the kitchen was closed for the day. During an interview on 02/24/26 at 7:30 A.M. the resident said:-He/She was waiting for breakfast, and he/she was hungry, he/she did not get a lot to eat for supper last evening;-His/Her daughter had to bring food in for him/her due to not getting a meal tray from the facility. During an interview on 03/05/26 at 11:15 A.M. the Dietary Manager said the following:-He/She is notified via a memo of any admissions that are coming that day;-He/She was not aware ahead of time of specific ordered diets, so he/she must wait for the resident to be in the facility and the nursing staff to enter the resident's information into the Electronic Medical Record (EMR) before he/she can enter their diet information into the dietary system;-If a resident was admitted before 7:00 P.M.; nursing should come to the dietary department and inform the dietary staff the resident is in the facility and nursing staff should ask the resident what they would like to have for the meal;-If nursing staff has not come back to the kitchen and informed them the resident has been admitted , then the dietary department will leave a tray in the window for nursing staff to take to the resident when they arrive at the facility;-On 02/23/26, the dietary department was notified via a memo earlier that day of several admissions arriving and they had made up three or four meal trays. There were not told Resident #10 was in the facility, so they left the tray in the kitchen window for the resident when he/she arrived;-He/She was not aware staff told the resident the kitchen was closed and the family had to purchase food for the resident;-The tray of food was in the kitchen window the next morning and staff had not passed the tray to the resident. This was not the first time this has happened;-Food was available when the resident was admitted , no one came to the kitchen to get the food. During an interview on 02/24/26 at 5:10 P.M. the Director of Nursing and the Administrator said if the resident was admitted after supper, they would expect nursing staff go to the kitchen and get the resident a meal tray. During an interview on 03/09/26 at 10:00 A.M. the Medical Director said he would expect all new admissions or residents who have returned from the hospital late to receive some type of nourishment, either a meal tray, sandwich, or what the resident might want. 2731343

Based on observation, interview, and record review, the facility failed to provide appropriate infection control measures for two residents (Residents #1 and #11), in a review of 18 sampled residents, when staff did not utilize enhanced barrier precautions (EBP, an infection control strategy in nursing homes that expands the use of personal protective equipment (PPE), specifically gowns and gloves, for high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs)), as directed in the facility policy. The facility census was 77. Review of the facility policy, Enhanced Barrier Precautions (EBP), dated March 2024, showed the following:-EBP is implemented as an intervention this facility uses to reduce transmission of resistant organisms that employs targeted PPE use during high contact resident care activities;-EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities;-Residents with the following conditions require EBP for all cares and services regardless of MDRO colonization status: -Wounds, including any skin opening requiring a dressing regardless of MDRO colonization status; -Indwelling medical devices regardless of MDRO colonization status, including but not limited to central line, urinary catheter, feeding tube, tracheostomy/ventilator;-Gowns and gloves are used during high-contact activities with increased risk for MDRO transmission to staff clothing and hands including but not limited to: -Dressing; -Bathing/showering; -Transferring; -Providing hygiene; -Changing linen; -Changing briefs or assisting with toileting; -Device care or use including but not limited to central line, urinary catheters, feeding tubes, tracheostomy/ventilator and wound care: any skin opening requiring a dressing;-All staff will be trained and in-serviced and will demonstrate competency at the time of hire, prior to providing direct care to any resident, with any outbreak of infection in the facility, at least annually, and any time a staff member's supervisor identifies a need for additional training;-If a situation occurs requiring implementation of this policy the facility's Infection Preventionist (IP) will immediately complete: -EBP are indicated for residents who are at increased risk of MDRO acquisition such as resident has a wound or indwelling medical device; -Post subtle, dignified, clear signage on the door or wall outside the appropriate room indicating type of precautions and required PPE including gown and gloves; -For EBP, signage will clearly indicate the high-contact care activities that require the use of a gown and gloves; -Make PPE, including gowns and gloves, available near or outside resident's room; -Incorporate periodic monitoring and assessment of adherence to recommended infection prevention practices including hand hygiene and appropriate use of PPE to determine need for additional training and education; -Provide education to staff, residents, family members and visitors with written and verbal educational tools;-Residents will be maintained in EBP throughout the duration of the resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed the resident at higher risk. 1. Review of Resident #11's undated face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 02/12/26, showed the resident had an indwelling urinary catheter (a tube inserted into the bladder to drain urine). Review of the resident's care plan for Enhanced Barrier Precautions related to the indwelling catheter, dated 02/12/26, showed the following:-Provide EBP as indicated;-Use PPE, specifically gowns and gloves, during high contact resident care activities (i.e., prolonged direct contact). Observation on 02/24/26 at 7:10 A.M. showed the following:-No sign on the resident's door indicating staff should utilize EBP when caring for the resident, and no gowns were available outside or inside the resident's room;-Certified Nurse Assistant (CNA) E entered the resident's room. The resident said he/she needed to use the bathroom;-The resident had a urinary catheter;-CNA E, without donning a gown or applying gloves, placed a gait belt around the resident's waist and transferred the resident from the recliner into a wheelchair, placed the urinary catheter collection bag on the side of the wheelchair and pushed the resident into the bathroom;-Once in the bathroom, CNA E put on a pair of gloves, did not put on a gown, placed his/her hands on the gait belt and assisted the resident to a standing position at the toilet;-CNA E pulled down the resident's pants and assisted the resident to sit on the toilet;-CNA E removed the resident's pants and unsoiled incontinence brief, pulled the urinary catheter through the pant leg, and attached it to the handrail;-The resident complained about a sore on his/her bottom;-CNA E removed his/her gloves, and without washing his/her hands, he/she exited the room;-Licensed Practical Nurse (LPN) I and CNA E entered the resident's bathroom, each wore gloves, but neither wore a gown;-CNA E assisted the resident to stand from the toilet;-LPN I wiped the resident's bottom with toilet paper. The resident cried out, Ouch! -LPN I noticed a couple drops of blood on the toilet tissue and said he/she would tell the resident's nurse. LPN I removed his/her gloves and left the room; -LPN F entered the resident's bathroom room wearing gloves, but no gown. LPN I sprayed wound cleanser on gauze and wiped the resident's buttock. Blood was visible on the gauze. LPN F applied a dressing on the open wound, removed his/her gloves, used hand sanitizer, and left the room;-CNA E wiped the resident's bottom with a wet wipe, pulled the catheter tubing through the leg of his/her pants, secured the tubing to the wheelchair, pulled up the resident's pants, transferred the resident back into the wheelchair, and pushed the resident back to the recliner. CNA E transferred the resident from the wheelchair into the recliner;-CNA E removed his/her gloves and used hand sanitizer to cleanse his/her hands before exiting the room. During an interview on 02/24/26 at 7:30 A.M. LPN E said EPB should be used when you put creams on the skin. During an interview on 02/24/26 at 7:45 A.M. CNA E said he/she was not sure what EBP was used for, he/she wore gloves when he/she took care of residents. 2. Review of Resident #1's Face Sheet showed the following:-The resident was admitted on [DATE];-The resident's diagnoses included end stage renal disease and dependence on renal dialysis (a life-sustaining treatment for kidney failure that involves filtering the blood to remove waste and excess fluid). Review of resident's admission MDS, dated [DATE], showed the following:-Occasionally incontinent of urine and always incontinent of bowel;-Dependent on staff for showering/bathing and toileting;-Required partial/moderate assistance with personal hygiene. Review of the resident's Care Plan, dated 02/15/26, showed the following:-The resident was on EBP related to wounds and dialysis central venous catheter (CVC; a tube inserted into a vein for rapid blood access);-Provide EBP as indicated;-Use PPE, specifically gowns and gloves, during high contact resident care activities (prolonged direct contact). Review of the resident's February 2026 Physician Order Sheet (POS), showed the following:-Cleanse gluteal (buttock) wounds with normal saline and apply medi-honey (an antimicrobial wound dressing) with foam dressing every day shift;-Cleanse right heel with normal saline and apply medi-honey with foam dressing every day shift;-Coccyx (tailbone) - cleanse wound with normal saline, apply medi-honey and cover with foam dressing. Change daily and as needed;-EBP for wounds and dialysis CVC;-Dialysis on Monday, Wednesday and Friday;-Monitor dialysis site left upper extremity (LUE) fistula, right chest CVC every Monday, Wednesday and Friday. Review of the resident's wound assessment, dated 2/19/26, showed the following: -Coccyx wound 0.6 centimeters (cm) by 0.4 cm by 0.2 cm;-Left buttock 0.6 cm by 0.6 cm by 0.2 cm;-Right arm 1.4 cm by 1.7 cm by 0.2 cm;-Right heel 0.8 cm by 2.2 cm by 0.4 cm. Observation on 2/23/26 at 10:19 A.M., showed no EBP sign on the resident's door and no PPE cart outside of the resident's room. During an interview on 2/23/26 at 11:03 A.M., CNA D said he/she knew when to wear a gown into a resident's room when there was a sign on the door. Observation on 2/23/26 at 3:55 P.M., showed no EBP sign on the resident's door and no PPE cart outside of the resident's room. Observation on 2/23/26 at 4:57 P.M., showed the following:-No EBP sign on the resident's door;-No PPE cart outside of the resident's room.-LPN A and an unidentified staff entered the resident's room and donned gloves. Neither staff put on a gown. Observation and interview on 2/23/26 at 5:02 P.M., showed the resident's guest left the resident's room after staff provided care. The guest said staff only wore gloves when they provided care to the resident. During an interview on 2/24/26 at 7:27 A.M., LPN A said the following:-He/She was not sure if the resident was on EBP;-He/She only wore gloves when he/she provided care to the resident (on 2/23/26). During an interview on 2/24/26 at 7:14 A.M., Registered Nurse (RN) C, a nurse manager, said the following:-Every resident who was on enhanced barrier precautions should have a PPE cart outside the room or PPE door hanger;-Residents with dialysis access and/or wounds should be on EBP;-He/She was not sure if the resident was on EBP;-The resident should be on EBP for dialysis access and wounds;-He/She guessed the EBP sign never got on the resident's room door. Observation on 2/24/26 at 7:22 A.M. showed no EBP sign on the resident's door and no PPE cart outside of the resident's room. During an interview on 2/24/26 at 7:22 A.M., resident's spouse said staff only wore gloves when they provided wound care to the resident. Observation on 2/24/26 at 8:08 A.M., showed the following:-No EBP sign on the resident's door;-No PPE cart outside of the resident room;-Certified Nurse Assistant (CNA) D changed the resident's linens while the resident lay in the bed;-CNA D only wore gloves and did not wear a gown. Observation on 2/24/26 at 9:17 A.M., showed the following:-The resident had an AV fistula (irregular connection between an artery and vein used for hemodialysis) in his/her left arm; -The resident had a central venous catheter (long, flexible tube inserted into a large vein in the neck, chest or groin with the tip resting near the heart to administer medications, fluids or blood products) in his/her upper chest. During an interview on 2/24/26 at 5:10 P.M., the Director of Nursing (DON) said the following:-Staff was to use EBP for any resident who had a history of MDRO, a draining wound, or an indwelling medical device that included catheters, intravenous lines, dialysis access, and central lines;-Nurse managers were responsible for setting up EBP; -She was responsible for ensuring EBP was in place for residents. During an interview on 2/24/26 at 5:10 P.M., the Administrator said he expected staff to know which residents should be on EBP. During an interview on 03/09/26 at 10:00 A.M., the Medical Director said he expected all staff to be knowledgeable regarding Enhanced Barrier Precautions and for staff to utilize all required personal protective equipment.